[Pre-operative cardiac assessment in non-cardiac surgery: a frequent dilemma simplified by a decision tree]. / Evaluation cardiologique préopératoire avant chirurgie non cardiaque: du choix cornélien a l'arbre décisionnel.

In patients undergoing non-cardiac surgery, cardiac events are the most common cause of perioperative morbidity and mortality. It is often difficult to choose adequate cardiologic examinations before surgery. This paper, inspired by the guidelines of the European and American societies of cardiology (ESC, AHA, ACC), discusses the place of standard ECG, echocardiography, treadmill or bicycle ergometer and pharmacological stress testing in preoperative evaluations. The role of coronary angiography and prophylactic revascularization will also be discussed. Finally, we provide a decision tree which will be helpful to both general practitioners and specialists.

[Preoperative cardiac assessment before non-cardiac surgery: cardiac risk stratification]. / Evaluation cardiologique préopératoire avant chirurgie non cardiaque: stratification du risque cardiovasculaire.

Perioperative cardiac events occurring in patients undergoing non-cardiac surgery are a common cause of morbidity and mortality. Current guidelines recommend an individualized approach to preoperative cardiac risk stratification prior to non-cardiac surgery, integrating risk factors both for the patient (active cardiac conditions, clinical risk factors, functional capacity) and for the planned surgery. Preoperative cardiac investigations are currently limited to high-risk patients in whom they may contribute to modify the perioperative management. A multidisciplinary approach to such patients, integrating the general practitioner, is recommended in order to define an individualized peri-operative strategy.

[Sudden cardiac death: epidemiology and modern therapy]. / La mort subite: de l' épidémiologie à la prévention.

Sudden Cardiac Death (SCD) has become an important public health challenge in the Western World. In Switzerland near 10,000 people suffer each year from SCD. The survival from SCD to hospital discharge is discouraging (near 5%). Large majority of events occur unexpectedly in the out-of-hospital environment and are not predicted with great accuracy by risk profiling. Because the majority of SCD occur by the mechanism of ventricular fibrillation, community-based defibrillation strategies have emerged as one approach to SCD problem. Newer strategies of defibrillation designed to respond faster to out-of-hospital cardiac arrest, including public access defibrillation, as well as aggressive primary and secondary prevention of coronary artery disease appears as the best approach for successful management of SCD.

Prospective survey of parenteral nutrition in Switzerland: a three-year nation-wide survey.

BACKGROUND AND AIMS: The goals of this national survey were to determine the current PN practices and admixture formulations used in Switzerland. METHODS: During three years, an annual questionnaire was sent to all heads of Swiss hospital pharmacies. RESULTS: 92% of Swiss hospitals with a full-time pharmacist participated. Different PN systems were commonly used for adult patients: 2 commercial formulas in 2 or 3 compartments bags, 2 commercial formulas with/without lipid, 3 formulas compounded by the hospital pharmacy. For hospitalized adults, 83% of PN bags were administered as commercial multicompartment bags. The compounding of individualized PN admixtures takes place primarily in pharmacies of medium to large size hospitals. For pediatric PN, hospital compounding is routine because of individualized PN compositions and absence of commercially available standardized admixtures. Long-term home-PN was mostly delivered by hospital pharmacies (57%) or by private nutrition support home delivery services (37%). Most PN formula compositions complied with European guidelines and represented 2.6+/-2.0% of the hospital drug budget. Multi-disciplinary nutritional support teams were present in 52% of hospitals. CONCLUSION: In Switzerland, most PN for hospitalized adults were administered as commercial multi-compartment bags. The compounding of individualized PN admixtures were still important for pediatric patients and long-term home-PN.

Economic investigation of the use of three-compartment total parenteral nutrition bag: prospective randomized unblinded controlled study.

Optimal strategy for total parenteral nutrition (TPN) administration is essential both in terms of clinical effectiveness and economic efficiency. The aim of the present economic analysis was to provide a systematic and comprehensive cost comparison of the application of three currently available TPN systems: Separate Bottles (SB), Hospital-Compounded Bags (HCB) and Three-Compartment Bags (TCB). Sixty patients, admitted to the Geneva University Hospital and requiring TPN, were randomly assigned to one of the three systems. Three standard TPN formulas were prescribed to meet the patients' protein energy needs. TPN-related activities of medical, nursing and pharmacy staff were timed for the 24 hours of TPN administration. Manpower, nutrient solutions and medical supplies costs were calculated on the basis of mean Swiss salaries and hospital prices. TCB was the least expensive TPN system. SB and HCB systems' application costs were 120 and 150% of TCB cost, respectively. All intersystems cost comparisons were statistically significant (ANOVA p < or = 0.01). SB system required more items and manipulations, resulting in higher nurses manpower cost. Pharmacy overhead cost due to compounding was responsible for the higher cost of HCB system. Detailed manpower data presented in this study allow for an estimation of TPN application costs in other hospitals, using local salaries, specific product prices and compounding costs.

[Recurrent severe lower gastrointestinal hemorrhage. Acute recurrent diverticulum hemorrhage in the cecum]. / Rezidivierende schwere untere Gastrointestinalblutung. Akute rezidivierende Divertikelblutung im Coecum.

This 83-year-old patient was admitted to the emergency room after a sudden and abundant rectal bleeding without any other abdominal symptoms. The physical examination showed normal abdominal findings. However, digital rectal examination revealed dark red blood. Upper and lower endoscopic examination did not show an active bleeding source. A diagnosis of an acute lower gastrointestinal bleeding probably originating from a diverticulum was made. The patient was dismissed two days later without any signs of further bleeding. However, the same day he was readmitted again because of acute rebleeding. Emergency colonoscopy was not conclusive because of massive hemorrhage. Angiography of the abdominal arteries was performed which showed marked active bleeding in the coecal region. Ileocoecal resection was performed and histopathological examination showed a solitary coecal diverticulum.

Effects of muscarinic agonists and depolarizing agents on inositol monophosphate accumulation in the rabbit vagus nerve.

The effects of muscarinic agonists and depolarizing agents on inositol phospholipid hydrolysis in the rabbit vagus nerve were assessed by the measurement of [3H]inositol monophosphate production in nerves that had been preincubated with [3H]inositol. After 1 h of drug action, carbachol, oxotremorine, and arecoline increased the inositol monophosphate accumulation, though the maximal increase induced by these agonists differed. Addition of the muscarinic antagonists atropine or pirenzepine shifted the carbachol dose-response curves to the right, without decreasing the carbachol maximal stimulatory effects. The KB for pirenzepine was 35 nM, which is characteristic of muscarinic high-affinity binding sites coupled to phosphoinositide turnover and often associated with the M1 receptor subtype. On the other hand, agents known to depolarize or to increase the intracellular Ca2+ concentration, e.g., elevated extracellular K+, ouabain, Ca2+, and the Ca2+ ionophore A23187, also increased inositol monophosphate accumulation. These effects were not mediated by the release of acetylcholine, as suggested by the fact that they could not be potentiated by the addition of physostigmine nor inhibited by the addition of atropine. The Ca(2+)-channel antagonist Cd2+, also known to inhibit the Na+/Ca2+ exchanger, was able to block the effects of K+ and ouabain, but did not alter those of carbachol. These results suggest that depolarizing agents increase inositol monophosphate accumulation in part through elevation of the intracellular Ca2+ concentration and that muscarinic receptors coupled to phosphoinositide turnover are present along the trunk of the rabbit vagus nerve.