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A passive data-driven method to localize a defect in a structure using the ambient noise is derived. The approach requires only acoustic measurements in a spatially random noise field and no knowledge of the structure. Measurements are taken before and after the perturbation has occurred and Green's functions are retrieved by cross-correlating acoustic measurements. The difference between measured data reveals the perturbation. A frequency domain method based on matched field processing is then performed to localize the perturbation. The Bartlett, minimum variance and white noise gain constraint processors are implemented and their performances are illustrated on a numerical experiment.

Background It is unclear whether HIV infection affects the long‐term prognosis after an acute coronary syndrome (ACS). The objective of the current study was to compare rates of major adverse cardiac and cerebrovascular events after a first ACS between people living with HIV (PLHIV) and HIV‐uninfected (HIV−) patients, and to identify determinants of cardiovascular prognosis. Methods and Results Consecutive PLHIV and matched HIV− patients with a first episode of ACS were enrolled in 23 coronary intensive care units in France. Patients were matched for age, sex, and ACS type. The primary end point was major adverse cardiac and cerebrovascular events (cardiac death, recurrent ACS, recurrent coronary revascularization, and stroke) at 36‐month follow‐up. A total of 103 PLHIV and 195 HIV− patients (mean age, 49 years [SD, 9 years]; 94.0% men) were included. After a mean of 36.6 months (SD, 6.1 months) of follow‐up, the risk of major adverse cardiac and cerebrovascular events was not statistically significant between PLHIV and HIV− patients (17.8% and 15.1%, P =0.22; multivariable hazard ratio [HR], 1.60; 95% CI, 0.67–3.82 [ P =0.29]). Recurrence of ACS was more frequent among PLHIV (multivariable HR, 6.31; 95% CI, 1.32–30.21 [ P =0.02]). Stratified multivariable Cox models showed that HIV infection was the only independent predictor for ACS recurrence. PLHIV were less likely to stop smoking (47% versus 75%; P =0.01) and had smaller total cholesterol decreases (–22.3 versus –35.0 mg/dL; P =0.04). Conclusions Although the overall risk of major adverse cardiac and cerebrovascular events was not statistically significant between PLHIV and HIV− individuals, PLHIV had a higher rate of recurrent ACS. Registration URL: https://www.clini​caltr​ials.gov ; Unique identifier: NCT00139958.

A reconfigurable broadband Doherty PA module for LTE HPUE (High Power User Equipment) applications is presented, which is the first to be based on an SOI-CMOS PA without predistortion and supply modulation. The PA die (1.3×1.7mm2) is fabricated in a 130nm SOI-CMOS process and assembled, using flip-chip, on a 3.2×3.7mm2 laminate package. From 1.9GHz to 2.7GHz, the PA provides 28dBm of output power (P out ) under 3.4V supply voltage (Vdd), with a PAE higher than 35% and an E-UTRA ACLR lower than -35dBc when using a 10MHz-50RB QPSK LTE uplink signal, without predistortion. At 2.3GHz, the proposed PA achieves 43.5% of PAE and -39.6dBc of ACLR at 28dBm of P out . When operating at Vdd=5V (HPUE mode), the PA reaches a saturated power of 4W with a maximum PAE of 57% and delivers a P out of 31dBm with 42.6% of PAE and -35.7dBc of ACLR using a 20MHz-100RB QPSK LTE signal.

International audience; Primary antibody deficiency (PAD) is characterized by a defective immunoglobulin production and recurrent infections, mostly involving respiratory and gastrointestinal tracts. Chronic or recurrent diarrhea is reported in up to 23%. Campylobacter infection is a common cause of infectious diarrhea, reported in 1.2% to 7.5% of patients with common variable immunodefi-ciency (CVID), the most frequent PAD. The aim of this study was to describe Campylobacter infection in patients with PAD included in a large nationwide study and analyze factors associ-ated with susceptibility to this pathogen. The DEFI (DEFicit Immunitaire) study is an ongoing large cross-sectional French multicentric study of adults with PAD, with retrospective collection of clinical data. All patients with a history of bacteriologically documented Campylobacter infection were identified, and clinical data were collected for each episode. Factors associated with recurrent infection were assessed as oddsratio (OR) and 95% confidence interval (CI), calculated by means of simple regression analysis. In patients with available material, strains of each episode were characterized using molecular analysis and compared (Table E1, available in this article’s Online Repository at www.jaci-inpractice.org). A com-parison of immunodeficiency-related characteristics of patients with and without Campylobacter infection was performed in the homogeneous group of patients with CVID. The control group included patients with CVID from DEFI centers who confirmed that patients did not develop Campylobacter infection after enrollment (Figure E1, available in this article’s Online Repository at www.jaci-inpractice.org). After correction for multiple comparisons, P

International audience; This paper presents the application of surface Rayleigh waves in nonlinear dynamic acousto-elastic testingfor the nondestructive evaluation of the concrete cover. Numerous physical phenomena, such as conditioningand slow dynamics, characterising the dynamic non-classical nonlinear elastic behaviour ofmany types of micro-heterogeneous solids, were observed in concrete. Rayleigh waves were used asprobing waves to evaluate the effect of local property changes in a concrete cover. The proposed methodwas validated for two typical problems of concrete durability, in a case of thermal damage – distributedmicro-damage – and in a case of carbonation – surface problem with determination of the carbonationdepth. In both cases, the results showed that the relative variation as a function of material changes ofthe nonlinear parameters was much higher than that of the ultrasonic pulse velocity.

Leptospirosis is a worldwide zoonosis with higher incidence in tropical areas and is a neglected disease in the Pacific region. French Polynesia (FP) is a French overseas territory located in the South Pacific. Data on the epidemiology in FP are scarce. In this study, we describe our understanding of leptospirosis epidemiology in FP and discuss the prospects concerning this disease and its surveillance to better address preventive actions. We report 11 years of surveillance data between 1 January 2007 and 31 December 2017. Over the study period, 1356 confirmed and probable leptospirosis cases were reported. The mean annual incidence rate was 46.0 (95% confidence interval, 43.6–48.5) cases per 100 000 inhabitants. We registered 864 (63.7%) hospitalizations; of these, at least 270 (19.9%) were in the intensive care unit, and 24 patients (1.8%) died. Even if the incidence of leptospirosis is lower in FP compared to most of other Pacific countries and territories, our data confirm that the disease is highly endemic in FP. Despite all the preventive measures taken, leptospirosis remains a major public health concern in FP, thus highlighting the need to maintain intensive leptospirosis surveillance, medical staff training and provision of information to the general population. Keywords: Epidemiology, incidence, leptospirosis/epidemiology, polynesia/epidemiology, public health/epidemiology, zoonoses

Introduction Les anticorps anti-facteur V acquis sont rares et peuvent se compliquer de manifestations thromboemboliques ou le plus souvent hemorragiques potentiellement graves. Nous rapportons l’observation d’une patiente ayant developpe un anticorps anti-facteur V responsable d’un syndrome hemorragique dans un contexte infectieux et de prise de clindamycine. Observation Mme C., 85 ans, est hospitalisee via les urgences pour un hematome du membre inferieur gauche compliquant un traitement par antivitamine K. Elle a comme principal antecedent une maladie thromboembolique (3 episodes de thrombose veineuse profonde, une embolie pulmonaire) compliquee d’hypertension arterielle pulmonaire et souffre, d’autre part, d’une ACFA. C’est pour ces deux indications qu’elle est traitee par warfarine depuis plusieurs annees. Les INR sont surveilles de facon reguliere et sont le plus souvent dans la zone therapeutique entre 2 et 3. Les autres antecedents notables sont une obesite, un diabete de type II insulinorequerent et une goutte. Elle est adressee par son medecin traitant en raison de l’apparition spontanee d’un hematome de la jambe gauche au huitieme jour d’un traitement par clindamycine debute pour une suspicion d’erysipele. L’examen clinique retrouve un volumineux hematome douloureux et indure de la jambe gauche associe a un autre hematome de la face interne de la cuisse. L’interrogatoire ne retrouve pas de notion de traumatisme recent. Il n’y a pas d’argument pour un erysipele. L’INR est a 9,96 avec un TP Malgre l’arret de la warfarine et l’administration de vitamine K1, le TP reste inferieur a 10 %. Le TCA est allonge avec un ratio malade/temoin a 6,7. L’exploration des cofacteurs du complexe prothrombinique montre des facteurs II et X respectivement a 63 et a 51 % mais un facteur V effondre d -dimeres sont negatifs et le facteur VIII est a 150 %. La recherche d’anticorps anti-facteur V est positive avec un titre par la methode Bethesda a 7 U. Il n’y a pas d’argument clinique, biologique ou a l’imagerie pour une insuffisance hepatocellulaire, une neoplasie sous jacente ou une maladie auto-immune. Une corticotherapie debutee a la posologie de 1 mg/kg permet une correction progressive du facteur V qui est a 50 % a j15 (TP a 48 %). Le TP est egal a 82 % apres un mois de corticotherapie. Discussion L’apparition d’anticorps anti-facteur V est une pathologie rare mais potentiellement grave a laquelle il faut penser devant une chute du TP sans insuffisance hepatocellulaire ou CIVD. Le mecanisme physiopathologique n’est pas univoque et les etiologies rapportees sont multiples : prise d’antibiotiques, exposition a de la colle biologique contenant de la thrombine bovine (dorenavant interdite), infection, neoplasie, maladie auto-immune, idiopathique dans 20 % des cas. La prise en charge therapeutique n’est pas codifiee et l’abstention therapeutique peut se discuter en l’absence de manifestation hemorragique. Les corticoides, les IgIV, le rituximab ont ete utilises pour tenter d’eradiquer les anticorps. En cas de complication hemorragique, la transfusion de plasma frais congele est inefficace et la transfusion de plaquettes ou d’un concentre de complexe prothrombinique active peut etre utile. Conclusion Il est difficile d’affirmer que la clindamycine est responsable de l’apparition des anticorps chez notre patiente. Neanmoins, l’evolution rapidement favorable sous corticoides et l’absence de recidive a leur arret en fait un suspect potentiel.

Objectives Errors are frequently made in the prescription of antiretroviral medication for hospitalized HIV-infected patients. We had for aim to evaluate the prescription of antiretroviral drug regimens at hospital admission and the impact of a strategy implemented to prevent errors. Methods HIV-infected patients managed by our hospital as outpatients and admitted between January 1, 2010, and December 31, 2010 (first period) and between February 1, 2011, and January 31, 2012 (second period) were included in the study. We retrospectively identified errors made in the prescription of antiretrovirals by comparing the drugs prescribed during hospitalization and the treatment documented in the outpatient file. During the second period, we implemented a strategy involving the pharmacist and the infectious disease specialist to reduce the number of errors. Results Thirty-five patients were treated during the first period for 56 admissions, and 43 patients for 77 admissions during the second one. We identified 39% of medication-related errors during the first period and 42% during the second one. The most common errors were drug omission, inappropriate dosage, or failure to adjust dosage for renal insufficiency. Our intervention, during the second period, allowed correcting 36% of errors. Conclusion In our study, errors made in the prescription of antiretroviral medication were frequent and our intervention allowed correcting 36% of errors. Other strategies, such as consulting a clinical pharmacist on admission, or training prescribers should be considered.

Introduction L’atteinte peripherique du nerf facial peut inaugurer ou emailler l’evolution d’une maladie auto-immune. En 2015, J. Birbaum decrit un nouveau syndrome associant entre autre paralysie faciale (PF) et maladie rhumatismale. Nous rapportons ici un nouveau cas avec une evolution favorable sous traitement. Observation M. M., un patient de 31 ans d’origine polynesienne, est adresse en consultation de medecine interne pour paralysie faciale recidivante. En dehors d’une mastectomie bilaterale a l’âge de 16 ans sur une obesite infantile, M. M. n’a pas d’autre antecedent personnel ou familial. En juin 2014, M. M. presente un premier episode de PF droite etiquetee a frigore traitee par valaciclovir et corticoides. La recuperation est totale en 3 semaines mais il recidive en aout 2014 puis en 2015 et 2016. Il est vu a plusieurs reprise en consultation de neurologie et il s’automedique aussi regulierement par valaciclovir et corticoides. Au huitieme episode, en mai 2017, un nouveau bilan est realise : il n’y a pas de syndrome inflammatoire, l’IRM cerebrale est normale, comme celle de 2014, ainsi que la ponction lombaire. Une biopsie des glandes salivaires retrouve une sialadenite chronique lymphocytaire focale avec un score 4 de Chisholm et Mason. C’est pour cette raison que M. M. est adresse en medecine interne. L’interrogatoire retrouve des douleurs des 2 chevilles, evoluant depuis quelques mois, plutot d’horaire mecanique. Il existe aussi, de facon inconstante, des gonalgies associees et des douleurs des MCP a droite. Il n’y a pas de syndrome sec oculaire ou buccal. M. M. se plaint surtout, depuis plusieurs semaines, de spasmes importants de l’hemiface droite avec rictus, apparaissant de maniere brutale et disparaissant en quelques secondes. Le phenomene est observe a 2 reprises lors de la consultation. Il se plaint aussi de vertiges sans acouphenes ou diminution de l’audition. L’examen clinique est pauvre, il n’y a pas de syndrome vestibulaire et l’examen des articulations est normal. Le bilan biologique ne retrouve pas de syndrome inflammatoire, pas d’anomalie de la formule sanguine, de la fonction renale ou hepatique et de l’EPP. Le bilan auto-immun ne retrouve ni AAN, ni anti-ENA ni ANCA, mais les facteurs rhumatoides ainsi que les anti-CCP sont positifs. Les radiographies des articulations sont normales mais l’echographie des 2 chevilles met en evidence une tenosynovite bilaterale des tendons fibulaires avec un aspect inflammatoire a droite et un epaississement de l’aponevrose plantaire a gauche. Dans l’hypothese d’une paralysie faciale associee a une polyarthrite rhumatoide, un traitement par methotrexate est debute permettant une nette amelioration des douleurs articulaires mais egalement une disparition complete des hemispasmes de la face. A six mois du debut du traitement, le patient ne presente plus de nouvel episode de paralysie faciale. La disparition des spasmes faciaux lui permet de retrouver une qualite de vie normale. Discussion L’atteinte du nerf facial est decrite dans differentes maladies rhumatismales et concerne avant tout la branche motrice du nerf. Si, apres un episode de paralysie faciale, les sequelles a type de syncinesie, trouble du gout, clignement anormal, refletant une regeneration aberrante ou incomplete du nerf sont frequentes, les spasmes faciaux sont beaucoup plus rares surtout apres une recuperation motrice complete. En 2015, J. Birbaum rapporte, dans Medicine, les observations de 3 patients souffrant de polyarthrite rhumatoide (n = 1) ou de syndrome de Goujerot–Sjogren (n = 2) associes a une PF et des hemispasmes faciaux. Les 3 malades se plaignent, par ailleurs, d’otalgies accompagnees de facon inconstante par des vertiges et/ou des acouphenes. Ce tableau clinique conduit l’auteur a definir un nouveau syndrome neurologique qui associe des maladies rhumatismales avec des paralysies faciales, des otalgies et des hemispasmes faciaux. Pour les 3 patients decrits, l’evolution est favorable sous traitement (IgIV, corticotherapie ou autre traitement non determine). Dans notre observation, M. M. ne se plaint ni d’acouphene ni d’otalgie mais a des sensations de vertiges. Contrairement aux patients decrits par Birnbaum, le diagnostic de polyarthrite rhumatoide de M. M. a ete porte apres les episodes de paralysie faciale. Conclusion L’association d’une paralysie faciale, d’hemispasmes faciaux avec otalgie ou atteinte de la VIIIe paire crânienne, semble definir un nouveau syndrome, associe aux maladies rhumatismales. Nous rapportons, ici, une nouvelle observation clinique de ce syndrome avec une efficacite precoce d’un traitement par methotrexate.

Since the onset of the human immunodeficiency virus (HIV) epidemic, the care of infected patients improved dramatically. Whereas the disease was almost always fatal, the development of new drugs and new therapeutic strategies now allow a prolonged survival. However, the complexity of patient care is increasing and physicians face new clinical events and treatment toxicities. Recent molecules and follow-up according to the recent French recommendations will be presented here. The objectives of the treatment is to decrease mortality and morbidity of the HIV infection, by restoring near normal CD4+ T cell counts and qualitative T CD4+ responses, associated with a sustained reduction in viral replication. This objective must be reached by minimizing toxicity of antiretroviral drugs. Newly developed drugs that are better-tolerated and new therapeutic classes should improve outcome at all stages of HIV infection. Whereas viral eradication remains unrealistic and protective vaccines will not be soon available, direct consequences of long term HIV infection and issues related to an ageing HIV infected population raise up new research topics. Prevention of new infections, improvement in the precocity of care by a better-targeted screening and assessment of therapy before an established immune deficiency appear as the main priorities for the coming years.

International audience; BACKGROUND:In 2014, the European Society for Immune Deficiencies (ESID) revised the common variable immunodeficiency (CVID) diagnosis criteria by incorporating new clinical and biological markers. The new definition appeared more restrictive but had not yet been evaluated in a large cohort of patients.OBJECTIVE:The objective of this study was to evaluate the impact of this new definition in a large cohort of patients with primary hypogammaglobulinemia.METHODS:Evaluation of 3 different CVID definitions (ESID/Pan-American Group for Immunodeficiency [PAGID] 1999, ESID 2014, DEFI 2015) in 521 patients included in the French DEFI study with a diagnosis of primary hypogammaglobulinemia.RESULTS:Using the ESID/PAGID 1999 definition, 351 patients were classified as CVID. The new ESID 2014 definition excluded 62 (18%) patients. Most of them (n = 56; 90%) had a less severe disease, whereas 6 (10%) presented with a severe disease with major T-cell defect. We propose different criteria (occurrence of opportunistic infection or very low naive CD4+ T-cell count) to define this population with severe T-cell defect. Sixty-two patients fulfilled these criteria, represented 20% of the initial CVID population but accounted for 77% of the deaths, with a 5-year overall survival of 67.6% (95% confidence interval, 51.0-79.6), and were considered as late onset combined immunodeficiency (LOCID).CONCLUSIONS:The new ESID definition for CVID still fails to exclude a large number of patients with severe T-cell defect. We propose a new definition (DEFI 2015) that excluded more patients with a T-cell defect and consider these patients as LOCID. This population has a poor outcome and should be considered as a distinct group requiring specific care.

Under-sodium imaging at high temperature is an important requirement in sodium cooled fast reactors during structural inspection. It aims at checking the integrity of immersed structures and assessing component degradation. The work presented in this paper focuses on designing an advanced ultrasound methodology for detecting damages such as deep crack defects. For that purpose, a topological imaging approach was implemented. This method takes advantage of all available prior knowledge about the environment through the integration of differential imaging and time reversal techniques. The quality of the topological energy distribution (the image) is further enhanced by applying a time gating related to each reconstructed pixel. Numerical and experimental results are presented using this method in order to confirm its reliability. These images are compared to a B-scan to emphasize the localization performances of this method.

In civil engineering, the testing of structures allows a large number of chemical, mechanical and micro–macro structural parameters to be determined. Within the scope of ultrasonic Non-Destructive Testing (NDT), which is often used to evaluate concrete, many different techniques can be employed to generate, propagate, and receive the ultrasound waves, and to process the corresponding signals. The SENSO project, developed by nine partners, provided an opportunity to test a large number of principles related to the material’s characteristics and properties. Concerning the acoustic techniques, the first approach was based on linear propagation with bulk waves and surface waves, or with backscattered waves. The second method involved nonlinear analysis using wave modulation. One aim of the SENSO project was to compare these different techniques, in order to select that having the most promising performance in the laboratory, before transferring the measurement techniques to the field. The objectives were to evaluate the porosity, degree of saturation, modulus of elasticity and compressive strength of concrete. In the present paper, the measurement techniques and measured parameters are presented, together with the improvements developed within the context of the SENSO project. The methodology used to classify and select the ultrasonic techniques is described. It takes into account the sensitivity of the method to changes in the material and associates measurement uncertainties. Finally, the most significant results to evaluate porosity, mechanical characteristics and degree of saturation of various concretes, are developed. The consistency of the results of the measurements is analysed. The advantages and drawbacks of each technique are discussed.

Introduction et but de l’etude La sleeve gastrectomie (SG) est aujourd’hui la technique operatoire la plus utilisee pour le traitement chirurgical de l’obesite. Les carences en micronutriments sont considerees comme peu frequentes apres SG mais peu d’etudes documentent cette affirmation. Materiel et methodes Afin de mieux evaluer le statut nutritionnel a long terme apres SG, en particulier en ce qui concerne les micronutriments, nous avons mene une etude retrospective sur 161 patients obeses operes consecutivement d’une SG entre Janvier 2008 et Decembre 2012 dans notre centre. Ces patients ont ete evalues en pre-operatoire (M0), tous les 3 mois (M3, M6, M9, M12) lors de la 1re annee post-operatoire, et 2 ans (M24) apres SG. Les differences de prevalence des carences nutritionnelles entre M0 et M3, M12 et M24 ont ete comparees a l’aide du test du Chi2 de Mc Nemar, alors que les concentrations plasmatiques moyennes des micronutriments entre M0 et M3, M12 et M24 ont ete comparees en utilisant le test t apparie de Student ou le test de Wilcoxon selon les cas (* p Resultats et Analyse statistique Les caracteristiques de la population (moyenne ± DS) etaient les suivantes : âge 42 ± 12 ans, sex ratio 28M/133F, poids M0 109,1 ± 18 kg, IMC M0 40,1 ± 4,9 kg/m 2 . Le pourcentage de perdus de vue etait de 29,8 % a M3, 52,8 % a 64,4 % et M12 a M24. La moyenne de perte d’exces de poids (%) etait de 39,5 ± 12 a M3, 65,5 ± 21 a M12 et 61 ± 19 a M24. La moyenne des apports energetiques totaux (kcal/j) etaient de 2 446 ± 988 a M0, 573 ± 230*** a M3, 955 ± 261*** a M12 et 1109 ± 563* a M24. Les apports protidiques moyens (g/j) etaient de 90 ± 33 a M0, 29 ± 11*** a M3, 45 ± 14*** a M12 et 49 ± 15*** a M24. De nombreuses carences en micronutriments etaient deja presentes avant la SG et/ou sont apparues lors de la premiere annee de suivi, en particulier pour la vitamine A (11,4 % a M0, 56,8 %*** a M3 et 31,8 %* a M12) et le selenium (38,1 % a M0, 71,1 %* a M3 et 50 % a M12). Une prealbumine Conclusion Nos resultats confirment l’efficacite de la SG sur la perte de poids jusqu’a 24 mois apres la chirurgie. Ils revelent 1/un nombre important de perdus de vue, justifiant le renforcement de l’education therapeutique avant et apres chirurgie, et 2/ des apports energetiques et protidiques tres faibles, surtout les 3 premiers mois, expliquant en partie les carences en micronutriments observees (vitamine A, B9, B12, selenium..). Ces donnees plaident pour une supplementation systematique en micronutriments immediatement apres SG, ainsi qu’a une vigilance accrue concernant les apports protidiques (recours aux CNO si necessaire).

Since the onset of the human immunodeficiency virus (HIV) epidemic, the care of infected patients improved dramatically. Whereas the disease was almost always fatal, the development of new drugs and new therapeutic strategies now allow a prolonged survival. However, the complexity of patient care is increasing and physicians face new clinical events and treatment toxicities. Recent molecules and follow-up according to the recent French recommendations will be presented here. The objectives of the treatment is to decrease mortality and morbidity of the HIV infection, by restoring near normal CD4+ T cell counts and qualitative T CD4+ responses, associated with a sustained reduction in viral replication. This objective must be reached by minimizing toxicity of antiretroviral drugs. Newly developed drugs that are better-tolerated and new therapeutic classes should improve outcome at all stages of HIV infection. Whereas viral eradication remains unrealistic and protective vaccines will not be soon available, direct consequences of long term HIV infection and issues related to an ageing HIV infected population raise up new research topics. Prevention of new infections, improvement in the precocity of care by a better-targeted screening and assessment of therapy before an established immune deficiency appear as the main priorities for the coming years.

Introduction Le risque de carences nutritionnelles apres gastrectomie longitudinale (sleeve gastrectomie) est considere comme faible. Cependant, il existe peu d'etudes documentant le statut nutritionnel apres cette chirurgie. Patients et methodes Etude retrospective sur 51 patients obeses consecutifs suivis avant (M0) et tous les trimestres (M3, M6, M9, M12). Resultats Le pourcentage de patients absents lors des bilans de suivis est de 29 % a M3, 43 % a M6, 49 % a M9, 49 % a M12. Le pourcentage de perte d'exces IMC est de 48 % a M3, 63 % a M6, 76 % a M9, 83 % a M12. L'AET journalier est de 610kcal a M3, 870kcal a M6, 780kcal a M9, 880Kcal a M12 ; l'apport proteique est de 30g a M3, 41g a M6, 34g a M9, 45g a M12. Le pourcentage d'insuffisances en vitamine D est environ de 80 % a M0 et reste stable durant le suivi. Plusieurs carences en micronutriments se constituent : en vitamine A : 8,3 % a M0, 45,7 % a M3, 44,8 % a M6, 20 % a M9, 27 % a M12 ; folates : 14,9% a M0, 36,4% a M3, 27% a M6, 37,5 % a M9, 17,4 % a M12 ; vitamine B12 : 4 % a M0, 8,5 % a M3, 10,3 % a M6, 16% a M9, 21,7% a M12 ; selenium : 23,7 % a M0, 64,7 % a M3, 48,1 % a M6, 30,4 % a M9, 48 % a M12. Conclusion Outre le nombre marque de perdus de vue, ce travail revele un apport proteino-energetique insuffisant la premiere annee expliquant en grande partie les carences en micronutriments mises en evidence. L'education therapeutique nutritionnelle au sein d'une equipe pluridisciplinaire prend tout son sens pour personnaliser la prise en charge et prevenir ou traiter ces carences.

A 78 year old woman with unstable angina due to significant stenosis of the left main coronary artery and occlusion of the right coronary artery was treated medically for 29 months because of a surgical contraindication. Resistance to drug therapy led to referral for complex angioplasty of the left main, left anterior descending and left circumflex arteries, successively by rotablator and balloon angioplasty. An immediate elastic recoil on the left main coronary artery led to implantation of a Palma-Schatz stent. There were no complications and the patient is asymptomatic twenty months later.

The aim of this retrospective study of 50 deep vein thromboses (DVT) of the lower limbs in patients aged 80 and over (35 women, including 2 with bilateral DVT and 13 men), mean age 83.37 +/- 2.72, hospitalised in a department of cardiology, was to assess the diagnostic value of ultrasound investigations, clinical parameters and results of treatment of thrombo-embolic disease in this age group. High DVT were found in 76 per cent of cases and pulmonary embolism occurred in 52.1 per cent of cases, its incidence increasing with age. One third of DVT were asymptomatic and presented as pulmonary embolism, the predominant clinical feature being edema in the absence of other signs. The existence of atrial fibrillation was associated in 90 per cent of cases with a pulmonary embolism. Venous Echo-Doppler is also the key investigation in the diagnosis of thrombo-embolic disease. Cardiac Echo-Doppler seems particularly useful in the diagnosis of pulmonary embolism when more than 40 per cent of the vascular bed is cut off. Thrombolytic treatment remains possible after the age of 80 in life-threatening situations. Overall hospital mortality remains high (10.4 per cent) and appears to be due chiefly to the onset of a pulmonary embolism which is not thrombolyzed since considered insufficiently serious or occurring in a situation in which fibrinolysis is theoretically contra-indicated.

Introduction La delivrance intraperitoneale de l’insuline utilisee dans les pompes implantees est plus physiologique que la voie sous-cutanee et permet un meilleur controle metabolique chez les patients diabetiques de type 1 presentant une instabilite glycemique et/ou des hypoglycemies severes a repetition. L’insulinotherapie fonctionnelle (IF) est une approche educative visant a un traitement insulinique plus physiologique. Nous rapportons les resultats metaboliques sur deux annees chez huit patients implantes ayant beneficie de l’association de ces deux approches therapeutiques physiologiques. Patients et Methodes Ces patients âges de 43 ± 8 ans (M ± DS), ayant une duree du diabete de 25,6 ± 11,5 ans et implantes depuis 8,8 ans ± 5,8, gardaient un equilibre metabolique mediocre. Ils ont beneficie d’une session d’IF en ambulatoire avec pose d’un holter glycemique. Resultats Les resultats montrent une variation significative de l’HbA1c durant les deux annees de suivi (respectivement 8,1 ± 1,7 ; 7,4 ± 0,9 ; 7,2 ± 0,6 ; 7,2 ± 0,7 ; 6,6 ± 0,5 % a T0, 3, 6, 12 et 24 mois apres l’IF (test de Friedman p Conclusion Certains patients gardent un equilibre glycemique insuffisant malgre une pompe implantee. Par le renforcement educatif, a l’aide du controle continu des glycemies et de l’IF, nos patients ont acquis une meilleure maitrise de leur maladie et du traitement du diabete. Pour ces patients, chez qui une pompe implantee etait indiquee, une intensification de l’education reste la base d’un bon controle metabolique a long terme.

We have realized an unicentric prospective study to assess the effects of Nitrendipine on carotid circulation and arterial blood pressure (BP) in essential, permanent, uncomplicated arterial hypertension. This randomized, double blind versus placebo trial concerned 21 mild to moderate hypertensive patients (pts) (WHO advices) aged from 35 to 65 years. After a 15 days washout, the pts were randomized in two groups: 11 pts received a 20 mg Nitrendipine tablet once a day and 10 pts received a placebo. BP control and ultrasonic carotid flowmetry were performed at J0 and J30. At J30, BP was normalized for 55% of pts under NT (versus 30% for placebo). This result correspond to a very significative decrease for systolic and diastolic BP and differential BP (Dif BP) without reflex tachycardia, under Nitrendipine, opposite to placebo. Ultrasonic carotid flowmetry variations are not significative excepting common carotid vasodilation under Nitrendipine. Under Nitrendipine, at J30, 5 pts show a decrease of a least 15% of the cerebral vascular resistances (responding patients); and 6 pts do not show any significative decrease of cerebral vascular resistances. For the responding pts, arteriolar vasodilation is then correlated to the decrease of BP and Dif BP, to the increase of carotid blood flow and to the arterial vasodilation; while there is no significative decrease of BP for non responding pts. It suggests an improvement of arterial compliance by a direct action on the arterial wall. Furthermore, inspite of a drop in diastolic parietal tension, there is not any group showing reflex tachycardia. Thus, antihypertensive efficacy of Nitrendipine seem to be principally subordinated to the improvement of arterial compliance.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report a case of solitary aneurysm of the interatrial septum documented by ultrasonography and angiography and revealed by two transient cerebral ischaemic accidents unexplainable by other causes. At surgery, performed later, the interatrial septum was redundant, and Botallo's foramen was about 17 millimetres in diameter, but no sacciform cavity was found. The reasons for the discrepancy between imaging techniques and operative findings and the mechanism of systemic embolism are discussed.

The authors report three cases of heparin-induced thrombocytopenia. Two cases were associated with deep venous thrombosis and pulmonary embolism and the other case was associated with arterial embolism. The clinical course was serious, with one death and one amputation of a limb. The thrombocytopenia developed suddenly, 10 to 15 days after the start of treatment; the platelet count was always below 100 000/mm3. The platelet aggregation test is an important diagnostic element, together with the rapid return to normal of the platelet count once the heparin is stopped. An anti-platelet antibody was detected in two patients, suggesting an immuno-allergic mechanism for this new complication of heparin treatment. The treatment consist of immediately stopping the heparin and replacing it with an anti-vitamin K drug or low-molecular weight heparin. The platelet count should be monitored systematically in all patients receiving heparin treatment for more than 8 days.

Ultrasonic investigations of the peripheral vessels (continuous Doppler with spectral analysis, echotomography) were performed to evaluate atherosclerosis of the main arteries (abdominal aorta, cervical arteries, lower limb arteries) in 50 coronary patients and 40 control subjects. In the main, our results support those of previously published series (epidemiological and autopsy studies): Atherosclerosis of the main arterial vessels is significantly more common (p less than 0.01) in coronary patients than in control subjects: carotid lesions: 70% (including 10% with severe stenosis) compared to 32% (no severe stenosis); aortic lesions: 50% (including 20% with severe stenosis) compared to 17.5% (7.5% severe stenosis); lower limb arteries: 58% (including 16% severe stenosis) compared to 12.5% (no severe stenosis). The difference of incidences of associations of atherosclerosed vessels between the two groups was significant (p less than 0.01): no peripheral vascular disease was detected in 57.5% of controls compared to only 12% of coronary patients; more than one territory diseased in 15% of controls compared to 58% of coronary patients. The severity of these lesions correlated with the presence of the three major cardiovascular risk factors which were studied (hypertension, smoking, hypercholesterolaemia) and was significantly higher (p less than 0.01) in coronary patients (38% had more than one major risk factor and only 10% had none) than in controls (47% had no risk factors and 6% had more than one). In addition, the preferential sites of atherosclerosis were also confirmed.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors present a case of acute renal ischemia resulting from embolism of its main artery on the occasion of the transient interruption of anticoagulant treatment for dental extraction, in a patient bearing a Björk-Shiley valvular prosthesis in the mitral position. Its progression is marked by the complete repermeabilisation of the artery under heparin therapy with complete recuperation of renal function. This classically exceptional observation suggests that the delay occurring between the initial obstruction and repermeabilisation does not alter the degree of renal distress, the estimation of which is unpredictable. The relative resistance of the kidney to ischemia and the occurrence of efficacious fibrinolysis suggests the possibility of therapy other than surgery. Prevention demands the maintenance of coagulants under guarantee of local hemostatic processes.

A typical case of advanced obstructive cardiomyopathy in a young subject was revealed by Streptococcal mitral valve endocarditis and was diagnosed by one and two dimensional echocardiography, which revealed a pedunculated vegetation on the large mitral valve and rupture of the chordae of the small mitral valve. This was complicated by biventricular heart failure, peripheral arterial embolism in the leg due to migration of the vegetation which disappeared on the repeat echocardiography and pulmonary embolism with arterial clot emboli due to heparin-induced thrombocytopenia. This condition resolved without requiring cardiac surgery. Patients with obstructive cardiomyopathy should be treated routinely with prophylactic antibiotics, particularly when dental treatment is required. Echocardiography has become an essential examination in the diagnosis of this disease and its complications, especially in cases with infectious endocarditis.

This retrospective study involved 37 subjects who were examined by means of intravenous digitalised angiography, vascular ultrasonography and spectral analysis of the Doppler signal. The last two examinations were found to give the most precise images and functional information. The concordances between angiography and ultrasonography on the one hand and spectral analysis on the other were 82 and 90 per cent. The authors have established a protocol in order to limit and systematize these examinations during screening for carotid atheroma: the risk factors are weighted; a score is obtained by summation; depending on the value of this score and the patient's age, the investigation procedure is pursued or not. The sequence always consists of ultrasonography followed by spectral analysis when plaque is detected and by angiography when the plaque is stenotic or ulcerated. In symptomatic patients, ultrasonography and digitalised angiography are performed routinely.

In this paper, the authors report the case of an 8-year-old boy with an isolated slit in his mitral valve, and who did not have a heart murmur detectable either by auscultation or by phonocardiography and who had no symptoms of heart failure. Two-dimensional echocardiography, with a left parasternal direction, in a transversal view revealed the presence of this abnormality of the endocardial leaflets accompanied by an accessory chorda tendina, and this procedure confirmed the absence of hemodynamic percussion. Doppler ultrasonography detected an abnormal turbulent systolic blood flow immediately behind the mitral valve, suggesting a minimal to moderate degree latent regurgitation. Two-dimensional echocardiography together with the Doppler ultrasound makes possible the diagnosis of an isolated slit of the mitral valve by non-invasive technique and the detection of concomitant latent mitral valve regurgitation, especially when the left atrium is not dilated and if the patient does not have low cardiac output.

The aim of this study is to show the clinical value of the echocardiography in the heritable disorders of connective tissue, within a series of 10 cases, from 7,500 echocardiograms reviewed between 1978 and 1985. Echocardiography visualized an aneurysm of the ascending aorta in three patients, a dilatation of the pulmonary artery in one case, a mitral valve prolapse in six patients associated with an aortic and tricuspid valve prolapse in two cases, and a tricuspid valve prolapse and aortic regurgitation in one case. In two patients, an aortic valve prolapse was isolated. Other echocardiographic features were intracardiac calcifications (4 cases), septal hypertrophy (2 cases) and an incompetent foramen ovale (2 cases). Echocardiographic examination must be performed in all connective tissue diseases because cardiovascular complications are responsible for the vast majority of deaths. Conversely, all the patients with valvular prolapse, dilatation of the great vessels, aneurysm of the sinuses of Valsalva or congenital heart defects type incompetent foramen ovale should be suspected of connective tissue disorders. Such diagnosis is crucial when a surgical intervention is being considered because of the fragility of the tissues.

12 patients (10 men and 2 women), of 59 +/- 10.5 years of age, including 4 with a patent cardiomyopathy and 7 with a cardiothoracic index higher than 0.52, presenting a permanent and complete atrio-ventricular block and fitted with a two-chambers cardiac stimulator, underwent a carotid output study by Doppler-sonography. The objective of this study was to determine the factors which could influence the carotid output: synchronous atrial systole, frequency of the electro-stimulated rhythm, atrio-ventricular delay in sequential mode, cardiomyopathy, increase of the cardiothoracic index, age and body area. It appears that the carotid output, for an identical stimulation frequency, is significantly higher in sequential mode than in one-chamber ventricular electrostimulation (p less than 0.05 at 70 c/min, p less than 0.01 at 80 c/min and p less than 0.001 at 90 c/min) and this is even more marked in case of cardiomyopathy (p less than 0.01 versus p less than 0.05). On the contrary, an elevated cardiothoracic index does not alter the nature of the results. An accelerated electrostimulated rhythm discloses an increase of the carotid output (p = 0.01) up to a threshold frequency of 70 c/min in the entire population and of 60 c/min in case of cardiomyopathy. Beyond that, the carotid output decreases. Sequential stimulation does not prevent this decrease from 80 c/min (p = 0.001). The carotid output is significantly lower (p less than 0.01) with an atrio-ventricular delay of 115 ms than with a delay of 165 ms. The carotid output decreases in direct ratio to age (p = 0.01) but the gradient of the regression axis is lower in sequential mode.(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this study of 6 cases of Marfan's or Marfan-like syndrome detected in 7077 echocardiographic examinations was to investigate the clinical value of echocardiography. The mean age of the patients was 40 years, and 4 of them (66 p. 100) were female. The diagnosis was based on the 4 criteria of Marfan's syndrome in 1 case, on 3 criteria in 2 cases and on 2 criteria in 3 cases. Four patients were known to have a previous cardiac murmur. Auscultation revealed a systolic murmur of mitral regurgitation in 3 cases (associated with a diastolic murmur of aortic regurgitation in 2 of them), a diastolic murmur of aortic regurgitation in 3 cases and a systolic murmur due to calcified bicuspid aortic valve in 1 case. ECG recorded a normal rhythm in 4 cases, atrial fibrillation in 2 cases of mitral regurgitation, and left ventricular hypertrophy in 3 cases. Chest X-ray showed cardiomegaly in 3 patients and severe kyphoscoliosis in one. Echocardiography visualized dilatation of the ascending aorta, severe (60 mm) in 1 case, in 3 patients; dilatation of the pulmonary artery in 1 patient; pansystolic mitral valve prolapse in 3 patients (associated with aortic and tricuspid valve prolapse in 2 of them after the disease had progressed); isolated aortic valve prolapse due to bicuspid valve in 2 patients; intracardiac calcifications in 3 patients; subaortic septal hypertrophy in 1 patient and calcified incompetent foramen ovale in 1 patient. Aortography performed in 3 patients disclosed an aneurysm of Valsalva's sinuses in 1 case and a mild aortic insufficiency in 2 cases. Two patients underwent cardiac catheterization for severe mitral regurgitation due to mitral valve prolapse requiring valve replacement, which was successfully done. Thus, echocardiography may provide an early diagnosis of Marfan's syndrome, since cardiovascular abnormalities are frequent in infancy. It also ensures a close follow-up of the disorders and it is useful in deciding whether treatment should be medical or surgical. It may detect formes frustes in a family with Marfan's syndrome, and it may define a borderline group of patients: those with Marfan-like syndrome. In these patients the cardiovascular lesions are more preponderant and appear later than in the classical Marfan's syndrome; they are often difficult to differentiate from the lesions of Barlow's syndrome.

The objective of this prospective study was to evaluate the effect of nifedipine administered at usual daily doses of 30 to 40 mg on the carotid flow in arterial hypertension. The study included 15 patients (8 men and 7 women), 50 to 79 (mean 59.5) years old suffering from long-standing, fixed essential hypertension becoming instable under central antihypertensive drug therapy. For calculating the carotid blood flow, vascular echotomography combined with Doppler ultrasonography and spectral analysis (Duplex probe) determining the vascular section and flow velocity were used. Arterial pressure using a mercury tonometer, flow velocity, common carotid artery diameter, carotid blood flow, Pourcelot's index, parietal tension and heart rate were measured before treatment and at the 8th day of nifedipine administration. It could be shown that the drug produced a significantly (p less than 0.001) increased carotid blood flow, in spite of a marked (p less than 0.001) decrease in systolic (p less than 0.001) and diastolic (p less than 0.005) blood pressure. The increase in carotid blood flow was directly related to the increase in flow velocity (p less than 0.001) and in the diameter of common carotid artery (p less than 0.01) and was associated with a significant decrease in the Pourcelot's index. Analysis of two groups of patients isolated from the total group according to the elevation of carotid blood flow, showed that the degree of hypotensive effect of nifedipine is negatively correlated with the baroreflex response determined by the variation of parietal tension.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular anomalies contributing to development of atrial fibrillation (AF) and subsequent cerebral repercussion have been studied by analysis of clinical, electrocardiographic and anatomicopathological data for 131 elderly (85.16 +/- 6.7 years) medium- and long-term hospital patients. AF was seen in 22.14% of cases and seems more frequent in the ninth decade than in the eight. Predisposing factors were coronary alterations of repolarization (p less than 0.001), myocardial hypertrophy (less than 0.01), hypertension with cardiac repercussions (p less than 0.01), intraventricular conduction disorders, left anterior hemiblock excepted (p less than 0.05) and mitral valvulopathy. AF developed in 12% of cases without apparent cardiopathy. The risk of cerebral infarct was marginally greater in the presence of AF than in its absence; the risk was clear for paroxysmal forms and nil when AF developed in a healthy heart. In contrast, intellectual deterioration and cerebral hypotrophy were significantly more marked (p less than 0.01) in patients presenting AF. This affirmation is evidence for long-term hemodynamic repercussions of arrhythmia affecting cerebral blood flow and constitutes an argument for re-establishment of sinusal rhythm.

This study compares two groups of patients: Group I with 44 patients who suffered recent acute myocardial infarction and Group II: 40 control subjects. In both groups, 2D Doppler echocardiography was performed to detect carotid atheroma, to determine the respective roles of vascular risk factors for two sites of atherosclerosis. Carotid atheroma affected 73 p. 100 of subjects in Group I and 22.5 p. 100 in Group II. Carotid stenosis of more than 40 p. 100 was found mainly in hypertensive patients who presented with acute myocardial infarction, and in patients with left ventricular hypertrophy. Smoking was more frequent in Group I than in Group II (p less than 0.001) irrespective of the frequency of carotid atheroma (p less than 0.05). Hypercholesterolaemia only favoured carotid atherosclerosis after acute myocardial infarction (p = 0.01). We did not find any difference in the incidence of diabetes mellitus in the two groups of patients. Age analysis indicated that carotid atheroma occurred earlier in Group I than in Group II. An association between a dominant risk factor for coronary disease (smoking or hypercholesterolemia) was found in 9 patients, all of whom had severe bipolar atherosclerosis with multivessel coronary lesions and carotid stenosis.

Echographic abnormalities of cardiac amylosis are now well known and quite useful to the diagnosis. Forms that are morphologically atypical are rare. From three observations (2 hypertrophic, asymmetrical and obstructive forms, and 1 hypertrophic and dilated form) and a review from the literature, we study the nosological, diagnostic and therapeutic problems presented by these atypical echographic of cardiac amylosis.

A prospective study of carotid artery atheroma by vascular echotomography and spectral analysis was performed in 40 patients with myocardial infarction and 40 control subjects. Carotid artery atheroma was commoner in the group of patients with myocardial infarction (72.5% +/- 6.8%), earlier (9 years), more commonly bilateral (37.5% +/- 7.6%) and more stenotic (32.5% +/- 7.4%) than in the control group (p less than 0.000a, p less than 0.0001 and p less than 0.002, respectively). The severity of carotid artery atheroma correlated with the site of coronary artery disease; the following significant relationships were found: stenosing 40% and/or bilateral carotid atherosclerosis and left anterior descending disease (p less than 0.02); carotid atherosclerosis and double or triple vessel disease (p less than 0.05). The authors conclude that detection of carotid artery atheroma after myocardial infarction is valuable for two reasons: it gives an indication as to the severity of the coronary disease; carotid endarterectomy may be considered at the same time as coronary artery bypass surgery.

A patient with typical Marfan's syndrome was monitored by echocardiography, which detected (in 1978) a prolapse of the mitral valve complicated by severe cardiac insufficiency, necessitating valve replacement. Seven years later an aneurysm of the ascending aorta (60 mm) was detected which caused prolapse of the aortic valve with valvular insufficiency, combined with prolapse of the tricuspid valve and a calcified foramen ovale the permeability of which was verified by peripheral injection of contrast medium. Echocardiography, notably two-dimensional, is an excellent examination for regular and atraumatic monitoring of Marfan's syndrome and detection of cardiovascular complications.

BACKGROUND Common variable immunodeficiency (CVID) is a primary immune deficiency defined by defective antibody production. In most series, a small proportion of patients present with opportunistic infections (OIs). METHODS The French DEFI study has enrolled patients with primary hypogammaglobulinemia and allows a detailed clinical and immunologic description of patients with previous OIs and/or at risk for OIs. RESULTS Among 313 patients with CVID, 28 patients (8.9%) presented with late-onset combined immune deficiency (LOCID), defined by the occurrence of an OI and/or a CD4(+) T cell count