Heart Rate Variability as an Indicator of Autonomic Nervous System Disturbance in Behcet's Disease.

BACKGROUND: Behçet's disease (BD) is a multisystemic vasculiti where cardiac involvement is not common. Previous studies have shown that the incidence of ventricular arrhythmia and sudden cardiac death (SCD) is higher in patients with BD than in the healthy population. Among various possible explanations, autonomic nervous system (ANS) dysfunction has been suggested. Few studies have evaluated ANS function in patients with BD, and the results obtained are controversial. OBJECTIVE: We aimed to assess cardiac autonomic function by heart rate variability (HRV) in patients with BD; to evaluate circadian changes in HRV; and to study the relationship between HRV parameters and disease parameters. METHODS: Thirty-six patients with Behçet's disease (median age 42 years, 28 men) and 36 age- and sex-matched healthy volunteers were included. HRV analyses were performed in the time and frequency domains for the entire 24-hour period and for the daytime and nighttime periods. BD activity was studied with Behcet's disease current activity form (BDCAF). RESULTS: Patients with BD had significantly lower values of SDNN compared to controls. PNN50, RMSSD, and HF components mean values were significantly reduced in patients than in controls implying parasympathetic impairment. LF was comparable between the two groups, whereas LF/HF ratio was significantly higher in BD group. The circadian rhythm of HRV was preserved in patient group. There was no significant correlation of CRP or disease duration with HRV indices in Behçet's subjects. BDCAF score was found to be negatively correlated with LF/HF. CONCLUSION: Patients with BD, despite no cardiovascular involvement, have reduced parasympathetic activity compared with controls. However, circadian rhythms of autonomic function were preserved. As known, there is strong evidence for the role of the ANS in the pathogenesis of ventricular arrhythmias. Thus, being a practical tool, HRV can be an interesting approach for the rhythmic follow-up of BD patients.

Alveolar Hemorrhage Following Thrombolytic Therapy for Acute Myocardial Infarction: Two Case Reports and Literature Review.

Alveolar hemorrhage (AH) is a heterogeneous clinical syndrome with a high mortality rate, characterized by extensive bleeding into the alveolar spaces. AH secondary to systemic thrombolysis treatment in the setting of acute myocardial infarction is an uncommon complication, but potentially fatal and can lead to acute respiratory failure. This entity is rarely reported in the literature. We report two cases of acute AH after intravenous thrombolysis for acute myocardial infarction, which could contribute to the literature on the subject, and discuss the risk factors as well as the clinical and radiological findings supporting the diagnosis. We overview also the rare previous published case reports in this context, and we contrast our findings with those reported in the literature.

Both mediastinal and pericardial hydatidosis revealed by ST elevation acute coronary syndrome.

Hydatidosis remains an endemic disease in some regions of the world, such as Tunisia. The liver and the lungs are the most common sites in adults. Mediastinal and pericardial hydatid cysts are very rare even in endemic areas and true incidence has not been described in the literature. We report the case of a 74-year-old woman with clinical, biological and electrocardiographic features of acute myocardial infraction. Two-dimensional echocardiography and detailed imaging revealed a mediastinal and pericardial hydatid cyst. The particularity of the clinical presentation, the complementary investigations as well as the management and follow-up of the patient are discussed. This case is of great interest since the rarity of concomitant hydatid cyst in two uncommon localizations: mediastinum and pericardium, and the unusual incidental discovery during a myocardial infarction.

The value of simulation in learning clinical reasoning.

BACKGROUND: Simulation allows learning in action, reflection and feedback. All these factors suggest the positive contribution of the simulation to the development of clinical reasoning. The main assessment tool for standardized testing of this skill is the script matching test. AIM: To assess the impact of teaching through high-fidelity clinical simulation on the clinical reasoning of third-year medical students, while assessing their teaching practices, satisfaction and confidence in the learning they received during this session. METHODS: We conducted an evaluative bicentric prospective study that included third-year medical students completing their cardiology internship during the first semester of the academic year 2019-2020 in the cardiology departments of Habib Thameur Hospital and Charles Nicolle Hospital, respectively. RESULTS: The study included 48 students. The students who participated in this study liked the teaching practices used in the simulation-assisted lessons. Their interest in these practices is validated by the average of 37,2±5,53 obtained for active learning, 8,04±1,85 for collaboration, 8,5±1,51 for diversity of styles and 8,02±1,72 for high expectations. In our study, the results showed that students were satisfied with the learning they had made during the simulation session. The average for the measurement of satisfaction by the 48 externals was 22,37±2,54. The results of our study indicated that students were confident that their learning would allow them to solve problems similar to those presented in the simulation in a real clinical setting. This is supported by the 31,48±4,63 average student confidence in their learning. Our study showed a progression of the students' clinical reasoning with simulation using a Script Concordance Test. The mark obtained by the students after the simulation session is significantly higher than the one obtained by the students before the simulation session with p=0.008. CONCLUSION: Simulation is an innovative pedagogical strategy and a contribution to optimizing the clinical reasoning process and improving the quality of care.

Impairment of left and right ventricular longitudinal strain in asymptomatic children with type 1 diabetes.

AIM: The relationship between type 1 diabetes (T1DM) and cardiac function in children is not well established. The purpose of this study was to investigate whether children and adolescents with T1DM present early asymptomatic abnormalities of left ventricular (LV) and right ventricular (RV) function. In addition, we evaluated the relationship of any such abnormalities with glycemic control and diabetes duration. METHODS: This was a prospective study. Standard echocardiography, tissue Doppler imaging, and two-dimensional strain analysis were performed prospectively in 52 children with T1DM. The results were compared with those from 52 healthy children matched for age and sex. RESULTS: There were no significant differences between the two groups in LV ejection fraction or RV systolic function. There was a difference between the two study groups in transtricuspid flow: the E-wave and A-wave velocities were significantly higher in the diabetic group. Left ventricular global longitudinal strain (LV GLS) was significantly lower in children with T1DM (-20.01 ± 1.86% vs. -22.99 ± 0.98%, respectively; P < .001), as was RV free-wall longitudinal strain (RV FWLS) (-29.13 ± 1.85% vs. -30.22 ± 1.53%, respectively; P = .002). LV GLS was correlated with diabetes duration (r = 0.444, P < .001) and glycated hemoglobin (HbA1c) (r = 0.683, P < .001); however, no correlation was found between RV FWLS and HbA1c or diabetes duration. CONCLUSIONS: Our findings suggest that LV GLS and RV FWLS are impaired in children with T1DM and that the decrease in LV GLS is correlated with diabetes duration and HbA1c levels.

Early outcomes of cardiac surgery in elderly patients.

BACKGROUND: Due to the increase in average life expectancy and the higher incidence of cardiovascular disease, more elderly patients present for cardiac surgery nowadays. At the same time, age has been considered a predictor of morbidity and mortality. AIM: To evaluate the short-term outcomes of cardiac surgery in elderly patients. METHODS: We conducted a descriptive retrospective study including elderly patients who underwent cardiac surgery from January 2012 to 31st of December 2016. All patients were hospitalized before and after cardiac surgery in the cardiology department of Habib Thameur Hospital. RESULTS: Our study included 55 patients. Average age was 72±6 years old and sex-ratio was two. Eighty-five percent presented with angina, 18% with dyspnea and one patient with an aortic prosthetic valve endocarditis. Mean left ventricular function was 54 ±9 %. Mean EuroSCORE II was 1.91±1.18. Twenty-six per-cent had an urgent surgery. Mean extracorporeal circulation time was of 77±26 min and mean extubation time was 8±6 h. Eighty-four per cent had a coronary artery bybass grafting and 16% a valve replacement. Four per cent had a redux and 4% a combined surgery. Stay in surgical department varied between 3 and 10 days with average of 4.6±1.2 days. Early mortality rate was of 2% and 98% had complications. Ninety-eight complications occurred after surgery: 35 reintervention for mediastinal bleeding or tamponade, 28 bleedings requiring transfusions, eight heart rhythm disorders, an atrioventricular conduction block requiring ventricular, five atrial fibrillation, two ventricular tachycardias, a ventricular fibrillation, eight low cardiac outpout, seven prolonged mechanical ventilation and eight pneumonias. In univariate analysis, recent myocardial infarction and chronic kidney disease were predictive of early complications. CONCLUSION: Our data shows cardiac surgery is feasible in elderly patients with acceptable risk in terms of mortality and an increased morbidity due to their frailty. Careful patient selection is needed for the success of cardiac surgery in elderly patients.

Evaluation of patients' knowledge on their vitamin K antagonist treatment.

INTRODUCTION: Vitamin K antagonists (VKA) are currently the most prescribed oral anticoagulant treatment in Tunisia. Despite the standardization of biological monitoring and the better definition of therapeutic objectives, their side effects are a frequent reason for hospitalization. AIM: To evaluate patients' knowledge about their VKA treatment. METHODS: We realized a cross-sectional descriptive study in the Cardiology Department of HabibThameur Hospital from September to October 2016. A questionnaire consisting of 14 items was used in a semi-directed interview in order to assess patients' knowledge on their VKA treatment. RESULTS: Our study included one hundred patients. Mean age was 61 ± 12 years and sex ratio of 1.8. Forty-eight per cent were illiterate. The median duration of AVK intake was 5 years. Atrial fibrillation (AF) was the most frequent indication (57%). Eighty percent of patients had more than five correct answers on the eight items of knowledge: VKA's name (96%), tablet description (93%), dose (99%), time (94%), VKA's effect (70%), INR (56%), treatment's risk (49%) and the target INR (20%). Twenty-two percent had more than four correct answers on the 6 items of know-how: what to do in case of haemorrhage (70%), what to do in case of oblivion (45%), interactions precautions to be observed with food (13%), activities advised against (49%) and medical procedures advised against (27%). In multivariate analysis, only prior VKA information was significantly associated with a better knowledge of VKA (p = 0.027). CONCLUSION: Our patients' knowledge on their VKA treatment was insufficient to ensure the safety and efficacy of treatment. The creation of a therapeutic education program on is therefore necessary to reduce the iatrogenic risk of this treatment.

Effect of ramadan fasting on acenocoumarol-induced antocoagulant effect.

Eating patterns, food intake and type of alimentation vary greatly during the month of ramadan. Furthermore, fasting, which practiced during the month of ramadan, can have an impact on drug's metabolism. These two factors, fasting and eating habits changes during the month of ramadan, may impact acenocoumarol anticoagulant effect, translated by variations of INR values. The aim of our study was to see ramadan fasting effects on INR variations in patients treated by acenocoumarol. A prospective monocentric study was conducted during the ramadan month on fasting outpatients that were treated by acenocoumarol. Baseline INR values (e.i. most recent available value before the month of ramadan) were compared to INR values obtained during the month of ramadan. All patients were monitored for signs of secondary haemorrhagic complications linked to treatment by anti-vitamin K (AVK). Thirty patients were included in the study with a sex ratio 1. Patients mean age was 65 years. Around two thirds of the patients were treated by AVK for atrial fibrillation. The majority of patients (94%) have been treated by AVK for more than a year. Mean INR was significantly higher during the month of ramadan than baseline (3.51 vs 2.52; p< 0.0001). There were also more overdoses during the month of ramadan than baseline (9 vs. 0; p=0.014). The increased INR values highlights the need of a close monitoring of INR values during the month of ramadan, particularly in patients with a high haemorrhagic risk.

Trends in infective endocarditis.

INTRODUCTION: Infectious endocarditis (IE) is a rare disease with a high mortality. In 2009, the European society of cardiology restricted antibiotic prophylaxis to a smaller number of cardiac conditions with very high risk for IE. Did these changes in the guidelines have an impact on the epidemiological and bacteriological profile of IE? AIM: The main aim of our work was to study the evolution of the microbiological profile of IE from 1991 to 2016. METHODS: We realized an analytic retrospective study comparing two groups: group 1 included patients admitted for a certain IE before September 2009 and group 2 those admitted after that date. RESULTS: Patients mean age was 46 ± 13 years and sex ratio was of 1.5. Forty percent of the patients were at high risk of IE. Blood cultures were positive in 19 cases. The most frequently isolated germ was Staphylococcus (10 patients). Serology was performed in six patients and was positive for Chlamydia Trachomatis in two cases. Forty-two patients had surgical treatment, 17 had a valve culture that was positive in 3 cases only. Clinical and paraclinic characteristics were comparable among the two groups. Negative blood cultures rates decreased from 72% to 68% between group 1 and 2 (p = 0.789). Staphylococcus positive blood cultures increased from 13% to 21% (p = 0.49). In contrast, Streptococcal positive blood cultures decreased from 11% to 5% in 2009 (p = 0.69). CONCLUSION: Our data suggest that there has been no change in the bacteriological profile of IE after the reduction in antibiotic prophylaxis.