Le point sur l'ergométrie en 2012 dans le diagnostic de la maladie coronarienne.

Background In patients presenting with acute cardiac symptoms, abnormal ECG and raised troponin, myocarditis may be suspected after normal angiography. Aims To analyse cardiac magnetic resonance (CMR) findings in patients with a provisional diagnosis of acute coronary syndrome (ACS) in whom acute myocarditis was subsequently considered more likely. Methods and results 79 patients referred for CMR following an admission with presumed ACS and raised serum troponin in whom no culprit lesion was detected were studied. 13% had unrecognised myocardial infarction and 6% takotsubo cardiomyopathy. The remainder (81%) were diagnosed with myocarditis. Mean age was 45615 years and 70% were male. Left ventricular ejection fraction (EF) was 58610%; myocardial oedema was detected in 58%. A myocarditic pattern of late gadolinium enhancement (LGE) was detected in 92%. Abnormalities were detected more frequently in scans performed within 2 weeks of symptom onset: oedema in 81% vs 11% (p<0.0005), and LGE in 100% vs 76% (p<0.005). In 20 patients with both an acute (<2 weeks) and convalescent scan (>3 weeks), oedema decreased from 84% to 39% (p<0.01) and LGE from 5.6 to 3.0 segments (p¼0.005). Three patients presented with sustained ventricular tachycardia, another died suddenly 4 days after admission and one resuscitated 7 weeks following presentation. All 5 patients had preserved EF. Conclusions Our study emphasises the importance of access to CMR for heart attack centres. If myocarditis is suspected, CMR scanning should be performed within 14 days. Myocarditis should not be regarded as benign, even when EF is preserved

Micronutrient Deficiencies in Medical and Surgical Inpatients

Inpatients are threatened by global malnutrition, but also by specific micronutrient (i.e., trace element and vitamins) deficiencies that frequently are overseen in the differential diagnosis of major organ dysfunctions. Some of them are related to specific geographic risks (iodine, iron, selenium, zinc, vitamin A), while others are pathology related, and finally many are associated with specific feeding patterns, including low dose enteral feeding. Among the pathologies in which laboratory blood investigations should include a micronutrient outwork, anemia is in the front line, followed by obesity with bariatric surgery, chronic liver disease, kidney disease, inflammatory bowel disease, cardiomyopathies and heart failure. The micronutrients at the highest risk are iron, zinc, thiamine, vitamin B12 and vitamin C. Admission to hospital has been linked with an additional risk of malnutrition-feeding below 1500 kcal/day was frequent and has been associated with a structural additional risk of insufficient micronutrient intake to cover basal needs. Although not evidence based, systematic administration of liberal thiamine doses upon admission, and daily complementation of inpatients' food and enteral feeding solutions with multi-micronutrient tablets might be considered

MDCT-findings in patients with non-occlusive mesenteric ischemia (NOMI): influence of vasoconstrictor agents.

To evaluate the influence of vasoconstrictor agents (VCAs) on signs of vasoconstriction and bowel ischemia on MDCT detected in patients with non-occlusive mesenteric ischemia (NOMI). This 8-year single-center retrospective study consecutively included all patients with histopathologically proven NOMI who underwent MDCT ≤ 48 h prior to surgical bowel resection. Two blinded radiologists jointly reviewed each examination for signs of bowel ischemia, abdominal organ infarct, mesenteric vessel size and regularity, and ancillary vascular findings. VCA administration (length and dosage), clinical and biochemical data, risk factors, and outcomes were retrieved from patients' medical records. Subgroup comparisons were performed. Ninety patients were included (59 males, mean age 65 years); 40 (44.4%) had received VCAs before MDCT. Overall mortality was 32% (n = 29), with no significant difference between the two groups. In patients treated with VCAs, the calibre of the superior mesenteric artery (SMA) was smaller (p = 0.032), and vasoconstriction of its branches tended to be more important (p = 0.096) than in patients not treated with VCAs. The presence and extent of bowel ischemia did not significantly correlate with VCA administration, but abdominal organ infarcts tended to be more frequent (p = 0.005) and involved more organs (p = 0.088). The VCA group had lower mean arterial pressure (p = 0.006) and lower hemoglobin levels (p < 0.001). Several biomarkers of organ failure and inflammation, differed significantly with VCA use, proving worse clinical condition. MDCT demonstrates more severe SMA vasoconstriction and tends to show increased abdominal organ infarcts after VCA administration in NOMI patients compared to NOMI patients not treated with VCAs. • In critically ill patients with NOMI, MDCT demonstrates VCA support via increased vasoconstriction of the main SMA and its branches. • VCA administration in NOMI patients tends to contribute to the development of organ infarcts, as shown on MDCT. • An important degree of vasoconstriction in NOMI patients may indicate insufficient resuscitation and, thus, help clinicians in further patient management

EBV-positive large B-cell lymphoma with an unusual intravascular presentation and associated haemophagocytic syndrome in an HIV-positive patient: report of a case expanding the spectrum of EBV-positive immunodeficiency-associated lymphoproliferative disorders.

Intravascular large B-cell lymphoma is a rare and aggressive EBV-negative large B-cell lymphoma with a dismal outcome. Here, we describe the case of a 76-year-old HIV-positive patient with an acute presentation of systemic symptoms and rapidly fatal outcome. Autopsy revealed a disseminated large B-cell lymphoma with an intravascular distribution involving the liver, lymph nodes, spleen, and bone marrow and associated to fibrin thrombi in hepatic capillary haemangiomas. The neoplastic B cells (CD79a + / - , CD20 + / - , CD30 + , MUM1 + , PD-L1 +) showed a Hodgkin and Reed-Sternberg-like morphology and were EBV-positive with a latency type II (LMP1 + , EBNA2-). Haemophagocytosis was documented in the bone marrow and lymph nodes. This case illustrates the diagnostic challenges of large B-cell lymphoma with intravascular presentation. We found only five other cases of EBV-positive large B-cell lymphoma with an intravascular presentation in the literature, three of which had an underlying immunodeficiency adding to the broad spectrum of EBV-associated lymphoma in the setting of immunosuppression

Simple equations to predict the effects of veno-venous ECMO in decompensated Eisenmenger syndrome.

Adult patients with uncorrected congenital heart diseases and chronic intracardiac shunt may develop Eisenmenger syndrome (ES) due to progressive increase of pulmonary vascular resistance, with significant morbidity and mortality. Acute decompensation of ES in conditions promoting a further increase of pulmonary vascular resistance, such as pulmonary embolism or pneumonia, can precipitate major arterial hypoxia and death. In such conditions, increasing systemic oxygenation with veno-venous extracorporeal membrane oxygenation (VV-ECMO) could be life-saving, serving as a bridge to treat a potential reversible cause for the decompensation, or to urgent lung transplantation. Anticipating the effects of VV-ECMO in this setting could ease the clinical decision to initiate such therapeutic strategy. Here, we present a series of equations to accurately predict the effects of VV-ECMO on arterial oxygenation in ES and illustrate this point by a case of ES decompensation with refractory hypoxaemia consecutive to an acute respiratory failure due to viral pneumonia

A first update on mapping the human genetic architecture of COVID-19

peer reviewe

Evolution des traitements des patients brûlés traités aux soins intensifs du centre des brûlés du CHUV, de 1996 à 2014: Une étude de cohorte

Introduction : Parmi les patients de soins intensifs, la nutrition joue un rôle particulièrement important chez les patients brûlés, contribue à leur survie et fait donc partie intégrante de la réanimation. Dans les années 80 est né le concept de l'hyperalimentation. Pour lutter contre la perte de masse maigre, les patients recevaient alors jusqu'à 4000-6000 kcal par jour, en se basant sur l'équation de Curreri. Il est rapidement devenu évident que cette nutrition agressive pouvait à son tour mener à des complications (infections, stéatose hépatique, hyperglycémie) et augmenter la mortalité. Ceci a conduit à une tendance générale à diminuer les apports énergétiques. Récemment, des recommandations nutritionnelles européennes sur les brûlés ont été publiées, reflétant ces changements. Les cibles caloriques sont actuellement basées sur les valeurs de calorimétrie indirecte ou en leur absence, sur l'équation de Toronto. Les recommandations d'apports protéiques sont plus élevées que pour les autres pathologies (1.5-3 g/kg/j). Notre centre des brûlés a suivi l'évolution de ces recommandations. Le but de ce travail était de suivre l'impact des changements de notre pratique nutritionnelle, de contrôler l'adhésion aux recommandations et de détecter d'éventuelles dérives. Méthodes : Etude rétrospective uni-centrique sur l'ensemble de la cohorte des patients admis aux soins intensifs (SI) du centre des brûlés du CHUV à Lausanne entre juin 1999 et décembre 2014. Critères d'inclusion : durée de séjour >7 jours, admission au jour 1 de la brûlure uniquement. Critères d'exclusion : Patients non-brûlés (par ex. syndrome de Lyell), retraits thérapeutiques, réadmissions. Quatre périodes (P) ont été définies selon les dates de modifications du protocole interne de prise en charge. (P1 :1999-01, P2 : 2002-05, P3 : 2006-10, P4 : 2011-14). Les modifications principales du protocole étaient une diminution des cibles énergétiques de 1,3x la valeur de calorimétrie (MEE) en P1 à 1x MEE en P3 et l'introduction de glutamine et de solutions de nutrition entérale enrichies en protéines dès P3. L'âge, la surface brûlée (TBSA) et la présence ou non d'un syndrome d'inhalation (définition standardisée depuis 2006) ont été recueillis, ainsi que les scores de sévérité, la durée de séjour et de ventilation. Sur le plan infectieux, les valeurs de CRP et le nombre de complications infectieuses ont été enregistrées. Les données nutritionnelles ont également été collectées : poids, apports énergétiques, protéiques, glucidiques, lipidiques et en glutamine, valeurs de calorimétries (MEE), cibles caloriques et valeurs de préalbumine. Les apports non-nutritionnels (par ex. propofol) ont également été comptabilisés. L'ensemble des données ont été enregistrées jusqu'au jour 21, extraites des dossiers médicaux et du système informatisé des soins intensifs (MetaVision®). Les périodes ont été comparées par ANOVA, x2 et test de Fisher. Les aires sous la courbe (AUC) des poids du jour 14 au jour 21 ont été calculées par la méthode trapézoïdale. La corrélation entre la cible énergétique prescrite et les valeurs de calorimétries ont été analysées par un test de Spearman puis représentée graphiquement par la méthode de Bland-Altman. Les statistiques et les graphiques ont été réalisées à l'aide du logiciel STATA 12 (StataCorp LP, College Station, TX, USA). Résultats : 240 patients ont rempli les critères d'inclusion sur un nombre total de 529 patients admis durant la période étudiée. L'âge médian était de 43'ans (IQR 32), le TBSA médian était de 25% (IQR 23) avec 15% (IQR 22) de surface chirurgicale ; 66% des patients étaient de sexe masculin et 58% des patients avaient un syndrome d'inhalation. Les valeurs de calorimétrie indirecte (MEE) sont restées stables durant les 4 périodes étudiées avec une valeur médiane de 32 kcal/kg (IQR 10). On a observé par contre une diminution significative des cibles caloriques prescrites (P1 : 33 kcal/kg, IQR 7, P4 : 28 kcal/kg, IQR 8, p<0.001) et une diminution également significative des apports énergétiques en dessous de 30 kcal/kg (P1 : 30 kcal/kg, IQR 23, P4 : 25 kcal/kg, IQR 12, p<0.001). Les apports protéiques ont significativement augmenté (P1 :1.04 g/kg, IQR 0.90, P4 :1.26, IQR 0.99, p<0.001). L'analyse des AUC des poids de J14 à J21 a révélé une diminution significative (p=0.02), bien que la diminution de poids à J21 ne soit tout juste pas significative en P4 (P1 : 97.1% du poids préadmission, IQR 7.7, P4 : 94.1%, IQR 15.4, p=0.06). Les valeurs de préalbumine étaient significativement plus basses en P4 (P1 :150mg/L, IQR 110, P4 : 80mg/L, IQR 70, p=0.003). L'analyse des complications infectieuses et des CRP a montré une augmentation en P2 et P4. Conclusions : La compliance avec le protocole de nutrition a été bonne durant les périodes 1 à 3, mais mauvaise en période 4. La diminution observée des apports énergétiques en-dessous de 30 kcal/kg est associée à une diminution des poids et des valeurs de préalbumine, sans nette corrélation avec les complications infectieuses. Ceci confirme que les patients brûlés ont des besoins énergétiques plus importants que les autres catégories de patients de soins intensifs

Nutrition in burn injury: any recent changes?

After major progress in the 1980s of burn resuscitation resulting, the last years' research has focused on modulation of metabolic response and optimization of substrate utilization. The persisting variability of clinical practice is confirmed and results in difficult comparisons between burn centers. Recent research explores intracellular mechanisms of the massive metabolic turmoil observed after burns: very early alterations at the mitochondrial level largely explain the hypermetabolic response, with a diminished coupling of oxygen consumption and ATP production. The metabolic alterations (elevated protein and glucose turnover) have been shown to be long lasting. Modulating this response by pharmacological tools (insulin, propranolol, and oxandrolone) results in significant clinical benefits. A moderate glucose control proves to be safe in adult burns; data in children remain uncertain as the risk of hypoglycemia seems to be higher. The enteral feeding route is confirmed as an optimal route: some difficulties are now clearly identified, such as the risk of not delivering sufficient energy by this route. Major burn patients differ from other critically ill patients by the magnitude and duration of their inflammatory and metabolic responses, their energy and substrate requirements. Pieces of the metabolic puzzle finally seem to fit together

Maladie de Weil: à propos d'un cas de leptospirose acquise en Suisse [Weil's disease: a case report of acquired leptospirosis in Switzerland].

Leptospirosis is a rare disease in Switzerland. However its incidence is probably underestimated, due to its broad spectrum of presentations, including subclinical benign forms and the ictero-hemorragic form of the Weil's syndrome, whose mortality is high. We describe here a case of Weil's syndrome acquired in Switzerland with a favourable outcome under antibiotherapy. Even in the absence of any travel, the association of an acute renal insufficiency and jaundice with only moderate hepatic cytolysis should lead to the suspicion of leptospirosis. Clinical and epidemiological aspects of the disease are discussed in the article