[Selection and preoperative follow-up of heart transplantation candidates in the French part of Switzerland]

Heart transplantation (HTx) started in 1987 at two university hospitals (CHUV, HUG) in the western part of Switzerland, with 223 HTx performed at the CHUV until December 2010. Between 1987 and 2003, 106 HTx were realized at the HUG resulting in a total of 329 HTx in the western part of Switzerland. After the relocation of organ transplantation activity in the western part of Switzerland in 2003, the surgical part and the early postoperative care of HTx remained limited to the CHUV. However, every other HTx activity are pursued at the two university hospitals (CHUV, HUG). This article summarizes the actual protocols for selection and pre-transplant follow-up of HTx candidates in the western part of Switzerland, permitting a uniform structure of pretransplant follow-up in the western part of Switzerland.

[Chest pain, dyspnea, discomfort with swallowing]

Achalasia is a rare neuromuscular disease of the gastrointestinal tract, often characterized by unspecific chest pain, dysphagia and regurgitation. Our case shows the slowly progression of the disease and its frequent relapse. All possible treatment options are only for palliation, but depending on the method with good (long-term) results. In end-stage disease resection of the oesophagus is a possible treatment.

[Management of prolactinomas: what's new in 2010?]

Prolactinomas represent the most frequent pituitary adenomas. Dopaminergic agonists, especially cabergoline, are the first choice treatment. The efficacy of cabergoline in the normalization of prolactin level and in the tumoral volume reduction is well documented. Following more than two years of cabergoline treatment, in case the level of prolactin is normalized and the MRI shows no tumor residue, the medication can be withdrawn with chance of remission. Valvular heart disease has been associated with cabergoline in patients with Parkinson's disease. However due to the lack of systematic data on the subject, cabergoline is still prescribed in case of prolactinoma. Echocardiography could be proposed as a follow up diagnostics to the subjects treated with high dose of cabergoline for a long period.

Unexpected neurological sequelae following propofol anesthesia in infants: Three case reports

Propofol is a widely used hypnotic agent for induction and maintenance of pediatric anesthesia with a well known safety profile. Experimental in vitro studies suggest that propofol may be toxic to developing neurons. We report the cases of three infants who underwent surgery before 2 months of age for different benign pathologies. Propofol was used for induction and maintenance of anesthesia in all cases. The three patients developed convulsions with similar clinical characteristics (cluster of recurrent clinical and subclinical seizures) between the 23th and 30th hours following anesthesia. Clinical and electroencephalographic improvement was obtained between the third and fourth day of management in pediatric intensive care unit. The seizures never recurred, and the three patients underwent further uneventful general anesthesia without propofol. Follow-up of the three patients disclosed unexpected neurological dysfunction: progressive microcephaly (head circumferences were normal at birth), developmental impairment with cognitive and behavioural disturbances in two cases, and bilateral symmetrical white-matter abnormalities on cerebral magnetic resonance imaging.

CONCLUSION

The causal relationship between propofol anesthesia and the neurological symptoms of our patients remains difficult to ascertain, but we believe that pediatricians, anesthetists and intensive care-givers should be aware of this possible adverse reaction that has never been described before.

[Acute inflammatory polyradiculoneuropathy and membranous glomerulonephritis following Epbstein-Barr virus primary infection in a 12-year-old girl]

Acute inflammatory polyradiculoneuropathy, or Guillain-Barré syndrome (GBS), is characterized by peripheral nerve demyelination, which leads to rapidly progressive weakness, loss of sensation, and loss of deep tendon reflexes. It is a prototype of postinfectious autoimmune disease, whose pathophysiology is well described in the forms provoked by certain bacteria (molecular mimicry with Campylobacter jejuni), but remains unclear for the forms related to other organisms (cytomegalovirus, Epstein-Barr virus and other herpes group viruses, Mycoplasma pneumoniae). Glomerular lesions can be associated with the neurological symptoms and have also been described after various infections, independently of any signs of polyradiculoneuropathy. We report the observation of a 12-year-old girl who presented with Guillain-Barré syndrome with facial diplegia, ataxia, and intracranial hypertension following Epstein-Barr virus (EBV) primary infection. During the course of the neurological disease, membranous glomerulonephritis (MGN) was diagnosed. The neurological impairment was regressive within 6 months after intravenous immunoglobulin treatment followed by intravenous then oral corticosteroid administration. Viremia remained high more than 6 months after the onset of symptoms. Glomerulopathy progressed independently and finally required immunosuppressant medication with cyclosporine. EBV might be the factor that triggered the autoimmune disorders, as previously reported for systemic lupus erythematosus and multiple sclerosis in children. To the best of our knowledge, this association of 3 conditions (GBS, MGN, and EBV primary infection) has never been reported in the literature.

[What is new in the medical management of acute heart failure?]

Acute heart failure (AHF) is a frequent medical condition associated with a poor prognosis. Based on systolic blood pressure at presentation, patients with AHF can be classified into 5 clinical profiles enabling a more targeted use of standard medications including diuretics, vasodilators and inotropes. The most recent guidelines underline the importance of a rapid management and the favorable impact of heart failure programs, which reduce morbidity and mortality after an admission for AHF. New therapeutic perspectives include ultrafiltration, vasopressin and adenosine antagonists, relaxin and new inotropes such as istaroxime.

[Hypoactive sexual desire disorder in men: clinical approach in sexual medicine]

Hypoactive sexual desire disorder in men: clinical approach in sexual medicine Hypoactive sexual desire disorder (HSDD) has a high prevalence in the population, representing an important cause of consultations in sexual medicine. Although HSDD affects women mostly, it also affects men. HSDD in men can be due to different factors. A precise medical evaluation of these factors is needed to start an efficient therapy. Along these lines, HSDD evaluation must follow a precise schema that integrates psychological factors and also endocrinological, toxic and psychiatric factors. A specific formation in sexual medicine is recommended for an optimal evaluation of HSDD. The present article describes the milestones of the adequate evaluation of HSDD to help the physicians in their daily clinical practice.

[Acute motor deficit in childhood: diagnosis management]

Acute motor deficit is not uncommon in childhood, with various neurological etiologies. Pertinent semiological analysis allows correct diagnosis management, with adequate paraclinical investigations. The authors describe this clinical diagnosis strategy. The most common clinical situations and various etiologies are presented; paraclinical investigations confirming the diagnosis are discribed, with specific attention to central nervous system imaging according to the most recent sequences.

[High resolution sonography of the dorsal radiocarpal and intercarpal ligaments: findings in healthy subjects with anatomic correlation to cadaveric wrists]

PURPOSE

To assess the value of ultrasound (US) imaging of the dorsal radiocarpal and intercarpal ligaments of the wrist, after characterization of their imaging features on cadaveric specimen.

MATERIALS AND METHODS

Two wrist dissections of fresh cadaver were performed. The orientations and the osseous insertions of the ligaments were clarified, allowing development of an US examination protocol. Then, forty wrists of asymptomatic volunteers were analyzed prospectively with US. The visibility and thickness of both ligaments were estimated at their midpoint and at their osseous insertions.

RESULTS

The dorsal radiocarpal and intercarpal ligaments were visualized as thin, hyperechoic and fibrillar structures, extending between their respective osseous insertions. The mid portions of the ligaments were visible at all volunteers. The osseous insertions were completely or partially visible in 90% of cases, except for the radial insertion of the dorsal radiocarpal ligament, visible in 77.5% of cases.

CONCLUSION

US, based on good anatomical knowledge and a standardized protocol, which we describe in this work, enables evaluation of the dorsal radiocarpal and intercarpal ligaments of the wrist.

[Contribution to comparative ophthalmo-morphology: the eye of the brown trout]

BACKGROUND

The aim of this study was to assess similarities and differences between the trout eye and the human eye.

MATERIALS AND METHODS

Gross and microscopic examinations of the formalin-fixed eyes of each five trout and human eyes (donor eyes not suitable for keratoplastic) were carried out.

RESULTS

Compared to the human eye, the trout showed a flattening of the anterior-posterior axis, and cartilage-stabilized sclera. The peripheral cornea was much thicker than the central, had a multilayered thick epithelium, a distinct Bowman layer, and an implied Descement membrane. A ring-shaped ligament filled up the angle of the anterior chamber and linked the iris to the cornea. The lens showed a spherical aspect with a thick capsule and missing zonular fibres, however, a suspensory ligament of a superior part of the lens was present. Ventrally, at the end of the falciform process, a small, pigmented structure was in contact with the lens. The retina was similarly differentiated, but the choroid showed special structures like choroidal gland, falciform process and the argentea compared to the human eye.

CONCLUSIONS

Great variations between the ocular anatomy of the trout and the human exist. However, the retina of the trout is fully differentiated and remarkably similar to that of human eyes.

Macula-off retinal detachment--a matter of time?

BACKGROUND

The aim of this study was to determine the influence of the lag time between macular detachment and surgical intervention on post-operative visual acuity gain in patients with rhegmatogenous macula-off retinal detachment.

PATIENTS AND METHODS

We retrospectively evaluated the medical records of 62 consecutive patients having undergone scleral buckling surgery for rhegmatogenous macula-off retinal detachment. The correlation of gender, age, refraction, number of retinal breaks, development of cataract during follow-up, pre-operative visual acuity and timing of surgical intervention with final visual acuity and post-operative visual acuity gain were determined. Mean follow-up time was 12.7 months.

RESULTS

A correlation with final visual acuity was found for pre-operative visual acuity and lag between the beginning of symptoms and surgical intervention. A correlation with visual acuity gain was found only for timing of surgical procedure. When divided into subgroups operated after 0, 1-3, 4-6, or 7-9 days, respectively, visual recovery was better the earlier the patients underwent surgical repair. Compared to surgery at day 0, statistical significance was found only for patients operated 4 or more days after the occurrence of symptoms.

CONCLUSION

The first three days seem to represent a relatively safe period during which surgery for macula-off retinal detachment may be postponed without compromising the patient's visual prognosis.

Adrenaline-induced chronic ocular hypertension in adult rabbits

BACKGROUND

The aim of this study was to develop a new animal model to enhance our understanding of the biological pathomechanisms involved in glaucoma.

MATERIALS AND METHODS

Forty white giant rabbits were divided into a treated (N = 30) and a control group (N = 10). Boli of adrenaline hydrochloride (0.1 mL 0.1% solution) were repeatedly injected into the veins of the ears of the rabbits and physiological saline in the control group, respectively, for three months. Intraocular pressure (IOP) and outflow facility of the aqueous humour were measured prior to, during and after treatment (4-6 months, 7-9 months, 10-12 months).

RESULTS

In comparison to the control group, the adrenaline-treated group showed a significant increase in IOP both during treatment (25%) and 12 months after treatment (57%). Comparative analysis further showed that the aqueous humour outflow facility of the treated group increased by 16.5% during the treatment, and showed a continuous decrease of 60 % after treatment.

CONCLUSION

This rabbit model could be useful for further investigations of the pathomechanisms involved in glaucoma.

[Treatment specificity of age-related sexual dysfunction]

Despite an increase in life expectancy and ever growing demands for treatment aimed at age-related sexual dysfunction, it remains underdiagnosed among the elderly because of lack of information. Proper evaluation is critical because treatment is available and such a dysfunction often acts as a signal for an underlying pathology. This paper intends to clarify treatment specificity. Hormonal deficiencies, such as Symptomatic Late-Onset Hypogonadism (SLOH) should be treated using an interdisciplinary approach. For women, hormonal deficiency is not the unique cause of sexual dysfunction. Psychosocial factors also play an important role. Sexual dysfunction should be considered as an indicator of general health. Screening for hormonal deficiency should be systematic.

High incidence of severe ischaemic complications in patients with giant cell arteritis irrespective of platelet count and size, and platelet inhibition

OBJECTIVE

Vision loss and ischaemic stroke are feared complications in GCA. We investigated how platelet count and size and platelet inhibition with ASA relate to ischaemic complications in patients with GCA.

METHODS

Charts of patients with GCA were retrospectively analysed. Jaw claudication, amaurosis fugax, blurred vision, ischaemic stroke and permanent visual loss were classified as 'ischaemic events'; ischaemic stroke and permanent visual loss were sub-grouped as 'severe ischaemic events'. The incidence of ischaemia and the association to the pre-defined covariates age, fever, ESR, platelet count and size and ASA treatment were assessed.

RESULTS

Eighty-five patients (mean age 73 yrs, 60% women, 78% biopsy-proven) were included in the analysis. Of the 85 patients, 62 (73%) presented with ischaemic events, 29/85 patients (34%) with severe ischaemic events. At the time of diagnosis 22/85 patients (26%) were treated with ASA. Of these 22 patients, 15 (68%) presented with ischaemic events, 7/22 patients (32%) with severe ischaemic events. In multivariate analysis, neither platelet count nor size or ASA treatment were significantly associated with ischaemic or severe ischaemic events.

CONCLUSIONS

The incidence of severe ischaemic events in patients with GCA was high, irrespective of platelet count and size and established ASA treatment.

Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial

BACKGROUND

Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives are scarce. This prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections.

MATERIALS AND METHODS

Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean time to first flatus passed, first defecation, and first solid food tolerated; GI-3). Secondary endpoints were incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay, and visual analogue scores for pain, cramps, and nausea.

RESULTS

One hundred sixty-nine patients were analyzed, and 31 patients discontinued the study. Groups were comparable in baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7 days, P = 0.007). Of the single parameters defining GI-3, there was a 1-day difference in time to defecation in favor to the bisacodyl group (3.0 versus 4.0 days, P = 0.001), whereas no significant difference in time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints was seen. Morbidity and mortality did not differ between groups.

CONCLUSION

Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.

High rate of early virological failure with the once-daily tenofovir/lamivudine/nevirapine combination in naive HIV-1-infected patients

BACKGROUND

The combination of one non-nucleoside reverse transcriptase inhibitor (NNRTI) with two nucleoside reverse transcriptase inhibitors is a validated first-line antiretroviral (ARV) therapy. The once-daily combination of lamivudine, tenofovirDF and nevirapine has not been evaluated in a clinical trial.

METHODS

Randomized, open-label, multicentre, non-inferiority trial comparing lamivudine, tenofovirDF and nevirapine once daily (Group 2) with zidovudine/lamivudine and nevirapine twice daily (Group 1), in naive HIV-1-infected patients with a CD4 count <350/mm(3). We planned to enroll 250 patients.

RESULTS

As of May 2006, 71 patients had been enrolled (35 in Group 1 and 36 in Group 2) and an unplanned interim analysis was done. The groups were comparable at baseline: median CD4 count was 195 and 191/mm(3) and median plasma viral load was 4.9 log(10) and 5.01 log(10), respectively, in Groups 1 and 2. Eight early non-responses (22.2%) were observed, all in Group 2, while two later viral rebounds occurred. Resistance genotypes for the nine Group 2 failing patients showed the mutations M184V/I (n = 3), K65R (n = 6), one or more NNRTI resistance mutations in all cases. At baseline, the nine Group 2 patients who failed had higher median plasma viral load (5.4 log(10)) and lower median CD4 count (110/mm(3)) than the other Group 2 patients (4.7 log(10), P = 0.002 and 223/mm(3), P = 0.004). Nevirapine trough concentrations were not different between the two groups, nor between patients with full viral suppression or those who failed in Group 2. Due to slow recruitment, and those results, the steering committee decided to stop the trial at 12 months.

CONCLUSIONS

In ARV-naive HIV-1-infected patients, the once-daily lamivudine, tenofovirDF and nevirapine regimen resulted in a high rate of early virological failures. The reasons for the failures remain unclear.

Continuous-infusion vancomycin therapy for preterm neonates with suspected or documented Gram-positive infections: a new dosage schedule

BACKGROUND

Intermittent infusion of vancomycin is widely used to treat late-onset sepsis in neonates. On the other hand, the continuous infusion of vancomycin could improve bactericidal efficacy since its action is time dependent.

OBJECTIVE

To evaluate a simplified dosage schedule for continuous-infusion vancomycin therapy.

METHODS

Prospective study in premature neonates (<34 weeks) with suspected coagulase-negative staphylococci (CoNS) sepsis. Before antibiotics at time zero (T0), serum creatinine was measured and blood cultures were collected. Vancomycin dosage began with 25 mg/kg/day or 15 mg/kg/day (period 1) and 30 mg/kg/day or 20 mg/kg/day (period 2) depending on whether serum creatinine was below or above 90 mumol/l. Two days after beginning treatment (first timepoint: T1), serum vancomycin was measured and second blood cultures were collected.

RESULTS

Between June 2002 and December 2005, 145 neonates were evaluated. At birth, the median (interquartile range) body weight was 920 (500-1160) g and gestational age was 28 (26-29) weeks. At T1, serum vancomycin was within the required range in 74.5% of neonates (108/145). Serum vancomycin levels were higher in period 2 than in period 1 (20 mg/l vs 13 mg/l, p<0.05). At T0, 55% (80/145) of blood cultures were positive for CoNS, but 71% (57/80) were negative at T1. Four days after beginning treatment, 92% of subjects had recovered without removing the central venous catheter.

CONCLUSION

Using this simplified dosage schedule, bactericidal efficacy was maintained and most subjects had serum vancomycin concentrations within the therapeutic range.

A PER/TIM/DBT interval timer for Drosophila's circadian clock

Circadian rhythms in Drosophila are supported by a negative feedback loop, in which PERIOD (PER) and Timeless (TIM) shut down their own transcription as they translocate once a day from the cytoplasm of clock-containing cells to the nucleus. Period length is partially determined by an interval of cytoplasmic retention of the TIM and PER proteins. To study this process, we examined PER/TIM/Doubletime (DBT) physical interactions and nuclear translocation by imaging individual cultured Drosophila cells. Using live cell video microscopy and green fluorescent protein (GFP) tags, we observed dynamic patterns of stability and localization for DBT, PER, and TIM that resembled those previously found in vivo. These studies suggest that a cytoplasmic interval timer regulates nuclear translocation of these proteins. The cultured cell assay provides a potent system to study interactions among new and known genes involved in the generation of circadian behavior.

French medical research: the risk of 'demedicalization'

French medical research is at present financed almost entirely by INSERM (Institut National de la Santé et de la Recherceh Médicale). The INSERM budget (286 million francs in 1975) supports research in laboratoreis in university hospitals by doctors who have both clinical and teaching commitments and, especially, by more than a thousand 'statutory research workers' employed by INSERM. Research in INSERM laboratories now tends to be fundamental biological research rather than directed towards pathological problems. Among the reasons for this are (i) the mode of recruitment of staturtory research workers; (ii) the difficulties of clinical investigation, which are due mainly to the way the hospitals function and to lack of interest by the hospital administration in medical research; (iii) the small number of university doctors actively involved in research. Research on fundamental biological problems in INSERM laboratories is making excellent progress, due to the quality of the research workers, and it may pay in the long run. But medical research is now tending to become an 'ivory tower' for the victorious researchers, who sometimes scorn the clinicians. Medical research will, if no measures are taken, 'demedicalize.' Institutes of pure biological research could soon be isolated within the medical faculties and doctors may become even less scientific and investigative than they are today. This situation could be modified by: (i) re-evaluating the role of research in a university hospital career, making it impossible for a doctor to attain high levels of promotion unless he does some research (this could be done by asking doctors interested in such a career to work for several years in an INSERM laboratory after their training and before they take up clinical responsibilities); (ii) awarding clinicians, exceptionally, the status of research worker; (iii) increasing considerably the participation of the universities in financing medical research, a participation which at present is absurdly low and is every decreasing.

[Endocrinology]

Treatment and follow-up of differenciated thyroid carcinoma and use of recombinant human TSH in the case of ablative radio-iodine treatment or thyroglobulin stimulation are discussed in the context of new international recommandations. Subclinical thyroid disease and abnormal thyroid function tests during pregnancy are the other topics. Treatment of subclinical hyperthyroidism is recommended when TSH is below 0.1 mU/l because of cardiac and bone complication while a substitutive thyroid hormone therapy is proposed when TSH is above 10 mU/l in subclinical hypothyroidism. During pregnancy, T4 replacement is recommended in women with subclinical and overt hypothyroidism because of adverse outcome for either the fetus or the mother. By contrast, treatment should be initiated only in over hyperthyroidism with propylthiouracil as a first-line drug.

Haemodilution induced by hydroxyethyl starches 130/0.4 is similar in septic and non-septic patients

BACKGROUND

Fluid therapy induces haemodilution related to plasma volume expansion. The aim of our study was to compare haemodilution after a single hydroxyethyl starches (HES) 130/0.4 infusion in two groups of patients, one with and one without sepsis. We hypothesized that a single HES challenge would induce similar sustained haemodilution in both groups.

METHODS

In this prospective preliminary study, patients predicted to require a single further volume-expander infusion were included immediately before receiving 500 ml of 6% HES 130/0.4 over a 15-min period. No additional fluid was administered over the next 8 h. Haematocrit, and serum albumin and protein were determined immediately before HES infusion then after 1, 2, 3, 4, and 8 h.

RESULTS

Twelve patients were included in each group. In both groups, all three haemodilution markers had significantly lower values after 1 h than at baseline. None of the values after 1 and 3 h differed significantly between the two groups. Neither did any of the other study variables show significant differences between the groups with and without sepsis.

CONCLUSION

We found that a starch-based compound was as effective in inducing haemodilution in patients with sepsis as in controls without sepsis, suggesting that HES may remain within the intravascular space even in patients with sepsis. Haemodilution parameters such as haematocrit, serum albumin and serum protein are useful for assessing the duration of plasma volume expansion induced by fluid therapy in critically ill patients.