[Severe hypercalcemia of unusual cause, looking for the culprit: Case report and review of the literature]. / Hypercalcémie sévère de cause inhabituelle, à la recherche du coupable : cas clinique et revue de la littérature.

INTRODUCTION: Hypercalcemia is not a rare event and can lead to severe consequences. Its main etiologies are primary hyperparathyroidism and neoplasic conditions. The iatrogenic etiology by vitamin D intoxication is more rarely found. CASE PRESENTATION: A 76-year-old finish woman comes to the emergency room for chest pain. Her medical history is impossible to specify due to the language barrier and initial confusion. She has severe hypercalcaemia (4.14mmol/L), renal insufficiency, cardiac arrhythmia later complicated by an ischemic cardiac episode. Clinic and biologic examinations initially guided the research towards a hematological and neoplasic pathology. The iatrogenic etiology will be permitted by the contribution of details on its medical history and treatment learnt secondly. She was treated for post-surgical hypoparathyroidism by dihydrotachysterol, a vitamin D derivative. The cessation of substitution, treatment with hydration and biphosphonates allowed the rapid correction of hypercalcemia. DISCUSSION: Dihydrotachysterol intoxication is a rare etiology of hypercalcemia. Because of the longer half-life of this molecule, the risk of hypercalcemia seems to be greater than with other vitamin D derivatives. This molecule, withdrawn from the French market in 1982, is not detected by the dosage of 25 and 1.25 OH vitamin D. CONCLUSION: We report an original case of intoxication by dihydrotachysterol. The risk of hypercalcemia encountered with this molecule must be known. The close medical follow-up recommended in case of hypoparathyroidism seems to be particularly necessary in case of supplementation by this molecule.

[Home blood pressure monitoring in addition to office blood pressure determination is useful in patients with systolic hypertension before their inclusion into a drug trial]. / L'automesure tensionnelle en complément de la mesure de consultation est utile pour l'inclusion dans un essai clinique de sujets avec une HTA systolique.

OBJECTIVE: In patients with uncontrolled systolic hypertension, to estimate the value of home blood pressure monitoring in addition to office blood pressure for inclusion in a trial. METHODS: 80 patients with systolic hypertension, defined as SBP > or =140 mmHg and pulse pressure > or =60 mmHg, were treated for 4 weeks with a thiazide diuretic at usual dose (25 mg HCTZ or 1.5 mg indapamide or methyclothiazide 5 mg). Blood pressure was measured using an automatic monitor (Omron M6) at office and at home in the 3 days prior the visit. Subjects with an uncontrolled hypertension were included in the second part of the trial only if there fulfilled inclusion criteria: office SBP > or =140 mmHg and home SBP > or =135 mmHg (mean of 18 measurements obtained on 3 consecutive days) and office pulse pressure > or =60 mmHg. RESULTS: After 4 weeks with diuretic treatment, 62% of patients fulfilled 3 criteria and were included in the second part of the trial. It was observed 76% of patients with office SBP > or =140 mmHg, 72% with office pulse pressure > or =60 mmHg and 70% with both office SBP and PP criteria. However, only 67% of patients had home SBP > or =135 mmHg. Discrepancy between office and home SBP was observed and subjects with a white coat hypertension was noticed in 14% and masked hypertension in 5%. CONCLUSION: If patients with systolic hypertension have to be included into a drug trial because there are uncontrolled, home blood pressure monitoring in addition to office blood pressure is a very useful criteria for inclusion because misclassifications due to white coat or masked hypertension is frequent in these patients.

[Systolic blood pressures are not comparable when home blood pressure is measured with a wrist or an arm validated monitor]. / Comparaison des valeurs de PAS/PAD obtenues lors d'une utilisation séquentielle d'un auto-tensiomètre de bras ou de poignet.

OBJECTIVES: To compare home blood pressure values obtained with two validated OMRON (wrist or arm) monitors used sequentially in the same subject. METHODS: In 265 hypertensive subjects referred to hypertension specialists, a self measurement of blood pressure was performed sequentially with an OMRON M4-I (arm cuff, A/A, BHS validation) or OMRON RX-I (wrist cuff, B/B, BHS validation). Each patient recorded home blood pressure during two periods of 4 days with 3 measures in the morning and 3 in the evening. Order for use of each monitor was randomised. With wrist devices, subjects were advised to keep the arm at heart level during measurements. BP values were reported on a standardized document. Patients were asked by a questionnaire about the tolerance and feasibility of the 2 methods. RESULTS: In this population, aged 59 +/- 14 years, with 60% of men and a mean blood pressure of 152 +/- 21 / 86 +/- 14 mmHg, the home blood pressure values were 143 +/- 20/81 +/- 11 mmHg with the arm monitor and 135 +/- 10 / 80 +/- 11 mmHg with the wrist monitor. Mean SBP adjusted on age, initial blood pressure level and period order was significantly lower when home blood pressure monitoring has been recorded with a wrist monitor as compared to an arm monitor (p < 0.001). Self measurement of blood pressure was felt as easy in 92% with the arm monitor and in 96% with the wrist monitor (p < 0.05). Self measurement of blood pressure was felt as constraining in 14% with the arm monitor and in 7% with the wrist monitor (p < 0.01). The feasibility between the two devices was good with none of the value missing in 86% with the arm monitor and in 85% with the wrist monitor. The missing values were in 56% the fourth day. CONCLUSION: Despite the use of two validated monitors, mean SBP is significantly lower when home blood pressure monitoring is recorded with a wrist monitor as compared to an arm monitor. Uncertainty in the arm position with the use of wrist device could explain these results. When advising home blood pressure monitoring, care should be taken to recommend only the use of validated devices and to prefer the use of arm devices in order to avoid the uncertainty of an inadequate utilisation.

[Long-term follow-up after primary angioplasty: is stenting beneficial?]. / Angioplastie primaire a long-terme: quel bénéfice des endoprothèses?

BACKGROUND: Primary stenting leads to a better short-term outcome than balloon angioplasty for acute myocardial infarction in randomised trials. However few data are available about the long-term outcome of primary stenting in acute myocardial infarction (AMI). OBJECTIVES: The aim of this study was to compare the three-year outcome after primary stenting versus balloon angioplasty in patients with acute myocardial infarction. METHODS: We conducted a retrospective study including 157 patients with AMI in a single center. Patients underwent balloon angioplasty (N = 48) or primary stenting (N = 109) within six hours after the onset of chest pain. We looked at the outcome during three years focusing on global mortality, major adverse cardiac events (MACE), reinterventions and target vessel revascularization (TVR). RESULTS: The two groups are similar for their baseline characteristics. No difference was noted for in-patient mortality in the balloon angioplasty group and the primary stenting group (2.1 vs 2.8%; P = ns). The three-year mortality was not significantly different in the two groups. Regarding MACE (27.8 vs 31.7; P = 0.95), reinterventions (20.4 vs 24.7%; P = 0.98) and TVR (18.6 vs 17.8%; P = 0.69), both groups were statistically not different. CONCLUSION: In the long-term patients treated with stent placement have similar rates of MACE, reinterventions or TVR than patients undergoing balloon angioplasty. If few studies noted a benefit in short-term outcomes, primary stenting doesn't improve the prognosis of acute myocardial infarction on long-term follow-up, which is dependent on atherosclerosis.

Angiotensin I-converting enzyme gene polymorphism in a low-risk European population for coronary artery disease.

An insertion/deletion (I/D) polymorphism of the angiotensin I-converting enzyme (ACE) has been associated with an increased risk of coronary artery disease (CAD) and myocardial infarction (MI). However, this finding has not been fully investigated in European populations with very low CAD risk. In a case-control study on a population from Southern Europe (Toulouse, France), we evaluated the ACE I/D polymorphism in 405 men, aged 35-65 years, who underwent coronary angiography and in 357 representative control men within the same age range. We also explored associations in the patients between this polymorphism and CAD severity. The ACE genotype was not associated with the presence of either CAD or MI. The ACE genotype was not a marker for angiographically assessed CAD severity. In a sample in one of the European populations with the lowest CAD risk, ACE I/D polymorphism was not associated with an increased risk for CAD or MI and did not influence the extent of CAD.

Prognostic value of ventricular arrhythmias in systemic hypertension.

OBJECTIVE: Hypertensive left ventricular hypertrophy is associated with an increased risk of arrhythmias and mortality. However, no clinical study has demonstrated a significant relationship between ventricular arrhythmias and mortality in systemic hypertension. DESIGN AND METHODS: To evaluate the prognostic value of arrhythmogenic markers, we included, prospectively, 214 hypertensive patients aged (mean+/-SD) 59.1+/-12.8 years, without symptomatic coronary disease, myocardial infarction, systolic dysfunction or electrolyte disturbances. At inclusion, a 12-lead electrocardiogram (ECG) with QT dispersion calculation, a 24 h Holter ECG (204 patients) with Lown classification of ventricular arrhythmias, echocardiography (reliable in 187 patients) and a signal-averaged ECG (125 patients) with ventricular late potentials were recorded. RESULTS: At baseline, echocardiographic left ventricular hypertrophy was found in 63 patients (33.7%). Non-sustained ventricular tachycardia (Lown class IVb) was recorded in 33 patients (16.2%) and late potentials in 27 patients (21.6%). After a mean follow-up of 42.4+/-26.8 months, all-cause mortality was 11.2% (24 patients); 17 patients died of cardiac causes (7.9%); of these, nine (4.2%) died suddenly. In univariate analysis, age, Lown class IVb and a QT dispersion > 80 ms were significantly related to global, cardiac and sudden death (P < 0.01). The left ventricular mass index was related to cardiac mortality (P= 0.002). In multivariate analysis, only Lown class IVb was an independent predictor of global and cardiac mortality, increasing the risk of global death 2.6-fold (95% confidence interval 1.2-6.0) and cardiac death 3.5-fold (95% confidence interval 1.2-9.7). CONCLUSION: In hypertensive patients the presence of non-sustained ventricular tachycardia has prognostic value.

Coronary stenting of bifurcation lesions using "T" or "reverse Y" configuration with Wiktor stent.

The purpose of this study was to determine the immediate and long-term angiographic and clinical results of coronary stenting of bifurcation lesions using the "T" or "reverse Y" configuration with a Wiktor GX stent. This series demonstrates that stents can be placed with a high rate of success in coronary bifurcation lesions and the techniques described will overcome the potential limitations of coronary angioplasty in such lesions.

Ten-year clinical and angiographic follow-up of coronary wallstent.

Although stents have been implanted in human coronary arteries since 1986, the long-term angiographic outcome of coronary stenting is unknown. We performed 10-year angiographic follow-up in 8 patients who had undergone stent implantation without acute complications or 6-months' restenosis. Analysis of the changes in minimal luminal diameter within the stent and the reference vessel diameter of the stented segment at 10 years do not suggest that atherosclerosis is accelerated or prolonged beyond 6 months within coronary stents.

Identification of coronary thrombus after myocardial infarction by intracoronary ultrasound compared with histology of tissues sampled by atherectomy.

This study compares the ability of intracoronary ultrasound (ICUS) to identify thrombus by means of actual criteria, with the histologic studies of tissues removed by directional atherectomy in patients treated previously with thrombolytic therapy. Coronary angiography and intravascular ultrasound imaging were performed before atherectomy in 34 patients who had received intravenous thrombolytic therapy for acute myocardial infarction a mean of 6 days before. The lesion morphology and the percentage of stenosis were defined on the angiogram. The ultrasound characteristics of the narrowing were described as intraluminal thrombus, mural thrombus, mixed plaque, and dense plaque. Thirty patients were studied. Thrombus was suspected in 8 patients on angiography. By ICUS, the presence of thrombus was predicted in 21 patients. Histologic studies of excised tissues found thrombus in 20 of the 30 patients. When ICUS was compared with histology, the true-positive rate was 80% and the false-positive rate was 50%; the true-negative rate was 50% and the false-negative rate was 20%. The correlation between observers was high. These observations suggest that ICUS may be useful in identifying fresh thrombus. The findings of this study help to confirm the criteria for diagnosing intraluminal thrombus by ICUS imaging.

Comparison of direct coronary stenting with and without balloon predilatation in patients with stable angina pectoris. BET (Benefit Evaluation of Direct Coronary Stenting) Study Group.

The purpose of this study was to compare the effects of stent placement with and without balloon predilatation on duration of the procedure, reduction of procedure-related costs, and clinical outcomes. Although preliminary trials of direct coronary stenting have demonstrated promising results, the lack of randomized studies with long-term follow-up has limited the critical evaluation of the role of direct stenting in the treatment of obstructive coronary artery disease. Between January and September 1999, 338 patients were randomly assigned to either direct stent implantation (DS+; 173 patients) or standard stent implantation with balloon predilatation (DS-; 165 patients). Baseline clinical and angiographic characteristics were similar in the 2 groups. Procedural success was achieved in 98.3% of patients assigned to DS+ and 97.5% of patients assigned to DS- (p = NS), with a crossover rate of 13.9%. Compared with DS-, DS+ conferred a dramatic reduction in procedure-related cost ($956.4 +/- $352.2 vs $1,164.6 +/- $383.9, p <0.0001) and duration of the procedure (424.2 +/- 412.1 vs 634.5 +/- 390.1 seconds, p < 0.0001). At 6-month follow-up, the incidence of major adverse cardiac events including death, angina pectoris, myocardial infarction, congestive heart failure, repeat angioplasty, or coronary artery bypass graft surgery was 5.3% in DS+ and 11.4% in DS- (p = NS). Multivariate analysis demonstrated that major adverse cardiac events rates were related to stent length of 10 mm (relative risk [RR] 3.25, 95% confidence intervals [CI] 1.36 to 7.78; p = 0.008), stent diameter of 3 mm (RR 2.69, 95% CI 1.03 to 7.06; p = 0.043), and complex lesion type C (RR 2.83, 95% CI 1.02 to 7.85; p = 0.045). Thus, in selected patients, this prospective randomized study shows the feasibility of DS+ with reduction in procedural cost and length, and without an increase in in-hospital clinical events and major adverse cardiac events at 6-month follow-up.

Lack of haemodynamic effects of nitric oxide on post-capillary pulmonary hypertension induced by acute sino-aortic denervation.

1. The aims of the present experiments were to define a new experimental model of pulmonary hypertension induced by a post-capillary mechanism and to assess the haemodynamic effects of nitric oxide on post-capillary pulmonary hypertension. 2. Cardiopulmonary variables of 28 male beagle dogs, anaesthetized with chloralose, 16 spontaneous breathing and 12 with assisted ventilation, were studied before and after sino-aortic denervation (SAD). The haemodynamic effects of inhaled nitric oxide (25 p.p.m., 10 min). N(omega)-nitro-L-arginine methyl ester (20 mg kg-1, i.v.), urapidil (0.5 mg kg-1-, i.v.) and propranolol (300 micrograms kg-1, i.v.) were studied after SAD. 3. SAD induced an acute and transient pulmonary hypertension, more marked in spontaneous breathing dogs. This pulmonary hypertension involved a post-capillary mechanism, secondary to the left ventricular haemodynamic effects of the acute increase of left ventricular after-load induced by systemic hypertension. In fact, the increase of mean pulmonary arterial pressure after SAD and the decrease of this parameter after urapidil or propranolol were strongly correlated with the variations of pulmonary capillary wedge pressure. Furthermore, no significant change in pulmonary vascular resistance was found after SAD or administration of alpha or beta-adrenoceptor antagonists. 4. Inhaled nitric oxide did not reverse pulmonary hypertension induced by SAD. N(omega)-nitro-L-arginine methyl ester had no significant haemodynamic effect of pulmonary circulation. 5. In conclusion, the lack of effect of inhaled nitric oxide and nitric synthase inhibitor on pulmonary circulation parameters SAD suggest that endothelium-derived oxide is not involved in the mechanisms leading to post-capillary pulmonary hypertension.

Hemoperitoneum in patients receiving hemodialysis.

Acute abdominal pain in chronic hemodialysis patients has well-known causes, including acute pancreatitis, mesenteric arterial insufficiency, or complicated duodenal ulcer. Others, such as hemoperitoneum, are far less common. Although hemoperitoneum occurs in patients receiving peritoneal dialysis, dialysis is seldom if ever the direct cause of the bleeding. Hemoperitoneum is often related to menses or ovulation, particularly to ovarian cyst rupture; therefore, it is more common in young women. In most cases, no specific treatment is required. Hemoperitoneum is rarely considered as the cause of acute abdominal pain in chronic hemodialysis patients. In this report of hemoperitoneum confirmed by emergency laparotomy in 3 women, bleeding was not related to gynecologic origin. All of the women were younger than age 50 and undergoing long-term hemodialysis. All patients had a history of acute abdominal pain associated with shock. The cause of bleeding was always an organ lesion: hepatic amyloidosis with suspected portal hypertension or sclerosing peritonitis and acute hemorrhagic pancreatitis. Coagulation abnormalities and the use of anticoagulants during hemodialysis sessions may have been aggravating factors in all three patients. Hemoperitoneum is difficult to diagnose, particularly in the minor forms, and consequently its incidence may be underestimated. Therefore, it should be considered whenever a chronic hemodialysis patient presents with persistent acute abdominal pain.

Tissue factor coagulation pathway and blood cells activation state in renal insufficiency.

INTRODUCTION: Atherosclerotic cardiovascular disease is the leading cause of the increased morbidity and mortality observed in uremic patients. Thrombosis is an important contributor to the evolution of atherosclerotic lesions. The physiologically-relevant blood clotting depends on binding of activated factor VII (FVIIa) to exposed tissue factor (TF) on activated/damaged cells. MATERIALS AND METHODS: A cross-sectional study was performed on three age- and sex-matched groups of individuals: one group of 50 patients on maintenance hemodialysis (D group), one of 50 patients with a non-dialysed renal insufficiency (ND group) and one of 50 healthy controls (HC group). We studied basal plasma concentrations of FVIIa, factor VII-related antigen (FVIIAg), soluble TF, tissue factor pathway inhibitor (TFPI), TF-dependent circulating monocytes procoagulant activity (TF-dMPA), tissue factor-dependent plasma reactivity to activated protein C (TF-aPC), D-dimers (D-Di), and circulating markers of cellular activation/injury: soluble thrombomodulin (sTM), circulating microparticles (microP), soluble leukocyte, endothelial and platelet selectins (sL-selectin, sE-selectin, sP-selectin), soluble intercellular adhesion molecule 1 and vascular cell adhesion molecule 1 (sICAM-1 and sVCAM-1). Their variations induced, in hemodialysis patients, by a dialysis run were thereafter studied RESULTS: Values of FVIIa, FVIIa/FVIIAg ratio, sTF, TFPI, TF-dMPA, D-Di, sTM, microP, sL, sE and sP selectins, sICAM-1 and sVCAM-1 increased all along the hierarchy HC group/ND group/D group. Microparticles were mainly of platelet origin, to a lesser extent of monocyte origin. Dialysis induced an increase of FVIIa, sTF, TF-dMPA and circulating markers of cellular activation/injury. Strong correlations were observed between FVIIa/FVIIAg ratio and serum creatinine levels, sTF, TF-dMPA, sTM, sE-selectin, sVCAM-1. The TF-aPC was impaired in the ND and the D group, and the lower values were, in the D group, associated with antecedents of vascular access thrombosis. CONCLUSION: Renal insufficiency is associated to an activation of the tissue factor coagulation pathway, to a platelet, monocyte and endothelial activation/injury and to a deficient tissue-factor induced response to activated protein C which culminate in end-stage disease and are increased by hemodialysis runs. This contributes to linked coagulation and cellular conditions for an enhanced atherosclerosis progression. Due to the TF pathway activation, the therapeutic use of recombinant TFPI should be evaluated.

Relationships between catecholamine or 3-methoxy 4-hydroxy phenylglycol changes and the mental performance under submaximal exercise in man.

Eleven young students were tested to determine the relationship between the improvement of mental performances observed under prolonged submaximal work and central or peripheral catecholamine changes. The subjects pedaled a bicycle ergometer for 1 h at a work load individually calculated to approximate 75% of maximal oxygen uptake. The mental test, consisting of 1-h sessions of time-limited word tests and arithmetical calculations, required a high degree of concentration (vigilance and short-term memory). Catecholamines [epinephrine (E), norepinephrine (NE), dopamine (DA)], metanephrine (MN), normetanephrine (NMN) and the glucuronide conjugate of 3-methoxy 4-hydroxyphenylglycol (MHPG) were assayed in urine to assess peripheral activity: E and MN as indexes of adrenomedullary secretion, NE, NMN and MHPG glucuronide as markers of NE metabolism in sympathetic nerves. Urinary MHPG sulfate was determined as a possible marker of central noradrenergic metabolism. When compared to the effect of single tests, the combination of prolonged submaximal work and mental task induced significant increases in MHPG sulfate and E + MN excretions. Both these increases were correlated each to one another and also correlated to the number of discriminated words. Altogether, the present data show that prolonged submaximal work under mental load activates catecholamine systems and suggest that a relationship exists between adrenomedullary activation and the improvement of mental performance. Based on literature data, the possible modulatory role of peripheral E on mental processes and central noradrenergic activity is discussed.

Autoantibody to plasma fibrinopeptide A in a patient with a severe acquired haemorrhagic syndrome.

We describe a 50-year-old man with a severe acquired haemorrhagic syndrome. He had slightly prolonged clotting times using bovine thrombin, human thrombin and reptilase. His plasma contained a polyclonal IgG which interfered with the generation of fibrin monomers without inhibiting the aggregation of preformed monomers. The inhibitor delayed thrombin-induced fibrinopeptide A release. The IgG bound to insolubilized synthetic fibrinopeptide A (one binding site per molecule) and, with higher affinity, to fibrinogen (two binding sites per molecule). It did not bind to insolubilized fibrin monomers. The IgG did not impair the catalytic activity of thrombin toward a small synthetic substrate but inhibited the binding of thrombin to fibrinogen without binding to thrombin. The binding of the anti-fibrinopeptide A autoantibody to fibrinogen might have impaired thrombin-induced fibrinogen to fibrin conversion in vivo. This may have favoured the reported haemorrhagic syndrome which was associated with severe chronic renal insufficiency.

Experience of pain after subcutaneous administration of different preparations of recombinant human erythropoietin: a randomized, double-blind crossover study.

Subcutaneous erythropoietin (SCEPO) is considered to be more effective than intravenously administered erythropoietin. Patient compliance with SC injections will be important in long-term therapy as there have been reports of pain associated with SCEPO. A double-blind randomized study was performed upon 18 ESRD hemodialysis patients receiving regular subcutaneous erythropoietin replacement therapy for treatment of their anemia. The study involved pain assessment by a visual analogue scale VAS and a verbal descriptive scale VDS following 2 subcutaneous injections of preparation A: rhEPO 2000 IU in 1 ml (Cilag), preparation B: rhEPO 2000 IU in 1 ml (Boehringer Mannheim) and 0.9% saline 1 ml (placebo) over a two-week period. The injections were all administered by the same person and replaced the normal EPO injections for the patient during the study period. Results by VAS and VDS based upon 107 responses showed that preparation A was significantly more painful than preparation B (p less than 0.001) or saline (p less than 0.01). An unexpected finding was that preparation B was less painful than the placebo for VAS (p less than 0.05). It seems unlikely that the erythropoietin itself was responsible for the difference. Further work will be necessary to determine the pain causing factor in preparation A, and the possible local anaesthetic factor in preparation B.

Chronic hypernatremia, hypovolemia and partial hypopituitarism in sarcoidosis: a case report.

A syndrome of chronic hypernatremia (range 148 to 161 mmoles/l) and partial hypopituitarism (growth hormone and gonadotropin deficiencies) is reported in a 27 year-old man with sarcoid hypothalamic involvement. The patient did not complain of thirst and spontaneous fluid intake was not sufficient to restore the serum sodium to normal. However, when larger amounts of water were given (50 ml/kg for 180 min), the plasma osmolality returned to normal values in 3 hours. Blood volume values were found subnormal on two occasions on free diet (63 and 74% of the theorical normal values) and plasma renin activity was elevated (22 ng/ml/hour). Plasma vasopressin (AVP) concentrations (range < 1 to 1.9 pg/ml) were inappropriately low for the degree of plasma osmolality and remained markedly subnormal when hypertonic saline was infused (NaCl 5%, 10 ml/min for 60 min). However, the secretory stores and hemodynamic control of AVP release were intact since a rise in plasma AVP to 10.8 pg/ml was observed after induction of arterial hypotension with sodium nitroprusside infusion. These results provide further direct evidence fo the dysfunction of the thirst mechanism and the osmotic contol of AVP release. They support the concept that osmoreceptor areas are anatomically distinct from the neurohypophyseal AVP secretory system and that neural inputs from baroreceptor and osmoreceptor cells are completely separated.

Combined idiopathic retroperitoneal and mediastinal fibrosis with pericardial involvement.

We report the case of a 54-year-old woman with renal failure related to bilateral hydronephrosis. Clinical and radiologic findings were consistent with retroperitoneal fibrosis associated with pleuro-pericardial involvement. These features matched criteria for combined idiopathic retroperitoneal fibrosis and idiopathic mediastinal fibrosis. There are few reported cases of pericardial involvement in this combined disorder. In our observation, nuclear-magnetic resonance was the radiologic procedure of choice for aortic exploration. The responsibility of therapeutic agents (beta-adrenoreceptor-blocking drugs and ergotamine) and therapeutic options for the sclerosing disease are also discussed. Bilateral ureteral stents and corticosteroids produced favorable outcome without recurrence one year after treatment was stopped.

Mycobacterium haemophilum and mycobacterium xenopi associated infection in a renal transplant patient.

The case is presented of a renal-transplant patient in Europe with a Mycobacterium haemophilum infection in association with M. xenopi infection. Clinical signs suggested the diagnosis of mycobacteriosis, which was confirmed by a skin biopsy. Despite antitubercular treatment which rapidly eliminated M. xenopi, the patient's condition did not improve until M. haemophilum was identified. Minimal inhibitory concentrations of various antimicrobial compounds showed a lack of efficacy of isoniazid, and rifampin had no clinical effect. The patient recovered only after careful surgical drainage of the lesions and the administration of minocycline. The pathogenesis of such mycobacterioses is discussed, with focus on the immunodepressive status which in our patient may have been partially induced by a cytomegalovirus reinfection.

Prognostic value of heart rate variability in time domain analysis in congestive heart failure.

AIMS: Analysis of heart rate variability is a noninvasive tool that allows to study autonomic control of the heart. Several studies have shown disturbed heart rate variability in patients with chronic heart failure (CHF). We sought to assess the prognostic value of time domain measures of heart rate variability in CHF. METHODS AND RESULTS: We prospectively enrolled 190 patients with CHF in sinus rhythm, mean age 61+/-12 years, 109 (57.4 %) in NYHA class II and 81 (42.6 %) in class III or IV, mean cardiothoracic ratio 57.6+/-6.4 % and mean left ventricular ejection fraction 28.2+/-8.8 %, 85 (45 %) with ischemic and 105 (55 %) with idiopathic dilated cardiomyopathy. Time domain measures of heart rate variability were obtained from 24 h Holter ECG recordings. During follow-up (22+/-18 months), 55 patients died. In multivariate analysis, independent predictors for all-cause mortality were: ischemic heart disease, cardiothoracic ratio > or =60 % and standard deviation of all normal RR intervals <67 ms (RR=2.5, 95 % CI 1.5--4.2). CONCLUSIONS: Depressed heart rate variability has independent prognostic value in patients with CHF.