[Vitamin K in the neonate: Recommendations update]. / Vitamine K chez le nouveau-né : mise à jour des recommandations.

Hemorrhagic disease of the newborn is not common but may be very serious, with cerebral, hepatic, or adrenal gland bleeding. Its prevention is based upon vitamin K1 administration from birth. Scientific studies to validate appropriate treatment policies are scarce, with recommendations coming from expert opinions, retrospective studies, or controversies on possible side effects. After analysis of recent literature data, we propose an oral administration of three doses of 2mg of vitamin K1 at birth, at discharge from the maternity ward, and at 1 month postnatal age for term infants. For premature infants born with a birth weight above 1500g, a weekly dose of 2mg up to term equivalent age may be recommended. For premature infants below 1500g, a weekly dose of 1mg up to 1500g body weight, then a weekly dose of 2mg up to term equivalent age seems appropriate. If oral administration is not possible, the intravenous or intramuscular route may be used with a 50% reduction in dosing.

[Orientation after peripartum asphyxia in the maternity ward: which infants should be transferred to pediatric care units?]. / Orientation en salle de naissance après une asphyxie per-partum: quels nouveau-nés garder? quels nouveau-nés transférer?

Per-partum anoxia is a frequent situation facing the pediatrician in the maternity ward. The question is to decide which infants require care in a specialized unit. If transfer is decided, the infant must be referred to an appropriate pediatric unit (intensive care or neonatal unit). Cases of severe anoxia are exceptional. Intermediary situations are however much more frequent and raise difficult evaluation problems due to the lack of any specific test. The pediatrician must rely on a combination of elements from the clinical presentation, the medical history, the clinical course, and laboratory tests. Different elements suggest a prudent approach with referral to a pediatric unit. These elements include: imperfect clinical recovery (5-min Agpar <7), major intensive care at delivery (intubation, ventilation, vasoactive agents), anomalies in the cord blood or first hour blood tests (cord pH<7, base deficit 12, cord or blood lactate 9 mmol/l). Obstetrical circumstances which led to per-partum anoxia must be well identified because those interrupting placental flow (abruptio placenta, uterine rupture) suggest prudence is necessary even if the infant appears to have recovered well. All neonatal disorders (macrosomia, prematurity, infection, respiratory distress) increase the risk of rapid decompensation and may argue for hospitalization. Likewise, if even minimal signs of neurological, respiratory or hemodynamic disorders are present from birth to two hours, surveillance in a specialized unit is required, the level depending on local facilities. Certain situations nevertheless always require referral to a pediatric intensive care unit: use of vasoactive drugs, respiratory distress, abnormal neurological exam, poor recovery (5-min Agpar <4).Finally, it must be remembered that per-partum anoxia is rarely predictable and can occur any at any time of day or night. The pediatrician must also train other delivery room personnel, including the midwives, in intensive care techniques.

[Has the obligation to inform patients changed our mode of practice?]. / L'information du patient a-t-elle modifié notre comportement?

From January 2000, the Council of State has harmonised the jurisprudence with the Court of Appeal, changing the responsibility of medical practitioners by requiring them to provide proof that information was both given and understood by their patients. This obligation to inform patients raises several questions: who should give the information? to whom should the information be addressed? how can proof of this information be provided? what should the information be? The authors sent a questionnaire to practicing cardiologists by the internet site of the French Society of Cardiology from the 1st December 2002 to 15th January 2003. Three hundred and thirty-two replies were received of which 305 could be exploited. The activities of the cardiologists who replied were mainly in public hospitals (51.8%), private (18.2%) or mixed (30%). Patient information was mainly performed before invasive procedures, especially coronary angiography (90%) or cardiac pacing (77.3%). On the other hand, it was less commonly undertaken before exercise stress tests (63.2%) or transoesophageal echocardiography (61.4%), although these percentages are much higher than those recorded during previous enquiries in 2000 and 2001. The information given was, in the large majority of cases, that proposed by the French Society of Cardiology and it was usually the practitioner who ordered the investigation who informed the patient (45.4%). In 2002, the role of the nurse was much greater as the nurse informed the patient in 27.2% of cases. The patient was generally given the information the day before the procedure was carried out (74.1%) with complementary information (90.7%), and less than 1% of patients declined the investigation under these conditions. In order to provide proof of patient information, the practitioner usually required the patient's signature (58.3% of cases); less commonly, the referring physician was informed by letter (13.9% of cases) or a note was made in the patient's file (33.9% of cases). The new requirements for patient information have changed medical practice in nearly 53.5% of cases. Finally, although patient information is considered to be part of the normal patient-doctor relationship in most cases (42.7%), doctors thought that patients interpreted this procedure as a cover for the medical team in 18.2% of cases. The information bases most commonly used to determine the methods of informing patients and the nature of the information to be provided were medical reviews (38.9%) or the internet (30.5%). The authors conclude that patient information is carried out before complementary cardiological investigations. The new laws of the Code of Public Health are not well known. Finally, the proof of patient information is not easily provided and the majority of cardiologists request written patient consent, which is not a legal requirement.

[Patient information and the cardiologist]. / L'information du patient et le cardiologue.

AIM OF THE STUDY: The patient's information prior to paraclinical testings is a part of the medical deontology and takes on increasing legal importance since new laws. METHODS: From December 2001 to January 2002, we administered to cardiologists through the website of the French Society of Cardiology a questionnaire in order to determine the way the information is dispensed to patients and to compare the results to the survey performed in 2000. RESULTS: Among the 293 answers obtained, 243 were utilizable. The answers were obtained from cardiologists working on private medicine (27.5%), public medicine (52.8%) or mixed (19.7%). Information was more frequently dispensed for invasive procedures: coronary angiography (92.2%), cardiac pacing (76.8%) than non invasive assessments: transesophageal echocardiography (47.6%) and treadmill test (44.7%). The most frequent information document given to patients was the one edited by the French Society of Cardiology (71.6%). In the great majority of cases, there is the prescribing cardiologist (35.9%) and/or the one performing the assessment who dispenses the information, generally the day prior the examination (73.5%) with additive explanations (91.4%). Few patients refuse the examination after information. The situation where the assessment is performed on a patient without the faculty of understanding modalities and the necessity of that examination is in emergency (45%). In 63.4% of cases, the cardiologist requires the patients signature on the information document. CONCLUSION: Information dispensation prior to an examination is generally well done by cardiologists. The evidence of the information's dispensation is not at ease and most of cardiologists require written document from their patients, which is not legally necessary.

[Patient information. First evaluation]. / L'information au patient. Premier bilan.

The recent harmonisation of the jurisprudence between the Court of Appeal and State Council has affected medical responsibility because it is now the physician's obligation to prove that the information to the patient has been properly given: it is, therefore, a current issue. A first evaluation was undertaken to determine the modalities of patient information in cardiology by an enquiry of cardiologists working in the public and private sectors. The results show that information to patients was given concerning complementary investigations such as exercise stress testing, transoesophageal echocardiography, coronary angiography and cardiac pacing; the information was more often given for invasive procedures. In the great majority of cases (92%), it is the prescribing or operating physician who gives this information, usually the day before the procedure, with complementary oral explanations in about 90% of cases. Patient information, therefore, seems to be well done by cardiologists. However, the proof of information is not always easy, written consent, signed by the patient, not being compulsory at present.

Fetal magnetic resonance imaging (MRI) of ischemic brain injury.

The aim of the present study was to demonstrate the usefulness of fetal magnetic resonance imaging (MRI) in ischemic brain injury. We report seven cases of fetal brain ischemia prenatally suspected on ultrasound (US) and confirmed by fetal MRI. Sonographic abnormalities included ventricular dilatation (n=3), microcephaly (n=1), twin pregnancy with in utero death of a twin and suspected cerebral lesion in the surviving co-twin (n=3). MRI was performed with a 1.0 T unit using half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequences between 28 and 35 weeks of gestation. US and MRI images were compared with pathologic findings or postnatal imaging. MRI diagnosed hydranencephaly (n=1), porencephaly (n=2), multicystic encephalomalacia (n=2), unilateral capsular ischemia (n=1), corpus callosum and cerebral atrophy (n=1). In comparison with US, visualization of fetal brain anomalies was superior with MRI. The present cases demonstrate that MRI is a valuable complementary means of investigation when a brain pathology is discovered or suspected during prenatal US.

[Myocardial bridge: description, significance, treatment]. / Pont myocardique description, signification, traitement.

The myocardial bridge is a well known anomalous trajectory of the coronary arteries, the significance of which has been discussed for a long time. It now appears that some myocardial bridges may cause myocardial ischaemia with clinical electrocardiographic, scintigraphic or metabolic signs--even myocardial infarction or sudden death. In these symptomatic cases, treatment is usually medical and rarely surgical. In the last few years, angioplasty and stenting have been used more frequently in cases resistant to medical therapy and appear to be an effective alternative to surgery.

[Mechanical and functional predictive factors for restenosis and arterial remodeling after experimental angioplasty]. / Facteurs prédictifs mécaniques et fonctionnels de la resténose et du remodelage artériel après angioplastie expérimentale.

Arterial remodelling plays an important part in post-angioplasty restenosis but the physiopathology of this process is not fully understood. Abundant collagen synthesis and endothelial dysfunction have been demonstrated after angioplasty, but their role in restenosis and remodelling has not been studied. The aim of this study was therefore to assess endothelial function and collagen with respect to the severity of restenosis and the type of arterial remodelling. Atherosclerosis was induced by an association of endothelial abrasion and a high cholesterol diet in the femoral arteries of 22 white New Zealand rabbits. Four weeks later, angioplasty was performed. The acetylcholine endothelium-dependant vasomotricity (expressed as % inhibition of contraction to phenylephrine), collagen and morphology were assessed 28 days after angioplasty. The change in acetylcholine endothelium-dependant vasomotricity was greater in severe restenosis (r = 0.61, p = 0.02). Endothelium-dependant relaxation was not significantly altered when remodelling was expansive and very abnormal when it was constrictive (35.5 +/- 13.0 vs 3.7 +/- 7.9%; p = 0.04). Restenosis was associated with an increase in collagen (r = 0.69, p = 0.004). The density of collagen was significantly higher in constrictive remodelling than in expansive remodelling (34.5 +/- 4.5 vs 18.2 +/- 4.7%; p = 0.03). Endothelial dysfunction and collagen accumulation are correlated with the severity of restenosis and with constrictive remodelling after angioplasty in an experimental model.

Angiotensin-converting enzyme inhibitor therapy improves respiratory muscle strength in patients with heart failure.

STUDY OBJECTIVES: Respiratory muscle strength has been shown to be reduced in patients with chronic heart failure. The purpose of this prospective study was to determine whether long-term therapy with the angiotensin-converting enzyme (ACE) inhibitor perindopril improves respiratory muscle strength in patients with chronic heart failure. PATIENTS AND METHODS: Eighteen patients with stable chronic heart failure were administered perindopril, 4 mg/d, in addition to their standard therapy for a period of 6 months. Fourteen patients completed the study. Maximum inspiratory pressure (PImax) and maximum expiratory pressure (PEmax) expressed in percentage of predicted values, left ventricular ejection fraction (LVEF) determined by means of two-dimensional echocardiography, and pulmonary volumes were obtained before and after therapy. MEASUREMENTS AND RESULTS: As compared to baseline, there was a significant increase in both PImax and PEmax after therapy (57 +/- 27% predicted vs 78 +/- 36% predicted and 62 +/- 20% predicted vs 73 +/- 15% predicted, respectively; each p < 0.05). LVEF increased (34 +/- 5% vs 41 +/- 10%; p < 0.05); functional class improved by > or = 1 New York Heart Association (NYHA) class in five patients. There were no changes in pulmonary volumes. No correlation was found between changes in PImax and PEmax and changes in either LVEF or NYHA functional class. CONCLUSIONS: In patients with chronic heart failure, long-term therapy with the ACE inhibitor perindopril improved respiratory muscle strength, as indicated by significant increases in PImax and PEmax.

Resting heart rate as a predictive risk factor for sudden death in middle-aged men.

OBJECTIVE: A relative hyperadrenergic tone related to abnormalities of the autonomic nervous system is suspected in the mechanisms of sudden death. Therefore, we assessed the role of an elevated basal heart rate in the occurrence of sudden death in a long-term cohort study. METHODS: 7746 subjects aged 42--53 years, underwent ECG and physical examination conducted by a physician under standardized conditions, provided blood samples for laboratory tests, and answered questionnaires administered by trained interviewers. The vital status was obtained from specific inquiries up to the time of retirement and then by death certificates. Men with known ischemic heart disease were further excluded from analysis which was conducted on the 7079 remaining subjects. RESULTS: After an average follow-up period of 23 years, there were 2083 deaths, among which were 603 cardiovascular deaths including 118 sudden deaths and 192 following myocardial infarction. The crude risk of sudden death increased linearly with the level of resting heart rate and the risk in men in the highest quintile of heart rate was 3.8 fold than in those in the lowest quintile, whereas rates were approximatively twice higher for fatal myocardial infarction, cardiovascular and total mortality (all P<0.01). When age, body mass index, systolic blood pressure, tobacco consumption, parental history of myocardial infarction and parental history of sudden death, cholesterol level, diabetic status, and sport activity were simultaneously entered into the survival model, resting heart rate remained an independent risk factor for sudden death (P=0.03) but not for fatal myocardial infarction. CONCLUSION: An elevated heart rate at rest was confirmed as an independent risk factor for sudden death in middle-aged men.

[Physical reproduction of cardiac sutures. A new field of investigation in cardiology]. / Reproduction physique des structures cardiaques. Une nouvelle voie d'exploration en cardiologie.

A new technique of physical reproduction of cardiac anatomy has been developed from volumetric data and its practical value assessed in cardiological practice. The acquisition of the volumetric data was by 3D echocardiography. Parallel and equidistant 2D views were selected from this information. The images were printed at a scale adjusted to the true dimensions of the structures of interest and then stuck on a support, the thickness of which was identical to the distance between the views, and the slices were superimposed while respecting the initial orientation. This technique has been adapted secondarily to modern industrial processes of rapid prototyping (3D printing and powdering) allowing automatic tooling of models. Several physical models have been made: whole heart in end diastole, mitral valve stenosis and prolapse, atrial septal defect with insertion of a percutaneous prosthetic device, great vessels at the base of the heart. There are many possible cardiological applications of physical models: investigation of complex cardiac disease, pre- and per-operative simulation of surgical procedures, elaboration of prosthetic material, physiopathological studies, teaching and training, patient information.

[Three-dimensional echocardiography: methodology trial]. / Echocardiographie tridimensionnelle: essai de méthodologie.

A method has been developed for systematic and reproducible exploration by three-dimensional echocardiography. An associated technical terminology has also been introduced, and the application principles have been examined together with a number of useful clinical examples. After a period of technical and clinical validation, three-dimensional echocardiography has now entered the stage of practical clinical application, in particular for mitral valve disorders and intraauricular communications. The methodology that has been proposed is intended to provide user training, facilitate communication with teams working in the field, and also between echography operators and surgeons, and catheter or clinical staff.

Endothelial dysfunction and collagen accumulation: two independent factors for restenosis and constrictive remodeling after experimental angioplasty.

BACKGROUND: Constrictive remodeling plays a prominent role in restenosis after balloon angioplasty, but its regulation remains unclear. Because endothelial dysfunction and changes in extracellular matrix have been reported after angioplasty, this study was designed to simultaneously evaluate endothelial function and collagen and elastin changes after restenosis and arterial remodeling. METHODS AND RESULTS: Atherosclerosis was induced in femoral arteries of 22 New Zealand White rabbits by air-desiccation and a high-cholesterol diet. One month later, angioplasty was performed. Histomorphometry and in vitro assessment of endothelial function were performed 4 weeks after angioplasty. Restenosis correlated with constrictive remodeling (r=0.60, P=0.01) but not with neointimal growth (r=-0.06, P=0.79). Restenosis correlated with an impaired relaxation to acetylcholine (ACh; r=0.61, P=0.02) but not with the response to the endothelium-independent vasodilator sodium nitroprusside (r=-0.25, P=0.40). Restenosis correlated positively with collagen accumulation (r=0.69, P=0.004) and inversely with elastin density (r=-0.48, P=0.05). Relaxations to ACh were significantly more decreased in arteries with constrictive remodeling than in those with enlargement remodeling (3.7+/-7.9% versus 35.5+/-15.0%, P=0.04). Neointimal collagen density was significantly higher in arteries with constrictive remodeling than in those with enlargement remodeling (34.5+/-4.5% versus 18.2+/-4.7%, P=0.03). Endothelial function and collagen and elastin density were independent predictors of restenosis in the study. CONCLUSIONS: These results demonstrate that the severity of restenosis after angioplasty correlated with both defective endothelium-dependent relaxation and increased collagen density.

Idiopathic atrial fibrillation as a risk factor for mortality. The Paris Prospective Study I.

AIMS: Idiopathic atrial fibrillation describes atrial fibrillation of unknown origin occurring without heart disease. Mortality is considered unaffected by idiopathic atrial fibrillation. We used the long follow-up period (23 years on average) of the Paris Prospective Study I to assess the mortality of idiopathic atrial fibrillation subjects in middle-aged men. METHODS: 7746 working Frenchmen, aged 43-52 in 1967-72, underwent a physical examination plus ECG, answered questionnaires, and provided blood samples. Strict exclusion criteria were used to select idiopathic atrial fibrillation only, and men with known cardiac disease were further excluded from analysis. At 1 January 1994, vital status was unknown for 4.6% of the subjects. The analysis was conducted on the 6722 remaining subjects. RESULTS: Twenty-five subjects had idiopathic atrial fibrillation at inclusion. The relative risk (and 95% confidence interval) associated with idiopathic atrial fibrillation was 4.22 [2.10-8.47] for cardiovascular mortality (P=0.0001) and 1. 97 [1.14-3.40] for total mortality (P=0.01). When age, systolic blood pressure, cholesterol, body mass index and tobacco consumption were entered into a Cox model, idiopathic atrial fibrillation remained an independent risk factor for cardiovascular (P=0.0008) and total death (P=0.04). CONCLUSION: With a long follow-up period, idiopathic atrial fibrillation was associated with higher mortality in middle aged Frenchmen.

Predicting sudden death in the population: the Paris Prospective Study I.

BACKGROUND: Sudden death was found to share the same set of usual risk factors as coronary events and therefore could not be specifically predicted in the population. It appears, however, that parental history of sudden death has not been investigated yet as a risk factor for sudden death. Therefore, we assessed risk factors, including parental sudden death, associated with the occurrence of sudden death in a long-term cohort study. METHODS AND RESULTS: We included 7746 men employed by the city of Paris who were 43 to 52 years of age in 1967 to 1972 in the Paris Prospective Study I. Each subject underwent a physical examination and an ECG, provided blood for laboratory tests, and answered questionnaires administered by trained interviewers who paid particular attention to family medical history. Men with known ischemic cardiac disease were further excluded from analysis. For 95.5% of the men, vital status was obtained from specific inquiries until retirement, then by death certificates. Resting heart rate, systolic or diastolic blood pressure, tobacco consumption, body mass index, diabetes status, serum cholesterol, and parental history of sudden death were independent factors associated with sudden death during follow-up (23 years on average). When adjusted for confounding variables, including parental history of myocardial infarction, relative risk of sudden death associated with parental sudden death was 1.80 (95% CI, 1.11 to 2.88). CONCLUSIONS: Parental sudden death is an independent risk factor for sudden death in middle-aged men. The existence of familial risk factors for sudden death may help provide better identification of subjects at high risk of and early prevention of sudden death.