10 plantes de chez nous / 10 domestic plants

Dix cas cliniques succincts presentes a la Societe Royale Belge d'Homeopathie avec une etude repertoriale et de la matiere medicale pour chacun des remedes

Digitalis enfant / Digitalis enfant

Si vous étiez un nain ou un elfe, n'auriez-vous pas choisi une des multiples excroissances florales qui habille la tige de Digitale, pour vous en faire un bonnet, non pas pointu comme celui de Lerlin, mais cassé à sa pointe, à la... (AU)

Impaired cardiac adrenergic innervation assessed by MIBG imaging as a predictor of treatment response in childhood dilated cardiomyopathy.

OBJECTIVE: To evaluate the prognostic value of metaiodobenzylguanidine (MIBG) imaging in childhood cardiomyopathy. DESIGN: Prospective cohort study. SETTING: Tertiary referral centre. PATIENTS: 40 children (21 boys, 19 girls; mean (SD) age, 7.0 (5.6) years) with heart failure resulting from idiopathic dilated cardiomyopathy (n = 23) or various other disorders (n = 17). METHODS: At the initial examination, cardiac (123)I-MIBG uptake and release, circulating noradrenaline (norepinephrine) concentration, x ray cardiothoracic ratio, and echocardiographic variables were recorded. Cardiac MIBG uptake was obtained by measuring the heart to mediastinum activity ratio on the planar image obtained four hours after MIBG injection. MIBG washout rate was evaluated using relative decrease in cardiac activity measured at 20 minutes and four hours. Patients were treated with angiotensin converting enzyme inhibitors, diuretics, and digitalis, and were followed up for 12 (10) months. Fifteen patients did not respond to medical treatment (12 heart transplants; three deaths), and 25 did respond (improved or stable). RESULTS: Cardiac MIBG uptake was positively correlated with x ray cardiothoracic index (r = 0.55, p = 0.0008) and echocardiographic left ventricular fractional shortening (r = 0.68, p < 0.0001). Among all the clinical and laboratory variables tested, multivariate discriminant analysis showed that the only independent predictor of an unfavourable outcome was a low MIBG uptake (p < 0.001). Survival curves had a mean threshold value of 1.54 for MIBG uptake. CONCLUSIONS: Impaired cardiac adrenergic innervation is strongly related to adverse outcome in children with dilated cardiomyopathy, independently of the aetiology. MIBG imaging may help to stratify risk in such patients.

Treatment at discharge after myocardial infarction in 2,102 patients. The PRIMA study. Prise en charge de l'Infarctus du Myocarde Aigu.

OBJECTIVE: This study sought to examine the use of treatments at discharge in patients hospitalized for myocardial infarction in a French region. METHODS AND RESULTS: Data from 2,102 patients discharged after myocardial infarction were prospectively collected at 48 university, community, and private hospitals in three departments in the Rh ne-Alpes region between September 1, 1993 and January 31, 1995. Beta-blockers were prescribed in 59% of the patients, calcium channel blockers in 22%, nitrates in 59%, antiplatelet agents in 82%, anticoagulants in 26%, angiotensin-converting enzyme inhibitors in 36%, diuretics in 33%. Beta-blockers were prescribed less often in older patients, and in patients with higher Killip classes or a history of pulmonary disease. Calcium channel blockers were prescribed more often in older patients, and in patients with a history of diabetes, pulmonary disease, or non-Q wave myocardial infarction. Nitrates were prescribed more often in older patients. Angiotensin-converting enzyme inhibitors were prescribed more often in patients with a history of diabetes, hypertension, or anterior myocardial infarction, and less often in patients with a history of renal failure. Diuretics were prescribed more often in older patients, and in patients with a history of renal failure, diabetes, hypertension, or higher Killip classes. CONCLUSIONS: There is still underuse of beneficial treatments, particularly in elderly patients.

The old but reliable digitalis: persistent concerns and expanded indications.

Digitalis has been an old but reliable drug for 240 years. Concerns regarding its clinical indications and benefits still exist in the absence of a reduction in all-cause mortality. While intravenous digitalis is used without question in cases of atrial fibrillation, it is still controversial in sinus rhythm, despite the Digitalis Investigation Group (DIG) study showing a significant reduction in death and the need for hospitalisation for congestive heart failure in both diastolic and systolic dysfunction. The influence of digitalis in acute myocardial infarction, coronary artery disease and sudden cardiac death remains speculative. In cases of uncomplicated hypertension, it appears to prevent the onset of left ventricular dysfunction and myocardial infarction. Thus, digitalis can be a cost-effective agent with added benefits.

[Symptoms of primary endocardial fibroelastosis in a young adult]. / Symptomatik der primären Endokardfibroelastose im Erwachsenenalter.

HISTORY AND ADMISSION FINDINGS: A 21-year-old woman with known endocardial fibroelastosis diagnosed when aged 3 months was admitted because of progressive dyspnoea. The physical examination revealed symptoms of heart failure, with pulmonary rales, mild hepatomegaly, and tachyarrhythmia. INVESTIGATIONS: The electrocardiogram showed atrial fibrillation, complete right bundle branch block and right ventricular hypertrophy. Echocardiography indicated hypertrophy and dilatation of the right ventricle (61 mm) with tricuspid regurgitation and hypoplasia of the left ventricle. Heart catheterization confirmed pulmonary hypertension (60/46 mmHg) as well as dilatation and hypokinesia of the right ventricle. Right ventricular biopsy showed severe myocardial hypertrophy resulting from secondary pulmonary hypertension, while no evidence of myocarditis or idiopathic dilated cardiomyopathy was found. TREATMENT AND COURSE: Symptoms of heart failure improved under medical treatment with digitalis, angiotensin-converting enzyme inhibitor and diuretics. CONCLUSION: Primary endocardial fibroelastosis of the contracted type must be included in the differential diagnosis of heart failure occurring in young adults.

[Economic study of carvedilol in heart failure. A cost effectiveness study in France]. / Etude économique du carvédilol dans l'insuffisance cardiaque. Une étude coût-efficacité appliquée à la France.

A programme of four phase III clinical trials carried out in the USA on 1094 patients showed that Carvedilol, associated with the usual bitherapy and eventually with digitalis, reduced the mortality and number of hospital admissions of patients with cardiac failure. These results, transposed to the French population, may be used to evaluate the economic advantages of Carvedilol by developing a cost-effectiveness study which consists in relating the direct expenses (drugs and hospital admissions) of each of the two strategies, with or without Carvedilol, to their respective mortalities. Hospital expenses were estimated with respect to the H.M.G. corresponding to each hospital stay at 1997-1998 values. The cost in the Carvedilol group was 2,823 FF per patient (including 1,491 FF for the drug itself) but 2,056 FF were economised in hospital expenses. With an increased cost of 767 FF but a 50% reduction in mortality corresponding to a difference in mortality of 45@1000, the cost-effectiveness of Carvedilol was 17,040 per life saved and 2,130 FF per additional year of life expectancy. A study of the sensitivity produced even more favourable results of Carvedilol. An evaluation of hospital expenses on the basis of AP-HP data indicates that the addition of Carvedilol is associated with a 4,425 FF reduction in hospital expenses, which makes it a cost saving strategy.

[Digitalic therapy. Historical outline]. / Acerca de la terapéutica digitálica. Bosquejo histórico.

The action of medical drugs obtained from many vegetables aroused a great interest of naturalists and physicians in all time. Moreover, it was always required that those persons destined to medical practice have a good knowledge of botany. Among the medicinal plants utilized by ancient peoples of the Anahuac, yoloxochitl or heart flower (Talauma mexicana) is mentioned, which seems to have a digitalis-like action. Research in our century demonstrated a positive inotropic and bradycardic effect of the leavels of Magnolia grandiflora or Talauma mexicana extract. Since the end of the XVIII century, digitalis was employed. It was considered initially as a diuretic and later as a cardiotonic agent. The action of digitalic glycosides upon the cardiac tissues was studied experimentally in Mexico. At the present-time there are positive inotropic agents derived from pyridine, as is the case of Milrinone, which have a beneficial action on the failing human myocardium. However, following the opinion of distinguished pharmacologists, "in the case of heart failure associated to atrial fibrillation, digitalis cannot be substituted".

[Nutritional myocardial disorders].

It is well known that the nutritional deficiency possibly causes cardiac dysfunction. Although social hygiene has successfully diminished these cardiac dysfunction in developed countries, patients could be found in certain number under altered clinical profiles than before. Excess intake of carbohydrate drinks and carbohydrates should make beri-beri heart in youth. Not only deficiency but recent dietary habits of excessive nutrition in these developed countries are causing new types of nutritional cardiac dysfunctions such as obesity cardiomyopathy in morbid obese. On the other hand, anorexia nervosa which sometimes shows heart failure and sudden death combines with psychosomatic disorders. In this article, the pathogenesis and treatments are discussed focusing on these three cardiac disorders.

Segmental degradation of left ventricular wall motion after persistent coronary fistula in a posttransplantation patient: a case report and short review of literature.

A 50-year-old man received an orthotopic heart transplant because of severe coronary heart disease and congestive heart failure. Two years after the transplantation, a continuous murmur occurred at the left sternal edge after repeated endomyocardial biopsies. Echocardiography and coronary angiography revealed a dilated left anterior descending artery with a fistula to the right ventricle. The circumflex was large with an equally postero-lateral branch, and the right coronary artery was rather small with collaterals to the distal part of the left anterior descending branch. The patient had refused any intervention to close the fistula. The left ventricular levogram was normal. Two years later, in a follow-up angiogram, the left ventricular ejection fraction had decreased as a result of hypo- and akinesis of the apex and posterior wall. We suggest that this local wall motion disturbance derives from a steal phenomenon rather than being a sequela of rejection. The decrease in left ventricular ejection fraction was associated with shortness of breath upon moderate exercise. Standard heart failure medication relieved the patient's symptoms. The observation of local wall motion disturbances in this case, as well as conflicting views in the literature, raises the question whether postbiopsy coronary fistulas in transplant patients should be closed.

Effect of beta-blocker on left ventricular function and natriuretic peptides in patients with chronic heart failure treated with angiotensin-converting enzyme inhibitor.

To evaluate whether or not beta-blockers can improve the condition of patients with heart failure treated with a combination of diuretics, digitalis and angiotensin-converting enzyme inhibitor (ACEI), 52 patients with chronic heart failure who have been treated with ACEI for more than 6 months were enrolled. They were divided into 2 groups: 26 patients continued the same therapy another 6 months or more (group A), and 26 patients were given oral metoprolol for 6 months or more, in addition to the ACEI (group B). Echocardiographic parameters and atrial and brain natriuretic peptides (ANP, BNP) were measured. The left ventricular dimensions at end-diastole and end-systole were significantly decreased and fractional shortening was significantly increased in group B after 6 months' treatment with the beta-blocker, but these parameters remained unchanged in group A. Plasma levels of both ANP and BNP were significantly decreased in group B, but remained unchanged in group A. These results indicate that concomitant beta-blocker therapy can improve left ventricular function and attenuate plasma ANP and BNP levels in patients with chronic heart failure treated with ACEI.

Magnesium supplementation in the prevention of arrhythmias in pediatric patients undergoing surgery for congenital heart defects.

BACKGROUND: The efficacy of magnesium in the prevention of arrhythmias in pediatric patients after heart surgery remains unknown. Therefore we prospectively examined the effect of magnesium treatment on the incidence of postoperative arrhythmias in pediatric patients undergoing surgical repair of congenital heart defects. METHODS AND RESULTS: Twenty-eight pediatric patients undergoing heart surgery with cardiopulmonary bypass were prospectively, randomly assigned in a double-blind fashion to receive intravenous magnesium (magnesium group, n = 13; 30 mg/kg) or saline (placebo group, n = 15) immediately after cessation of cardiopulmonary bypass. Magnesium, potassium, and calcium levels were measured at defined intervals during surgery and 24 hours after surgery. Continuous electrocardiographic documentation by Holter monitor was performed for 24 hours after surgery. Magnesium levels were significantly decreased below the normal reference range for patients in the placebo group compared with the magnesium group on arrival in the intensive care unit and for 20 hours after surgery. Magnesium levels remained in the normal range for patients in the magnesium group after magnesium supplementation. In 4 patients in the placebo group (27%), junctional ectopic tachycardia developed within the initial 20 hours in the intensive care unit. No junctional ectopic tachycardia was observed in the magnesium group (P =.026). CONCLUSIONS: Although this study was originally targeted to include 100 patients, the protocol was terminated because of the unacceptable incidence of hemodynamically significant junctional ectopic tachycardia that was present in the placebo group. Thus low magnesium levels in pediatric patients undergoing heart surgery are associated with an increased incidence of junctional ectopic tachycardia in the immediate postoperative period.

[Do cytokines have any value in the patients with chronic blood circulation insufficiency?]. / Czy cytokiny maja znaczenie u chorych na przewlekla zastoinowa niewydolnosc krazenia?

Heart failure is a common and increasing public problem. Neurohormonal activation plays a role in the pathophysiology of heart failure, but is probably also affected by cytokines. We studied 75 patients with heart failure NYHA functional class II and III-IV, who were treated with angiotensin converting enzyme inhibitor (enarenal), diuretics (furosemide) and digoxine. Their mean age was 63.9 years/range 65-86/, left ventricular ejection fraction in the patients NYHA functional class II and III-IV classes was 68.9% and 47.3% respectively; 12 were females. Significant improvements in NYHA classification were shown. The levels plasma TNF-alpha (tumor necrosis factor-alpha) and interleukin-6 (IL-6) were analysed before and after therapy. The authors showed increased plasma levels TNF-alpha and IL-6 in patients with chronic heart failure. After the treatment the plasma IL-6 levels decreased only in the patients III-IV NYHA functional classes, whereas the treatment had no effect on the plasma TNF-alpha levels.

Symptomatic systolic ventricular failure.

Over the past 20 to 30 years there have been significant advances in the management of heart failure related to improved understanding of pathophysiology, better methods of assessment, and improved drug treatments. The aims of treatment have broadened, with increased emphasis on earlier intervention. Clinical research activity in this area has been considerable, increasingly allowing an evidence-based approach to management. Most earlier trials of treatment were relatively short-term, small-group studies with various clinical end points, including severity of symptoms, exercise performance, and left ventricular function assessment; however, increasingly a higher standard of evidence has been required, including a provision of reliable, large-scale mortality trial data. This has been further encouraged, if not mandated, by the relatively recent appreciation that some agents may demonstrate dissociation of treatment effects, possibly dose related, with improved short-term outcomes but adverse effects on survival with prolonged treatment. The general principles of management of congestive heart failure encompass patient evaluation and confirmation of the diagnosis, consideration, and correction of underlying remediable causes and precipitating factors, pharmacological treatment, patient education and counseling, and planned follow-up, as summarized in recently published guidelines. This review focuses primarily on the available randomized controlled clinical trial evidence related to the pharmacological treatment of the clinical congestive heart failure syndrome. Other aspects of management, such as patient education, counseling, and planned follow-up, should be regarded as complementary to pharmacological treatment and important to ensure compliance and optimal long-term outcomes.

Pearls and pitfalls in the use and abuse of diuretics for chronic congestive heart failure.

The main purpose of using diuretics is usually lost sight of, i.e. it is for the relief of dyspnea by using the least amount of a diuretic. The production of a low output state and hypercoagulation in an attempt to achieve dry weight by lowering blood volume excessively are among the hazards of using more diuretic than is absolutely necessary to achieve the goal of relieving dyspnea. The use of jugular venous pressure measurement and the status of dyspnea should have precedence over body weight in determining diuretic dose adjustment. Often forgotten in using diuretics is that potassium without magnesium will not enter cells and that the almost universal preference for furosemide over thiazides threatens to increase the incidence of osteoporosis. Also, the tendency to ignore loss of the water-soluble vitamins thiamine and ascorbic acid may result in refractory edema and the inability to manage the stresses of congestive heart failure.