[General recommendations for medical treatment after heart transplantation]

Heart transplantation remains the treatment of choice in selected patients with severe heart failure (HF) despite optimal medical therapy. Since long-term survival after HTX is improving, there is a growing need for evidence-based strategies that reduce long-term mortality resulting from both immunological and non-immunological risk. This manuscript summarizes recommendations for treatment of transplant vasculopathy, malignancy after transplantation, and prevention of corticosteroid induced bone disease. Based on actual understanding of cardiovascular risk factors in the population, preservation of renal function, prevention and treatment of hyperlipidemia and diabetes, as well as blood pressure control play an important role in the long-term follow-up after heart transplantation.

Partial acute transverse myelitis is a predictor of multiple sclerosis in children

Background:

Acute transverse myelitis (ATM) in children is a rare and often severe disease for which there are few known prognostic factors, particularly the subsequent risk of multiple sclerosis (MS) diagnosis.

Objectives:

To determine the clinical course and prognostic factors after a first episode of ATM in children.

Methods:

Thirty children below 16 years of age diagnosed with a first neurological episode of ATM were included retrospectively. Clinical evaluation, treatment, laboratory, and MRI data were collected.

Results:

Median age at onset was 11 years (range 3–15 years). Follow-up data were available for a median of 4 years (range 0.5–16.7 years). Five patients subsequently had a diagnosis of MS (17%), which was associated with acute partial transverse myelitis (odds ratio 5; 95% confidence interval 2.3–11), with a 60% probability of having a relapse at five years ( p < 0.01). The 2011 Verhey criteria correctly identified MS in children with the highest specificity (96%) and sensitivity (80%).

Conclusion:

Acute partial transverse myelitis and brain MRI abnormalities at initial presentation are significantly predictive of a subsequent diagnosis of MS in children with ATM. These findings suggest that closer brain MRI monitoring after acute partial transverse myelitis might make the earlier introduction of disease-modifying therapies possible.

[General anesthesia in pediatric radiotherapy]

BACKGROUND

The majority of children under 3 years require anesthesia for radiotherapy.

METHODS

This work reports the experience of Paul-Strauss Center over a 4-year period on 15 children and covering 386 general anesthesia.

RESULTS AND CONCLUSION

The rate of anesthesia-related complications was low (0.5%) subject to the experience of the anesthesiologists and follow-up recommendations.

Efficacy of second intra-tendinous platelet-rich-plasma injection in case of incomplete response of the first injection: three-year follow up experience

PURPOSE

Tendinopathy is a frequent and ubiquitous disease developing early disorganized collagen fibers with neo-angiogenesis on histology. Peritendinous injection of corticosteroid is the commonly accepted strategy despite the absence of inflammation in tendinopathy. Platelet-rich plasma (PRP) might be a useful strategy to rapidly accelerate healing of the tendinopathy but there is a lack ok knowledge about the amount of PRP to be injected and the opportunity of a second injection in case of partial pain relief. The aim of our study was to assess the potential therapeutic effect of early second PRP intra-tendinous to treat persistent painful tendon tear and tendinosis in a long-term follow-up by ultrasonography (US) and clinical data in case of incomplete efficiency of first PRP treatment injection.

MATERIALS AND METHODS

Twenty-four consecutive patients referred for US treatment of tendon tear or tendinosis (T+) were included retrospectively. All had previously received a single intra-tendinous injection of PRP under US guidance (PRPT+) and benefited of a second PRP injection (PRPT2+) under US guidance in order to treat persistent painful. US and clinical data were collected for each anatomic compartment for upper and lower limbs before treatment (D0), 6 weeks (W6) after first treatment, 6 weeks (W12) after second treatment and until 32-month follow-up. We used Mac Nemar test and regression model to compare US and clinical data.

RESULTS

The residual US size of lesions was not significantly lower at W12 after PRPT2+ as compared to W6 (P=0.86 in upper and P=NS in lower member) independently of age (P=0.22), gender (P=0.97) and kind of tendinopathy (P=NS). Quick dash test values and WOMAC values were not significantly lower in PRPT+ at W12 (average: 21.5 months) as compared to W6 (P>0.66) and long-term follow-up (P>0.75) independently of age (P=0.39), gender (P=0.63) and kind of tendinopathy (P=NS). Nevertheless, comparison between D0 and long-term follow-up (LTF) functionnal score was statistically significant (p<0.001 in upper and lower member).

CONCLUSION

Our study suggests that second early intra-tendinous PRP injection under US guidance does not permit rapid decrease of tendinopathy area in US, nor does it quickly improve clinical pain and functional data in case of incomplete efficiency of first PRP injection. However, in long-term follow-up, patients improved their ability to mobilize pathologic tendons.

[Sport and type 1 diabetes]

Physical activity is recognised to be an efficient measure in improving glycemic control in the treatment of type 2 diabetes. This evidence is lacking in type I diabetes but type 1I diabetics benefit from the same advantages like the general population. For many type I diabetics, especially younger patients, sport represents an important modality in the treatment of their disease but also of their quality of life. However, this is often a challenge for the patient as well as for the physician regarding the metabolic consequences (hypo- but also hyperglycemia) which can appear in relation with physical activity. There are existing general recommendations concerning the intake of carbohydrates and the reduction of insulin doses but those have to be adapted individually for each patient and depend significantly on different sports and on the intensity of sport.

[Constraints of the dentist are consistent with the results of an optimal irradiation with modulated intensity in N0 oropharyngeal cancer]

PURPOSE

We compared intensity-modulated radiotherapy and 3D-conformal irradiation in oropharyngeal cancers according to the requirement of dentists.

MATERIAL AND METHODS

From the files of seven patients with cancer of the oropharynx, two dosimetry plannings for 3D-conformal radiotherapy and intensity-modulated radiotherapy with tomotherapy were performed. The dose distributions in the target volumes and organs at risk in relation to the dental sphere were compared.

RESULTS

For the planning target volume of the primitive tumour sites, average values of V95%, D2%, D98% and of the conformal index were statistically in favour of tomotherapy. For the planning target volume of node areas, averages values of V95%, D2%, D98% were statistically in favour of tomotherapy. For ipsi- and controlateral parotide glands, average values of V15Gy, V26Gy, V30Gy, V40Gy were significantly lower for tomotherapy. For the submaxillary glands, average values of mean doses and V40Gy were statistically in favour of tomotherapy. For the buccal cavity, the average values of V45Gy were statistically in favour of tomotherapy. For ipsi- and controlateral masseter muscles, the average values of mean doses were statistically in favour of tomotherapy. For the ipsi- and controlateral temporomandibular joints, average values of mean doses and V60Gy were statistically in favour of tomotherapy. For mandibular bone, average values of mean doses and V40Gy, V50Gy, V60Gy and V70Gy were statistically in favour of tomotherapy. For maxillary bone, average values of V40Gy, V50Gy and V60Gy were statistically in favour of tomotherapy.

CONCLUSION

The radiation oncologist can constrain the intensity-modulated radiotherapy dosimetry to the needs of dentists to prevent or improve dental care and quality of life.

[Long-term mechanical circulatory support: where do we stand in 2013?]

With the advent of new technologies, experience with long-term mechanical circulatory support (MCS) is rapidly growing. Candidates to MCS are selected based on concepts, strategies and classifications that are specific to this indication. As results drastically improve, supported by stronger scientific evidence, the trend is towards earlier implantation. An adequate pre-implant follow-up is mandatory in order to avoid missing the best window of opportunity for implantation. While on chronic support, the hemodynamic profile of patients with continuous-flow ventricular assist devices is unique and remarkably influenced by the hydration status. Optimal management of these patients from the pre-implant phase to the long-term support phase requires a multidisciplinary approach that is similar to that already long validated for organ transplantation.

[Endocrinology in 2012: what's new?]

Maternal hypothyroidism has been associated with intellectual impairment in offspring and, subsequently, routine thyroid screening during pregnancy remains controversial. However current literature has reported no benefit of systematic thyroid screening and substitution with levothyroxine of hypothyroid pregnant women on cognitive function in offspring. Recent studies suggest that subclinical hypothyroidism and hyperthyroidism, especially those with TSH >10 mIU/l or <0.1 mIU/l are associated with cardiovascular morbidity and mortality. Genetic markers are being studied in order to clarify the nature of benign or malignant thyroid nodules after fine-needle aspiration whom cytology is indeterminate. They could avoid the need for surgery in many cases.

[Amiodarone and thyroid]

Amiodarone, an iodine-rich drug, results in mild disturbances of thyroid function in most patients and in thyroid dysfunction in approximately 20% of them. Hypothyroidism, mainly found in countries without iodine deficiency, is substituted with levothyroxine and does not need amiodarone to be discontinued. Hyperthyroidism, commonly found in areas of iodine deficiency, is more complex and usually motivates discontinuation of amiodarone. Type I hyperthyroidism, induced by iodine overload, is treated with antithyroid drugs, and type 2, resulting from the cytotoxic effect of amiodarone, may be treated with glucocorticoids. Considering the risk of thyroid dysfunction in patients treated with amiodarone, it is recommended to check regularly TSH level.

[Central diabetes insipidus: diagnosis and management]

Central diabetes insipidus (CDI) is caused by deficient secretion of antidiuretic hormone (ADH) due to different conditions that can affect the hypothalamic neurons. It results in an inability to retain normal quantities of free water, which leads to polyuria, including at night, and polydipsia. In adults, it is mostly due to the "idiopathic" form or present after pituitary surgery or a traumatic brain injury. In rare cases, an underlying systemic disease is found. The diagnosis of CDI is based on the water deprivation test. Pituitary MRI and specific clinical and biological work-up are recommended to precise etiology. Treatment of choice is desmopressin, a synthetic analogue of the endogenous ADH hormone. A multidisciplinary team generally provides management and monitoring of CDI.

[Athlete's heart: frontier between physiology and pathology]

Athletes often exhibit structural and electrical cardiac adaptations that are influenced by several factors including sporting discipline, gender and ethnicity. These changes are considered physiological and reversible in most cases. However, recent data indicate that atrial and right ventricular remodeling in athletes may represent pathological changes leading to arrhythmias. Sudden cardiac death in athletes is a rare but dramatic event. The differential diagnosis between the athlete's heart and heart diseases that are potential etiologies of sudden cardiac death, such as hypertrophic cardiomyopathy, may be challenging. New recommendations about electrocardiogram interpretation in athletes may help to improve prevention strategies.

[Treatment of differentiated thyroid cancer]

The prevalence of thyroid cancer is steadily rising and the fortuitous discovery of a thyroid nodule is a frequent situation for the clinician. The clinical importance is the need to exclude thyroid cancer. In this article we present the initial work up and treatment options for differentiated thyroid cancer. Initial diagnosis is done with a dosage of thyroid stimulating hormone and a fine needle aspiration guided by ultrasonography, which permits classification of the lesion and guides the choice of treatment.

[Endocrinology]

Recent discoveries in molecular biology offer new perspectives in the treatment of endocrine tumors. There is currently no medical therapy for Cushing's disease that targets the pituitary adenoma. Pasireotide, a new somatostatin analog, demonstrates a strong affinity for somatostatin receptors expressed by corticotroph adenomas. Some recent clinical trials showed a decrease of urinary free cortisol with pasireotide. This new treatment could be useful in case of pituitary surgery failure. Thyroid tumorigenesis involves kinase signaling cascade. Tyrosine-kinase inhibitors have now been tested in the treatment of progressive differentiated iodine refractory thyroid carcinomas or medullary carcinomas and showed modestly encouraging results.

[Maternal heart disease and pregnancy: a multidisciplinary approach]

In developed countries, cardiovascular diseases are becoming one of the first causes of maternal death. Myocardial infarction, dissection of the thoracic aorta and cardiomyopathies are the leading causes. However, preexisting maternal cardiac diseases, such as congenital heart diseases, are more commonly encountered and may be associated with significant maternal and perinatal morbidity. This article reviews hemodynamic changes occurring during pregnancy, proposes a risk stratification according to pre-existing cardiac diseases, and discusses the monitoring and overall management of these patients. Finally, two pregnancy-triggered cardiac diseases are discussed: coronary artery disease and peripartum cardiomyopathy.

[Childhood parvovirus B19 encephalitis]

INTRODUCTION

Human parvovirus B19 (PVB19) causes erythema infectiosum or 5(th) disease in childhood, which mainly affects children between 3 and 15 years of age. PVB19 infections have also been described in association with a variety of neurologic manifestations including encephalitis.

CASE REPORT

This 3-year 8-month-old boy developed febrile encephalitis (mental status change with seizures and left limb hypertonia) associated with a rash. The electroencephalographs revealed focal slowing with some spikes in front of the left centro-temporo-occipital areas ; bacteriological and biochemical cerebrospinal fluid (CSF) analysis were normal, brain radiologic studies (tomography and magnetic resonance imaging) were normal. The diagnosis of encephalitis associated with PVB19 primo infection was based on viral DNA detection in the serum and CSF using PCR and on the specific immunoglobulin M (without immunoglobulin G) detection in the serum.

DISCUSSION

In France, encephalitis etiology is unknown in 48% of the cases. PVB19 accounts for 4.3% of undiagnosed meningoencephalitis in children. Although there is no specific sign, seizures and rash are reported in about one-half and one-quarter of cases, respectively.

CONCLUSION

Even if PVB19 research is not cited in the French or American infectious disease society recommendations on the diagnosis and management of infectious encephalitis, this virus may be responsible, especially in cases of child febrile rash. Therefore, PVB19 research seems reasonable if the clinical presentation is concordant in children due to its diagnostic simplicity and efficacy.

[Use of 64-slice tomodensitometry after cardiac arrest]

Acute coronary occlusion is the leading cause of out-of-hospital cardiac arrest, so patients are usually referred for immediate coronary angiography and angioplasty. We report here the observation of such a patient who previously underwent a coronary artery bypass intervention and who had a difficult arterial access. Moreover, the nature of the grafts was unknown (saphenous and/or mammary arteries). Multi-slice cardiac tomo-densitometry was performed rather than a conventional coronary angiography and it allowed the analysis of native arteries and grafts. There was no stenosis and angioplasty was unnecessary.

[Fine needle aspiration of the thyroid: the value of on-site evaluation]

Thyroid nodules are very common in the general population and most of them are benign. Fine needle aspiration (FNA) of the thyroid is routinely used because it is a rapid, simple, accurate and cost-effective technique which allows the adequate selection of patients who should be managed surgically. However, the diagnostic yield of FNA is variable and depends of multiple factors including the one who performs FNA, the aspiration and cytological slide preparation techniques, and cytopathologist's experience. On-site evaluation of thyroid FNA material and close clinico-pathological collaboration offer many advantages and optimizes the yield of FNA.