Incidental, non-gated thoracic CT angiographic detection of proximal right coronary artery total occlusion associated with acute myocardial infarction.

Herein, we present a case of a right coronary artery proximal occlusion and acute myocardial infarction with absence of the reverse attenuation gradient sign that was incidentally identified in the emergency room with non-gated computed tomography angiography of the aorta performed to rule out aortic dissection. This case highlights the importance of assessing the heart and coronary arteries even on non-gated computed tomography angiography.

Arrhythmic Risk Following Recovery of Left Ventricular Ejection Fraction in Patients with Primary Prevention ICD.

BACKGROUND: Left ventricular ejection fraction (LVEF) recovers during follow-up in a significant proportion of patients implanted with a cardioverter defibrillator (ICD) for primary prevention. Little is known about the midterm arrhythmic risk in this population, particularly in relation to the presence or absence of ischemic cardiomyopathy. METHODS AND RESULTS: We retrospectively analyzed 286 patients with an ICD implanted for primary prevention between 2002 and 2010. Patients were divided into two groups based on their last LVEF assessment: (1) Recovery, defined as an LVEF > 35%; and (2) No-Recovery, defined as an LVEF ≤ 35%. Kaplan-Meir curves and multivariate Cox regression analysis were performed separately for patients with ischemic (211 patients) and nonischemic (75 patients) cardiomyopathy. Forty-nine patients (17.1%) had LVEF recovery to >35% at last follow-up. Overall, 72 patients (25.2%) experienced ventricular arrhythmias requiring ICD therapy during a median follow-up of 4.4 years. With multivariate Cox regression, LVEF recovery was associated with a lower arrhythmic risk in the whole cohort (hazard ratio [HR]: 0.38 [0.13-0.85]; P = 0.02) and in the nonischemic cardiomyopathy cohort (HR: 0.10 [0.005-0.55]; P = 0.005), but not in the ischemic cardiomyopathy cohort (HR: 0.84 [0.25-2.10]; P = 0.74). CONCLUSION: In conclusion, patients with nonischemic cardiomyopathy who improved their LVEF to >35% after primary prevention ICD implantation were at very low absolute arrhythmic risk. Our study raises the possibility that the LVEF cutoff to safely withhold ICD replacement might be higher in patients with ischemic compared to nonischemic cardiomyopathy. This will need to be confirmed in prospective studies.

Impact of methicillin resistant Staphylococcus aureus contact isolation units on medical care.

BACKGROUND: Patient isolation using contact precautions has gained widespread use to halt MRSA transmission, however supportive data is scarce and concerns regarding patient safety and satisfaction have been raised. At our institution, MRSA patients are isolated on a dedicated ward (cohort isolation), rather than in separate rooms. Our objectives were (1) to determine the proportion of bedside medical visits to patients on an isolation ward, (2) to quantify complications in those patients and (3) to determine if those complications are related to isolation and if they can be prevented. METHODS: This retrospective case-control study was performed on the two sites of a tertiary teaching hospital in Sherbrooke, QC, Canada. We matched MRSA patients with an admission diagnosis of heart failure or chronic obstructive pulmonary disease to similar non-isolated controls. The proportion of bedside visits was ascertained through the number of progress notes with subjective elements or with a physical examination. Complications were sought through an extensive file review, and events were analysed according to Baker's CAES causality and preventability scales. RESULTS: Overall, 111 patient pairs were analysed (35 with heart failure and 76 with COPD). Isolated patients received less bedside visits (subjective notes/1,000 patient-days: 849.6 vs. 983.3, p = 0,001). Attending physicians (454.5 vs. 451.4, p = 0,02) and residents (347.0 vs. 416.9, p = 0.01) are responsible for this discrepancy, while medical students appear to visit isolated and non-isolated patients equally (116.5 vs. 114.9, p = 0.90). Isolated patients showed a tendency towards longer stay and more preventable complications, although no difference in the total number of complications was observed. CONCLUSION: Isolated patients have less documented care that suggests less bedside visits from the medical staff, which could hamper the therapeutical relationship. Further studies are needed to explain this finding.

Streptococcus anginosus pyogenic liver abscess following a screening colonoscopy.

A previously healthy 58-year-old man presented with a septic thrombosis of the right hepatic vein and a pyogenic liver abscess (PLA) one week after undergoing a screening colonoscopy. Blood cultures and a radiological drainage specimen were both positive for Streptococcus anginosus. Evolution was favourable after six weeks of antibiotherapy. To the authors' knowledge, the present report is the first to describe a PLA following a screening colonoscopy with no intervention. The authors hypothesize that silent microperforations during colonoscopy contributed to the infection. Although 20% to 40% of reported PLA cases are cryptogenic in the literature, it may be because of failure to recognize and report a precipitating factor such as colonoscopy. As more cases similar to the present case are reported, the number of cryptogenic cases may decrease.

Un homme de 58 ans auparavant en santé a consulté en raison d'une thrombose septique de la veine hépatique droite et d'un abcès hépatique à pyogènes (AHP), une semaine après une coloscopie de dépistage. Les analyses sanguines et l'échantillon de drainage radiologique étaient tous deux positifs au Streptococcus anginosus. L'évolution était favorable après six semaines d'antibiothérapie. En autant que le sache les auteurs, le présent rapport est le premier à décrire un AHP après une coloscopie de dépistage sans autre intervention. Les auteurs postulent que des microperforations silencieuses pendant la coloscopie ont contribué à l'infection. Même si de 20 % à 40 % des cas d'AHP déclarés sont de nature cryptogénique dans les publications, ce peut être en raison du défaut de dépister et de signaler un facteur précipitant comme la coloscopie. À mesure que plus de cas similaires à celui présenté seront signalés, le nombre de cas de nature cryptogénique pourrait diminuer.

Effect of age and sex on echocardiographic left ventricular diastolic function parameters in patients with preserved ejection fraction and normal valvular function.

BACKGROUND: We conducted a retrospective study to specify the effect of age and gender on echocardiographic left ventricular diastolic function parameters. METHODS: We included echocardiograms done in our institution between 1995 and 2007, for which data on diastolic function were available. In order to target a population as close aspossible to healthy subjects, echocardiograms reporting abnormal contraction, valvulopathy or extreme data were excluded. RESULTS: A total of 14,298 patients (mean age 58.53 years; men 49.1%) were included in the study. Sex did not influence E/A ratio (p = 0.298) but age decreased it significantly (p < 0.001). E/e ratio increased significantly with age (p < 0.001) and was higher in women than in men (p < 0.001). After the age of 40, more than 10% of the patients had an E/e ratio superior than 8. CONCLUSIONS: To our knowledge, this is the most imposing study - in terms of number of patients from first to tenth decade of life that were included - addressing the effect of age and gender on diastolic function. Our results stress the need for future prospective trials to establishnormal diastolic function parameters according to age and gender, notably for the E/e ratio for which a significant proportion of our population had a ratio superior of what is actually considered normal.

Acute and recurring pericarditis: More colchicine, less corticosteroids.

Acute and recurring pericarditis are frequently encountered clinical entities. Given that severe complications such as tamponade and constrictive pericarditis occur rarely, the majority of patients suffering from acute pericarditis will have a benign clinical course. However, pericarditis recurrence, with its painful symptoms, is frequent. In effect, recent studies have demonstrated a beneficial role of colchicine in preventing recurrence, while also suggesting an increase in recurrences with the use of corticosteroids, the traditional first-line agent.