Focus on malignant ventricular premature contractions.

Premature ventricular contractions (PVCs) are common. Although often benign, they can also be associated with increased morbidity and mortality. The aim of this review was to assess the risk evaluation of PVCs in patients with or without structural heart disease and discuss the management of this arrhythmia. Reports published in English were searched in PubMed with the following search terms: premature ventricular contraction, ectopic ventricular beat, ventricular extrasystole, antiarrhythmic drugs, ablation, ventricular arrhythmia, ventricular tachycardia, ventricular fibrillation and torsade de pointe. This analysis suggests that all patients with frequent PVCs should be assessed for PVC burden, symptom status and the presence of structural heart disease. PVCs in patients with structurally normal hearts was once considered a benign phenomenon. Uncommonly, PVCs may provoke life-threatening arrhythmias. Ventricular fibrillation is the initial mode of malignant rapid ventricular arrhythmias (MRVAs). Patients with malignant PVC and PVC burden >10% are at increased risk of MRVA in case of myocardial infarction and heart failure. MRVA is the primary cause of sudden cardiac death in patients with and without structural heart disease. Therapeutic options include medical therapy and catheter ablation, the latter more effective and potentially curable, particularly in patients with left ventricular dysfunction. The timely recognition and effective treatment of malignant PVCs in symptomatic patients with underling cardiomyopathy are mandatory to initiate early therapies before the occurrence of adverse clinical outcomes and to improve the long-term prognosis.

Risk stratification in hypertrophic cardiomyopathy.

Sudden cardiac death (SCD) is the most devastating complication of hypertrophic cardiomyopathy (HCM). The greatest challenge in the management of HCM is identifying those at increased risk, since an implantable cardioverter-defibrillator (ICD) is a potentially life-saving therapy. We sought to summarize the available data on SCD in HCM and provide a clinical perspective on the current differing and somewhat conflicting data on risk stratification, with balanced guidance regarding rational clinical decision-making. Additionally, we sought to determine the status of the current implementation of guidelines compiled by HCM experts worldwide. The HCM Risk-SCD model helps improve the risk stratification of HCM patients for primary prevention of SCD by calculating an individual risk estimate that contributes to the clinical decision-making process. Improved risk stratification is important for decision-making before ICD implantation for the primary prevention of SCD.

Inherited primary arrhythmia disorders: cardiac channelopathies and sports activity.

Sudden cardiac death (SCD) in an apparently healthy individual is a tragedy. It is important to identify the cause of death and to prevent SCD in potentially at-risk family members. Inherited primary arrhythmia disorders are associated with exercise-related SCD. Despite the well-known benefits of exercise, exercise restriction has been a historical mainstay of therapy for these conditions. However, since familiarity with inherited arrhythmia conditions has increased and patients are often children and young adults, it is necessary to reassess the treatment guidelines regarding exercise constraints. The aim of this review is to analyze the risk of exercise-induced SCD in patients with inherited cardiac conditions and explore the challenges faced when advising patients about exercise limitations. We searched for publications on cardiac channelopathies in PubMed with the following medical subject headings (MeSH): "long QT syndrome"; "short QT syndrome"; "Brugada syndrome"; and "catecholaminergic polymorphic ventricular tachycardia". The abstracts of these articles were scanned, and articles of relevance, along with pertinent references, were read in full. The analysis was restricted to reports published in English. The findings of this analysis suggest that exercise with low-to-moderate cardiovascular demand may be possible under regular clinical follow-up in inherited primary arrhythmia disorders. Recent data show that patients with inherited primary arrhythmia disorders are at low risk for events once a comprehensive treatment program has been established. Recreational activity is likely safe for these individuals, with personalized management based on individual patient preferences and priorities.

[Vitamin C+sodium bicarbonate versus sodium bicarbonate alone in preventing contrast-induced nephropathy]. / Vitamine C+sérum bicarbonaté versus sérum bicarbonaté seul dans la prévention de la néphropathie induite par les produits de contraste.

INTRODUCTION: Contrast-induced nephropathy (CIN) is a common and severe complication in interventional cardiology. OBJECTIVE: The aim of our study was to compare the incidence of contrast-induced nephropathy in two accelerated hydration protocols: the first one by the serum bicarbonate and the second combining the serum bicarbonate and oral vitamin C. METHODS: This is a multicenter prospective, randomized study conducted between October 2012 and May 2013, including 160 patients. RESULTS: The mean age of our study population was 60.8±9.3 years (36-83 years). The two study groups were comparable in terms of cardiovascular risk factors, concomitant medication, and baseline serum creatinine. The CIN incidence was 6.3% in the vitamin C group and 10% in the control group (P=0.38). No significant difference was observed in terms of CIN incidence between the different subgroups analyzed. CONCLUSION: According to our study, ascorbic acid administered orally as part of an accelerated hydration protocol does not reduce the incidence of CIN.

[Arrhythmia and sleep apnea syndrome]. / Syndrome d'apnée du sommeil et troubles du rythme cardiaque.

CONTEXT: Arrhythmia is a major cause of morbidity and mortality in Europe and in the United States. The aim of this review article was to assess the results of the prospective studies that evaluated the risk of arrhythmia in patients with sleep apnea syndrome and discuss the management of this arrhythmia. EVIDENCE ACQUISITION: Reports published with the following search terms were searched: sleep apnea syndrome, atrial flutter, supraventricular arrhythmia, ventricular arrhythmia, ventricular tachycardia, ventricular fibrillation, torsade de pointe, atrial fibrillation and sudden death. The investigation was restricted to reports published in English and French. EVIDENCE SYNTHESIS: The outcome of this analysis suggests that patients with untreated overt sleep apnea syndrome are at increased risk of arrhythmia. CONCLUSIONS: The timely recognition and effective treatment of sleep apnea syndrome in patients with arrhythmia are mandatory because the prognosis of arrhythmia may be improved with the appropriate treatment of sleep apnea syndrome.

[Utility of cardiovascular magnetic resonance in hypertrophic cardiomyopathy: when is it superior to echocardiography?]. / Imagerie par résonance magnétique dans la cardiomyopathie hypertrophique : qu'apporte-t-elle de plus par rapport à l'échocardiographie ?

The diagnosis of hypertrophic cardiomyopathy is usually established by echocardiography. Recently, there has been greatly increased use of cardiac magnetic resonance (CMR) because of its precise determination of myocardial anatomy and the depiction of myocardial fibrosis. In this review, we describe the role of echocardiography and magnetic resonance in the assessment of this complex disease. In conclusion, there is a complementarity between cardiovascular magnetic resonance imaging and echocardiography for the diagnosis and the management of HCM.

Arrhythmia and thyroid dysfunction.

CONTEXT: Arrhythmia is a major cause of morbidity and mortality in Europe and in the United States. The aim of this review article was to assess the results of the prospective studies that evaluated the risk of arrhythmia in patients with overt and subclinical thyroid disease and discuss the management of this arrhythmia. EVIDENCE ACQUISITION: A literature search was carried out for reports published with the following terms: thyroid, hypothyroidism, hyperthyroidism, subclinical hyperthyroidism, subclinical hypothyroidism, levothyroxine, triiodothyronine, antithyroid drugs, radioiodine, deiodinase, atrial flutter, supraventricular arrhythmia, ventricular arrhythmia, ventricular tachycardia, ventricular fibrillation, torsade de pointes, amiodarone and atrial fibrillation. The investigation was restricted to reports published in English. EVIDENCE ANALYSIS: The outcome of this analysis suggests that patients with untreated overt clinical or subclinical thyroid dysfunction are at increased risk of arrhythmia. Hyperthyroidism increased atrial arrhythmia; however, hypothyroidism increased ventricular arrhythmia. CONCLUSION: The early recognition and effective treatment of thyroid dysfunction in patients with arrhythmia is mandatory because the long-term prognosis of arrhythmia may be improved with the appropriate treatment of thyroid dysfunction.

Wolff-Parkinson-white syndrome mimics a conduction disease.

Background. It is important to recognise Wolff-Parkinson-White (WPW) syndrome in electrocardiograms (ECG), as it may mimic ischaemic heart disease, ventricular hypertrophy, and bundle branch block. Recognising WPW syndrome allows for risk stratification, the identification of associated conditions, and the institution of appropriate management. Objective. The present case showed that electrophysiological study is indicated in patients with abnormal ECG and syncope. Case Report. A 40-year-old man with Wolff-Parkinson-White syndrome was presented to emergency with syncope. A baseline ECG was a complete right branch block and posterior left hemiblock. He was admitted to the cardiac care unit for pacemaker implantation. The atypical figure of complete right branch block and posterior left hemiblock was thought to be a "false positive" of conduction abnormality. But the long anterograde refractory period of the both accessory pathway and atrioventricular conduction may cause difficulty in diagnosing Wolff-Parkinson-White syndrome, Conclusion. A Wolff-Parkinson-White Syndrome may mimic a conduction disease. No reliable algorithm exists for making an ECG diagnosis of a preexcitation syndrome with conduction disorders. This can lead to diagnostic and therapeutic dilemmas in the context of syncope.

Cardiac resynchronization therapy allows the optimization of medical treatment in heart failure patients.

AIM: Cardiac resynchronization therapy (CRT) is recommended for selected patients with advanced heart failure (HF) despite optimal medical treatment. However, the doses of pharmaceuticals in this population are often limited by adverse effects. We compared the drug regimens of 21 patients before and 6 months after they underwent the implantation CRT systems. METHODS: We studied 17 men and four women (mean age=63.4 ± 11 years) presenting in New York Heart Association HF classes III-IV, and with a left ventricular ejection fraction (LVEF) ≤ 35% and cardiac dyssynchrony, who underwent implantation of CRT systems. RESULTS: At baseline, 52% of patients were treated with ß-adrenergic blockers (ß-B), though in optimal doses in only 19%. The introduction of (ß-B) was complicated by cardiogenic shock in three patients. At baseline, all patients were treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), of whom 76% received optimal doses. After 6 months of CRT, ß-B were administered to 76% of patients, in optimaklon ACE or ARB but 75% of them were receiving maximal doses. After 6 months of CRT, ß blockers have been introduced in 72% of patients and maximal doses have been achieved in 60% of them. Maximal doses of ACE or ARB were reached in 95% of the study population. We noticed that systolic blood pressure was higher after implantation. There was also a significant improvement in functional status and left ventricular ejection fraction compared to baseline. CONCLUSION: CRT is an efficacious adjunctive device therapy to standard medical therapy for patients with heart failure and cardiac dyssynchrony. Its benefits are in addition to those afforded by standard pharmacological therapy. Achieving maximal doses of medical treatment and the possibility of introducing ß blockers after CRT prove that CRT and pharmacological treatment are complementary strategies and should not be considered as competitive.

[Dermatomycosis due to Trichophyton verrucosum in Sfax-Tunisia]. / Les dermatomycoses àTrichophyton verrucosum à Sfax-Tunisie.

UNLABELLED: Trichophyton verrucosum is a zoophilic dermatophyte. It can be responsible of various clinical aspects especially inflammatory lesions of skin and scalp. The aim of this study was to determine the clinical and epidemiological characteristics of dermatophytosis due to T. verrucosum. PATIENTS AND METHODS: It is a retrospective study realized on 35,918 patients suspected to have superficial mycoses in a 13-year-period (from 1998 to 2010). RESULTS: T. verrucosum was isolated in 178 patients corresponding to 1.2% of all dermatophytosis. Ochraceum variety was the most frequent (60%), followed by album variety (40%). Frequency of isolated T. verrucosum increased passing from one case in 1998 to 37 cases in 2010. The mean age was 22.7 years (range: 1.5-71 years). A percentage of 74.2 of our patients were male and 61% were from urban regions. A percentage of 32.5 could link their clinical lesions to contact with an animal (mainly cattle and sheep). Other family members were infected by tinea in 7.3% of cases. Tinea corporis was the most frequent (62.2%), followed by tinea capitis (31.6%). Ten cases of sycosis, one case of tinea pedis and one case of pubic tinea were diagnosed. Lesions of skin were erythemato-squamous (82.5%) and pustulo-inflammatory (17.5%), affecting mainly upper limb (58.3%) and face (25.8%). For tinea capitis, lesions were squamous (30.8%) and pustulo-inflammatory (41%). Eleven cases of kerion celsi were diagnosed (28.2%). Patients were affected in one site (79.7%), two sites (16.9%) and three or more (3.4%). CONCLUSION: Dermatophytosis due to T. verrucosum is in recrudescence in our region. This finding may be explained by changing behaviors and activities of the population with a low socioeconomic level who kept a larger number of domestic animals at homes.

Assessment of heart failure and left ventricular systolic dysfunction after cardiac pacing in patients with preserved left ventricular systolic function.

BACKGROUND: There is an accumulating data suggesting the deleterious effects of right ventricular pacing on left ventricular performance. Such pacing mimics left bundle branch block resulting in a prolonged QRS duration and causes ventricular asynchrony. AIMS: The purpose of this study is to assess heart failure and left ventricular systolic function after cardiac pacemaker implantation in patients with atrioventricular block and preserved systolic left ventricular function. Secondly, we sought to search for predictive factors of developing left ventricular dysfunction after pacing. METHODS: In this prospective study, we included patients who had been implanted for at least six months. They underwent medical history and examination, 12 leads electrocardiogram and echocardiography before pacemaker implantation and when attending to routine pacemaker follow up. RESULTS: Forty-three patients (22 men and 21 women, age 71+/-12 years) were included in this study. Twenty-nine patients had DDD pacing and 14 VVI pacing. The ventricular lead was implanted in the apex in all patients. After a median follow up of 18+/-11 months, 11 patients (25%) developed signs of congestive heart failure. NYHA was higher after implantation (1.64+/-0.7 versus 2.27+/-0.8, p>0.00001). Left ventricular ejection fraction decreased significantly during follow up (60+/-6% versus 51+/-13%, p=0.0002). Eleven (25%) patients developed left ventricular dysfunction. We compared patients who had left ventricular ejection fraction (LV EF) less or equal to 40% (group A) and patients having LV EF greater than 40% (group B) after implantation. Patients in group A had a paced QRS width significantly larger than group B (181+/-32 ms versus 151+/-26 ms, p=0.002), a significantly prolonged intra left ventricular electromechanical delay (115+/-59 ms versus 45+/-35 ms, p<0.0001) and interventricular delay (44+/-29 ms versus 27+/-18 ms, p=0.02). Age, sex, diabetes hypertension, pacing mode and percentage of ventricular pacing were similar in both groups. A paced QRS width of 180 ms had the best sensitivity and specificity for detecting left ventricular dysfunction: sensitivity=54% and specificity=93%, p=0.01, area under the curve=0.75. CONCLUSION: Patients with atrioventricular block and preserved left ventricular systolic function at baseline decrease significantly left ventricular ejection fraction after pacing. Induced ventricular asynchronism plays a major role in the deterioration of left ventricular function. Prolonged paced QRS width is a good predictor of left ventricular dysfunction after pacing. Larger prospective studies are needed to confirm these data.

[Uveitis of children: a report of 18 cases]. / Les uvéites de l'enfant: étude de 18 observations.

UNLABELLED: Childhood uveitis is a rare but serious disease that may causes visual loss. Causes are various and an underlying disease is not always found. PURPOSE: To analyse clinical features and prognosis of uveitis in children. PATIENTS AND METHODS: A retrospective, descriptive study of cases observed in a general pediatric unit over a period of 15 years (1990-2005) at Tunis. RESULTS: We gathered 18 cases of uveitis (girls 55.6% ,boys 44.4%). Mean age at the diagnosis was 8+/-3 years. Diagnosis was made after a decreased of visual acuity in 55.6% of cases. Localization of uveitis was anterior (6 cases), intermediate (1 case), posterior (3 cases) and total (8 cases). An underlying disease was found in only 5 patients: Behçet's disease (3 patients), juvenile chronic arthritis (1 patient), possible dermatopolymyositis (1 patient). The evolution was favorable in 10 cases with local treatment, systemic corticotherapy and/or immunosuppressive agents. Complications occurred in 3 cases. CONCLUSION: Causes of uveitis in childhood remains most often undiagnosed Our study illustrates the pending risk of severe visual impairment and strict ophtalmology follow-up is mandatory.

Sodium lauryl sulfate-induced irritation in the human face: regional and age-related differences.

The particular sensitivity of the human face to care products prompted us to study irritation induced by sodium lauryl sulfate (SLS) in its various regions. We examined regional and age-related differences, correlating basal transepidermal water loss (TEWL) and capacitance to SLS irritation. SLS (2% aq.) was applied under occlusion for 1 h to the forehead, cheek, nose, nasolabial and perioral areas, chin, neck and forearm to two groups of subjects--one with 10 subjects with an average age of 25.2 +/- 4.7 years and another with 10 subjects with an average age of 73.7 +/- 3.9 years. TEWL was measured before and 1 h and 23 h after patch removal. Baseline stratum corneum hydration was also measured. Irritation was assessed by the changes in TEWL (deltaTEWL = TEWL after patch removal - basal TEWL) after corrections to the control. In the younger group, all areas of the face and the neck reacted to SLS, whereas the forearm did not. In the older group, the nose, perioral area and forearm did not react. In both age groups, some significant differences between the regions of the face were detected. The younger group showed higher changes in TEWL than the older group in all the areas studied, but only in the chin and nasolabial area were the differences statistically significant. Significant correlations were found between basal TEWL and deltaTEWL in 5 of the 7 areas which reacted to SLS. Baseline TEWL is one parameter that correlates with the susceptibility of the face to this irritant.

[Syphilitic aortic aneurysm. A case report]. / Anévrysme aortique d'origine syphilitique. A propos d'un cas]

The incidence of tertiary syphilis has declined in recent years owing to the early recognition of the disease and use of antibiotics. As a result, syphilitic aortic aneurysms are rarely encountered nowadays. We report the case of a 65 years old man, who was admitted to our hospital in June 2004 for dyspnea, cough and chest discomfort. On physical examination, blood pressure was 130/80 mmHg with no significant laterality, pulse rate was 70 per minute and there was a decrease of breath sounds over the right lung. Laboratory findings revealed a slight elevation of the erythrocyte sedimentation rate. Serological studies for syphilis showed a positive venereal disease laboratory test (VDRL) at 1/32 and a positive Treponema pallidum hemagglutination test (TPHA) at 1/2560. The chest radiography showed a right para cardiac opacity measuring 16 x 12 cm. Fiber optic bronchoscopy showed an extrinsic compression of the right upper lobar bronchus. Gadolinium-enhanced magnetic resonance angiography and 16 multidetector-row spiral computed aortography showed a huge partially thrombosed saccular aneurysm of the ascending aorta measuring 132 mm in diameter. The circulating lumen measured 53 mm in its largest diameter. This aneurysm involved the innominate artery. There was no other arterial involvement. The patient was given a three week course of intravenous penicillin followed by a successful surgical procedure in September 2004 with ascending aortic replacement and innominate artery reimplantation. This case illustrates well a formerly common, but now extremely rare disease.

Identification of Malassezia species from Tunisian patients with pityriasis versicolor and normal subjects.

BACKGROUND: The genus Malassezia (Pityrosporum), recognized as a member of microbiological flora of the skin in humans and warm-blooded animals, has been recently revised to include 10 Malassezia species. The aim of the study was the isolation, identification and analysis of Malassezia species distribution in skin of healthy volunteers and lesions of pityriasis versicolor (PV). MATERIAL AND METHODS: Specimens were taken from 100 patients with PV and 30 healthy volunteers. Cultures were made in modified Dixon agar medium and the isolates were identified by morphological and physiological methods: macroscopy, microscopy, catalase, beta-glucosidase and lipid assimilation tests. RESULTS: Malassezia globosa was the predominant species in lesional skin of PV (65%). It was isolated alone in 47% of cases and associated in 18% with M. furfur (13%) or M. sympodialis (5%). In healthy skin M. globosa was found alone in 7.77% and associated in 15.54%, respectively, with M. furfur (4.44%), M. sympodialis (4.44%), M. restricta (3.33%) and M. slooffiae (1.11%). CONCLUSION: From these findings it was suggested that M. globosa presents the main species implicated in the pathogenicity of PV and M. furfur as the second agent of importance.

[Urgent penetrating keratoplasty in perforated infectious corneal ulcers]. / Kératoplastie transfixante à chaud dans les ulcères cornéens infectieux perforés.

PURPOSE: To evaluate anatomical and functional prognosis of urgent penetrating keratoplasty in perforated infectious corneal ulcers. METHODS: Seven eyes of seven patients had an urgent penetrating keratoplasty for perforated infectious corneal ulcers. Anatomical success was defined by eradication of infection and preservation of eye from enucleation and phthisis bulbi. Corneal graft survival was defined by the presence of a clear graft. RESULTS: The patients'mean age was 40.5 years. Four eyes had bacterial corneal ulcer and three eyes had herpetic corneal ulcer. Anatomical success was obtained in six eyes. The graft remained clear in two eyes. Graft rejection was noted in four eyes after a mean period of 4.5 months. Postoperative complications were ocular inflammation (one eye), ocular hypertension (three eyes), cataract (one eye), peripheral anterior synechiae (one1 eye), graft ectasia (one eye), bacterial infection (one eye) and recurrent herpetic keratitis (one eye). The mean follow-up period was 22 months, ranging from 9 to 32 months. CONCLUSION: Urgent penetrating keratoplasty can preserve eye integrity and eradication of the infectious process in a large part of perforated bacterial and herpetic corneal ulcers. Visual rehabilitation is often a secondary objective. Adapted antimicrobial treatment reduces graft reinfection and steroid treatment reduces the frequency of some complications, especially graft rejection.