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STUDY QUESTION Can early pregnancies be accurately and cost-effectively diagnosed and managed using a new medical computerized tool? SUMMARY ANSWER Compared to the standard clinical approach, retrospective implementation of the new medical software in a gynaecological emergency unit was correlated with more accurate diagnosis and more cost-effective management. WHAT IS KNOWN ALREADY Early pregnancy complications are responsible for a large percentage of consultations, mostly in emergency units, with guidelines becoming complex and poorly known/misunderstood by practitioners. STUDY DESIGN, SIZE, DURATION A total of 780 gynaecological emergency consultations (446 patients), recorded between November 2018 and June 2019 in a tertiary university hospital, were retrospectively encoded in a new medical computerized tool. The inclusion criteria were a positive hCG test result, ultrasonographical visualization of gestational sac, and/or embryo corresponding to a gestational age of 14 weeks or less. Diagnosis and management suggested by the new computerized tool are named eDiagnoses, while those provided by a gynaecologist member of the emergency department staff are called medDiagnoses. PARTICIPANTS/MATERIALS, SETTING, METHODS Usability was the primary endpoint, with accuracy and cost reduction, respectively, as secondary and tertiary endpoints. Identical eDiagnoses/medDiagnoses were considered as accurate. During follow-up visits, if the updated eDiagnoses and medDiagnoses became both identical to a previously discrepant eDiagnosis or medDiagnosis, this previous eDiagnosis or medDiagnosis was also considered as correct. Four double-blinded experts reviewed persistent discrepancies, determining the accurate diagnoses. eDiagnoses/medDiagnoses accuracies were compared using McNemar’s Chi square test, sensitivity, specificity, and predictive values. MAIN RESULTS AND THE ROLE OF CHANCE Only 1 (0.1%) from 780 registered medical records lacked data for full encoding. Out of the 779 remaining consultations, 675 eDiagnoses were identical to the medDiagnoses (86.6%) and 104 were discrepant (13.4%). From these 104, 60 reached an agreement during follow-up consultations, with 59 medDiagnoses ultimately changing into the initial eDiagnoses (98%) and only one discrepant eDiagnosis turning later into the initial medDiagnosis (2%). Finally, 24 remained discrepant at all subsequent checks and 20 were not re-evaluated. Out of these 44, the majority of experts agreed on 38 eDiagnoses (86%) and 5 medDiagnoses (11%, including four twin pregnancies whose twinness was the only discrepancy). No majority was reached for one discrepant eDiagnosis/medDiagnosis (2%). In total, the accuracy of eDiagnoses was 99.1% (675 + 59 + 38 = 772 eDiagnoses out of 779), versus 87.4% (675 + 1 + 5 = 681) for medDiagnoses (P LIMITATIONS, REASONS FOR CAUTION The retrospective study design is a limitation. Some observed improvements with the medical software could derive from the encoding by a rested and/or more experienced physician who had a better ultrasound interpretation. This software cannot replace clinical and ultrasonographical skills but may improve the compliance to published guidelines. WIDER IMPLICATIONS OF THE FINDINGS This medical computerized tool is improving. A new version considers diagnosis and management of multiple pregnancies with their specificities (potentially multiple locations, chorioamnionicity). Prospective evaluations will be required. Further developmental steps are planned, including software incorporation into ultrasound devices and integration of previously published predictive/prognostic factors (e.g. serum progesterone, corpus luteum scoring). STUDY FUNDING/COMPETING INTEREST(S) No external funding was obtained for this study. F.B. and D.G. created the new medical software. TRIAL REGISTRATION NUMBER NCT03993015

Study question Can early pregnancies be accurately and cost-effectively diagnosed and managed using a new medical computerised tool, named “eDiagEPU”? Summary answer Compared to the standard clinical approach, the retrospective implementation of “eDiagEPU” in a gynaecological emergency unit was correlated with sharper diagnoses and more cost-effective managements. What is known already Early pregnancies complications are responsible for a large percentage of consultations, mostly in emergency units. Moreover, clinical guidelines updates for the management of Intrauterine Pregnancies of Uncertain Viability (IPUV) have become increasingly complex and seem to be unknown or misunderstood by several practitioners. Specifically, a recently published prospective multinational survey revealed a limited knowledge regarding early pregnancy guidelines, with 69.0% of the participants reporting incorrect managements of IPUV and 86.6% misinterpreting the evolution of serum human chorionic gonadotropin (hCG). In an attempt to aid practitioners with the diagnosis and management of early pregnancies, a software, named “eDiagEPU”, was developed. Study design, size, duration A total of 780 consultations, recorded between November 2018 and June 2019 in the gynaecological emergency unit of a tertiary university hospital, were retrospectively encoded in eDiagEPU. Positive hCG, ultrasonographical visualisation of gestational sac or/and embryo corresponding to a gestational age of 14 weeks gestation or less were the inclusion criteria. Diagnoses and managements suggested by eDiagEPU are named “eDiagnoses”. The ones provided by a gynaecologist member of the emergency department staff are called “medDiagnoses”. Participants/materials, setting, methods Identical eDiagnosis and medDiagnosis were considered as correct (gold standard). During follow-up examinations, if they became both identical to a previous discrepant eDiagnosis or medDiagnosis, this previous eDiagnosis/medDiagnosis was considered as correct. Persistent discrepancies were reviewed by four double-blinded experts whose majority defined the correct eDiagnosis/medDiagnosis. The accuracies of eDiagnoses/medDiagnoses were compared using McNemar’s Chi square test, computing diagnostic values (Sensitivity, Specificity, and predictive values) and 95% Confidence Intervals (CI). Cost reduction was also analysed. Main results and the role of chance Only one datum (0.1%) from 780 registered medical records was missing to process using “eDiagEPU”. Out of the 779 consultations that could be fully encoded until obtaining an eDiagnosis, 675 eDiagnoses were identical to the medDiagnoses (86.6%) and 104 discrepant (13.4%). From these 104, 60 reached an agreement during follow-up controls with 59 medDiagnoses finally changing into the initial eDiagnoses (98%) while only one discrepant eDiagnosis turning later into the initial medDiagnosis (2%). Finally, 24 remained discrepant at all subsequent checks and 20 were not reevaluated. Out of these 44 discrepancies without identical diagnoses/managements during follow-up controls, the double-blinded experts majority chose 38 eDiagnoses (86%) and 5 medDiagnoses (11%) including 4 twin pregnancies whose twinness was the only discrepancy. One discrepant eDiagnosis/medDiagnosis reached no majority (2%). In total, eDiagnoses accuracy was 99.1% (675 + 59 + 38=772 eDiagnoses out of 779 final diagnoses), vs 87.4% (675 + 1 + 5=681) for medDiagnoses accuracy (p Retrospectively, “eDiaEPU” was usable (99.9%), more accurate for each diagnosis except twinning report and more cost-effective than standard clinical approach. Limitations, reasons for caution The retrospective design is a limitation, as well as the quality of ultrasound interpretation. Some improvements could not derive exclusively from “eDiagEPU” but also from the encoding by a rested or more experienced physician. This software cannot replace clinical and ultrasonographical skills but can improve the diagnostic and therapeutic reasoning. Wider implications of the findings An improved “eDiagEPU” version, considering the diagnosis and management of multiple pregnancies with their specificities (potentially multiple locations, chorioamnionicity) has been developed. Prospective evaluations will be required. Further development steps are considered, including software incorporation into ultrasound devices and integration of previously published predictive/prognostic factors (serum progesterone, corpus luteum scoring...). Trial registration number NCT03993015

The best transportation strategy for patients with suspected large vessel occlusion (LVO) is unknown. Here, we evaluated a new regional strategy of direct transportation to a Comprehensive Stroke Center (CSC) for patients with suspected LVO and low probability of receiving intravenous thrombolysis (IVT) at the nearest Primary Stroke Center (PSC).Patients could be directly transported to the CSC (bypass group) if they met our pre-hospital bypass criteria: high LVO probability (i.e., severe hemiplegia) with low IVT probability (contraindications) and/or travel time difference between CSC and PSC15 minutes. The other patients were transported to the PSC according to a "drip-and-ship" strategy. Treatment time metrics were compared in patients with pre-hospital bypass criteria and confirmed LVO in the bypass and drip-and-ship groups.In the bypass group (n=79), 54/79 (68.3%) patients met the bypass criteria and 29 (36.7%) had confirmed LVO. The positive predictive value of the hemiplegia criterion for LVO detection was 0.49. In the drip-and-ship group (n=457), 92/457 (20.1%) patients with confirmed LVO met our bypass criteria. Among the 121 patients with bypass criteria and confirmed LVO, direct routing decreased the time between symptom discovery and groin puncture by 55 minutes compared with the drip-and-ship strategy (325 vs. 229 minutes, P0.001), without significantly increasing the time to IVT (P=0.19).Our regional strategy led to the correct identification of LVO and a significant decrease of the time to mechanical thrombectomy, without increasing the time to IVT, and could be easily implemented in other territories.

Forensic dentistry is the branch of forensic science concerned with the study of teeth and jaws. To facilitate the work of experts, new comparative identification tools are emerging, with digital techniques such as the intra-oral camera, which are revolutionising current techniques in forensic dentistry. Objective The aim of this study is to evaluate the diagnostic quality of the post-mortem odontogram carried out remotely via a video of the oral cavity using an intra-oral camera. The gold standard is the post-mortem odontogram obtained via the standard identification technique during the clinical examination. Materials and methods 25 deceased patients were included in the study and the data were collected in the Forensic Medicine and Thanatology Department at the University Hospital of Montpellier. The protocol was divided into three stages: the gold standard consultation, the recording of videos with the Soprocare® camera, and the remote analysis of the images obtained. The gold standard consultation and the remote analysis were carried out by two separate dental surgeons responsible for completing a clinical file, used to establish the odontogram of the deceased patient. Results The study was carried out on 25 deceased subjects, between 13 May and 12 June 2019. Our sample was composed of 68% men and 32% women. A sensitivity threshold of 0.97 was observed for the performance of the odontogram, i.e., for all the teeth actually present in the mouth for all subjects in the study, 97% of them were identified with the videos taken using the intraoral camera. The examination with the intra-oral camera demonstrated a good diagnostic performance in the detection of missing teeth with a PPV of 97.9% and a NPV of 98.2%. Practitioner became more skilled at recording the videos with the intra-oral camera. One can therefore note an ease in the handling of this digital tool, which gradually improved with the number of subjects included in the study Conclusions The Soprocare® intraoral camera has an acceptable diagnostic validity in establishing the odontogram of the deceased. It enables fundamental elements to be detected with optimal efficiency. However, several points still need to be improved, in order to make the use of the camera during data collection as easy and efficient as possible.

Aims Intra-aortic balloon pump (IABP) utilization was expected to be quickly abandoned following the IABP-shock trial and its class III, level B of recommendation in the 2016 ESC guidelines. The aim of this study was to evaluate the use of IABP compared to other mechanical support devices in a nationwide approach. Methods We conducted a retrospective study based on the French national hospital discharge database. All patients implanted by an assist device either by IABP, extracorporeal membrane oxygenation (ECMO) or IMPELLA® from 2014 to 2018 (2 years before/2 years after the 2016 guidelines) were included. The primary endpoint was the incidence of IABP implantation over the years. Secondary endpoints were incidence of total assist devices implantations, ECMO and IMPELLA® implantation. Results From 2014 to 2018, a total of 18,872 patients benefited from mechanical support by IABP (n=6,637, 35.2%), ECMO (n=11,833, 62.7%) or IMPELLA® (n=402, 2.1%) in France. The incidence of total mechanical support implantations (ECMO and IABP) was constant over the years. IABP implantation decreased progressively from 1,725 implantations in 2014 to 976 in 2018 (−44%). By contrast, ECMO implantation increased progressively from 1,919 implantations in 2014 to 2,715 implantations in 2018 (+42%). IMPELLA® implantations remained stable over the years from 63 (1.7%) implantations in 2014 to 83 (2.1%) in 2018. Conclusion In this nationwide real-life study, despite a significant decline in IABP implantations over the years since the ESC guidelines, this device remained used in clinical practice with around 1,000 implantations in 2018. The size of the centers is not strictly correlated with this use, suggesting differential uses depending of the local background. Funding Acknowledgement Type of funding source: None

Introduction L’amelioration du pronostic a court terme des patients atteints de vascularites, grâce aux strategies combinant la corticotherapie et les traitements immunosuppresseurs, a vu emerger l’interet de mieux caracteriser les comorbidites des patients. Les comorbidites s’ajoutent aux atteintes d’organes secondaires a la vascularite et pourraient en modifier le pronostic. Peu de donnees sont disponibles sur l’impact des comorbidites sur l’evolution de la vascularite et la qualite de vie. L’objectif de ce travail etait de determiner l’association entre les comorbidites a l’inclusion et le pronostic des patients. Patients et methodes Les patients suivis pour vascularites associees aux ANCA, dont la granulomatose avec polyangeite (GPA), la granulomatose eosinophilique avec polyangeite (GEPA) et la polyangeite microscopique (PAM), ont ete inclus prospectivement dans une etude de soins courant evaluant les comorbidites et les sequelles (cohorte OSTEOVAS). La mesure de la densite minerale osseuse, la composition corporelle et le contenu en tissu adipeux visceral (VAT) et sous-cutane (SAT) ont ete calcules par absorptiometrie biphotonique a rayons-X. Les scores du VDI, le HAQ et le SF36 ont ete calcules a l’inclusion. Le critere de jugement principal (CJP) etait un critere composite defini par la survenue de deces, d’evenements indesirables graves (EIG) attribuables au traitement ou d’une rechute majeure de la vascularite a 3 ans. Le CJP a ete analyse par un modele de Cox, et l’association aux scores par des modeles lineaires. En criteres secondaires, nous avons etudie l’association entre les comorbidites et les scores de qualite de vie et de sequelles. Resultats Un total de 103 patients (57 femmes, âge moyen 52,4 ± 17,4 ans, duree moyenne de la maladie 6 ans ± 6,4) a ete suivi au moins 3 ans, incluant 62 patients avec GPA, 29 GEPA, et 12 PAM. A 3 ans de suivi, 37 patients (36 %) ont atteint le CJP: EIG attribuable au traitement (n = 26), rechute majeure (n = 10) ou deces (n = 6). En analyse univariee, comparativement a un taux de pre albumine inferieur a 0,2 g/l, un taux de pre-albumine superieur a 0,4 g/l a l’inclusion etait significativement associe a une moindre survenue d’un evenement a 3 ans (HR = 0,18 [0,08–0,31]; p = 0,007), alors qu’un taux normal ne l’etait pas. L’osteoporose (presente chez 27 %) (HR 1,73 [0,69–4,12]; p = 0,11) et la sedentarite (presente chez 21 %) (HR 1,78 [0,71–4,53]; p = 0,12) tendaient a etre associees au CJP. Parmi les criteres de jugement secondaires, l’hypertension arterielle (HTA), la sedentarite et le tertile superieur du ratio VAT/SAT etaient significativement associes au retentissement fonctionnel de la vascularite (HAQ eleve a l’inclusion, p Conclusion L’etat nutritionnel evalue par la prealbumine, l’osteoporose et la sedentarite semblent avoir un impact important sur la qualite de vie et le devenir des patients atteints de vascularite systemique, en termes de complications et de sequelles. Le contenu en tissu adipeux visceral et l’HTA pourraient avoir un impact sur le handicap fonctionnel et les capacites physiques des patients.

Introduction Le syndrome de Sjogren primaire (pSS), la polyarthrite rhumatoide (PR) et le lupus erythemateux systemique (LES) sont les trois maladies auto-immunes (MAIs) les plus frequentes. L’evaluation de l’activite de ces MAIs en pratique clinique est parfois complexe. Il existe donc un reel besoin de nouveaux biomarqueurs impliques dans leur physiopathologie et refletant leur activite. L’objectif de ce travail etait d’identifier des biomarqueurs correles a l’activite du pSS selon le score ESSDAI, a l’activite de la PR selon le score DAS28-CRP, et a l’activite du LES selon le score SLEDAI. Patients et methodes Nous avons recrute prospectivement des patients suivis pour un pSS, une PR ou un LES au centre hospitalier universitaire de Montpellier. Les concentrations seriques de 63 biomarqueurs, impliques dans les processus inflammatoires ou immunologiques, ont ete mesurees pour chaque patient. Le kit Bio-Plex Pro™ Human Inflammation Panel 1, 37-Plex (BioRad) a ete utilise. Tous les tests ELISA ont d’abord ete valides pour la reproductibilite et la sensibilite avant d’effectuer le dosage serique des patients. Les tests de biomarqueurs ont ete effectues en double pour chaque echantillon, selon les recommandations des fabricants. Le test de correlation entre la concentration des biomarqueurs et les scores d’activite a ete effectue a l’aide du test de correlation de Spearman. Resultats On observait une correlation significative entre l’activite du pSS et les concentrations de sCD163 (r = −0,3386), sgp130 (r = −0,3792), MPIF-1/CCL23 (r = −0,3335) et SCYB16/CXCL16 (r = −0,3072). L’activite de la PR etait significativement correlee aux concentrations de TPS2 (r = −0,4239) et sTNF-R1 (r = −0,4443). L’activite du LES etait significativement correlee aux concentrations de BDNF (r = 0,4954), SPARC (r = 0,5435), GM-CSF(r = 0,4631) et SDF1a + b/CXCL12 (r = 0,4034). Conclusion Nous avons donc identifie des biomarqueurs associes a l’activite du pSS, de la PR et du LES, qui pourraient etre specifiquement impliques dans la physiopathologie de ces MAIs. Devant la divergence des donnees de la litterature, et le caractere novateur de certains biomarqueurs, des etudes complementaires semblent necessaires pour valider l’utilisation ces biomarqueurs en pratique clinique.

Introduction Le syndrome de Sjogren primaire (pSS) est une maladie auto-immune heterogene complexe qui peut etre difficile a differencier de la polyarthrite rhumatoide (PR) ou du lupus erythemateux systemique (LES). Le manque de specificite des anticorps anti-SSa/SSb et l’association du syndrome de Sjogren avec ces deux maladies auto-immunes (AID) peuvent parfois rendre le diagnostic du pSS difficile. De nouveaux biomarqueurs diagnostiques et pronostiques sont necessaires pour mieux caracteriser le pSS. L’objectif de ce travail etait d’identifier des biomarqueurs discriminant le pSS de la PR et du LES. Patients et methodes Nous avons recrute prospectivement des patients suivis pour un pSS, une PR ou un LES au centre hospitalier universitaire de Montpellier. Tous les patients repondaient aux criteres diagnostiques ACR/EULAR pour chaque MAI et le recueil des informations cliniques et biologiques a ete realise de facon prospective. Les concentrations seriques de 63 biomarqueurs, impliques dans les processus inflammatoires ou immunologiques, ont ete mesurees pour chaque patient. Le kit Bio-Plex Pro™ Human Inflammation Panel 1, 37-Plex (BioRad) a ete utilise. Tous les tests ELISA ont d’abord ete valides pour la reproductibilite et la sensibilite avant d’effectuer le dosage serique des patients. Une analyse multivariee par regression logistique multiple a ete effectuee, et ajustee en fonction de l’âge pour le LES. Resultats La probabilite de pSS par rapport a la PR etait associee a l’augmentation des concentrations de BDNF (OR = 0,493 [0,273–0,891]) et I-TAC/CXCL11 (OR = 1,344 [1,027–1,76]). La probabilite de pSS par rapport au LES etait associee a l’augmentation des concentrations de sCD163 (OR = 0,803 [0,649–0,994]), Fractalkine/CX3CL1 (OR = 0,534 [0,287–0,991]), MCP-1/CCL2 (OR = 0,839 [0,732–0,962]) et TNF-a (OR = 0,479 [0,247–0,928]). L’association de concentrations faibles de BDNF et Fractalkine/CX3CL1 etait specifique du pSS (96,2 % ; VPP 80 %) mais peu sensible (19 %). Conclusion Le pSS possede donc une signature proteique serique differente de la PR et du LES. Nos resultats suggerent des mecanismes physiopathologiques specifiques pour le pSS. Des etudes complementaires sont cependant necessaires pour valider l’utilisation de ces biomarqueurs en pratique clinique.

Background:Joint replacement is a therapeutic option increasingly widespread among osteoarthritis (OA) patients. Besides improving operating techniques and postoperative management, it is important to pursue the best preoperative conditions in order to achieve the desired result. As physical activity (PA) potentially acts on the preoperative predictors, knowing the effect of leisure and occupational PA should be of great interest to obtain a positive outcome.Objectives:To investigate the influence of preoperative PA on the clinical outcomes of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in OA patients.Methods:Data from the Knee and Hip OsteoArthritis Long-term Assessment (KHOALA) cohort (1), a multi-regional French cohort of 878 patients with symptomatic hip and/or knee OA, were analysed. We included in our study patients undergoing THA or TKA during a 7-year-follow-up period. The level of total and leisure-time preoperative PA was measured with the Modifiable Activity Questionnaire (MAQ). Outcomes were measured one year after surgery. For the primary endpoint, quality of life (QoL) was measured with the OsteoArthritis Knee and Hip Quality Of Life questionnaire (OAKHQOL). For secondary endpoints, QoL was measured with Short Form 36 (SF-36), pain with the Visual Analogue Scale (VAS), function with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and with walking distance. The population characteristics were described using frequency or mean and standard deviation (SD), depending on the distribution of the variable. Association between exposures and outcomes was calculated with a multivariate linear analysis with backward selection, adjusting for confounders (age, sex, body mass index, site of joint replacement, polyarticular OA, OA duration, comorbidities, radiological grade of OA, inclusion centre, rehabilitation after surgery, previous joint issues, instruction level). A p-value Results:150 patients were included. 58.7% underwent TKA and 41.3% THA. The mean age at the time of surgery was 66.6 years (±7.7 SD). The majority of patients were female (75%), overweight (mean BMI 29.63 kg/m2, ±5.5 SD) and had polyarticular OA (60%). 53% of patients met the World Health Organization recommendations on PA before surgery. For the primary endpoint, a high preoperative total PA was associated with a better relationship with the partner (β = 0.55, p = 0.02) one year after surgery. As for secondary endpoints, a high two-year preoperative total PA was associated with an impaired SF-36 Mental Component Summary score (β = -0.87, p = 0.02), but a longer walking distance (β = 442.81, p < 0.01). Leisure-time PA also showed a positive impact on walking distance (β = 76.25, p = 0.02), but a negative one on social functioning in SF-36 (β = -0.47, p = 0.01). No statistically significant association between preoperative PA and pain nor WOMAC was found.Conclusion:In this cohort study, the preoperative level of PA demonstrated a heterogeneous effect on the various aspects of QoL one year after THA and TKA in OA patients. Preoperative PA was directly associated with gain of function, measured as walking distance, after surgery. Considering the increasing prevalence of OA and the crucial role of PA on health, further studies on this relevant topic are needed.References:[1]Guillemin F, Rat A-C, Roux CH, Fautrel B, Mazieres B, Chevalier X, et al. The KHOALA cohort of knee and hip osteoarthritis in France. Joint Bone Spine. 2012 Dec 1;79(6):597–603.Disclosure of Interests:Enrica Vandelli: None declared, Claire Duflos: None declared, Sandrine Akouete: None declared, Francis Guillemin Grant/research support from: Francis Guillemin received a grant from Expanscience paid to his institution., Anne-Christine Rat: None declared, Yves-Marie Pers: None declared

Introduction Les inhibiteurs de l’enzyme de conversion (IEC) et les sartans induisent des angiœdemes (AE) par defaut de catabolisme enzymatique bradykinique chez 0,1 a 2,2 % des patients traites (10 % de reaction croisee IEC/sartans). Un AE aux IEC/sartans (AE-IEC) est evoque devant tout AE chez un patient sous IEC/sartans ou en ayant pris dans les 6 mois precedents, avec un taux de C1-inhibiteur normal, les contre-indiquant a vie. Des recidives d’AE-IEC malgre l’arret de l’IEC sont decrites (50 % des cas apres arret de l’IEC, surtout le 1er mois). Devant toute persistance/recidive des AE plus de 6 mois apres l’arret des IEC, le diagnostic d’urticaire chronique (UC) sous forme d’AE histaminiques isoles doit etre evoque. La presence d’urticaire superficielle associee est un argument diagnostique, les AE histaminiques isoles ou inauguraux sont decrits (respectivement 10 et 40 % des UC). L’UC ne contre-indique pas la reprise de l’IEC/sartan. Aucun marqueur biologique ne permet actuellement de differencier les AE sous IEC dans le cadre d’une UC et les AE-IEC. Leur pronostic et traitement sont tres differents. L’objectif principal de cette etude etait d’evaluer l’imputabilite des IEC/sartans dans une population de patients presentant des AE sous IEC/sartans et d’identifier d’eventuels facteurs predictifs d’AE-IEC. Patients et methodes Etude retrospective monocentrique incluant tous les patients sous IEC/sartan consultant pour AE isoles entre 2007 et 2017, a C1-inhibiteur normal, avec recueil de donnees cliniques a M0 et M6 ou plus. Les donnees epidemio-cliniques etaient comparees entre les groupes AE-IEC et UC avec les tests de Fisher et de Student. Resultats Soixante-dix patients ont ete inclus entre 2007 et 2017, 56 (80 %) sous IEC et 14 (20 %) sous sartans, dont 44,3 % de femmes, d’âge moyen de 69 ans. Le traitement etait arrete chez 65 (91,4 %) patients et une UC diagnostiquee chez les 5 patients l’ayant poursuivi. Trente-deux (45,7 %) patients ont rechute apres 5,1 semaines en moyenne. Une urticaire superficielle secondaire est survenue chez 14 (20 %) patients. Une UC etait diagnostiquee a posteriori chez 33 (47,1 %) patients versus 34 (48,6 %) AE-IEC, 3 patients ont ete perdus de vue (4,3 %). Parmi les donnees suivantes : âge (p = 0,15), sexe (p = 0,09), terrain atopique personnel (p = 0,79), dysthyroidie auto-immune (p = 1), delai de survenue apres introduction du traitement (p = 0,15), duree des AE (p = 0,75), presence d’une atteinte endobuccale (p = 0,239) ou d’une toux aux IEC (p = 0,49), seul l’antecedent d’urticaire etait predictif du diagnostic final d’UC (p = 0,023). Conclusion Tous les patients consultant pour AE isole(s) survenu(s) sous IEC/sartan devraient etre revus apres 6 mois d’arret pour proposer une re-introduction de traitement cardio/nephroprotecteur en cas de diagnostic final d’UC. Seul l’antecedent d’urticaire a ete retrouve comme facteur predictif d’UC dans cette etude retrospective.

La ginecologia pediatrica trata a la nina prepuber y a la joven adolescente. La exploracion fisica, fundamental en la valoracion de los problemas ginecologicos de esta edad, conlleva ciertas especificidades. En este articulo se desarrolla su realizacion con el objetivo de que el medico pueda conseguir las informaciones mas precisas sin trauma para la nina. Las vulvitis y las afecciones vulvares benignas son un motivo frecuente de consulta en ginecologia pediatrica. Se detallan aqui sus caracteristicas y su tratamiento. Las hemorragias genitales prepuberales se deben, el alrededor del 70% de los casos, a una causa local vulvar o vaginal identificable desde la primera exploracion. Las causas hormonales, mucho mas raras, estan representadas por los quistes y tumores ovaricos secretores. Los trastornos del ciclo afectan al 75% de las adolescentes, ya se trate de dismenorrea, menorragias, espaniomenorrea o incluso de amenorrea. Abarcan un amplio campo de etiologias, desde los trastornos funcionales hasta patologias graves. La patologia mamaria de la adolescente es el resultado de una anomalia de la embriogenesis o del desarrollo de la glandula mamaria. Esta dominada por las anomalias morfologicas y la patologia tumoral benigna. El cancer a esta edad es muy excepcional.

Resume Objectif Evaluer les performances de l’IRM fonctionnelle (IRMF) effectuee par des radiologues generalistes (RG) dans la detection de l’extension extracapsulaire lobe specifique (EECLS) du cancer de la prostate (CaP). Methode Nous avons analyse retrospectivement 79 patients ayant eu une IRMF avec antenne pelvienne avant une prostatectomie radicale (PR) realisee au CHU de Nimes. Douze RG (dont trois au CHU) ont interprete les images durant leur pratique quotidienne. Les resultats de l’IRMF ont ete dichotomises en positif ou negatif et confrontes a l’anatomopathologie pour l’EECLS et l’envahissement des vesicules seminales lobe specifique (EVSLS), avec calcul des valeurs diagnostiques. L’influence du delai entre biopsie et IRMF, de la sequence de diffusion et de l’intensite de l’IRMF sur les performances diagnostiques ont ete evaluees par un test de Fisher. Resultats Une EECLS et un EVSLS ont ete observes a l’IRMF et a l’anatomopathologie respectivement sur 14 (8,8 %) et 38 (24,1 %) lobes prostatiques et sur six (3,8 %) et sept (4,4 %) lobes prostatiques. La sensibilite, specificite, les valeurs predictives positives et negatives de l’IRMF pour l’EECLS etaient respectivement de 24 %, 96 %, 64 % et 80 % ; et pour l’EVSLS de 14 %, 97 %, 17 % et 96 %. Le delai entre biopsie et IRMF, l’intensite de l’IRMF et la sequence de diffusion, n’influencaient pas la sensibilite et la specificite de l’IRMF au test de Fisher. Conclusion Cette etude a observe que l’IRMF prostatique preoperatoire realisee par des RG avait une bonne specificite, mais une sensibilite mediocre dans la prediction de l’EEC lobe specifique presente sur la piece de PR.

Resume La gynecologie pediatrique concerne l’enfant prepubere et la jeune adolescente. L’examen clinique, qui est fondamental dans l’evaluation des problemes gynecologiques de cet âge, comporte des specificites. Sa conduite est developpee dans la premiere partie afin que le praticien puisse obtenir les informations les plus precises sans traumatisme pour l’enfant. Les vulvites et les affections vulvaires benignes sont un motif frequent de consultation en gynecologie pediatrique. Leurs caracteristiques et leurs prises en charge sont detaillees. Les saignements genitaux prepubertaires sont dus sept fois sur dix a une cause locale vulvaire ou vaginale identifiable des le premier examen clinique. Les causes hormonales beaucoup plus rares sont representees par les kystes et tumeurs ovariens secretants. Les troubles du cycle affectent 75 % des adolescentes, qu’il s’agisse de dysmenorrhee, menorragies, spaniomenorrhee voire amenorrhee. Ils recouvrent tout un champ d’etiologies qui va de troubles fonctionnels a des pathologies severes. La demarche diagnostique et la prise en charge therapeutique selon l’etiologie sont analysees. Enfin, la pathologie mammaire de l’adolescente resulte d’une anomalie de l’embryogenese ou de developpement de la glande mammaire. Elle est dominee par les anomalies morphologiques et la pathologie tumorale benigne. Le cancer a cet âge est tres exceptionnel.

Introduction Chez les patients insuffisants cardiaques, les facteurs pronostiques de mortalite bien connus sont cliniques. La Haute Autorite de sante met aussi l’accent sur les facteurs organisationnels modifiables, qui pourraient etre d’autres facteurs pronostiques. Notre objectif est de caracteriser les grands types de parcours intra-hospitaliers pour la prise en charge de l’insuffisance cardiaque. Methodes Cette etude observationnelle retrospective sur dossiers a inclus tous les patients âges de plus de 65 ans, hospitalises pour insuffisance cardiaque (GHM 05M09, severite 1 a 4) a Lariboisiere durant 2013. Les variables ont ete recueillies a partir du PMSI et des dossiers medicaux. Les variables cliniques etaient : donnees demographiques, presentation clinique, diagnostic d’entree, comorbidites. Les variables de parcours etaient : unites frequentees, duree de sejour, modes d’entree et de sortie, realisation de procedures diagnostiques, traitement de sortie. Ces dernieres ont ete utilisees pour grouper les patients par une classification ascendante hierarchique sur les facteurs d’une analyse des correspondances multiples. Resultats La classification retenue donne cinq groupes. Les patients du groupe 1 ( n = 57) entrent par transfert, passent en USIC puis en cardiologie, et recoivent les prises en charges les plus proches des recommandations. Les patients du groupe 2 ( n = 15) passent plus souvent dans trois ou quatre unites differentes, et leur prise en charge est tres variable. Les patients du groupe 3 ( n = 70) passent dans une seule unite, dont deux tiers en cardiologie, et ont une bonne prise en charge. Les patients du groupe 4 ( n = 18) entrent frequemment via les urgences, ont un sejour long, et decedent lors du sejour. Les patients du groupe 5 ( n = 63) entrent via les urgences, ne sont pas hospitalises en cardiologie, et ont une prise en charge moins specialisee. Discussion/conclusion Nous identifions deux groupes de patients pour lesquels la prise en charge ne semble pas optimale selon les recommandations en vigueur. La complexite du sejour et l’absence de prise en charge cardiologique pourraient etre en cause. Cette hypothese peut ouvrir des pistes d’amelioration des parcours.

Resume La gynecologie pediatrique concerne l’enfant prepubere et la jeune adolescente. L’examen clinique, qui est fondamental dans l’evaluation des problemes gynecologiques de cet âge, comporte des specificites. Sa conduite est developpee dans la premiere partie afin que le praticien puisse obtenir les informations les plus precises sans traumatisme pour l’enfant. Les vulvites et les affections vulvaires benignes sont un motif frequent de consultation en gynecologie pediatrique. Leurs caracteristiques et leurs prises en charge sont detaillees. Les saignements genitaux prepubertaires sont dus sept fois sur dix a une cause locale vulvaire ou vaginale identifiable des le premier examen clinique. Les causes hormonales beaucoup plus rares sont representees par les kystes et tumeurs ovariens secretants. Les troubles du cycle affectent 75 % des adolescentes, qu’il s’agisse de dysmenorrhee, menorragies, spaniomenorrhee voire amenorrhee. Ils recouvrent tout un champ d’etiologies qui va de troubles fonctionnels a des pathologies severes. La demarche diagnostique et la prise en charge therapeutique selon l’etiologie sont analysees. Enfin, la pathologie mammaire de l’adolescente resulte d’une anomalie de l’embryogenese ou de developpement de la glande mammaire. Elle est dominee par les anomalies morphologiques et la pathologie tumorale benigne. Le cancer a cet âge est tres exceptionnel.

Localized breast lesions have been described in lupic or diabetic patients. However, the description of breast gigantomastia in women presenting with autoimmune diseases has not been reported.The study took place within the Department of Endocrinology and Reproductive Medicine, Necker Hospital, Paris, France.We describe eight patients with inflammatory gigantomastia, occurring in a context of immune-mediated diseases: myasthenia, chronic arthritis, or thyroiditis.Together with hormonal, immunological, and breast magnetic resonance imaging (MRI) evaluation, breast histology enabled us to perform immunocytochemical and indirect immunofluorescence studies. Control sera were obtained from patients with (n = 10) and without (n = 7) antinuclear antibodies.Six of the eight patients developed gigantomastia either at puberty or during pregnancy. Neither a hormonal oversecretion nor a specific immunological pattern was observed. All patients except one presented antinuclear antibodies. Histological study revealed a diffuse, stromal hyperplasia and a severe atrophy of the lobules. A rarefaction of adipocytes was also noted, as previously suggested on MRI. There was a perilobular lymphocytic infiltrate made of CD3+ lymphocytes. Study of sera from five of six cases of gigantomastia showed a nuclear immunofluorescence pattern in normal mammary ductal and lobular glandular epithelium, as well as in kidney and intestine epithelial cells. In control sera, a nuclear signal was observed only when antinuclear antibodies were present.We suggest that breast tissue may be a target tissue in autoimmune diseases, this process being favored by the hormonal milieu. However, the precise mechanism of such association is not individualized. The fact that stromal hyperplasia is the main histological feature justifies the search for the involvement of growth factors in such a process.

Resume Les thrombopenies secondaires aux chimiotherapies anticancereuses peuvent provoquer des hemorragies genitales severes au cours de l’adolescence. Un traitement œstroprogestatif entrainant une amenorrhee therapeutique est possible, mais peut augmenter les risques thromboemboliques et hepatiques de certaines chimiotherapies. Objectifs de l’etude. – Evaluer retrospectivement le risque d’hemorragie genitale pour des adolescentes presentant une thrombopenie severe apres chimiotherapie. Patientes et methodes. – Parmi les 140 jeunes filles âgees de 12 a 18 ans traitees entre 1991 et 1998 par chimiotherapie, 24 jeunes filles puberes ayant presente au moins un episode de thrombopenie severe (taux de plaquettes Resultats. – Six adolescentes sur 24 ont recu un traitement preventif œstroprogestatif. Un seul episode d’hemorragie genitale, sans risque vital associe, a ete observe, chez une adolescente ne recevant pas de traitement hormonal preventif. Trente-trois pour cent des patientes presentaient une amenorrhee spontanee avant la chimiotherapie et 17 % une insuffisance ovarienne secondaire definitive. Conclusion. – Le risque hemorragique est faible chez les adolescentes soumises a une chimiotherapie entrainant une thrombopenie. L’amenorrhee observee frequemment au debut du traitement, qu’elle soit fonctionnelle en rapport avec l’amaigrissement ou secondaire a la toxicite de la chimiotherapie, rend discutable la necessite d’un traitement hormonal preventif.

Long cycles and excessive uterine bleeding are the most common menstrual disorders in adolescents. Long cycles usually result from a benign transitory functional disorder which spontaneously resolves within two to three years after menarche; however, this diagnosis can only be retained in the absence of hirsutism or galactorrhea as revealing symptoms of functional ovarian hyperandrogenism, polycystic ovary syndrome, late form of congenital adrenal hyperplasia or hyperprolactinemia; ovarian failure will be considered in case of isolated long cycles persisting more than two years after menarche. Excessive uterine bleeding usually occurs early after menarche. Although the main cause is functional, resulting from anovulation and the related absence of progesterone, coagulation disorders must always be excluded. Management of these disorders are described.

To determine the clinical characteristics of pubertal metrorrhagia and its treatment, depending on severity; to evaluate the frequency of etiologies and the influence of hemostatic abnormalities; and to describe severe pubertal metrorrhagia. Design, setting and participants. This retrospective study examined all the files (n = 105) of adolescents presenting for pediatric gynecology consultation at a children's hospital between January 1979 and June 1993.The mean age of patients at the first consultation was 13 years. Metrorrhagia began in the year after the first menstrual period in 85% of cases. The causes were functional (83 cases), primary hemostatic disorder (14 cases), hemostatic disorder secondary to renal or hepatic disease (7 cases), or tumor (1 case). The cases were assigned to one of three groups, according to the severity of anemia; group I, mild anemia, hemoglobin Hb11 g%, 64 cases; group II, moderate anemia, Hb 8-11 g%, 23 cases; and group III, severe anemia, Hb8 g%, 18 cases. Of the 14 patients suffering from primary hemostatic disorders, 7 had been diagnosed before the onset of metrorrhagia; the disorder was revealed by the metrorrhagia in the remaining 7. Only 1 of these patients was severely anemic (known factor X deficiency). Four patients suffering from moderate von Willebrand's disease were discovered after specific tests; they were mildly or moderately anemic. The severe anemias (group III) all occurred during the first three periods. This group had functional disorders in 15 of 18 cases. Treatment continued to be required in 10 of 18 cases followed for more than 3 years. Treatment was progestin for group I and II patients or an estroprogestin, followed by a progestin, for group III. Curettage was never required.The most common cause of pubertal metrorrhagia is a functional disorder (80% of cases). Hemostatic disorders likely to cause severe menstrual hemorrhage were known before the age of menarche; these disorders must be controlled by hormone treatment begun before or at the time of the first menstrual period. Severe forms that arise during the initial three menstrual cycles are functional in most cases. These should be given a course of treatment lasting several years. There is a high risk of recurrence. Treatment is medical and hormonal in all cases.

Resume La coalescence des petites levres est une affection frequente, benigne et asymptomatique de la petite fille. Que le decollement soit fait avec ou sans pommade anesthesiante, avec ou sans preparation par les estrogenes ou sous anesthesie generale, il est toujours inutile, souvent traumatisant et dans la majorite des cas suivi de recidive. L’accolement regresse toujours spontanement au cours de l’enfance ou au plus tard lors des premieres modifications vulvaires qui accompagnent le demarrage pubertaire.

Summary Objective The efficacy and safety of height-limiting therapy with high-dose 17 β -oestradiol in girls with constitutionally tall stature (CTS) are controversial. We evaluated the effectiveness of high-dose 17 β -oestradiol in premenarchal girls with CTS treated until their bone age reached 14 years. Design We retrospectively reviewed the medical records of the girls managed between 1989 and 2000 with high-dose 17 β -estradiol for CTS with a predicted final height greater than +3SDs. Patients Tw enty-six girls met our inclusion criteria. At baseline, mean chronological age was 12·06 ± 1·51 years and mean height was 171·1 ± 6·5 cm with a height standard deviation score of 4·5 ± 0·24, and mean predicted final height was 183·0 ± 4·2 cm. Treatment was stopped when bone age reached 14 years; mean treatment duration was 1·62 ± 0·76 years. Measurements The following were obtained at 6-month intervals: height, body weight, Tanner stage, bone age, plasma cholesterol and triglycerides, plasma glucose and side effects. A mailed questionnaire on final height and satisfaction was sent 2 years after treatment discontinuation (response rate, 24/26). Results Final height was significantly ( P < 0·001) reduced, by 2·4 ± 3·2 cm, as compared to predictions. High-dose 17 β -estradiol therapy decreased growth velocity and significantly increased skeletal maturation ( P < 0·001). Linear growth after treatment discontinuation was 3·3 ± 1·9 cm. No serious side effects were recorded. Most of the patients were satisfied with the treatment. Conclusion High-dose 17 β -estradiol was moderately effective in reducing final height and should probably be reserved for selected patients, particularly as knowledge on potential long-term side effects is lacking.

Fibroadenomas and breast growth disorders are the most common breast diseases in adolescent women. Assessment of breast disorders in this age group generally involves clinical evaluation through history and physical examination and when is needed ultrasonography. Due to the absence of breast cancer in adolescent women, it is easy to reassure women at the first consultation. Breast growth disorders can lead great psychological and physical embarrassment. Treatment consists of surgical procedures when the cosmetic defect is severe. According to the ANDI classification, small fibroadenomas are normal, clinical fibroadenomas are a mild aberration of the normal processes, and giant or multiple fibroadenomas are placed to the disease end of the spectrum. Fibroadenomas can be treated conservatively provided diagnosis is confident. Giant fibroadenomas are treated by surgical enucleation. Breast abscess is mainly due to the duct ectasia. In adolescence, ectasia has been described as an exaggeration of sinus duct development and can be considered as a variant of normality. Diseases of the adolescent breast are usually benign and their management are simple using medical strategy and more rarely surgical therapy.

Fibroadenomas and breast growth disorders are the most common breast diseases in adolescent women. Assessment of breast disorders in this age group generally involves clinical evaluation through history and physical examination and when is needed ultrasonography. Due to the absence of breast cancer in adolescent women, it is easy to reassure women at the first consultation. Breast growth disorders can lead great psychological and physical embarrassment. Treatment consists of surgical procedures when the cosmetic defect is severe. According to the ANDI classification, small fibroadenomas are normal, clinical fibroadenomas are a mild aberration of the normal processes, and giant or multiple fibroadenomas are placed to the disease end of the spectrum. Fibroadenomas can be treated conservatively provided diagnosis is confident. Giant fibroadenomas are treated by surgical enucleation. Breast abscess is mainly due to the duct ectasia. In adolescence, ectasia has been described as an exaggeration of sinus duct development and can be considered as a variant of normality. Diseases of the adolescent breast are usually benign and their management are simple using medical strategy and more rarely surgical therapy.

Six-week-old male rats were placed on two high calcium regimens: one with calcium carbonate and monobasic calcium phosphate, with calcium content increased via calcium carbonate; and another with calcium phosphate and calcium gluconate, with calcium gluconate the source of increased calcium. Animals fed the gluconate-containing diets absorbed 29% of the ingested calcium over the entire calcium intake range, whereas those fed the calcium carbonate diets absorbed 25% over an intake range of 225 to 450 mg Ca/d, but at calcium intakes above 450 mg Ca/d their absorption reached a plateau at approximately 109 mg/d. Active calcium transport decreased with increased calcium intake in both the calcium carbonate- and calcium gluconate-fed groups. Nonsaturable transport was unchanged as a result of increasing calcium intake and did not differ among the diet groups. Because the absorptive processes were unaffected by the calcium source, events in the lumen must have been responsible for the observed differences. Because phosphate is nearly 18 times more soluble than carbonate, very little calcium of calcium carbonate origin can have been solubilized in the presence of phosphate and this, we conclude, accounts for the limit on calcium absorption observed in diets high in calcium carbonate. Moreover, when intake is expressed as soluble calcium, absorption approaches 50%, the value expected when intestinal transit time (approximately 3 h) is multiplied by 16%/h, the experimental value of nonsaturable absorption.

Ein 9jahriges Madchen wurde in die senologische Sprechstunde uberwiesen wegen einer seit 3 Monaten bestehenden Schwellung und lividen Verfarbung der linken Mamille, welche trotz lokaler antibiotischer, antimykotischer und Steroid-Therapie persistierte. Ipsilateral in der Axilla fanden sich einige vergroserte dolente Lymphknoten. Die genaue Anamneseerhebung ergab, das das Machen 4 Wochen vor Auftreten der Mamillenveranderung an der linken Mamma von einer Zecke gebissen wurde. Die Borrelien-Serologie ergab folgende Werte: IF-Abs-Test 5120 (normal bis 40), IF abs IgM 80, P39 EIA grenzwertig. Der Western-Blod auf Borrelia burgdorferi fiel im IgG- und IgM-Bereich positiv aus, wodurch eine Borreliose serologisch gesichert war. Histologisch konnte bei einer aus der linken Mamille entnommenen Probebiopsie die klinische Diagnose einer Lymphadenosis cutis benigna Bafverstedt nach Zeckenbis bestatigt werden. Unter systemischer antibotischer Therapie mit Fenoxypen 3x1 Mio/die wahrend 14 Tagen bildete sich die lokale Symptomatik deutlich zuruck.

The clinical outcomes of seven girls presenting with pseudosexual precocity caused by isolated autonomous ovarian follicular cysts are presented. Six of the seven girls, aged 11 months to 6.9 years, had a unilateral ovarian cyst detected by ultrasound at the first acute episode. Plasma oestradiol was raised in only five of the cases, but all had a low response to luteinising hormone releasing hormone stimulation. Follow up lasted for up to eight years with recurrent episodes of variable frequency and severity in all seven patients. Evidence of McCune-Albright syndrome appeared later in only three patients. It could not be predicted from the initial symptoms or the clinical course. Mutations of the G(s)alpha protein leading to activation were investigated in the lymphocytes and ovarian and bone tissues of four patients. Only one patient showed a mutation in bone tissue. Close follow up with repeated searches for skeletal lesions remains necessary since the distribution of somatic mutations cannot be assessed by molecular studies. Most patients with recurrent ovarian cysts require a conservative approach.

Faire le bilan de notre héritage des Lumières ne présente pas un intérêt simplement historique, c’est aussi devenu une question d’identité occidentale. Pour en donner une illustration : en octobre 2008 a eu lieu, à Pékin, un colloque qui confrontait la perception occidentale et la perception asiatique des Lumières dans le monde contemporain. Or, nous Occidentaux, sommes des héritiers ambivalents des Lumières, car notre héritage est double et contradictoire : D’un côté, le projet d’ém...