[Acute coronary syndrome]. / Syndrome coronarien aigu.

Acute coronary syndromes represent a major cause of mortality in our country. There is a very wide spectrum of clinical presentation since the actual classification of acute coronary syndromes is based on electrocardiographic presentation, that is to say based on absence or presence of ST segment elevation. When dealing with an acute chest pain, once the probability of acute coronary syndrome is established, the emergency care must follow the scientific guidelines. One of the critical steps is represented by the evaluation of ischaemic and hemorrhagic risk in order to tailor optimally antithrombotic and anticoagulation therapies and revascularization timing. This article summarizes the main points of the emergency care from the diagnosis to risk stratification.

Les syndromes coronariens aigus sont une des principales causes de mortalité dans notre pays. Il existe un large spectre de présentations cliniques. La classification actuelle des syndromes coronariens aigus est basée sur la traduction électrocardiographique, à savoir l'absence ou la présence d'un sus-décalage du segment ST. Devant une douleur thoracique, une fois la probabilité de syndrome coronarien aigu établie, la prise en charge en urgence devra suivre les recommandations des sociétés scientifiques. Une des étapes essentielles est l'évaluation du risque ischémique et hémorragique afin d'adapter au mieux les traitements antithrombotiques, anticoagulants et les délais de revascularisation. Le présent article résume les principes de cette prise en charge, du diagnostic à la stratification du risque, et en fonction de cette dernière, du traitement à instaurer.

Results of a trial of combined propamidine isethionate and neomycin therapy for Acanthamoeba keratitis. Brolene Study Group.

PURPOSE: To characterize patients with Acanthamoeba keratitis and to evaluate the safety and efficacy of propamidine isethionate 0.1% ophthalmic solution (Brolene) when administered concomitantly with neomycin-polymyxin B-gramicidin ophthalmic solution (Neotricin) in the treatment of Acanthamoeba keratitis. DESIGN: Prospective, noncomparative case series. METHODS: The authors report the clinical characteristics and outcomes of patients who entered this multicentered, open-label, clinical trial. Eighty-three patients with Acanthamoeba keratitis representing 87 infected eyes entered the trial. RESULTS: Sixty (69%) of the 87 eyes enrolled had data analyzed for treatment efficacy and safety. Of these 60 eyes, 50 (83%) experienced treatment success. Thirty (60%) patients successfully treated adhered to treatment protocol guidelines. Patients who broke protocol had disease exacerbation during the maintenance therapy phase. The only eyes lost/enucleated were 7 of 17 in which penetrating keratoplasty was performed before eradication of the infectious agent. CONCLUSION: Propamidine isethionate and neomycin are an effective treatment for Acanthamoeba keratitis. Penetrating keratoplasty should be performed only for visual rehabilitation and not to "debulk" an active infection. The authors advocate treating patients with topical medications, mainly Brolene, until all organisms are eradicated. There should be no signs of infection for at least 3 months in the patients not receiving antiamebic medications before penetrating keratoplasty is performed.

Complications of combined radial thermokeratoplasty and incisional keratotomy.

PURPOSE: To report complications of radial thermokeratoplasty (RTK) when used in combination with either radial keratotomy (RK) or astigmatic keratotomy (AK). METHODS: RTK is a technique for the surgical correction of hyperopia and presbyopia. 600 degrees C burns are applied to the peripheral cornea for 0.3 seconds using a specialized cautery probe. The thermal energy generated shrinks stromal collagen and flattens the peripheral cornea. The central cornea is steepened producing a myopic shift. RESULTS: Two patients who had RTK in combination with either RK or AK are reported. Patient 1 was bilaterally hyperopic and presbyopic. The patient had RTK performed on the left eye in an attempt to make that eye myopic. The goal was to allow the left eye to be used for near vision. After RTK, the left eye was significantly overcorrected. The patient then had RK in the left eye which resulted in profound overcorrection with return of hyperopia. Postoperatively, examination revealed gaping of the RK incisions and poor epithelial wound healing. The patient also complained of severe ocular pain. Despite suturing the RK incisions, the eye remained hyperopic. The patient underwent two additional RTK procedures which failed to correct the induced hyperopia. The second patient had induced hyperopic astigmatism after undergoing RK. RTK was then performed to correct the hyperopia. However, the result was a worsening of the astigmatism. Two t-cut astigmatic keratotomies were then performed which improved the astigmatism but subsequently exacerbated the hyperopia. A second RTK procedure was then performed; however, it failed to correct the induced hyperopia. CONCLUSIONS: RTK is an unproved surgical technique for the correction of hyperopia and presbyopia that needs much further evaluation before broad clinical application can be supported.

Calcium ATPase activity and membrane structure in clear and cataractous human lenses.

PURPOSE: Maintenance of calcium homeostasis is imperative for the clarity of the lens. Ca(2+)-ATPase is essential for the removal of cytosolic calcium, either across the plasma membrane or through intracellular organelles such as the endoplasmic reticulum. In this study, membranes prepared from clear lens epithelium were compared to membranes prepared from cataractous lens epithelium. METHODS: Human lens membranes were prepared by a protocol utilizing homogenization and centrifugation. Ca(2+)-ATPase activity was measured biochemically using Gamma-32P labeled ATP. Lipid order was measured using infrared and Raman spectroscopy. RESULTS: Ca(2+)-ATPase activity was similar in membranes prepared from cataractous lenses that were classified as nuclear subcapsular, nuclear and brunescent cataracts. Ca(2+)-ATPase activity was approximately 50% less in membranes prepared from cataractous lenses in comparison to clear lenses. Because clear lenses from Indian donors was unavailable, clear human lenses were used as a qualitative control for the measurement for Ca(2+)-ATPase activity. Lipid order was measured in lens fibers from cataractous and clear lenses from the United States donors. Lipid order increased from 55% in the hydrocarbon chains from clear lens fibers to 84% in cataractous lens fibers. CONCLUSIONS: These findings support the hypothesis that membranes are deranged in cataractous tissue, which should lead to altered levels of calcium.

Standardized color-coded maps for corneal topography.

PURPOSE: Modern videokeratoscopy is useful in assessing corneal shape. The purpose of this study is to compare color-coded topographic maps using standardized scales with 1.0- and 1.5-diopter (D) intervals. The authors assessed the use of the two scales for detecting clinically relevant features of corneal topography such as regular astigmatism, irregular astigmatism, early keratoconus, and contact lens-induced corneal warpage. METHODS: A total of 50 normal corneas, 50 corneas with contact lenses, 50 that had keratoconus (25 early to moderate and 25 advanced), 50 that had penetrating keratoplasty, 20 that had extracapsular cataract surgery, 17 that had excimer laser photorefractive keratectomy for myopia, 10 that had radial keratotomy, 3 that had aphakic epikeratophakia, and 2 that had myopic epikeratophakia were analyzed with a corneal topographic analysis system. Color-coded maps with 1.0-D intervals (Maguire/Waring scale) and 1.5-D intervals (Klyce/Wilson scale) were compared. RESULTS: There were no topographic characteristics that were not appreciated with either scale for corneas with dioptric powers that fell within their ranges. Conversely, for corneas that had powers outside the range of the 1.0-diopter scale, but within the range of the 1.5-diopter scale, the former produced a map in which the flattest or steepest areas were artifactually smoothed. CONCLUSIONS: This study suggests that the Klyce/Wilson scale (constant, 1.5-D intervals) provides the best combination of sensitivity for detection of clinically significant topographic features and the widest range of coverage of powers that are found on a variety of normal, pathologic, and surgically altered corneas. The adoption of the Klyce/Wilson scale by all manufacturers of corneal topographic instruments as a primary standard will facilitate communication and will make the interpretation of corneal topography easier for both the expert and the novice.

Tetralogy of Fallot with double aortic arch: successful staged repair. Case report and review of literature.

The rare association of DAA with TOF is reported in a young boy who underwent successfully at the age of 3 months an emergency shunt between the anterior (left) hypoplastic aortic arch and the LPA after the vascular ring was divided. Total correction of the cardiovascular malformation was performed at the age of 4 years. The cardiac catheterization, angiographic and operative findings as well as the management of the case are described. Ten other patients with this combination of anomalies were found on review of the literature, eight of whom had only palliative systemic to pulmonary artery shunts. Knowledge of the morphology of the DAA by angiocardiography is helpful in planning the management. Surgical shunts when done early for the treatment of a patient with repeated anoxic spells may reduce the gravity of psychomotor retardation. A staged surgical repair of TOF is recommended for infants having hypoplastic pulmonary arteries.