Modulation of Energy Metabolism and Epigenetic Landscape in Rainbow Trout Fry by a Parental Low Protein/High Carbohydrate Diet

Simple Summary

While the effects of parental diets on their progeny have been highly described in mammals, such studies are lacking in fish. To explore such a question in a high trophic level teleost fish, two-year old male and female rainbow trout were fed either a control diet (0% carbohydrate and 63.89% protein) or a high-carbohydrate diet (35% carbohydrate and 42.96% protein), for a complete reproductive cycle for females and for a period of 5 months for males. Neither the maternal nor the paternal high-carbohydrate diet alone had induced significant effects on their progeny. Nevertheless, when both parents were fed the high-carbohydrate diet, the energy metabolism and mitochondrial dynamics of their progeny were altered. Moreover, the epigenetic landscape was also highly affected. Even though, offspring growth was only slightly affected at the early stage of life; the effect of parental high-carbohydrate diet should be explored over the long term.

Abstract

It is now recognized that parental diets could highly affect offspring metabolism and growth. Studies in fish are, however, lacking. In particular, the effect of a parental diet high in carbohydrate (HC) and low in protein (LP) on progeny has never been examined in higher trophic level teleost fish. Thus, two-year old male and female rainbow trout (Oncorhynchus mykiss) were fed either a control diet (0% carbohydrate and 63.89% protein) or a diet containing 35% carbohydrate and 42.96% protein (HC/LP) for a complete reproductive cycle for females and over a 5-month period for males. Cross-fertilizations were then carried out. To evaluate the effect of the parental diet on their offspring, different phenotypic and metabolic traits were recorded for offspring before their first feeding and again three weeks later. When considering the paternal and maternal HC/LP nutrition independently, fry phenotypes and transcriptomes were only slightly affected. The combination of the maternal and paternal HC/LP diets altered the energy metabolism and mitochondrial dynamics of their progeny, demonstrating the existence of a synergistic effect. The global DNA methylation of whole fry was also highly affected by the HC/LP parental diet, indicating that it could be one of the fundamental mechanisms responsible for the effects of nutritional programming.

[Linking Interventional Cardiology clinical registry data with French hospital administrative data: Development and validation of deterministic record linkage]

BACKGROUND

To recreate the in-hospital healthcare pathway for patients treated with coronary angiography or percutaneous coronary intervention, we linked the interventional cardiology registry (ACIRA) and the pseudonymized French hospital medical information system database (PMSI) in the Aquitaine region. The objective of this study was to develop and validate a deterministic merging algorithm between these exhaustive and complementary databases.

METHODS

After a pre-treatment phase of the databases to standardize the 11 identified linking variables, a deterministic linking algorithm was developed on ACIRA hospital stays between December 2011 and December 2014 in nine interventional cardiology centers as well as the data from the consolidated PMSI databases of the Aquitaine region from 2011 to 2014. Merging was carried out through 12 successive steps, the first consisting in strict linking of the 11 variables. The performance of the algorithm was analyzed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Strategies complementary to the initial algorithm (change in the order of variables and base preprocessing) were tested. Comparative analysis of merged/unmerged patients explored potential causes of mismatch.

RESULTS

The algorithm found 97.2% of the 31,621 ACIRA stays to have sensitivity of 99.9% (95% CI [99.9; 99.9]), specificity of 97.9% (95% CI [97.7; 98.1]), PPV of 99.9% (95% CI [99.9; 99.9]) and NPV of 96.9% (95% CI [96.7; 97.1]). Complementary strategies did not yield better results. The unmerged patients were older, and hospitalized mostly in 2012 in two interventional cardiology centers.

CONCLUSION

This study underscored the feasibility and validity of an indirect deterministic pairing to routinely link a registry of practices using hospital data to pseudonymized medico-administrative databases. This method, which can be extrapolated to other health events leading to hospitalization, renders it possible to effectively reconstruct patients' hospital healthcare pathway.

Association between lipid lowering regimen intensity at discharge and long-term mortality in optimally-treated patients with acute myocardial infraction. The FAST-MI programme

Background

Randomised trials evaluate the efficacy of individual medications, irrespective of overall patient management. We assessed the association between lipid-lowering therapy (LLT) intensity and long-term mortality in otherwise optimally-treated patients with acute myocardial infarction (AMI).

Methods

FAST-MI consists in one-month nationwide French surveys of patients admitted for a recent AMI, repeated every 5 years. We used the 2010 and 2015 data with 3-year follow-up. Background optimal therapy was defined as use of PCI, together with ESC guideline-recommended treatment with beta-blockers, ACEi/ARB, when indicated, and optimal antithrombotic medications including type of P2Y12-i; of 9,460 patients included, 4,042 were optimally-treated, with 478 (12%), 1120 (28%), and 2,444 (60%) respectively receiving conventional-dose statins (Gr 1), moderate-intensity statins (atorvastatin 40 mg or rosuvastatin 10 mg) (Gr2) or high-dose LLT (atorvastatin 80 mg, rosuvastatin ≥20 mg or statin-ezetimibe combination) (Gr3).

Results

Baseline characteristics markedly differed in the 3 groups (Table 1).

Three-year Kaplan-Meier survival was 88.5%, 93.5% and 96.3% respectively for gr 1, 2 and 3, with Cox-adjusted HR of 0.75 (0.51–1.10), P=0.137, and 0.59 (0.41–0.86), P=0.006 for gr 2 and 3 compared with Gr1 (Figure).

Conclusion

In otherwise optimally-treated AMI patients, lipid-lowering regimen intensity at discharge was inversely associated with 3-year mortality. These results confirm that high-intensity lipid lowering therapy at discharge is likely beneficial even in patients receiving otherwise optimal therapy.

Figure 1. 3-year survival

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): MSD, AstraZeneca

Socioeconomic status influences delays in the management of acute ST-elevation myocardial infarction

Background

A prompt diagnosis to initiate the appropriate reperfusion therapy is crucial to improve clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients. Socio-economic status (SES) refers to parameters like income, educational status and occupation. A low SES negatively interferes with the prognosis of STEMI patients. However, the impact of SES on delay time in acute STEMI remains matter of debate.

Methods

We used databases from two French multicentric and prospective registries: ACIRA (patients undergoing coronary angiography in any catheterization laboratories of Aquitaine) and REANIM (acute STEMI patients supported by emergency medical system (EMS) in Aquitaine). An ecological indicator of social deprivation Fdep09 was calculated to describe geographical inequalities in health based on municipality of residence. The higher the value, the more disadvantaged the population. Low SES was defined as Fdep09 > median value.

Results

Two-thousand-eight-hundred-and-forty consecutive patients with acute STEMI undergoing coronary angiography from January 2017 to December 2018 in Aquitaine were included. Patients with lower SES were more often initially referred to emergency departments of non-percutaneous coronary intervention capable centers whereas patients with higher SES were more often directly transferred to PCI centers by the mobile emergency care units as recommended by the most recent European guidelines (p<10–4). Patients with low SES had longer delays from symptom onset to first medical contact (FMC) (116 [60–119] vs 98 [55–233] min, p=0.0078) and were more likely to receive fibrinolysis (9.9 vs 5.2%, p<10–4). Linear regression modeling showed that each point of the Fdep09 index was associated with increase in the delay from symptom onset to FMC by a factor 1.1 (95% CI: 1.04–1.17, p<10–3) after adjusting for potential confounders.

Conclusion

SES inequality has negative influence on the delays in the management of acute STEMI patients. Efforts to raise awareness of suspicious signs of acute MI among individuals in lower SES could be valuable.

FDep09 distribution

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): ARS Nouvelle-Aquitaine

New insights into methylmercury induced behavioral and energy-related gene transcriptional responses in European glass eel (Anguilla anguilla)

The effect of methylmercury (MeHg) was investigated in glass eel migration behavior and metabolism. To migrate up estuary, glass eels synchronize their swimming activity to the flood tide and remain on or in the substratum during ebb tide. Following seven days of exposure to MeHg (100 ng L^-1), glass eels migration behavior was expressed by their swimming synchronization to the water current reversal every 6.2 h (mimicking the alternation of flood and ebb tides) and their swimming activity level. In relation to their behavior, we then analyzed the energy-related gene expression levels in individual head, viscera and muscle. Results showed that MeHg decreased the number of glass eels synchronized to the change in water current direction and their swimming activity level. This last effect was more pronounced in non-synchronized fish than in synchronized ones, supporting the idea that non-synchronized glass eels could be more vulnerable to stress. As regard the expression of energy-related genes, no significant difference was observed between control and MeHg-exposed fish. In contrast, when the swimming activity levels were plotted against transcriptional responses, positive correlations were evidenced in viscera and especially in the head of exposed glass eels but not in control. Finally, it is noteworthy that non-synchronized glass eels displayed lower expression level of metabolism genes than their synchronized counterpart, but only in the head. Altogether, these results support the interest of focusing on the head to investigate the facultative migration behavior in glass eels and the effect of environmental stressors on this rhythmic behavior.

Electromagnetic analysis for optical coherence tomography based through silicon vias metrology

This paper reports on progress in the analysis of time-domain optical coherence tomography (OCT) applied to the dimensional metrology of through-silicon vias (TSVs), which are vertical interconnect accesses in silicon, enabling three-dimensional (3D) integration in microelectronics, and estimates the deviations from earlier, simpler models. The considered TSV structures are 1D trenches and circular holes etched into silicon with a large aspect ratio. As a prerequisite for a realistic modeling, we work with spectra obtained from reference interferograms measured at a planar substrate, which fully includes the dispersion of the OCT apparatus. Applying a rigorous modal approach, we estimate the differences to a pure ray tracing technique. Accelerating our computations, we focus on the relevant fundamental modes and apply a Fabry-Perot model as an efficient approximation. Exploiting our results, we construct and present an iterative procedure based on the minimization of a merit function, which concludes TSV heights reliably, accurately, and rapidly from measured interferograms.

[Caseous calcification of the mitral annulus, variable and revealing clinical picture, and the contribution of cardiac tomodensitometry to the diagnosis: report of two cases]

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification and a common echocardiographic finding. CCMA discovery is mostly incidental, considered as benign tumor and may be unrelated to patient symptoms. Multimodality imaging may have an additional value for the diagnosis of CCMA. We report the cases of two CCMA revealed by acute pulmonary oedema and stroke, respectively. The aims of this presentation are: to illustrate the variety of cardiac symptoms that led to the diagnosis of CCMA; and to highlight the usefulness of thoracic multisliced computed tomography for the diagnosis of CCMA.

[Intermediate term outcome in 70 patients with Tako-Tsubo syndromes]

BACKGROUND

Tako-Tsubo syndrome is a reversible left ventricular myocardial dysfunction. There are few publications on its evolution and the purpose of this study is to describe the medium-term outcome of patients who presented this pathology.

METHODS

This retrospective study included 70 patients presenting with Tako-Tsubo syndrome who were referred to Haut-Lévèque hospital between November 2003 and January 2012. The parameters included in follow-up were: number of cardiovascular events, recurrence, electrocardiographic and echocardiographic evolution.

RESULTS

Sixty-eight patients had a mean follow-up of 4.8±2.4 years. The survival rate was 92%, 39 patients (57%) showed no cardiovascular symptoms, 12 (18%) had one or more new episodes of chest pain and 4 (6%) had stage II dyspnoea on the NYHA classification scale. One patient had a recurrence 6.5 years later, triggered by the same stress as the first instance. Forty-five patients (64%) had ECGs which evolved in the early days to diffuse T-wave inversion. In the medium term, 32 (54%) patients had a normal ECG, 19 (32%) had inverted T-waves in precordial leads and 2 (3%) had Q-waves. In terms of echocardiography, left ventricular ejection fraction was normal in all with variable delays. Four patients continued to have apical hypokinesia.

CONCLUSION

This study shows that the medium-term outlook is favourable in terms of cardiovascular mortality and that recurrence is rare. It highlights, however, the persistence of electrocardiographic and echocardiographic abnormalities.

Main results of the European project NURESIM on the CFD-modelling of two-phase Pressurized Thermal Shock (PTS)

The European Platform for NUclear REactor SIMulations, (NURESIM project 2005 – 2008) addressed the creation of a Common European Standard Software Platform for modelling, recording, and recovering computer data for nuclear reactors simulations. One work package of the project was dedicated to the analysis and improvement of CFD capabilities for the simulation of two-phase PTS problems. Some SB-LOCA scenarios lead to a situation in which the cold leg is partially or totally uncovered when the Emergency Core Cooling injection is activated. The resulting complex two phase flow can be divided in characteristic flow regions: the jet flow with a free surface between steam and water, the zone of jet impingement, the horizontal two-phase flow and the flow in the downcomer. Many phenomena have to be reflected in a simulation of each separate region, but also when the simulations are coupled reflecting the integral process which is required to predict the thermal loads at the RPV wall. After analyzing the experimental database available for CFD model development and validation and identifying shortcomings of the models different activities were dedicated to the simulation of single flow regions as well as the integral flow. Based on these experiences recommendations for the CFD-simulation of the two-phase PTS problem were obtained.

Echocardiographic evaluation and N-terminal pro-brain natriuretic peptide measurement of patients hospitalized for heart failure during weaning from mechanical ventilation

BACKGROUND

Weaning patients with heart failure who have required mechanical ventilation remains challenging. We evaluated echocardiographic indexes and N-terminal pro-brain natriuretic peptide (NT-proBNP) as markers of acute cardiac dysfunction before and after spontaneous breathing trials (SBT) in such patients to assess their ability to predict subsequent successful extubation.

METHODS

Forty-four patients who underwent their first SBT were prospectively included. Plasma levels of NT-proBNP and transthoracic echocardiography indices including cardiac index, E/A ratio and E/Ea ratio were recorded immediately before commencing and just before the end of SBT.

RESULTS

Ten patients (22.7%) failed their SBT. No significant difference was observed concerning baseline echocardiographic data and NT-proBNP level between the patients who succeeded the SBT or those that failed. Cardiac index increased significantly at end-SBT in patients who passed (3.3 [3.06-3.77] vs. 3 [2.68-3.3] L/min/m(2), P<0.001), whereas it remained unchanged in those that failed. E/Ea ratio (16.8 [8.5-27.3] vs. 10.7 [6.7-20.5], P=0.006) and NT-proBNP level (8199 [3106-10949] vs. 4200 [1855-7125] pg/mL, P=0.004) increased significantly in those who failed the SBT, in contrast to the weaning success group where they remained unchanged.

CONCLUSION

Neither NT-proBNP level nor the studied echocardiographic indices before SBT were able to predict SBT outcome in patients presenting with severe heart failure. Failure to increase the cardiac index and increases in both E/Ea ratio and NT-proBNP levels were seen at end-SBT in patients who failed the SBT, and may reflect failure of myocardial reserve to cope with the stress of SBT.

[Multiple myocardial infarctions: pancoronary destabilization evaluated by cardiac MRI]

PURPOSE

Complete intravascular ultrasound study examination of all three coronary arteries in patients with first acute coronary syndrome very frequently revealed one or more atherosclerotic plaque ruptures associated with the culprit lesion. The aim of this study was to evaluate using cardiac MRI the incidence of multiple necroses in patients with myocardial infarction. The study sought to detect delayed enhancement in a zone different from the necrosis area concerned by the culprit occlusion.

METHODS

Eighty consecutive patients who were referred for a first myocardial infarction underwent angioplasty within the first 12 hours after chest pain beginning. Each patient was examined within four to eight days following the acute phase. Cardiac MRI evaluated left-ventricle function (TrueFISP sequence) and used a T2 weighted short-inversion-time, inversion recovery sequence (STIR) in order to visualize myocardial oedema; delayed enhancement imaging data were then acquired after injection of gadolinium.

RESULTS

In eight patients (10%), we observed two delayed enhancement areas associated with wall-motion abnormalities. One was attributed to the culprit occlusion; the second corresponded to a different coronary artery. In five patients, this second zone was related to an old coronary occlusion confirmed by angiography and the STIR sequence. However, in three patients, the second delayed enhancement area corresponded to a coronary artery stenosis with normal flow.

CONCLUSION

In patient with acute myocardial infarction, MRI sometimes detects a necrosis area which was not initially suspected. This observation illustrates the consequences of pancoronary destabilization.

[Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 24 procedures]

OBJECTIVES

We have examined the immediate and long-term patient outcomes following angioplasty of unprotected left main coronary artery stenoses.

BACKGROUND

Coronary disease of the unprotected left main artery is considered as an absolute contraindication for percutaneous intervention. Recently, several studies have reported good results with unprotected left main coronary artery stenting when surgical revascularization was contraindicated.

METHODS

From October 2004 to June 2006, 24 patients with a contraindication to surgery and with unprotected left main coronary artery stenoses received stents. Patients were surveyed at one, six and 12 months with telephone interviews.

RESULTS

The procedure's success rate was 100%. The percentage of stenosis and minimum lumen diameter (MLD) were respectively 63.4% (+/-15.4) and 1.1mm (+/-0.5) before procedure; 13.8% (+/-10.2) and 3.2mm (+/-0.5) after angioplasty. The size of stents averaged 3.79 mm (+/-0.46) with an average 1.04 stents per patient. During follow up, two deaths occurred (8.3%). No intrastent restenosis was found.

CONCLUSIONS

Stenting of unprotected left main coronary artery stenoses may be a safe and effective alternative to coronary artery bypass especially when surgical revascularization is contraindicated. However, further studies with larger patient populations are needed to assess the late outcome and to clarify the relevance of percutaneous intervention compared to surgery.

[Direct thrombin inhibitors in coronary angioplasty. Value of bivalirudin ]

During coronary angioplasty, the association of platelet inhibitors and antithrombin agents is required to prevent myocardial infarction. Bivalirudine, a synthetic direct thrombin inhibitor, has been widely validated in this context and has shown its efficacy and safety in several comparative studies. It is officially recommended as a replacement of NFH and LMWH associated or not with anti-GPIIb/IIIa agents because at comparable efficacy it causes fewer bleeding complications. In acute coronary syndromes without ST elevation, anti GPIIb/IIIa agents reduce angioplasty-related complications and mortality, especially in high risk patients in salvage situations. In the REPLACE-2 trial the clinical efficacy of bivalirudine (associated only when necessary with anti-GPIIb/IIIa agents) was no less than that of NFH associated systematically with anti-GPIIb/IIIa agents at the time of intervention. The incidents of serious adverse events at 30 days (death, infarctus, emergency revascularisation, major bleeding) in the bivalirudine group was 9.2% versus 10.2% in the NFH group. In a retrospective analysis, these results did not seem to be influenced by the prior administration of clopidogrel. Finally, the one year follow-up results showed a lower mortality in patients treated with bivalirudine (1.9% versus 2.5%), essentially in the high risk sub-groups such as the elderly, the diabetic or the renal failure patients. Clinical trials are underway (ACUITY) to study the interaction of anti GPIIb/IIIa agents with bivalirudine in the first hours of acute coronary syndromes and should confirm a major role of direct anti-thrombin drugs in the safety of angioplasty.

Primary osteoarthritis of hip, knee, and hand in relation to occupational exposure

AIM

To identify occupations with excess prevalence of osteoarthritis of the knee, hip, and hand in a nationwide survey and to compare occupations with and without excess prevalence with regard to biomechanical stresses and severity of osteoarthritis.

METHODS

Patients presenting with osteoarthritis of the knee, hip, or hand were recruited throughout France by their treating physician who collected information on history, including age at onset, occupation, and occupational stresses to joints. Severity was assessed using joint specific functional status questionnaires: Lequesne for the hip and knee and Dreiser for the hand. The distribution of osteoarthritis patients by occupation was compared with the distribution of occupations in all workers in France to obtain prevalence rate ratios.

RESULTS

Occupations with the greatest prevalence rate ratio were female cleaners (6.2; 95% CI 4.6 to 8.0), women in the clothing industry (5.0; 95% CI 3.9 to 6.3), male masons and other construction workers (2.9; 95% CI 2.6 to 3.3), and agriculture male and female workers (2.8; 95% CI 2.5 to 3.2). A twofold greater prevalence rate was observed within certain occupations between self-employed and salaried workers. Early onset of osteoarthritis was seen in the more heavy labour jobs with almost 40% of patients reporting their first symptoms before the age of 50.

CONCLUSION

The early onset and severity of osteoarthritis in certain occupations warrants an urgent need for occupation specific studies for the development and evaluation of preventive strategies in this leading cause of disability in Western countries.

[Isotretinoin: compliance with recommendations in childbearing women]

INTRODUCTION

The aim of this survey is to ascertain if the incidence of isotretinoin exposed pregnancies was reduced by the late recommendations of prescription and issue (AMM modification on 06/08/2001 and 25/09/2001).

METHODS

All isotretinoin exposed pregnancies registered by the French Regional Drug Monitoring Centres, the Information Centre for Teratogenic Agents and Roche (Roaccutane), Pierre Fabre (Curacné Gé) and Expanscience (Procuta Gé) laboratories, from January 1st, 1999 to December 31st, 2002, were analysed. Enforcement of the strengthening of isotretinoin prescription recommendations was analysed on a sample of 68 prescriptions from 45 pharmacies throughout France.

RESULTS

In 4 years, 103 isotretinoin exposed pregnancies (Roaccutane 97 p. 100, Curacné(R) Gé 3 p. 100) during teratogenic risk period, were registered. Pregnancy started less than one month after isotretinoin stopping (37 p. 100), during the treatment (43 p. 100), or was in progress when the treatment was initiated (20 p. 100). The reason of the 22 lacking contraception was known 12 times, i.e. an absence of prescription (6 times), a refusal to take a prescribed contraception (3 times) and a self-medication (3 times). Among the 71 pregnancies whose contraceptive status is known, 48 p. 100 could had been avoided if recommendations had been followed (pregnancies due to a premature stopping or an absence of contraception). The issue of pregnancies is a voluntary termination in 60 cases (87 p. 100). Malformations frequency is 25 p. 100. Incidence of isotretinoin exposed pregnancies remained stable, 0.26/1000 treated women (vs 0.34 after 2001's AMM modifications). Of 68 prescriptions studied, 23 (24 p. 100) carried all the legal warnings, which is close to the previous survey's results. Contraception was in accordance with the recommendations in 78 p. 100 of cases and women learned and applied information given in 38 p. 100 of cases. At last, only 6 patients (9 p. 100) have both a correctly written prescription, a contraception and a time between the pregnancy test date and prescription and issue dates, in accordance with the licence and have had a correct information and understood it. Regarding the previous survey, pregnancy test before treatment was more often prescribed (96 p. 100 vs 88 p. 100). On the other hand, less women knew the necessity to keep on taking contraception one month after isotretinoin stopping (82 p. 100 vs 93 p. 100).

CONCLUSION

Despite 3 successive isotretinoin prescription and issue recommendations strengthening in childbearing women, pregnancies can't be totally avoided. Bad compliance concerns the prescription and/or an incomplete or not understood information by the patient who does not scrupulously apply the care and contraception agreement. However, this study does not allow to assess the proportion of issued prescriptions despite their non-accordance with the licence criteria. The National Commission of Pharmacovigilance did not like to limit isotretinoin prescription to dermatologists only. It estimates that the administrative authority must intensify information by dermatologists, general practitioners and pharmacists, about measures to take to avoid an exposure to isotretinoin during pregnancy.

Primary osteoarthritis and occupations: a national cross sectional survey of 10 412 symptomatic patients

AIMS

To describe the age standardised prevalence of symptomatic osteoarthritis (OA) in a nationwide cross sectional survey of 10 412 patients in France, and their functional and work limitations.

METHODS

Cases in the survey were compared with their expected counterpart by age, gender, and occupational groupings using data from the 1998 French National Survey on Health Impairment and Disability.

RESULTS

Women represented 66.2% of the sample; mean age was 66.2 years. One third of patients had OA of the knee, 16% of the hip, and 12% of the hand; a third had multiple joint OA. Peak prevalence of symptomatic OA was in the 60-69 year category in women and in the 70-79 year category in men. Agricultural workers showed a significant excess prevalence of OA, with an observed to expected (O/E) ratio of 1.7 in women and 2.3 in men. Linear trends in prevalences between white collar, "mixed" collar, and blue collar workers were also significant, with odds ratios respectively of 1.0, 2.9, and 2.6 in women and 1.0, 1.2, and 1.7 in men. Specific excess prevalence was found in women among housekeepers (O/E 4.4), and in men among unskilled labour workers (O/E 10.3) and truck drivers (O/E 6.7). Total work disability was highest among blue collar workers and partial disability among agricultural workers.

CONCLUSION

Results contribute to the mounting evidence that OA is potentially aetiologically linked to occupation in a sizeable segment of the population and that OA can no longer be considered an inevitable disease of ageing.

[Fibrinolysis and thrombosis of mechanical valvular prosthesis: risk stratification by transesophageal echocardiography]

The place of fibrinolysis in the treatment of mechanical valvular prostheses is still much discussed. The aim of this work is to define the role of transoesophageal echocardiography in risk stratification. This monocentric study draws on 49 cases of thrombolysis preceded by transoesophageal echocardiography (average age 62.1 years, 37 mitral, 11 aortic, 1 tricuspid, 1 mitro-tricuspid). There were 41 obstructive thromboses (OT) and 8 non-obstructive thromboses (NOT). Clinical events and the effectiveness of fibrinolysis were studied as a function of the obstructive or non-obstructive character of the thrombosis and the size of the thrombus < 10 mm (n = 33) or > or = 10 mm (n = 16). Complete success was observed in 34 patients (69.4%). Follow up revealed 2 early cerebral haemorrhages (4.1%) of which one was in the NOT group, and six systemic emboli (12.2%) of which one was in the NOT group. There was a relationship between the size of the thrombus and embolus at the limit of significance in favour of an increased risk of embolus for a voluminous thrombus. Furthermore, the mobility of the thrombi went in hand with an increased rate of systemic emboli (p < 0.01). The rate of failure of fibrinolysis and/or complications correlated with the size of thrombus (complete success in 88% of the < 10 mm thrombus group, versus 35% in the > or = 10 mm; p < 0.01). This work underlines the significance of trans-oesophageal echocardiography in the therapeutic choice for valvular prosthesis thrombosis and suggests that the existence of a voluminous thrombus especially if mobile is a contra-indication for fibrinolysis.

Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death and long term results

OBJECTIVE

Repair of post infarction ventricular septal defect (VSD) is still a challenging procedure with a high risk of recurrence of the VSD and subsequent mortality. The aim of this retrospective study was to assess if technical change in the surgical procedure was followed by an improvement in recurrence of the VSD and operative results.

METHOD

This retrospective study from 1971 to 2001 included 85 patients operated on early (<15 days) after the occurrence of a post infarction VSD. Double patch technique was introduced in 1986. A total of 44 variables were studied by a uni- and multivariate analysis.

RESULTS

Hospital death occurred in 36 patients. Significant factors for hospital mortality included: preoperative and evolution of the clinical status, right ventricular function and type of repair (one or two patches). Moreover, no recurrence was observed in patients repaired with the double patch technique (P=0.09). None of the studied variables were significant for long term survival. Concomitant CABG was not associated with higher hospital mortality and long-term survival rate was similar in patients with or without concomitant CABG.

CONCLUSION

The use of the double patch technique and glue by avoiding recurrence of the VSD played a role in the reduction of the hospital mortality. This technique has to be recommended in the early repair of post infarction VSD. Concomitant CABG can be done safely to control the added risk of an associated coronary artery lesion.

[Fibrinolysis in myocardial infarction with EKG elevation. Optimization of myocardial reperfusion by treatment with antithrombotic agents]

In the case of acute coronary syndrome with prolonged ST elevation on ECG showing an acute coronary obstruction, the urgent institution of fibrinolysis is a widely validated treatment. Since the first placebo controlled studies with streptokinase until the development of bolus administration rt-PA varieties, fibrinolytic agents have lowered mortality. Associated anti-thrombotic drugs are multiplying in parallel. Their association is recognised as necessary in order to avoid early reocclusions which worsen the prognosis of infarction, the fibrinolysis triggering a harmful prothrombotic effect, notably due to the clot thrombin re-exposed during thrombolysis. Aspirin has an essential place formally demonstrated in ISIS 2. Non-fractionated heparin has more complex effects and its administration protocol in association with fibrinolysis has recently been reviewed with a reduction in dosage because prolonged clotting times during fibrinolysis have provoked a distinct increase in the risk of intracranial haemorrhage. The low molecular weight heparins seem to have become the adjuvant treatment of choice following publication of the ASSENT-3 trial. Pentasaccharide seems attractive. The place of hirudine and its derivatives in the acute phase of MI appear limited after the results of the HERO-2 trial, associating hirulog and streptokinase, with the earlier studies also having been disappointing. The GPIIbIIIa blockers in association with a half dose of fibrinolysis do not aggravate the intracerebral haemorrhagic risk before 75 years old and clearly reduce hospital morbidity in infarction, at the price however of an increase in transfusions.

[Anticoagulation in mechanical valve prostheses. A difficult situation]

Although long-term anticoagulant therapy in patients with mechanical valve prostheses is well codified, a number of difficult situations persists because of the high thromboembolic risk. The protocols of anticoagulation suggested in these situations are controversial as there are no large scale prospective therapeutic trials. However, modern protocols take more and more into account the thromboembolic risk in each individual case. The authors review the most common situations: the early postoperative period for which no precise consensus exists in the literature; anticoagulation in extra-cardiac surgery, a common situation for which the protocols remain very debatable; anticoagulation in pregnancy, a special situation because of the risk of embryopathy with oral anticoagulant therapy and the risk of thromboembolism with heparin; anticoagulation in cases of thromboembolic complications; anticoagulation during infectious endocarditis; anticoagulation during serious haemorrhage.

Stent placement compared with balloon angioplasty for small coronary arteries: in-hospital and 6-month clinical and angiographic results

BACKGROUND

Stenting has been demonstrated to be superior to balloon angioplasty in de novo focal lesions located in large native vessels. However, in small vessels, the benefit of stenting remains questionable.

METHODS AND RESULTS

A total of 381 symptomatic patients with de novo focal lesion located on a small coronary segment vessel (<3 mm) were randomly assigned to either stent implantation (192 patients; 197 lesions) or standard balloon angioplasty (189 patients; 198 lesions). The primary end point was the angiographic restenosis rate at 6 months, as determined by quantitative coronary angiography. On intention-to-treat analysis, angiographic success rate and major adverse cardiac events were comparable: 97.9% and 4.6% versus 93.9% and 5.8% in the stent group and the balloon group, respectively. After the procedure, a larger acute gain was achieved with stent placement (1.35+/-0.45 versus 0.94+/-0.47 mm, P=0.0001), resulting in a larger minimal lumen diameter (2.06+/-0.42 versus 1.70+/-0.46 mm, P=0.0001). At follow-up (obtained in 91% of patients), angiographic restenosis rate was 21% in the stent group versus 47% in the balloon group (P=0.0001), a risk reduction of 55%. Repeat target lesion revascularization was less frequent in the stent group (13% versus 25%, P=0.0006).

CONCLUSIONS

Elective stent placement in small coronary arteries with focal de novo lesions is safe and associated with a marked reduction in restenosis rate and subsequent target lesion revascularization rate at 6 months.

Study of the electrophysiological properties of intravenous bisoprolol in patients with and without coronary artery disease by programmed stimulation

The objective of this study was to assess the electrophysiological properties of intravenous bisoprolol in patients with and without coronary artery disease (CAD) by programmed stimulation. Sixteen inpatients subjected to an electrophysiological investigation because of dizziness or palpitations were given 10 mg of intravenous bisoprolol after basal measurement and were checked again 15 and 45 min after infusion. Eight patients with CAD (seven males and one female; mean age of 60+/-4 years) and eight patients without CAD (five males and three females; mean age of 59+/-4 years) were investigated after washout of prior antiarrhythmic drugs. For coronary patients, the CAD was documented by a history of myocardial infarction or by a confirmatory coronary arteriography. Main outcome measures were parameters of invasive electrophysiological exploration, with measurement of conduction intervals at rest and during pacing and of refractory periods by means of extrastimulus technique. No significant difference was noted at baseline between the two groups except for CSNRT. After infusion of 10 mg of bisoprolol, with the exception of CSNRT (increased in the group without CAD), no significant differences were noted on comparison between coronary and noncoronary patients. Bisoprolol significantly increased the sinus cycle length, SACT, and FRP of the atria. Regarding atrioventricular nodal conduction, bisoprolol significantly increased the AH 100, ERP, and FRP and significantly decreased the Wenckebach point. In the right ventricle, bisoprolol moderately, but significantly, decreased the corrected QT and induced a small, temporary, significant increase in ERP. Bisoprolol appears to be a very potent beta-blocker that is well tolerated at an intravenous dose of 10 mg. Its depressant effects concern mainly the atrial function and the nodal conduction, without significant differences between the two groups of patients. The decrease in QTc may be a favorable aspect regarding its electrophysiologic tolerance especially in the acute phase of myocardial infarction.

[Treatment of left atrial thrombosis by low-molecular-weight heparin. A preliminary study of 6 cases]

Left atrial thrombosis is a serious complication of atrial fibrillation because of its embolic potential, especially for the cerebral circulation. These thrombi are usually treated by oral anticoagulation. The authors studied the efficacy and tolerance of a low molecular weight heparin. Enoxaparin, in the treatment of this condition. This was a prospective study carried out over a 1 year period. Patient recruitment came from the transoesophageal echocardiography laboratory: of 15 thrombi detected, 6 were treated by ambulatory Enoxaparin therapy. Five of the 6 patients had no signs of left atrial thrombosis after 3 weeks of Enoxaparin therapy. The left atrial thrombus of the 6th patient remained hyperechogenic and had decreased in length from 27 to 24 mm. No cases of bleeding, haematoma, embolism or thrombopenia were observed with this treatment. This preliminary study shows that low molecular weight heparin may be used as an alternative to classical oral anticoagulation for the treatment of left atrial thrombosis.

The French Randomized Optimal Stenting Trial: a prospective evaluation of provisional stenting guided by coronary velocity reserve and quantitative coronary angiography. F.R.O.S.T. Study Group

OBJECTIVES

We sought to make a prospective comparison of systematic stenting with provisional stenting guided by Doppler measurements of coronary velocity reserve and quantitative coronary angiography.

BACKGROUND

Despite the increasing use of stents during percutaneous transluminal coronary angioplasty, it is unclear whether systematic stenting is superior to a strategy of provisional stenting in which stents are placed only in patients with unsatisfactory results or as a bail-out procedure.

METHODS

Two hundred fifty-one patients undergoing elective coronary angioplasty were randomly assigned either to provisional stenting (group 1, in which stenting was performed if postangioplasty coronary velocity reserve was <2.2 and/or residual stenosis > or =35% or as bail-out) or to systematic stenting (group 2). The primary end point was the six-month angiographic minimal lumen diameter (MLD). Major adverse cardiac events were secondary end points (death, acute myocardial infarction and target lesion revascularization).

RESULTS

Stenting was performed in 48.4% of patients in group 1 and 100% of patients in group 2 (p<0.01). Six months after angioplasty, the MLD did not differ between groups (1.90+/-0.79 mm vs. 1.99+/-0.70 mm, p = 0.39), as was the rate of binary restenosis (27.1% vs. 21.4%, p = 0.37). Among patients with restenosis, 13/32 (40.6%) in group 1 but 100% (25/25) in group 2 had in-stent restenosis (p<0.01). Target lesion revascularization (15.1% vs. 14.4% in groups 1 and 2 respectively, p = 0.89) and major adverse cardiac events (15.1% vs. 16.0%, p = 0.85) were not significantly different.

CONCLUSIONS

Systematic stenting does not provide superior angiographic results at six months as compared with provisional stenting.

A comparison of systematic stenting and conventional balloon angioplasty during primary percutaneous transluminal coronary angioplasty for acute myocardial infarction. STENTIM-2 Investigators

OBJECTIVES

In a multicenter, randomized trial, systematic stenting using the Wiktor stent was compared to conventional balloon angioplasty with provisional stenting for the treatment of acute myocardial infarction (AMI).

BACKGROUND

Primary angioplasty in AMI is limited by in-hospital recurrent ischemia and a high restenosis rate.

METHODS

A total of 211 patients with AMI <12 h from symptom onset, with an occluded native coronary artery, were randomly assigned to systematic stenting (n = 101) or balloon angioplasty (n = 110). The primary end point was the binary six-month restenosis rate determined by core laboratory quantitative angiographic analysis.

RESULTS

Angiographic success (Thrombolysis in Myocardial Infarction [TIMI] flow grade 3 and residual diameter stenosis <50%) was achieved in 86% of the patients in the stent group and in 82.7% of those in the balloon angioplasty group (p = 0.5). Compared with the 3% cross-over in the stent group, cross-over to stenting was required in 36.4% of patients in the balloon angioplasty group (p = 0.0001). Six-month binary restenosis (> or = 50% residual stenosis) rates were 25.3% in the stent group and 39.6% in the balloon angioplasty group (p = 0.04). At six months, the event-free survival rates were 81.2% in the stent group and 72.7% in the balloon angioplasty group (p = 0.14), and the repeat revascularization rates were 16.8% and 26.4%, respectively (p = 0.1). At one year, the event-free survival rates were 80.2% in the stent group and 71.8% in the balloon angioplasty group (p = 0.16), and the repeat revascularization rates were 17.8% and 28.2%, respectively (p = 0.1).

CONCLUSIONS

In the setting of primary angioplasty for AMI, as compared with a strategy of conventional balloon angioplasty, systematic stenting using the Wiktor stent results in lower rates of angiographic restenosis.

Carvedilol for prevention of restenosis after directional coronary atherectomy : final results of the European carvedilol atherectomy restenosis (EUROCARE) trial

BACKGROUND

In addition to its known properties as a competitive, nonselective beta and alpha-1 receptor blocker, carvedilol directly inhibits vascular myocyte migration and proliferation and exerts antioxidant effects that are considerably greater than those of vitamin E or probucol. This provides the basis for an evaluation of carvedilol for the prevention of coronary restenosis.

METHODS AND RESULTS

In a prospective, double-blind, randomized, placebo-controlled trial, 25 mg of carvedilol was given twice daily, starting 24 hours before scheduled directional coronary atherectomy and continuing for 5 months after a successful procedure. The primary end point was the minimal luminal diameter as determined during follow-up angiography 26+/-2 weeks after the procedure. Of 406 randomized patients, 377 underwent attempted atherectomy, and in 324 (88.9%), a </=50% diameter stenosis was achieved without the use of a stent. Evaluable follow-up angiography was available in 292 eligible patients (90%). No differences in minimal luminal diameter (1.99+/-0.73 mm versus 2.00+/-0.74 mm), angiographic restenosis rate (23.4% versus 23.9%), target lesion revascularization (16.2 versus 14.5), or event-free survival (79.2% versus 79.7%) between the placebo and carvedilol groups were observed at 7 months.

CONCLUSIONS

The maximum recommended daily dose of the antioxidant and beta-blocker carvedilol failed to reduce restenosis after successful atherectomy. These findings are in contrast to those of the Multivitamins and Probucol Trial, which raises doubts regarding the validity of the interpretation that restenosis reduction by probucol was via antioxidant effects. The relationship between antioxidant agents and restenosis remains to be elucidated.

[Hematoma of the aortic wall: from diagnosis to treatment]

Haematoma of the thoracic aortic wall is a relatively new concept, the physiopathology of which remains controversial. It results from an haemorrhage of the aortic wall due to rupture of the vasa-vasorum without communication with the arterial lumen. This is a diagnosis of elimination of dissection of the aorta which has been made possible by modern techniques of imaging, such as transoesophageal echocardiography, helicoidal scanner and magnetic nuclear resonance imaging. The prognosis of haematoma of the aortic wall is not as bad as that of dissection of the aorta. Recent studies have shown that the condition may stabilise, regress or progress towards complications of two types: early, dissection or fissuration of the aorta, and late, aortic aneurysm. This is a medico-surgical emergency, the treatment of which is not well codified. However, schematically, haematoma of the aortic wall should be managed in the same way as dissection of the aorta: surgery when the ascending aorta is affected, medical treatment in other cases in the absence of complications.

[Coronary atherectomy. An essential tool for specific indications]

Technological advances in the manufacturing of stents have extended the indications of angioplasty and considerably reduced the immediate complications, death and myocardial infarction. Nevertheless, intra-stent restenosis remains a problem and some complex lesions are still inaccessible. Atherectomy has not been shown to be effective in limiting restenosis but it has a primordial role in the treatment of lesions of bifurcation and could improve long-term results as a complement of angioplasty and stenting. Rotational atherectomy is still useful, even essential, for lesions which cannot be passed with the balloon and for calcified plaques of atheroma. A possible new indication may be the treatment of intra-stent stenosis. The indications of directional atherectomy are more limited, mainly non-calcified ostial stenosis and of bifurcations of large arteries. The association with stenting has given encouraging results which require confirmation. These techniques have a place in the in the angioplasty physician's arsenal even though they are reserved for specific anatomical situations.

Emergency coronary artery bypass surgery following coronary angioplasty and stenting: results of a French multicenter registry

This study investigates the influence of coronary stenting on the risk of emergency bypass surgery performed within 24 hr of percutaneous transluminal coronary angioplasty (PTCA) with particular concern for incidence and indication. Since 1995, coronary stenting has been increasingly performed in France during angioplasty procedures, altering significantly the role of emergency bypass surgery. The outcome of elective stenting and widespread use of coronary stenting and its influence on emergency surgery have not been evaluated so far. Through a retrospective (1995) and prospective (1996) registry, we analyzed the incidence, indication and results of emergency bypass surgery performed within 24 hr of PTCA in 68 and 57 centers, respectively, accounting for nearly half of all angioplasty procedures in France. Data were collected through questionnaires consisting of separate forms for every case report that were sent to every center. Over the two years, 26,885 and 27,497 procedures were investigated with a stenting rate of 46% and 64%, respectively. The observed need for emergency surgery was constantly low throughout this period (0.38% and 0.32%, respectively). Indications for surgery included complications directly due to stent in 37% of cases in the 2-year period. Outcome remained poor, with in-hospital mortality in 10% and 17% and myocardial infarction in 27% and 25% of cases, respectively. A comparison of the results in centers with and without surgical facilities showed no differences in outcome, despite a longer time to surgery (359 min +/- 406 min vs. 170 min +/- 205 min, P = 0.0001) and a lower incidence of emergency surgery (0.25% vs. 0.44%, P = 0.0001) in centers without on-site surgery backup. The French multicenter registry reveals an increase in the use of stents together with a dramatic decrease in the incidence of emergency bypass surgery (below 0.5%) following PTCA. There has been a significant evolution in the indication, and stent implantation now accounts for a third of the indications for emergency bypass surgery.

[Superiority of second harmonic imaging for echocardiographic measurement of lef ventricular volumes. Comparison with angiocardiography]

Analysis of left ventricular volumes is a prognostic factor in cardiovascular disease. Echocardiography is a means of obtaining these parameters but is limited by poor reproducibility. Recently, a new echocardiographic technique, second harmonic imaging (SHI), developed through contrast agent methods, significantly improved the quality of imaging. The aim of this study was to demonstrate the value of SHI for assessing left ventricular volumes. Thirty patients admitted for cardiovascular evaluation and requiring angiocardiography underwent echocardiography with calculation of end diastolic (EDV) and end systolic volumes (ESV) of the left ventricle in fundamental (FI) and second harmonic (SHI) imaging. These measurements were compared with those of angiocardiography. The reproducibility of SHI was calculated after repetition of the measurements by two independent observers for both echocardiographic modes. There was a significant improvement of the parameters of linear regression in SHI compared with FI both for EDV (r = 0.93 versus 0.76) and for ESV (r = 0.94 versus 0.83), the reproducibility was also significantly improved in SHI (relative error of 5% versus 12% for intra-observer error and 6% versus 13% for inter-observer error). The authors conclude that SHI significantly improves two-dimensional imaging and provides a reliable and reproducible measurement of left ventricular volumes.

[Infection of submucosal tumor after endosonography-guided needle biopsy]

Endosonography fine needle guided aspiration (EUS-FNA) biopsy is an interesting technique for the diagnosis of suspected gastrointestinal lesions, and is rarely complicated by infection. We report one case of severe infection after EUS-FNA of benign oesophageal leiomyoma, leading to an oesophagectomy. Recent studies about this technique described only infectious complications after biopsy of cystic lesions. They also show that EUS-FNA may misdiagnose leiomyosarcoma. Our report confirms these data, and relates a hitherto non-reported complication, i.e. the infection of a non-cystic lesion.

Successful radiofrequency ablation of a slow atrioventricular nodal pathway on the left posterior atrial septum

RF catheter ablation is highly effective in eliminating atrioventricular nodal reentrant tachycardia by targeting the slow pathway in the posteroinferior part of Koch's triangle in the right atrium. We report here a patient in whom "slow-fast" atrioventricular nodal reentrant tachycardia was eliminated only by ablation of the slow pathway in the left atrial posteroseptal region at the level of the mitral annulus after unsuccessful attempts at the traditional site on the right side.