Combination Therapy With Nicardipine and Isosorbide Dinitrate to Prevent Spasm in Transradial Percutaneous Coronary Intervention (from the NISTRA Multicenter Double-Blind Randomized Controlled Trial).

Verapamil and nitroglycerin are widely used to prevent radial artery spasm (RAS) during percutaneous cardiovascular procedures. However, these agents are not typically available in most African countries and consequently, isosorbide dinitrate is often the only spasmolytic treatment. Our aim was to compare the efficacy of isosorbide dinitrate alone versus isosorbide dinitrate used together with nicardipine to prevent RAS during transradial coronary procedures. This was a randomized controlled double-blind multicenter trial. Patients (n = 1,523) were randomized to receive either a sole therapy of isosorbide dinitrate (n = 760) or the combination of isosorbide dinitrate and nicardipine (n = 763). Our primary end point was the occurrence of RAS; defined as considerable perceived hindrance of catheter advancement. Our secondary end points were severe RAS; defined as (1) severe arm pain, (2) the need for either morphine or midazolam treatment, and (3) necessity for crossover to the contralateral radial or femoral artery. RAS incidence was reduced with the combination therapy versus isosorbide dinitrate alone (15% vs 25%, p <0.001), with a number needed to treat of 10 patients. There was also a significant reduction in the incidence of the secondary end points with combination therapy (3.6% vs 8.2%, p <0.001), with a number needed to treat of 22 patients. This result was driven by reductions in both femoral crossover (0.5% vs 2.4%, p = 0.003) and the use of morphine or midazolam injections (1.6% vs 3.5%, p = 0.02) with combination therapy. In conclusion, we demonstrated the superiority of the combination therapy of isosorbide dinitrate and nicardipine over isosorbide dinitrate alone in reducing the incidence of RAS.

Hypoxemia and if it is the liver? Hepatopulmonary syndrome : about a case.

The hepatopulmonary syndrome is defined as the triad of liver disease, pulmonary gas exchange abnormalities leading to arterial deoxygenation and widespread pulmonary vascular dilatation. It is one of the not infrequently cases of dyspnea within patients with liver disease. We report the case of a 32-year-old woman with cirrohsis and portal hypertention who presented with dyspnea worsning progressively. The blood gas revealed a deep hypoxemia with a PaO2 rate 42mmHg but clinically well tolerated. Pulmonary embolism and pneumonia were rapidly excluded by a CT pulmonary angiography. An echocadiography done in order to find any heart disease suspected a patent foramen ovale. A transthoracic contrast echocardiography showed an important pulmonary vascular dilatation.The association of cirrohsis, pulmonary vascular dilatation and hypoxemia made the diagnos of hepatopulmonary syndrome.

Place of the "Public health" in the Tunisian medical research on the cardiovascular diseases: a bibliometric study (Medline: 1988-2017).

BACKGROUND:   The management of the cardiovascular diseases, main public health problem in Tunisia, is generating many difficulties that a socially responsible research should reflect them. The aim of this study is to assess dimensions of public health of Tunisian research on the cardiovascular diseases during thirty last years. METHODS: we conducted a bibliometric study relating to the public health information of the Tunisian cardiovascular papers indexed in the Medline database between January 1st 1988 and December 31st 2017. The following qualifiers were selected to define the public health dimension of paper: "epidemiology", "mortality", "statistics and numerical data", "economy", and "prevention and control". RESULTS: During thirty years (1988-2017), 176 references were identified and only 136 Tunisian publications were retained following the application of the inclusion criteria (first author affiliated in a Tunisian structure of health or research). The two medical specialties of "cardiology" and "Preventive medicine and Community" produced 47% of these articles. The selected publications were mainly original articles, monocentric studies, analytical, and written in French language for the national journal "La Tunisie Medicale". Among the 136 selected articles, 34 (25%) explored the ischemic heart diseases. "Epidemiology" and the "Prevention/Control" were two dimensions of the "Public health" the most studied in the Tunisian publications on the cardiovascular diseases, respectively in 84% and 44% of the cases. CONCLUSION: The Tunisian publications in the cardiovascular field accompanied the epidemiologic transition along the three last decades. While they were focusing on the epidemiology and the prevention of the ischemic heart diseases. Other dimensions of public health must be treated on the set of the cardiovascular diseases, such as the economics and etiologics studies.

The nursing profession in Tunisia.

The Tunisian health care system is experiencing a significant period of change and needs reforms so as to adapt. The nursing profession, which is the main actor of this system, in terms of number and function, is barely known or utterly unknown. The present paper's authors, who are paramedical teachers, aim to shed light on the specificity of the nursing and the nursing profession based on data collecting, and rare articles and legislation texts. In four sections, the paper will discuss the following issues: the nursing population demography, providing several indicators, their training throughout the reforms period, their training which has been "hooked" to university studies, their job profile and career plan. This presentation will also address the situation in Algeria and Morocco, based on data available on the Web. The acquisition of "core" skills and skills "shared with other caregivers" represents the roadmap for the drafters of the training benchmarks currently under drafting. The higher institutes of nursing are looking of ways to secure the required trainers and resources needed to the opening of departments, prior to the launch of a 'doctoral school', which represents the only incubator of future teachers and researchers. Private training institutions representing a new investment sector are to be assessed in terms of overall employability. Perspectives, in 12 points, should be planned for a pedagogically accredited, professionally performing and socially responsible profession.

Left-sided congenital heart lesions in mosaic Turner syndrome.

In the era of the diseasomes and interactome networks, linking genetics with phenotypic traits in Turner syndrome should be studied thoroughly. As a part of this stratagem, mosaicism of both X and Y chromosome which is a common finding in TS and an evaluation of congenital heart diseases in the different situations of mosaic TS types, can be helpful in the identification of disturbed sex chromosomes, genes and signaling pathway actors. Here we report the case of a mosaic TS associated to four left-sided CHD, including BAV, COA, aortic aneurysms and dissections at an early age. The mosaicism included two cell lines, well-defined at the cytogenetic and molecular levels: a cell line which is monosomic for Xp and Xq genes (45,X) and another which is trisomic for pseudoautosomal genes that are present on the X and Y chromosomes and escape X inactivation: 45,X[8]/46,X,idic(Y)(pter→q11.2::q11.2→pter)[42]. This case generates two hypotheses about the contribution of genes linked to the sex chromosomes and the signaling pathways involving these genes, in left-sided heart diseases. The first hypothesis suggests the interaction between X chromosome and autosomal genes or loci of aortic development, possibly dose-dependent, and which could be in the framework of TGF-ß-SMAD signaling pathways. The second implies that left-sided congenital heart lesions involve sex chromosomes loci. The reduced dosage of X chromosome gene(s), escaping X inactivation during development, contributes to this type of CHD. Regarding our case, these X chromosome genes may have homologues at the Y chromosome, but the process of inactivation of the centromeres of the isodicentric Y spreads to the concerned Y chromosome genes. Therefore, this case emerges as an invitation to consider the mosaics of Turner syndrome and to study their phenotypes in correlation with their genotypes to discover the underlying developmental and genetic mechanisms, especially the ones related to sex chromosomes.

[Cardiac amyloidosis revealing multiple myeloma]. / Amylose cardiaque révélatrice d'un myélome multiple.

INTRODUCTION: Amyloidosis is a rare disease characterized by an extracellular accumulation of a protein polysaccharid complex (Amyloid). Cardiac involvement is considered as a major prognostic factor. OBSERVATIONS: We report the case of two women, hospitalized for heart failure. The diagnosis of cardiac amyloidosis was suggested by echocardiography: Left ventricular concentric hypertrophy and typical amyeloid infiltration with hyperechoic, shiny and granite-like aspect of the interventricular septum. The histological confirmation was obtained by gastric biopsy in the first case and biopsy of the salivary glands in the second revealing an amyloidosis AL. This cardiac amyloidosis was secondary to multiple myeloma: monoclonal Gammopathy with immunoglobulin Lambda in the first and Kappa in the second, and the presence of a plasmocyte infiltration in the sternal puncture. CONCLUSION: Amyloidosis is a rare pathology, the cardiac involvement is frequent in the type AL and can occur with or without clinical manifestations. Echocardiography should be systematic in patients with confirmed amyloidosis.

[Correlation of clinical and angiographic morphology in unstable angina]. / Corrélations cliniques et angiocoronarographiques au cours de l'angor instable.

The goal of this study was to compare the clinical presentation and angiographic morphology of patients having an unstable angina pectoris. A total of 321 patients were consecutively studied and underwent cardiac catheterization, mean age 59 + 6 years. According to Braunwald classification, class III was predominant (58%) On coronary angiography, 148 patients had single vessel disease, double-vessel in 92 and triple-vessel in 64. Morphology of coronary artery lesions was classified according to Ambrose's classification, 100 patients had simple lesions (type I or IIA), 204 patients had complex lesions (type IIB, III, intracoronary thrombus or total occlusion). Thoracic rest pain (class III) or postinfarction angina (class C), were associated with the presence of complex lesions. This subgroup of high risk patients would benefit from either Glycoprotein IIb/IIIa blockers with an early revascularisation strategy.