Simulation versus theoretical learning for the transradial approach: a randomized controlled trial in interventional cardiology.

INTRODUCTION: Simulation-based education (SE) in interventional cardiology improves knowledge acquisition and mastery of procedures including the conventional radial access (CRA). AIM: To evaluate the contribution of SE in CRA compared with theoretical learning alone. METHODS: This is a prospective randomized controlled study including cardiology residents and patients with normal radial pulses. Experienced residents as well as patients with contraindications to CRA, requiring urgent intervention, or with hemodynamic instability were not included. Missing the teaching sessions was the exclusion criteria. Residents were randomized into two groups: simulation versus control. They attended a theory lecture explaining CRA and were evaluated Only the simulation group attended an SE session with measurement of heart rate (HR) and stress level. A real application was then performed with measurement of HR and stress level. The primary outcome was success puncture rate. RESULTS: The success of the puncture was similar between the two groups (p=0.651). In the practical application, the stress level was significantly different before the procedure but similar after the end of the procedure. The stress level varied significantly within the same group before and after the procedure The simulation group was significantly less tachycardic both before and during the procedure with a significant difference between the two groups (p <10-3). CONCLUSION: This study demonstrated the interest of SE in novice residents for CRA as a complement to theoretical learning upstream of the real-life procedure.

The characteristics of conflict of interest in the doctor's pharmaceutical representative Relationship.

INTRODUCTION: Studies addressed the influence of pharmaceutical representatives in drug prescribing habits, in terms of quality and quantity. AIM: To describe the representatives' strategies, assess their impact on medical prescribing, and study the various factors influencing doctors' prescribing changes. METHODS: We conducted a cross-sectional study including 70 participants. All of them had an anonymous questionnaire to determine their socio-demographic data, the pharmaceutical representative visits details, the influence of gifts on the medical prescription, and the predictive factors of this influence. We also analyzed the solutions to alleviate the conflict of interest. RESULTS: We found that 52.8% of participants thought that gifts were the source of an ethical dilemma and 85.7% of them thought that the priority of the pharmaceutical representative was the promotion of the product rather than the scientific interest. However, 68.5% of them thought that the gifts were useful and therefore we can continue to receive them. Nineteen participants (27.1% of cases) thought that gifts can modify their medical prescription. However, there were significantly more subjects (p=0.049) who thought that other colleagues would be more influenced (72.8%). Factors that favor the prescription changing by gifts, were age (p=0.002, OR=1.2) and the number of visits per month (p=0.015, OR=8.8). CONCLUSIONS: There is a discrepancy between the growing awareness of this ethical issue and the daily practices of physicians who continue to accept gifts. The absence of training in bioethics explains these results.

The Fate of Hemodialysis Vascular Access After Kidney Transplantation: Why Ligation Should Not Be Systematically Performed?

BACKGROUND: After renal transplant, the haemodialysis (HD) vascular access (VA) is often maintained in the event of graft failure but evidence to recommend the systematic ligation/maintenance are lacking. We investigate the effects of VA preservation/ligation in successfully transplanted patients. METHODS: A retrospective analysis of all patients undergoing successful renal transplantation after HD were conducted. Patients with a functioning VA, those undergoing ligation or presenting with post-transplantation spontaneous thrombosis were included. Demographics, comorbidities, reasons for ligation, need for secondary interventions, complications and return in dialysis were assessed. RESULTS: Out of 542 HD patients, 114 (76, 66.7% male, median age 50 years, range 20-70) were included. Eight (7%) accesses thrombosed in a mean of 1.4 days (range 1-3) after transplant; 42 (36.8%) fistulas were ligated and 64 (56.1%) preserved. The reasons for ligation were patient's request (35, 83.3%), steal syndrome (5, 11.9%), heart failure (1, 2.4%) and aneurysmal degeneration (1, 2.4%).During a mean follow-up of 724.9 days (range 80-1082) 25 patients developed complications over the maintained access (40% of stenosis; 32% high flow and 28% thrombosis); 18 (15.8%) needed reoperation; 17 (15%) required further HD. Multivariate analysis showed that coronary artery disease (OR= 12.566 [2.056-76.805], P < 0.06) or age >60 years (OR=0.181 [0.044-0.735], P = 0.017) were risk factor for complications over unused VA. CONCLUSIONS: The ligation of a functioning VA after renal transplant should evaluated on an individualized basis. Patients with pre-existing cardiovascular disease or aged >60 years should be monitored closely up as they are at higher risk of complications.

One-stage surgery for both hepatic and left ventricular hydatid cysts using transthoracic route.

Hydatid disease is a major health problem. Multiorgan involvement including the heart and the liver is a very rare presentation. Management of multivisceral hydatidosis through a sole incision should be considered when possible. Median sternotomy is considered in our case.

Tailoring Hemodialysis Vascular Access in Diabetic Patients.

BACKGROUND: The objective of the study was to investigate which kind of native arterious-venous fistula guaranteed the best results in diabetic patients. METHODS: A retrospective case-control study with prospective follow-up was conducted on all consecutive patients undergoing creation of the first native vascular access (VA) at our Institution between January 2011 and December 2016. Patients were divided into 2 groups: diabetics (group A) and nondiabetics (group B), and results were evaluated in accordance with site chosen for VA creation. Primary outcomes were maturation and primary patency rate. Secondary outcomes were complications, rate of functional fistulas, and mortality. RESULTS: A total of 410 patients (n 155, 37.8% female; n 255, 62.2% male; mean age 64.21 ± 14.85 years, range 58-78) were divided into 2 nonstatistically different groups (group A: n 170, 41.5% and group B: n 240, 58.5%). Maturation and primary patency were statistically different for antebrachial (P = 0,038 and P = 0.044, respectively), but not for brachial access (P = 1 and P = 0.080, respectively) at 3 years. Hyperflow and steal syndrome rate did not differ between the 2 sites and groups. At a mean follow-up of 42.86 months (range 1-72), 5 patients died. Diabetics demonstrated the higher rate of overall complications at the long-term follow-up. CONCLUSIONS: Diabetes mellitus plays a detrimental role in maturation and primary patency of antebrachial fistula; however, brachial fistula results do not differ between diabetic and nondiabetic patients. More robust data and longer-term results from randomized studies are needed to affirm brachial fistula as preferential access in diabetic patients.

Bilateral pulmonary hydatidosis associated with uncommon muscular localization.

INTRODUCTION: The lung is the second most commonly affected organ by hydatidosis, and the bilateral involvement is rare even in endemic regions. CASE PRESENTATION: We report the case of a 27-year-old patient who presented with right basithoracic pain and cough evolving for three months. Thoracic CT scan revealed two homogeneous, rounded cystic formations enhancing after injection of the contrast media, located in the lateral basal segments of the lower lobe. An abdominal CT scan was performed to rule out a hepatic localization of the hydatid cyst, revealed a cystic formation of the left psoas muscle. The diagnosis of bilateral hydatid lung cyst associated with hydatid psoas muscle location was then made. The patient underwent a two-stage thoracic surgery. The second step involved partial cystectomy of the psoas muscle hydatid cyst via a left iliac incision and using an extraperitoneal approach. The postoperative course was uneventful. DISCUSSION: Management of bilateral pulmonary hydatid cyst is controversial. Some authors recommend operating bilateral cysts in two-stage surgery, with an interval of three to four weeks between procedures. The involvement of the psoas muscle is rare and is generally secondary to the rupture of splenic, hepatic or renal hydatid cysts. Generally, its diagnosis is delayed as the latter is most of the time asymptomatic. CONCLUSION: Bilateral pulmonary hydatidosis associated with hydatid cyst of the psoas muscle is a rare entity. Radiological investigations and especially CT scan are the mainstay of diagnosis. Surgery remains to be the treatment modality of choice.

Gigantic Mediastino-Abdominal Hydatic Cyst Through Esophageal Hiatus.

Hydatid disease is one of the most widespread and endemic infections causing a substantial health and economic burden. The liver and lungs remain the most affected viscera. We report the case of a 41-year-old man with an atypical presentation: a hydatid cyst of the liver with a massive extension to the mediastinum through the esophagus hiatus. This patient underwent a single-stage surgical session to treat the mediastinal and abdominal parts of the cyst through a unique thoracic route.

Post traumatic left cardiac luxation: A case report.

INTRODUCTION: Rupture of the pericardium complicating blunt thoracic trauma may lead to cardiac luxation if not early recognized and appropriately surgically treated. This condition is exceedingly rare and carries a high mortality rate. CASE PRESENTATION: A 37-year-old man presented with severe multiple injuries following a road traffic crash, including blunt trauma to the thorax and abdomen. He was in a hemodynamically stable condition. The chest radiograph and CT scan revealed a leftward heart herniation through a pericardial tear, there were also non surgical hepatic and splenic lesions. The diagnosis of left cardiac luxation with no associated valvular lesions was made. Surgical exploration via a midline sternotomy revealed a protruding heart herniating into the left pleural cavity through a large tear (15 cm) of the left pericardium. Sutures with Teflon felt pledgets were performed. The postoperative chest radiograph was normal and the postoperative course was uneventful. DISCUSSION: Post traumatic heart luxation diagnosis is clinically difficult because the scarcity of signs and lack of specificity. Chest X ray can be suggestive, and specific findings can only be detected by computed tomography, which is the most sensitive diagnostic method. Surgical management in this condition is mandatory to avoid fatal complications such as great vessels strangulation. It consists of replacing the heart in the pericardial sac and repairing the pericardial tear. CONCLUSION: Despite its rare occurrence, trauma surgeons must be aware of cardiac luxation. Any suspicion of such a diagnosis would warrant surgical exploration to avoid fatal complications.

Constrictive epicarditis.

Constrictive pericarditis is relatively uncommon. Constrictive phenomenon involves in the majority of cases the two layers of the pericardium namely the parietal pericardium and the visceral one. Chronic epicarditis is a distinct and very scarce form where only the visceral pericardium is interested by the pathologic process. We present herein the case of a 25 years old patient admitted in our department for surgical treatment of a chronic visceral pericarditis. We discuss along some important clinical and therapeutic points related to this specific presentation with a special interest to the right ventricular dysfunction after pericardiectomy.

Penetrating injury of the ascending aorta complicating a sternal biopsy.

Bone marrow aspiration and trephine biopsy are considered safe procedures. Some serious but rare adverse events directly attributable to these procedures have been related in a few reports in the literature. We report a rare case of ascending aortic injury following a sternal trephine biopsy.

Particularities of cardiac surgery in chronic hemodialysis patients.

INTRODUCTION: Cardiovascular disease is the most common cause of death in chronic hemodialysis patients(1). Cardiac surgery in hemodialysis patients exposes to higher risks inherent in the particular status of these patients. The aim of our study is to report the perioperative particularities of hemodialysis patients undergoing cardiac surgery, and to determine the impact of preoperative clinical status on hospital and late morbidity and mortality. METHODS: Between January 1998 and December 2012, 48 patients in chronic hemodialysis (HD) and candidates for cardiac surgery on cardiopulmonary bypass were retrospectively included. RESULTS:   The mean age was 56 years. Causes of renal insufficiency were dominated by diabetes (n = 20; 42%) and nephroangiosclerosis (n= 9, 18.8%). The duration of HD was 48.22 ± 44.5 months (1 month -11 years). Surgical procedures included coronary artery bypass grafting CABG (n = 33, 68.75%), Valvular replacement (n = 13, 27%) and combined surgery (n = 2, 4.25%). Nine patients (18.8%) underwent emergency surgery. The mean Euroscore I was 8.82 ± 7.76. Hospital mortality was 20.8%. Postoperative complications were observed in 87.5%patients. Age, diabetic nephropathy, Duration of hemodialysis greater than 54 months, preoperative hemoglobin <9 g / dl, combined surgery and emergency surgery were independent predictors of hospital mortality with odds ratio respectively 1.21; 2.7; 2.54; 1.83; 2.54 and 2.85. The survival rates at 1, 4 and 7 years were respectively 75, 65 and 50%. CONCLUSION:   Age, diabetic nephropathy, Duration of hemodialysis greater than 54 months, preoperative hemoglobin <9 g / dl, combined surgery and emergency surgery are predictive factors for hospital mortality. Early diagnosis of coronary and valvular damage and preoperative preparation considering these factors could improve the prognosis.