Population-based study of cardiovascular health in Atahualpa, a rural village of coastal Ecuador.

Giant cell arteritis (GCA) is the most common type of primary vasculitis in Western countries. Polymyalgia rheumatica (PMR) is the second most common inflammatory rheumatic disease of the elderly after rheumatoid arthritis. Glucocorticoids are the cornerstone of treatment for GCA and PMR, which are interrelated diseases. Glucocorticoids are effective, but adverse effects occur in a high proportion of patients. Careful use of glucocorticoids and the application of preventive strategies can minimize these adverse effects. Possible long-term complications of GCA include aneurysm and stenosis of vessels, even in patients with apparently clinically inactive disease; acute blindness is rare during glucocorticoid treatment. In PMR, whether subclinical chronic inflammation can lead to long-term damage is less clear. Management of both GCA and PMR is hampered by the lack of universally accepted definitions of remission and other disease states, such as low disease activity or vessel damage without active disease. In this Review, we outline current evidence on the monitoring and long-term management of patients with GCA and PMR, including the tapering of treatment.

Monitoring and long-term management of giant cell arteritis and polymyalgia rheumatica.

Two cases of diffuse dendriform pulmonary ossification (DPO) are presented, one of the secondary type and the other of the idiopathic type. Case 1 was an adult female patient who underwent thoracic surgery to remove a posterior mediastinal bronchogenic cyst, which was discovered on a computed tomography scan performed after an episode of pneumonia when traction bronchiectasis with interstitial lung disease/fibrosis was also suspected in the lungs. Histologic examination performed on the resected lung tissue revealed numerous scattered small osseous spicules on a background of intense interstitial inflammation and fibrosis, leading to further clinical and laboratory investigations and the final diagnosis of DPO secondary to lung involvement by scleroderma. Case 2 was an adult male patient who underwent thoracoscopic exploration after a computed tomography scan, which revealed traction bronchiectasis with linear thickening of the interstitial lung tissue. Histologic examination of the lung tissue specimen revealed numerous osseous spicules in the absence of interstitial septal inflammation. Noteworthy in this case were also some nodules of collagenized tissue similar to those seen in the lungs of patients affected by Ehlers-Danlos syndrome. The absence of any clinical sign or symptoms related to Ehlers-Danlos syndrome attest to the nonspecificity of these pulmonary fibrous nodules. No case of DPO secondary to scleroderma has been reported in the literature so far, although around half of the patients with scleroderma manifest pulmonary diseases. Idiopathic DPO is even rarer, usually discovered postmortem, with only 20 cases diagnosed in life with lung biopsies taken by open surgery or through a thoracoscopic approach. DPO is often misdiagnosed radiologically as bronchiectasis and/or interstitial lung disease/fibrosis.

Selected case from the Arkadi M. Rywlin international pathology slide series: diffuse dendriform pulmonary ossification: report of 2 cases with review of the literature.

The concentration of highly-sensitive troponin I is increased in patients with brain injury after mild head trauma.

Infective Endocarditis (IE) is an endocardial infection usually caused by bacteria that affects not only the native heart valves but also,with increasing frequency intravascular implanted devices and congenital heart diseases. Despite medical advances, IE remains a life-threatening disease with substantial morbidity and mortality. In Africa, its diagnosis and treatment are still a major challenge in clinical practice. The objective of this work was to study the epidemiological, clinical features,diagnostic techniques currently used in medical practice and the range of micro-organisms that are responsible. This was a retrospective study done at Principal Hospital of Dakar. We include all patients who were admitted with clinical manifestations of definite or possible IE according to the extended DUKE criteria between January 1st, 2005 and December 31st, 2014. We collected and analyzed epidemiological, clinical, paraclinical and outcomes data of 42 patients. Hospital prevalence of IE was 0.078% (42/53711). The mean age was 27.5+/- 18 years with a sex ratio (M/F) of 0.55. IE were more common in patients with damaged or abnormal heart valves (78.6%) and in thoses with underlying structural defects (14.3%). The most common presenting symptoms were fever (90%) and cardiac murmurs (81%). Extracardiac clinical manifestations were very rare. The usual laboratory parameters of inflammation were elevated in 90% of patients. Blood cultures were negative in 50% of cases and positive in 21.4%. The main organism found was Staphylococcus aureus. Echocardiography found vegetations in 95.2% of cases, chamber enlargement in 73.8% and mitral regurgiation in 83.3%. Broad-spectrum penicillins including ampicillin and gentamycine were used for all patients. Major complications were heart failure (47.6%). Strokes and cerebral abcess (23.8%) and Vascular emboli 14.3%. Hospital mortality was 31%. IE remains a life-threatening disease with hight mortality despites improved techniques of diagnosis and modern antibiotics.

Infective endocarditis in Principal Hospital of Dakar: a retrospective study of 42 cases over 10 years.

Prerequis: L'association d'anomalies electrocardiographiques (ECG), en particulier les troubles de la repolarisation, a une hemorragie sous arachnoidienne post traumatique (HSA) est decrite depuis plus de 50 ans. Tres peu d'etudes se sont interessees a ces anomalies cardiaques au cours de l'HSA post traumatique (HSA-t). But: Relever l'incidence des complications coronariennes au cours de l'HSA-t et etudier la valeur predictive de mortalite des anomalies ECG au cours de l'HSA-t Methodes: Cette etude prospective menee entre 2001 et 2009 au service de reanimation de l'institut national de Neurologie de Tunis concerne 35 patients consecutifs traumatises crâniens avec HSA-t a l'admission. Un electrocardiogramme a ete pratique quotidiennement pendant les six premiers jours ainsi qu'un dosage de la Troponine le au 1er jour post traumatisme puis au 3eme et au 5eme jour. L'analyse statistique etait basee sur le test de variance non parametrique de Kruskal-Wallis pour comparer les moyennes; et les tests chi 2 et Fisher pour comparer les pourcentages, avec un seuil de significativite 0.05. Des liaisons entre 2 variables quantitatives ont ete etudiees par le coefficient de correlation de Pearson. Nous avons calcule l'Odds ratio pour l'etude de la mortalite. Resultats: L'âge des patients est de 39 ± 17 ans (14-70). Le sex ratio est egal a 4 en faveur des hommes. On constate des anomalies de la repolarisation a type de modifications de l'onde T et du segment ST chez 20 patients (57%). Les anomalies de l'onde T sont les plus frequentes et observees chez 13 patients. La majorite de ces anomalies surviennent au 3eme jour. La Troponine Ic est elevee chez 12 patients soit 34%. Le maximum d'elevation a eu lieu au 3eme jour. L'elevation de la Troponine Ic est associee a un mauvais grade scannographique de FISHER (p=0.01) et aux anomalies de l'onde T(p=0.002). L'elevation de la Troponine le et les anomalies de l'onde T ressortent comme facteurs independants de mortalite d'apres une analyse bi variee. Conclusion: Nous deduisons que l'incidence des modifications ECG n'est pas rare au cours de l'HSA-t. Les troubles de la repolarisation et l'elevation de la la troponine IC constituent des facteurs predictifs independants de mortalite au cours de l'HSA-t.

Cardiac injury in traumatic subarachnoid hemorrhagea: prospective study in 35 patients.

BACKGROUND Diffuse pulmonary ossification is a rare entity with unknown pathogenesis. It presents with the formation of mature bone within the pulmonary parenchyma. Pulmonary ossification can be idiopathic or associated with diffuse and chronic lung disease, system disorders or heart disease essentially mitral stenosis. AIM We report a case of a 49 year-old woman with long standing mitral stenosis. CASE The patient had undergone a valve replacement with a mechanical prosthesis. She complains from dyspnea on exertion and dry cough. Frontal chest radiograph shows bibasilar confluent calcific areas of increased opacity. Computed tomography scans confirmed the presence of ossified acinar clusters. Other aetiologies of diffuse pulmonary ossification were eliminated by different complementary exams. CONCLUSION Diffuse pulmonary ossification is slowly progressive. Patients are generally asymptomatic or complain from mild symptoms. Most cases are of diffuse pulmonary ossification are diagnosed during autopsy. Establishing a prognosis is difficult as few living cases are diagnosed.

Mitral stenosis a rare antology of diffuse pulmonary ossification

BACKGROUND Atrial septal defect (ASD) is one of the most common causes of congenital heart disease manifested in adulthood. AIM To describe clinical and likelihood picture of adults over 60 years born with an ASD type II. METHODS We performed a retrospective study of adult'sASD referred toourinstitutionfrom 1985 through 2010. Clinical, electrocardiographic, echocardiographic and hemodynamic data were reviewed. On follow up study, patients were investigated by echocardiography, ECG and assessed for quality of life by a questionnaire RESULTS Among forty ASD type II manifested in adulthood which were referred to our department of cardiology five cases of ASD manifested in the sixth decades (2 men and 3 women). Complaints were dyspnea and palpitations in 4 cases and chest pain in only one patient. Slight anterior chest deformity was present in the older patient. Systolic murmur was found in the 3rd left intercostals space and the pulmonary second heart sound was accentuated in all patients. Complete right bundle branch block and right ventricular hypertrophy were found in all cases. Three patients presented atrial fibrillation. There was marked cardiomegaly in four patients. The pulmonary arteries were markedly enlarged and the peripheral vascular markings were increased. Echocardiographic data revealed large secundum ASD (mean 20 mm, ranged between 10 and 30mm), severe systolic pulmonary pressure in two cases (>5O mmhg). MeanQP/QS was 2.2 and contrast revealed bidirectional shunt in one patient. All patients were studied by venous cardiac catheterization. They showed a significant increase in the oxygen content of right atrial blood. Three patients underwent surgical atrial septal defect closure under general anesthesia. There were no operative or peri operative deaths. At mean follow up of 50±75 months, there was one late death from heart failure in a patient with advanced preoperative heart failure. The oldest patient is in the medical group and he is 75years old. Most survival patients remain in good clinical condition. Some of them were symptomatic at the last follow up and complained of shortness of breath on effort and palpitations in two cases. Two patients were in chronic atrial fibrillation developed during follow up. However, chest RX showed reduction in cardiothoracic ratio postoperatively. Echocardiographic examination confirmed that there was no residual shunt in across the atrial septum in any patient. Systolic pulmonary pressure felled only in 2 patients in the surgery group. CONCLUSION To our knowledge, thesepatients havealongue life span, although survivors with ASD described in the world. There is a lack of evidence regarding treatment options for adults with an ASD aged more than 60years. Given the higher risks of surgery in advanced age, the defect should be repaired as early as possible to prevent hemodynamic complications.

Natural history of atrial septal defect in the sixth decade : study of 5 cases.

BACKGROUND Infective endocarditis (IE) is a serious pathology which is in a continuum evolution in the setting of diagnosis and therapeutic fields AIM To describe clinical, echocardiographic, microbiological, therapeutic and outcome characteristics of infective endocarditis in a Tunisian population. METHODS The records of 135 patients admitted to adult cardiology department of la Rabta hospital between January 1981 and December 2011 were collected. The diagnosis of certain IE was retained according to modified Duke Criteria. RESULTS The mean age of patients was 38.5 ± 16 years, with a male predominance (sex ratio: 1.4). IE affected native valves in 77% of cases, prosthetic valve in 15.5% of cases, congenital heart disease in 2% and pacemaker in 1.48% of patients. The portal of entry was identified in 43.7% of the patients, the oral origin was predominant. Blood cultures were positive in only 34% of patients. Causative microorganism was staphylococcus in 43.6%, streptococcus in 43.6% and negative bacill gram in 17.4% of patients. Echocardiography showed vegetation in 98% of patients, cardiac abscess in 23.7% of patients and valve mutilation in 17.7% of cases. Prosthesis dehiscence was present in 4.5% of cases. Complications were primarily hemodynamic (57%) followed by embolic events (34%). Surgery occurred in 57.7% of patients, it was early in 69% of cases. The indication was mainly hemodynamic and mixed in 70%of patients. Hospital mortality was 28% with predictor's factors: left heart (p=0.02), prosthesis (p <0.05), staphylococcus (p<0.005), heart failure (p<0.05) and neurological complications (p=0.04). CONCLUSION According to our study, infective endocarditis has always touched a young population in Tunisia, rheumatic valve disease is still the predominant underlying heart disease and both streptococcus and staphylococcus are most frequently isolated. Mortality remains high despite considerable progress in terms of diagnosis and therapy.

[Epidomiological characteristics of infective endocarditis: a study of 135 cases].

Background Non-invasive examination of coronary artery disease is an attractive and rapidly evolving possibility. In certain clinical situations ,multi-detector computed tomography coronarography (MDCT) is currently considered as a promising technique alternative to conventional coronary angiography (CCA). Purpose We suggest from our personal study and from a review of the literature, to analyze diagnostic accuracy of MDCT , its limits and to deduct, its practical implications and its indications. Methods 105 patients underwent 64-slice MDCT . Coronary angiography was performed every time when the MDCT was pathologic. In two cases the MDCT was realized in complement of inconclusive coronary angiography .Study of coronary arteries was based on "per -segment" and "per- patients" analyse Results : The mean age was 63,3 years., sex ratio was 0 ,7. Hypertension was noted in 63% of cases 29 ,9 % of patients had mellitus diabetes.The initial clinical presentation was unusual chest pain in 46 patients, exercise chest pain in 40 cases. the MDCT was done for the detection of silent ischemia In 5 cases, for screening of CAD in patients with dilated cardiomyopathy in 5 cases , before cardiac surgery in 3 case and before non cardiac surgery in 2 cases. MDCT was normal in 30 patients ( 28% ) so coronary angiography was avoided in 60% of patients with unusual chest pain, and in 50% of patients with dilated cardiomyopathy and in also in 50% of patients selected for cardiac or non cardiac surgery. In per-segment study the sensitivity, specificity, positive and negative predictive value of the MDCT in detecting coronary stenosis were respectively 89 %,98% , 91% and 97% versus, 98%,89%,94%, 95% the per-patient evaluation .The MDCT was inclusive in10 patients because .of calcifications in 8 cases and because uncontrolled unchecked heart rate in 40 cases Conclusion : our results for negative predictive value of MDCT are similar to reports from the literature. This suggests that in this clinical setting , MDCT may replace coronary in patients with low probability of coronary artery diseases, its is also useful for assessment of cardiomyopathy and before cardiac or non cardiac surgery.

Rim Lakhdhar

Papers

Cardiac injury in traumatic subarachnoid hemorrhagea: prospective study in 35 patients.

Mitral stenosis a rare antology of diffuse pulmonary ossification

Natural history of atrial septal defect in the sixth decade : study of 5 cases.

[Epidomiological characteristics of infective endocarditis: a study of 135 cases].

[Diagnostic accuracy, limits and practical implications of Multidetector Computed Tomography Coronarography. About 105 cases].