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Resume Propos Il s’agit de revoir les donnees de la litterature concernant les consequences therapeutiques d’un bilan de thrombophilie et d’en deduire les indications de ce bilan. Actualites et points forts La recherche de thrombophilies constitutionnelles a fait l’objet d’une extension de ses indications depuis la decouverte d’anomalies fortement prevalentes, comme la mutation Leiden du facteur V ou la mutation G20210A du gene de la prothrombine. Neanmoins, la presence d’une thrombophilie ne parait pas globalement influer sur le risque de recidive, en tous cas beaucoup moins que le caractere spontane de la maladie veineuse thromboembolique. Lorsque l’on regarde l’impact des differentes thrombophilies, la mutation Leiden du facteur V confere un sur-risque modere de recidive, la mutation G20210A du gene de la prothrombine un sur-risque au plus tres faible. Pour les autres anomalies, il n’y a pas de conclusion possible, mais il est probable que le deficit en antithrombine donne un risque accru de recidive. Perspectives et projets Finalement, la recherche d’une thrombophilie constitutionnelle ne change la plupart du temps pas grand chose aux decisions de duree de traitement, mais certaines anomalies (deficit en antithrombine, mutations homozygotes du gene du facteur II ou du facteur V, associations de thrombophilies) ont des consequences sur la strategie therapeutique. Il ne faut pas perdre de vue que la recherche d’un syndrome des antiphospholipides, dont l’impact n’est pas conteste, doit toujours etre associee a la recherche d’une thrombophilie constitutionnelle. Enfin, l’impact du bilan est generalement nul apres un evenement de type thrombose veineuse profonde distale (a l’exception des antiphospholipides) ou thrombose veineuse superficielle.

Endothelial dysfunction is a key event in cardiovascular disease. Measurement of endothelial dysfunction in vivo presents a major challenge, but has important implications since it may identify the clinical need for therapeutic intervention, specifically in primary prevention. Several biological markers have been used as indicators of endothelial dysfunction. The soluble adhesion molecules sICAM-1 and sVCAM-1 lack specificity and are increased in inflammatory processes. Both markers are increased in coronary artery disease. sICAM-1 level predicts the risk for cardiovascular disease or diabetes mellitus in healthy individuals. sE-selectin is specific for the endothelium and is increased in coronary artery disease and diabetes mellitus. sE-selectin is also associated with diabetic risk. The endothelium-specific marker, soluble thrombomodulin, is associated with severity of coronary artery disease, stroke or peripheral occlusive arterial disease and is not increased in healthy or asymptomatic subjects. Interestingly, thrombomodulin decreases during treatment of hypercholesterolemia or hyperhomocysteinemia. In contrast, von Willebrand factor is the best endothelial biomarker and predicts risk for ischemic heart disease or stroke.

Resume Introduction. – Le syndrome des ecchymoses douloureuses decrit par Gardner et Diamond en 1955 est caracterise par l'apparition spontanee d'ecchymoses douloureuses, sans anomalies biologiques associees, chez des jeunes femmes au profil psychologique pathologique. Exegese. – Nous rapportons trois observations de jeunes filles presentant un syndrome des ecchymoses douloureuses. Dans un cas, la mise en place d'une psychotherapie a entraine une nette amelioration des manifestations cutanees et articulaires et dans un autre cas, la placebotherapie a permis la disparition de la symptomatologie de facon prolongee. Conclusion. – Plusieurs hypotheses physiopathologiques sont proposees dans le syndrome de Gardner et Diamond. Cependant, les observations rapportees dans la litterature plaident en faveur d'une origine psychogene. C'est une prise en charge globale, a la fois psychologique et somatique, qui doit etre proposee a ces malades.

A.D. Blann*, J. Constans, P. Carpentier, M. Renard, B. Satger, V. Guerin, M.R. Boisseau, N. Neau-Cransac, C. Conri Haemostasis, Thrombosis and Vascular Biology Unit, University Department of Medicine, City Hospital, Dudley Road, Birmingham, B18 7QH, UK Service de Medecine Interne et Pathologie Vasculaire, Hopital St Andre, 1 rue Jean Burguet, 33075 Bordeaux, France Service de Medecine Interne et Vasculaire, Hopital de la Tronche, BP217, 38043 Grenoble, France Laboratoire d’Hematologie, Universite Victor Segalen-Bordeaux II, 33076 Bordeaux, France Laboratoire d’Immunologie, Hopital Pellegrin, 33076 Bordeaux, France

The purpose of this paper was to revisit the old concept of cannabis arteritis first described in the 1960s and report 10 new cases. Ten male patients, with a median age of 23.7 years developed subacute distal ischemia of lower or upper limbs, leading to necrosis in the toes and/or fingers and sometimes to distal limb gangrene. Two of the patients also presented with venous thrombosis and three patients were suffering from a recent Raynaud's phenomenon. Biological test results did not show evidence of the classical vascular risk factors for throm bosis. Arteriographic evaluation in all cases revealed distal abnormalities in the arteries of feet, legs, forearms, and hands resembling those of Buerger's disease. A collateral circulation sometimes with opacification of the vasa nervorum was noted. In some cases, arterial proximal atherosclerotic lesions and venous thrombosis were observed. All patients were moderate tobacco smokers and regular cannabis users. Despite treatment with ilomedine and heparin in all cases, five amputations were necessary in four patients. The vasoconstrictor effect of cannabis on the vascular system has been known for a long time. It has been shown that delta-8- and delta-9-tetrahydrocanabinols may induce peripheral vasoconstrictor activity. Cannabis arteritis resembles Buerger's disease, but patients were moderate tobacco smokers and regular cannabis users. These cases show that prolonged use of cannabis could be an additive risk factor for juvenile and young adult arteritis. Cannabis arteritis is a forgotten and severe occlusive vascular disease occurring in young adults. Search for cannabis use may be an important tool for a better knowledge of arteritis in young smokers.

We report two observations of significant left heart involvement in patients with the carcinoid syndrome assessed by transthoracic and transoesophageal echocardiography. Echocardiographic lesions of this kind have only been reported twice. In the present cases, there was mitral involvement with mitral regurgitation in one case and a mitro-aortic involvement with mitral and aortic regurgitation in the other. The mechanism of left heart lesions is unclear since in both cases no right-to-left cardiac shunt was present, as attested by colour Doppler and saline contrast transoesophageal echocardiography. The location of the primary tumour was unknown in one case and ileal in the other; no pulmonary metastasis was detected. The use of transoesophageal echocardiography might make it possible to detect left-sided cardiac lesions more frequently since they were found in anatomical series, in 30% of patients with carcinoid syndrome.