Cardiovascular imaging modalities in the diagnosis and management of rheumatic heart disease.

Rheumatic heart disease (RHD) is prevalent in sub-Saharan Africa, where the capacity for diagnosis and evaluation of disease severity and complications is not always optimal. While the medical history and physical examination are important in the assessment of patients suspected to have RHD, cardiovascular imaging techniques are useful for confirmation of the diagnosis. Echocardiography is the workhorse modality for initial evaluation and diagnosis of RHD. Cardiovascular magnetic resonance is complementary and may provide additive information, including tissue characteristics, where echocardiography is inadequate or non-diagnostic. There is emerging evidence on the role of computed tomography, particularly following valve replacement surgery, in the monitoring and management of RHD. This article summarises the techniques used in imaging RHD patients, considers the evidence base for their utility, discusses their limitations and recognises the clinical contexts in which indications and imaging with various modalities are expanding.

Cardiac Structure and Function in Morbidly Obese Parturients: An Echocardiographic Study.

BACKGROUND: The increasing prevalence of obesity worldwide is a major threat to global health. Cardiac structural and functional changes are well documented for obesity as well as for pregnancy, but there is limited literature on morbidly obese parturients. We hypothesized that there are both cardiac structural and functional differences between morbidly obese pregnant women and pregnant women of normal body mass index (BMI). METHODS: This prospective cross-sectional study was performed in 2 referral maternity units in Cape Town, South Africa, over a 3-month period. Forty morbidly obese pregnant women of BMI ≥40 kg·m (group O) were compared to 45 pregnant women of BMI ≤30 kg·m (group N). Cardiac structure and function were assessed by transthoracic echocardiography, according to the recommendations of the British Society of Echocardiography. The 2-sample t-test with unequal variances was used for the comparison of the mean values between the groups. RESULTS: Acceptable echocardiographic images were obtained in all obese women. Statistical significance was defined as P < .0225 after applying the Benjamini-Hochberg correction for multiple testing. Mean (standard deviation) mean arterial pressure was higher in group O (91 [8.42] vs 84 [9.49] mm Hg, P < .001). There were no between-group differences in heart rate, stroke volume, or cardiac index (84 [12] vs 79 [13] beats·minute, P = .103; 64.4 [9.7] vs 59.5 [13.5] mL, P = .069; 2551 [474] vs 2729 [623] mL·minute·m, P = .156, for groups O and N, respectively). Stroke volume index was lower, and left ventricular mass was higher in group O (30.14 [4.51] vs 34.25 [7.00] mL·m, P = .003; 152 [24] vs 115 [29] g, P < .001). S' septal was lower in group O (8.43 [1.20] vs 9.25 [1.64] cm·second, P = .012). Considering diastolic function, isovolumetric relaxation time was significantly prolonged in group O (73 [15] vs 61 [15] milliseconds, P < .001). The septal tissue Doppler index E' septal was lower in group O (9.08 [1.69] vs 11.28 [3.18], P < .001). There were no between-group differences in E' average (10.7 [2.3] vs 12.0 [2.7], P = .018, O versus N) or E/E' average (7.85 [1.77] vs 7.27 [1.68], P = .137, O versus N). Right ventricular E'/A' was lower in group O (1.07 [0.47] vs 1.29 [0.32], P = .016). CONCLUSIONS: Cardiac index did not differ between obese pregnant women and those with normal BMI. Their increased left ventricular mass and lower stroke volume index could indicate a limited adaptive reserve. Obese women had minor decreases in septal left ventricular tissue Doppler velocity, but the E/E' average values did not suggest clinically significant diastolic dysfunction.

Benefits of task-shifting HIV care to nurses in terms of health-related quality of life in patients initiating antiretroviral therapy in rural district hospitals in Cameroon [Stratall Agence Nationale de Recherche sur le SIDA (ANRS) 12110/Ensemble pour une Solidarité Thérapeutique Hospitalière en Réseau (ESTHER) substudy].

OBJECTIVES: The World Health Organization (WHO) recommends task-shifting HIV care to nurses in low-resource settings with limited numbers of physicians. However, the effect of such task-shifting on the health-related quality of life (HRQL) of people living with HIV (PLHIV) has seldom been evaluated. We aimed to investigate the effect of task-shifting HIV care to nurses on HRQL outcomes in PLHIV initiating antiretroviral therapy (ART) in rural district hospitals in Cameroon. METHODS: Outcomes in PLHIV were longitudinally collected in the 2006-2010 Stratall trial. PLHIV were followed up for 24 months by nurses and/or physicians. Six HRQL dimensions were assessed during face-to-face interviews using the WHO Quality of Life (WHOQOL)-HIV BREF scale: physical health; psychological health; independence level; social relationships; environment; and spirituality/religion/personal beliefs. The degree of task-shifting was estimated using a consultant ratio (i.e. the ratio of nurse-led to physician-led visits). The effect of task-shifting and other potential correlates on HRQL dimensions was explored using a Heckman two-stage approach based on linear mixed models to adjust for the potential bias caused by missing data in the outcomes. RESULTS: Of 1424 visits in 440 PLHIV (70.5% female; median age 36 years; median CD4 count 188 cells/µL at enrolment), 423 (29.7%) were task-shifted to nurses. After multiple adjustment, task-shifting was associated with higher HRQL level for four dimensions: physical health [coefficient 0.7; 95% confidence interval (CI) 0.1-1.2; P = 0.01], psychological health (coefficient 0.5; 95% CI 0.0-1.0; P = 0.05), independence level (coefficient 0.6; 95% CI 0.1-1.1; P = 0.01) and environment (coefficient 0.6; 95% CI 0.1-1.0; P = 0.02). CONCLUSIONS: Task-shifting HIV care to nurses benefits the HRQL of PLHIV. Together with the previously demonstrated comparable clinical effectiveness of physician-based and nurse-based models of HIV care, our results support the WHO recommendation for task-shifting.

Surgical treatment of extraluminal pelvic recurrence from rectal cancer: oncological management and resection techniques.

Local recurrence (LR) after curative surgery for rectal cancer occurs in 4 to 33% of cases especially with suboptimal surgery (non-TME). For numerous patients, diagnosis of LR is done at late stage of the disease because of the high rate of asymptomatic patients. MRI and PET-scan are the most performing exams to assess the local and general extension, with high diagnostic accuracy (sensibility 85% and specificity 92%). For extraluminal pelvic recurrences from rectal cancer, pelvic exenterations alone or with irradiation (preoperative and/or intraoperative) can afford a R0 resection rate ranging from 30% to 45% with acceptable morbidity. Morbidity and mortality rates are high for total exenteration and abdominosacral resection. After curative surgery, 5-year global survival from 30% to 40% is observed. Careful selection of patients with better preoperative status before resection is needed to achieve more curative resections and increase long-term survivor rates.

Adjustable gastric banding in a public university hospital: prospective analysis of 400 patients.

BACKGROUND: Laparoscopic application of an adjustable gastric band (LAGB) is considered the least invasive surgical option for morbid obesity. It has the advantage of being potentially reversible and can improve quality of life. METHOD: Between April 1997 and January 2001, 400 patients underwent LAGB. There were 352 women and 48 men with mean age 40.2 years (16-66). Preoperative mean body weight was 119 kg (85-195) and mean body mass index (BMI) was 43.8 kg/m2 (35.1-65.8). RESULTS: Mean operative time was 116 minutes (30-380), and mean hospital stay was 4.55 days (3-42). There was no death. There were 12 conversions (3%). 40 complications required an abdominal reoperation (10%), for perforation (n = 2), gastric necrosis (n = 1), slippage (n = 31), incisional hernia (n = 2) and reconnection of the tube (n = 4). We noticed 7 pulmonary complications (2 ARDS, 5 atelectasis) and 30 minor problems related to the access port. At 2 years, mean BMI had fallen from 43.8 to 32.7 kg/m2 and mean excess weight loss (EWL) was 52.7% (12-94). CONCLUSION: LAGB is a very beneficial operation with an acceptable complication rate. EWL is 50% at 2 years if multidisciplinary follow-up remains assiduous. Surveillance for late anterior stomach slippage within the band is essential.

[Laparoscopic gastroplasty for morbid obesity: prospective study of 300 cases]. / Gastroplastie laparoscopique pour obésité morbide: étude prospective de 300 cas.

STUDY AIM: Laparoscopic gastric banding for morbid obesity is noninvasive and reversible. The aim of this prospective study was to report the preliminary results of this procedure in the first 300 patients. PATIENTS AND METHODS: From April 1997 to January 2000, 300 patients were laparoscopically operated for severe obesity: 266 women, 34 men, with a mean age of 40.1 years (range: 16-66). The mean preoperative weight was 118 kg (range: 85-195) and the mean body mass index (BMI) was 43.6 kg/m2 (range: 35.1-65.8). This is a recent and complete series with a mean follow-up of 10 months (range: 3-31). The primary endpoint was excessive weight loss (EWL) and the secondary endpoints were tolerance and morbidity. RESULTS: There were no postoperative deaths. The mean operating time was 129 minutes (range: 50-380). A conversion to laparotomy was necessary in 11 patients. The mean hospital stay was 4.76 days (range: 3-42). There were 29 complications (9.6%), 16 among the first 50 procedures: 14 patients underwent an abdominal reoperation (2 perforations, 3 early slippages, 7 late slippages, 2 incisional hernias); 6 had respiratory complications with 2 ARDS and 9 developed a complication related to the port. At one year, BMI decreased from 43.6 to 33.7 kg/m2 and EWL reached 44.2%; 80% of the patients lost 60% of their excess weight. CONCLUSION: Our experience is encouraging with an acceptable complication rate (5%) after 50 procedures. Slippage remains the main reason for close surveillance. Half of the excess weight can be comfortably lost in one year when the whole medical and surgical staff provide close support for each patient.

[Laparoscopic gastroplasty for severe obesity. 300 cases, evaluation of the first 150]. / La gastroplastie par laparoscopie pour grands obèses. 300 cas, évaluation des 150 premiers.

OBJECTIVES: The laparoscopic approach for gastroplasty is gaining widespread acceptance for morbid obesity. Less invasive and potentially reversible, this gastroplasty guarantees better quality of life. We thus evaluated perioperative complications in our consecutive series of 300 patients and followed the excessive weight loss (EWL) for the first 150. PATIENTS AND METHODS: Between April 1997 and January 2000, 300 patients underwent laparoscopic gastroplasty for severe obesity according to the NIH criteria: 266 women, 34 men, mean age 40.1 years (16-66 years). Mean preoperative weight was 118 kg (85-195 kg) and mean body mass index (BMI) was 43.4 kg/m2 (31.5-65.8). Two hundred one patients had 1.3 comorbidity due to excess weight. The first 150 patients were followed 15.5 months (12-31) without any lost to follow-up. Medical, dietary and psychological data were recorded every 3 months for 18 months. The main evaluation criteria was EWL; others were tolerance and morbidity. RESULTS: There was no death. Mean operative time was 129 minutes (50-380), mean hospital stay was 4.76 days (3-42). There were 11 conversions (3.6%). There were 29 complications (9.6%): 11 were postoperative (5 underwent an abdominal operation for 2 perforations, 3 early slippages; and 6 respiratory problems with 2 ARDS) and 18 were late complications (7 late slippages, 2 incisional hernias and 9 port problems). Follow-up of the first 150 patients was complete: at one year, BMI fell from 43.6 to 33.8 kg/m2 and EWL reached 50.5% at 18 months. CONCLUSION: Our experience is recent, but in light of the danger of the spontaneous course of morbid obesity, the results are encouraging due to the absence of mortality and the low rate of complications after the first 50 procedures. Half of the excess weight can be lost in one and a half years. Patient comfort remains quite acceptable with the active support of the surgery and medical teams.

Effect of intracoronary nicardipine on methylergonovine-induced coronary artery spasm in patients with variant angina.

In a double-blind, randomized placebo controlled study, the effect of intracoronary (IC) nicardipine (0.4 mg) on methylergonovine (0.4 mg) induced coronary artery spasm was assessed in 16 patients with a history of variant angina. Reversal of the methylergonovine-induced coronary artery spasm was observed in 100% of patients treated with IC nicardipine and 25% of patients treated with placebo (p less than 0.01). There were no significant differences between the nicardipine and placebo treatment groups with respect to heart rate, blood pressure, proportion of patients experiencing chest pain or ST segment changes. These findings demonstrate that IC nicardipine is safe and could be effective in the reversal of coronary artery spasm in patients with variant angina.

[Compression of the cervical spinal cord in achondroplasia]. / Compression de la moelle cervicale dans l'achondroplasie.

Two cases of tetraparesis due to cervico-occipital spinal cord compression in infants with achondroplasia are reported. Neurological disorders in achondroplasia are produced by structural anomalies of the cranium and spinal canal. They can be divided into two categories: hydrocephalus and radicular and spinal cord compression syndromes. Cervico-occipital compression is more frequent in childhood and may occur very early, in the first months of life. Early diagnosis of this complication and anatomic evaluation can now be obtained by computed tomography, which shows the exact dimensions of the foramen magnum, and myelography. Achondroplasia requires very close neurologic monitoring and, when findings are abnormal, radiologic investigations of the cervico-occipital zone. This allows for early surgical management which is the only means of obtaining significant therapeutic results.

[Hepatic schistosomiasis and sarcoidosis with voluminous subdiaphragmatic adenopathies]. / Schistosomiase et sarcoïdose hépatiques avec volumineuses adénopathies sous-diaphragmatiques

The authors report a case of a West-Indian with sarcoidosis and peripheral, mediastinal and, above all, sub-diaphragmatic lymph nodes. The latter were very large and palpable through the abdomen, confirmed by lymphography and found to be due to S. Mansomi schistosomiasis. Liver biopsy carried out under peritoneoscopy, showed schistosomal granulomatosis with sarcoidosic granulomatosis. The authors consider that the rareness of this association is only apparent and does not correspond to the frequency of bilharziasis nor that of sarcoidosis in these subjects. They emphasize the mistakes which may result in interpretation of liver biopsy. They recall a few special characteristics of sarcoidosis in West-Indians, in particular, the possibility of failure of corticosteroid therapy as in their case, due to the onset of miliary lung disease under treatment, and show the lymphographic appearances of sarcoidosis.