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Thrombotic microangiopathy or "TMA" including thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) became a public health problem following the European outbreak of E. coli (O104:H4) gastroenteritis in 2011. A rapid diagnosis and therapy in an intensive care unit provide better patient survival and lower cost for society. Supportive treatment has significantly improved the prognosis over the past decade and includes fresh frozen plasma for TTP, plasmapheresis for HUS, and recently a new therapeutic agent: anti-C5 antibodies. We will provide in this article, through the current literature and four cases encountered in our department, to establish an algorithm to manage patients with TMA.

Pain is a leading cause of office visits. In the geriatric population, it is known that the prevalence of renal failure increases exponentially with age, modifing the elimination of drugs and of their metabolites. What analgesia should be offered to these patients? The holy grail would be a medication without renal elimination, without toxic metabolites and without nephrotoxicity. Based on the literature we try to propose a specific approach to analgesia in older patients with kidney insufficiency, in order to help practitioners to better prescribe for this group of patients.

Cerebral small vessel disease (cSVD) represents the sum of lesions which define a rather new clinical entity. Indeed, lacunar infarcts which are acute events of cSVD, represent 25% of all ischemic strokes. However, only few studies have dealt with acute and long term management of such stroke. Despite its rather early description around the XIXth century, the "lacune", the cardinal anatomopathological lesion of cSVD, remains only partially explained and pathogenesis is still debated. The purpose of this paper is to better define the anatomical lesions, to discuss physiopathological hypotheses and to present the most salient clinical features. Once identified cSVD should not be further overlooked.

Osteoporosis and atherosclerosis seem to be epidemiologically correlated. Several medical conditions are risk factors for both osteoporosis and atheromatosis (i.e. age, diabetes, end stage renal disease, sedentarity, smoking), but a common pathogenic link may be present beyond this. The burden of cardiovascular events and of osteoporotic fracture is considerable for the health care system in term of costs and resources. However, both diseases are rarely managed together. This article is a review of the recent studies in this new field.

Since the publication of the Institute of Medicine's report, "To Err is Human", in 1999, patient safety has become an economic and political objective. The notion of safety involves willingness and initiation of measures to reduce or eliminate errors leading to preventable adverse events. Morbidity and mortality conferences are useful tool to improve local care management through the discussion of adverse events and medical errors and the conception of alternative approaches. In addition, MMCs have an educational value for the entire medical and nursing staff. The involvement of the head of the department is crucial to achieve a cultural change within the caregivers by developing the concept of "useful error" during MMCs.

Drug-induced liver injury (DILI) is the most common cause of drug withdrawal of the market though it remains quite seldom. Actually, its incidence reaches about 1/100000 prescriptions. Antibiotics are the most implicated substances: 3 clinical cases are presented. The clinical manifestations are broad, appear between 5 to 90 days after the introduction of the drug and range from an asymptomatic patient to an acute hepatic failure. This diagnosis is difficult to establish. After excluding a biliary obstruction and a septic cholangitis at first, many additional investigations can be performed, but induce considerable costs. Drug history is the key element of the diagnostic approach. An algorithm is presented at the end of this article to prevent expensive, invasive and useless investigations.

Early reperfusion with prompt re-establishment of coronary blood flow improves survival in patients suffering from acute ST-elevation myocardial infarction (STEMI). Leaving systemic thrombolysis for primary percutaneous coronary intervention (PCI) is justified by clinical results in favor of PCI. Nevertheless, primary PCI necessitates additional transfer time and requires an efficient territorial networking. The present article summarizes the up-to-dated management of patients with acute STEMI and/or overt cardiogenic shock.

Microscopic hematuria is common in medical practice; its prevalence in the adult population varies between 2.5 and 13%. Currently available data are insufficient to determine an algorithm based on evidence of the most effective diagnostic strategy of hematuria. Avoid invasive tests for the patient and expensive for the community, determine whether the hematuria of glomerular origin or not, facilitate the clinician referral to a nephrologist or urologist for the etiological diagnosis, should be the basic principles of any approach to develop such an algorithm. We try to answer on this question in this article.

Despite enormous progress made in cardiovascular prevention and treatment, sudden death remains the first manifestation of ischemic heart disease for too many subjects. A better individual cardiovascular risk assessment would definitely help select the most efficacious interventions allowing to prevent the development of atherosclerosis and its complications. Risk scores, although not used as frequently as expected in everyday practice are a first step towards helping decision making to reduce cardiovascular diseases. The use of vascular markers for early atherosclerosis detection should be even more profitable to reduce CV diseases. Pulse wave velocity, intima-media thickness and ankle brachial index measurements are among the most simple and promising markers of early vascular disease are discussed briefly in this paper.

Atherosclerotic peripheral arterial disease (PAD) is often asymptomatic. If symptomatic, patients present intermittent claudication, ischemic rest pain or tissue necrosis. The prevalence of PAD increases with age and affects about 2% of patients at 60 years. Patients with PAD have an increased risk of coronary or cerebro-vascular events. Measure of the ankle-brachial index (ABI) allows early detection of asymptomatic patients, and allows early preventive interventions, in order to reduce their cardio-vascular risk. The most important interventions are smoking cessation, normalisation of blood pressure and lipid levels, and introduction of an antiplatelet agent, such as aspirin 75 to 160 mg/d.

Peripheral artery disease (PAD) is frequently overlooked because of its silent evolution for quite a long period and because it has not been considered as harmful as other atherothrombosis complications such as myocardial infarction or stroke. PAD is readily diagnosed by measuring the ankle brachial index (ABI). A reduced ABI is able to identify an asymptomatic PAD in a high risk patient and provides a very valuable predictor of cardiovascular events allowing to better profile the individual risk of the patient. The awareness of PAD as a mark of a generalized atherothrombosis disease holds the potential to increase the doctor's view of the true individual risk of his patient and to enforce cardiovascular risk prevention as suggested by recent studies.

Cardiovascular diseases (CVD) remain the main cause of morbidity and mortality in our society. CoLaus is a population-based health examination survey started in 2003 in Lausanne in order to assess: 1. Prevalence of cardiovascular risk factors, 2. New genetic determinants of cardiovascular risk factors such as hypertension, 3. Association of mood disorders with incidence of cardiovascular events and 4. Trends in prevalence of cardiovascular risk factors. In order to do so, over 6000 subjects (ages 35-75 years) provided data on CVD risk factors. Herein we provide preliminary results of this study, in particular on classical risk factors such as hypertension, obesity and diabetes. Implications and perspectives of this population based-study for public health and genetic studies are also discussed.

Background: The superficial femoral vein (SFV) is a well-established alternative conduit for infra-inguinal reconstructivenous hypertension after SFV harvest may however result in significant morbidity. This study reports the efficiency of SFV as conduit for infra-inguinal reconstructions and characterize the anatomic and physiologic changes in harvest limbs and their relationship to the development of venous complications., Methods: From May 1999 through November 2003, 23 SFV were harvested from 21 patients undergoing infra-inguinal reconstructions. Bypasses were controlled by regular duplex-ultrasound. The venous morbidity was assessed by measurements of leg circumferences, strain-gauge plethysmography and quality of life, investigated by the VEINES-QOL scale., Results: At a mean follow-up of 10.4 months (range 1-56), primary, secondary patency and limb salvage rates of infra-inguinal bypasses using SFV are 71.4%, 76.2% and 85.7% respectively. No patient had major venous claudication. Oedema was significantly present in nine patients. Strain-gauge plethysmography showed outflow obstruction in all patients. The VEINES-QOL assessment showed no limitation in social and domestic activity, moderate complain about leg heaviness despite presence of oedema., Conclusion: The SFV harvest is a reliable conduit for infra-inguinal reconstructions and results in moderate venous morbidity in terms of functional consequences and quality of life.

Drug addicts very often present with vascular complications. A great number of these lesions require medical care. Vascular problems are diverse and multiple affecting both veins and arteries, the latter being often the most dramatic. This article attempt to describe the most frequent lesions observed in drug addicts considering two different mechanisms; traumatic versus drug induced complications.

According to the guidelines, the global assessment of cardiovascular risk is based on traditional risk factors. The emergence of new cardiovascular risk factors may be helpful. However, at every level of risk factor exposure, there is a substantial variation of atherosclerosis. Thus, subclinical disease measurements, representing the end result of risk exposure may be useful for improving cardiovascular risk prediction. In comparison to the ankle-brachial index, the high resolution B-mode ultrasound is a more promising tool to detect early atherosclerosis both on carotid and femoral arterial wall in asymptomatic patients. It appears as a new approach to predict the risk of cardiovascular disease and to monitor the cardiovascular therapy.

Identification of atherosclerotic lesions in asymptomatic subjects improves the stratification of their absolute cardiovascular risk. Several methods allowing detection of atherosclerosis rely on sophisticated and expensive apparatus. Only simple and inexpensive methods can be used in general practice. The ankle-brachial index (ABI) is a very simple, cheap and easy to learn method to identify peripheral artery disease, one of several clinical manifestations of atherosclerosis. ABI is not only a marker of atherosclerosis but a strong predictor of cardiovascular mortality. Pulse wave velocity a marker of large artery stiffness is another strong predictor of cardiovascular morbidity and mortality. It is presently used only for clinical studies but may soon be part of the vascular assessment performed in general practice.

Background: Local Pulse Pressure (PP) is an independent determinant of carotid artery wall thickness, stronger than mean BP. The present study was designed to assess whether a beta-adrenoceptor antagonist or an ACE inhibitor-based treatment was able to reduce carotid artery wall hypertrophy through the reduction in carotid PP rather than by lowering mean BP, and whether the influence of local PP reduction could also be detected at the site of a muscular artery, the radial artery., Methods and Results: Ninety-eight essential hypertensive patients were randomised to 9 months of double-blind treatment with either celiprolol or enalapril. Arterial parameters were determined with high resolution echotracking systems. PP was measured locally with PP applanation tonometry, and independently of mean BP. After 9 month's treatment, mean BP, carotid PP and intima-media thickness (IMT) decreased significantly, with no difference between the tow groups. The reduction in carotid pression pulsée, but not in mean BP, was a major independent determinant of the reduction in carotid IMT. Radial artery IMT and PP decreased significantly with both treatments. However, the reduction in radial artery IMT was not related to the changes in radial artery PP., Conclusion: The regression of carotid artery wall hypertrophy during long-term antihypertensive treatment was dependent on the reduction in local PP rather than on the lowering of mean BP. The effect of PP lowering on IMT reduction was observed at the site of an elastic artery but not at the site of a muscular artery.

The effects of estrogens and gestagens on veins and circulation have been studied since prescription of these hormones as oral contraception and description of related thromboembolic events. The identification of different receptors and the description of these receptors in venous walls have helped to understand some hormonal effects. However, the actual knowledge remains insufficient to explain the complexity of the actions of hormones on venous function. The distribution, the density and the receptor types vary with age, gender, hormonal status and vascular bed. Gestagens mainly reduce the tone of venous walls, whereas estrogens have various effects. Between 25% and 50% of European adults and even 80% or more in some risk groups complain about heavy legs, with or without chronic venous insufficiency. The number of women to whom hormonal substitution is or could be prescribed increases along with aging of populations and the better understanding of potential benefits. The need for a better understanding of vascular effects of sexual hormones is growing, since the incidence of chronic venous insufficiency of the legs increases with age. The life prognosis will not be affected by a deterioration of a chronic venous insufficiency. In contrast, the quality of life, morbidity and the cost of treatment will be expected to change. In addition, thromboembolic events have to be considered, as has been shown in recent studies. These findings outline the need for further studies on the relation between hormones and venous function and for some caution when prescribing hormonal substitution.

Many studies have shown a close correlation between intima-medial thickness of the carotid artery measured by high resolution ultrasonography and the presence of coronary artery disease or atherogenic risk factors. However, reference values for the value of intima-medial thickness (IMT) in healthy subjects have not yet been established. The aim of this study was, therefore, to determine the reference values of carotid (C-IMT) and femoral intima-medial thickness (F-IMT) with respect to age and gender in healthy subjects (53 women and 45 men) aged 20 to 60, with no family or personal history of cardiovascular disease or atherogenic risk factors, underwent high resolution colour echo-Doppler examination. The mean C-IMT was 556 +/- 57 microns in women and 573 +/- 70 microns in men (NS), and the femoral equivalent was 543 +/- 63 microns in women and 562 +/- 74 microns in men (NS). Between the ages of 20 and 60, the C-IMT increased by 1.8 microns per year (p < 0.03) in women and 3.4 microns (p < 0.001) in men, the variations being respectively 1.2 microns (NS) and 3.1 microns (p < 0.002) in the femoral artery. Multiple regression analysis including gender and individual values of age, body mass index and lipid profile confirmed that only age was significantly correlated to the increase in thickness. The authors conclude that the reference values of IMT do not differ with gender or site of analysis, but there is a slight influence with respect to age.

Recently, the material available for endovascular aneurysm repair (covered stents and application systems), real time medical imaging and operator experience have significantly improved. Hence, more and more complex vascular lesions, well beyond the original indications, can now be treated by endovascular surgery. Since 1996 our group has implanted 55 endovascular systems in the clinical setting: 45/55 (80%) for classical indications and 11/55 (20%) for extended indications. In the latter group four different endoprosthetic systems were used according to either their performance and availability or the type of lesion to be treated. For the 11 patients undergoing endovascular procedures with extended indications, 6/11 had thoracic aortic lesions (55%) and 5/11 (45%) had aorto-iliac lesions requiring either progressive embolisation of the internal iliac arteries or suprarenal anchorage. For these extended indications hospital mortality was 0/11 (0%). One patient died after hospital discharge. 1/11 patients (9%) had to be converted to open surgery during the interval between iliac embolisation and endovascular repair. There has been no conversion to open surgery during or after the endovascular procedures. Two major endoleaks were detected (2/11: 18%). One has been corrected by an additional covered stent and endovascular repair is planned for the other one. Spontaneously regressive functional hypoperfusion has been observed in 4/5 patients with progressive internal iliac embolisation. There was no irreversible renal insufficiency. Early results of endovascular aneurysm repair for extended indications are promising. Although the long-term outcome is unknown, it can already be said that traditional open surgery can be avoided for a considerable amount of time in an increasing number of patients.

Background: The treatment of infra-renal abdominal aortic aneurysms (AAA) with endovascular stent-graft prostheses is receiving increasing attention as an alternative to major abdominal surgery. Numerous systems are under clinical investigations. We report our preliminary clinical results with the new Talent straight and bifurcated endografts., Method: We treated 5 patients with 3 straight and 2 bifurcated stent-grafts implanted by surgical femoral arteriotomies and placed under fluoroscopic guidance. Control CT and angiographic examinations were performed during an average follow-up of 5.3 months., Results: In the first patient the procedure had to be converted to an open surgical operation to repo sition the distal end of the prosthesis. We had no mortality, or major systemic complication. Three patients had a postimplantation syndrome. All aneurysms showed a decreased size at 3 months, in spite of 3 small persisting leaks., Conclusion: The Talent endograft is safe, and efficacious in the endovascular treatment of AAA. This method requires a good cooperation between the vascular surgeon and the interventional radiologist. Learning curves influence preliminary results.

Congenital homocysteinuria is a rare inherited metabolic disorder with early onset atherosclerosis and arterial and venous trombosis. Moderate hyperhomocysteinemia is more frequently encountered and is recognized as an independent cardiovascular risk factor. Several case-control studies demonstrate an association between venous thromboembolism and moderate hyperhomocysteinemia. A patient with moderate hyperhomocysteinemia has a 2-3 relative risk of developing an episode of venous thromboembolism. The occurrence of mild hyperhomocysteinemia in heterozygotes for the mutation of Leiden factor V involves a 10-fold increase in the risk of venous thromboembolism. The biochemical mechanism by which homocysteine may promote thrombosis is not fully recognized. Homocysteine inhibits the expression of thrombomodulin, the thrombin cofactor responsible for protein C activation, and inhibits antithrombin-III binding. Treatment with folic acid reduces the plasma level of homocysteinemia, but no study has demonstrated its efficacy in reducing the incidence of venous thromboembolism or atherosclerosis. Hyperhomocysteinemia should be included in the screening of abnormalities of hemostasis and thrombosis in patients with idiopathic thromboembolism, and mild hyperhomocysteinemia may justify a trial of folic acid.

Chronic arterial insufficiency of the lower limbs is characterized by intermittent claudication often localized to the calf. These early clinical symptoms are the results of the atherosclerotic process of the vasculature of the lower extremities. The treatment is aimed at reducing or eliminating the ischemic pain and at preventing progression of the atherosclerotic disease. Whether surgical or nonsurgical measures are used, the cornerstone of patient care lies in correction of the risk factors. Smoking cessation and exercise therapy remain the fundamental measures in medical treatment of intermittent claudication. percutaneous transluminal angioplasty is an appropriate therapeutic option under certain criteria, especially for the iliac arteries. In the absence of randomized studies, surgery remains the treatment of choice for peripheral revascularization in presence of limb-threatening ischemia or ischemic ulcers. New procedures and materials are presently under trial to test the safety and efficacy of alternative methods or revascularization that would provide better long-term patency rates and shorter hospitalization periods.

Hypertension is well recognized as a risk factor that is associated with an increased incidence of stroke and myocardial infarction. The early detection of atherosclerosis is a real challenge and should be carried on at a cost and with a degree of risk and invasiveness that does not preclude its use in subjects with cardiovascular risk factors. For this purpose we have developed a non-invasive approach using a high resolution echotracking device making it possible to measure internal diameter and wall thickness of conduit arteries as well as their biomechanical properties. We present here a methodological overview of the system with a brief clinical study addressing the biomechanical properties of a medium size artery in hypertension as compared with normotension.

Pulse pressure waves are damped by the elastic properties of the blood vessels. This damping capacity can be evaluated by measuring vascular compliance a parameter which expresses changes of volume with respect to changes of pressure. Arterial compliance varies continuously with respect to intravascular pressure. Our group has developed an ultrasonograph which functions in the A mode capable of measuring the diameter of peripheral arteries during the cardiac cycle. This system is coupled to a photoplethysmograph which records non-invasively and continuously finger blood pressure. This enables construction of pressure-diameter graphs and the determination of arterial compliance and distensibility at each pressure value.

Genomic DNA extracted from heavily infiltrated spleens of 5 patients with hairy cell leukaemia was hybridized with genomic probes for immunoglobulin genes. The rearrangement pattern, correlating well with the immunohistochemical findings, was that of a clonal B-cell proliferation in all cases. Analysis of the lambda light chain genome with two different probes enabled more accurate localization of the clonal rearrangements within this genome. A small additional T-cell population identified in 3 cases was immunogenotypic of polyclonal (reactive) nature.