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As chronic pain (CP) interferes with an individual's lifestyle by limiting meaningful activities and health-related quality of life (HRQoL), occupational therapy (OT) plays an important role in CP management interventions. This pilot study aimed to explore the influence of a 13-week French-Canadian Lifestyle Redesign

Supplemental material, sj-pdf-1-otj-10.1177_1539449220982908 for Pilot Study of French-Canadian Lifestyle Redesign® for Chronic Pain Management by É. Lagueux, J. Masse, M. Levasseur, R. Pagé, A. Dépelteau, M.-H. Lévesque, Y. Tousignant-Laflamme and A.-M. Pinard in OTJR: Occupation, Participation and Health

Giant cell arteritis is the most common primary vasculitis of large-vessel occurring in subjects over 50 years of age. Many imaging techniques has been evaluated to improve the diagnosis of giant cell arteritis. Among these imaging techniques, ultrasound has shown good performances to detect inflammatory involvement of the temporal arteries as well as branches of the aorta. Several publications and recent EULAR recommendations have emhasized the place of this tool in the diagnosis of giant cell arteritis.

The adult emergency department at Rouen University hospital (CHU) welcomes over 100.000 patients per year. In order to streamline unscheduled hospital admissions from the emergency room (ER), a 20-bed pre-hospitalization unit and a centralized bed management system (bed manager, bed manager software, dedicated beds) have been put into place.Emergency admissions have increased by (+3.5% between 2017 and 2018) with 20% direct hospitalization from the ER to other conventional units (2/3 in medicine, 1/3 in surgery). In 2018, 3450 patients, of which 54% aged over 75 years have been admitted in the pre-hospitalization unit with an average length of stay of 1.3±1.4 days: 35.4% stayed less than 24hours and 34.8% more than 48hours of which 5.2% stated more than 4 days, 132 patients (3.8%) died, 805 patients (23.3%) were discharged at home, 220 (6.4%) transferred to another facility, and 2287 (66.3%) were secondarily hospitalized in another hospital unit: more than 9 times out of 10 in a medicine unit (internal medicine 30%, geriatrics 27.9%, respiratory medicine 12.2%). This unscheduled emergency hospitalization allowed a daily hospitalization of 50 short stay inpatients beds. It has to be noted that the number of available inpatient beds clearly decreases during the week-ends. The main pathologies were respiratory infections (14.2%), heart diseases (9.7%), metabolic disorders (3.9%), and urinary tract infections (13.6%).This pre-hospitalization unit associated with a centralized bed management system has clearly improved the unscheduled hospital admissions, in particular concerning the emergency medical sector. The lack of inpatient beds at the week-end and the management of epidemic periods still remain a challenge that has to be taken up.

Carpal tunnel syndrome is a common peripheral neuropathy, usually idiopathic or post-traumatic due to the compression of the median nerve. Numbness and paresthesias in the median nerve distribution are the most common symptoms associated with this condition. Persistent median artery is a rare anatomic variation, thrombosis of this additional artery can be responsible for an acute carpal tunnel syndrome, and patients frequently complain about coldness and acute hand swelling. These unusual features must lead clinicians to think of a vascular cause. The diagnosis can be easily confirmed by using ultrasound doppler, but CT-scan and MRI are sometimes helpful. We describe 2 cases of acute carpal tunnel syndrome due to thrombosed persistent median artery, including a case of thromboangiitis obliterans. These thrombosis might also be due to traumatic causes. No guidelines are currently available to help physicians for the management of carpal tunnel syndrome from thrombosed persistent median artery. Antiplatelet therapy, statin, anticoagulant might be helpful, and surgery has sometimes be reported as effective.

The anti-melanoma differentiation-associated gene 5 (MDA5) autoantibody is specifically associated with dermatomyositis (DM). Nevertheless, anti–MDA5 + -patients experience characteristic symptoms distinct from classic DM, including severe signs of extramuscular involvement; however, the clinical signs of myopathy are mild or even absent. The morphological and immunological features are not yet described in adulthood. Data concerning the pathophysiology of anti-MDA5 DM are sparse; however, the importance of the interferon (IFN) type I pathway involved in DM has been shown. Our aim was to define morphological alterations of the skeletal muscle and the intrinsic immune response of anti–MDA5-positive DM patients. Immunohistological and RT-PCR analysis of muscle biopsy specimens from anti-MDA5 and classic DM were compared. Those with anti-MDA5 DM did not present the classic features of perifascicular fiber atrophy and major histocompatibility complex class I expression. They did not show significant signs of capillary loss; tubuloreticular formations were observed less frequently. Inflammation was focal, clustering around single vessels but significantly less intense. Expression of IFN-stimulated genes was up-regulated in anti-MDA5 DM; however, the IFN score was significantly lower. Characteristic features were observed in anti-MDA5 DM and not in classic DM patients. Only anti-MDA5 DM showed numerous nitric oxide synthase 2–positive muscle fibers with sarcoplasmic colocalization of markers of regeneration and cell stress. Anti–MDA5-positive patients demonstrate a morphological pattern distinct from classic DM.

Resume Introduction Le recours a une transfusion de culots de globules rouges chez un patient drepanocytaire majeur est parfois indispensable. L’hemolyse post-transfusionnelle retardee est une complication rare mais potentiellement grave. Cette manifestation peut survenir a tout âge. Elle est probablement sous-diagnostiquee du fait du peu de signes specifiques. Observations Nous decrivons dans cet article, les signes cliniques, biologiques et les aleas de la prise en charge therapeutique de trois cas d’hemolyse post-transfusionnelle retardee. La chromatographie haute performance evaluant le pourcentage d’HbA1 est l’examen permettant d’etablir le diagnostic. La physiopathologie de cet evenement est encore mal connue. Plusieurs traitements ont ete utilises, cependant, la prise en charge therapeutique reste discutee a l’heure actuelle. Conclusion La transfusion de tout patient susceptible d’avoir une hemolyse post-transfusionnelle retardee est fortement deconseillee car elle risque d’aggraver l’hemolyse. La prevention d’une recidive est primordiale.

Cardiovascular events are the second leading cause of death in France. The assessment of overall cardiovascular risk using a personalized assessment with weighting risk factors can predict the risk of cardiovascular events in ten years. The validated treatments to reduce cardiovascular mortality in primary prevention are few. The use of statins in primary prevention is discussed. We report in this review the updated conclusions from clinical trials regarding the treatment with statins in primary prevention.

Small fiber neuropathy (SFN) is still unknown. Characterised by neuropathic pain, it typically begins by burning feet, but could take many other expression. SFN affects the thinly myelinated Aδ and unmyelinated C-fibers, by an inherited or acquired mechanism, which could lead to paresthesia, thermoalgic disorder or autonomic dysfunction. Recent studies suggest the preponderant role of ion channels such as Nav1.7. Furthermore, erythromelalgia or burning mouth syndrome are now recognized as real SFN. Various aetiologies of SFN are described. It could be isolated or associated with diabetes, impaired glucose metabolism, vitamin deficiency, alcohol, auto-immune disease, sarcoidosis etc. Several mutations have recently been identified, like Nav1.7 channel leading to channelopathies. Diagnostic management is based primarily on clinical examination and demonstration of small fiber dysfunction. Laser evoked potentials, Sudoscan

Although extremely rare, acquired haemophilia A (AHA) can cause severe bleeding, which may be fatal. The underlying causes of autoantibody development are not fully understood. Treatment goals are bleeding control and autoantibody eradication. At the time of our study, there was no consensus on a standard treatment strategy for AHA. Previous data were mainly retrospective or from single-centre cohorts. We conducted a prospective, controlled, registry-based study of patients with AHA in France. The prospective French registry (Surveillance des Auto antiCorps au cours de l'Hemophilie Acquise [SACHA]) collected data on prevalence, clinical course, disease associations and outcomes for haemostatic treatment and autoantibody eradication in 82 patients with a 1-year follow-up. Similar to earlier studies, the prevalence of AHA was higher in the elderly, with two thirds of patients aged >70 years. Around half of AHA cases were associated with underlying disease, most commonly autoimmune disease and cancer in younger and older patients respectively. Haemostatic treatment was initially administered to 46% of patients. Complete resolution or improvement of initial bleeding occurred in 22/27 (81%) rFVIIa-treated patients and in all six cases receiving pd-aPCC. The majority of patients (94%) received immunosuppressive therapy, with complete remission at 3 months in 61% (36/59) and in 98% (50/51) at 1 year. Overall mortality was 33%: secondary to bleeding in only three patients but to sepsis in 10. Bypassing agents were effective at controlling bleeding in patients with AHA. Immunosuppressive therapy should be used early but with caution, particularly in elderly patients.

Erythromelalgia is a rare intermittent vascular acrosyndrome characterized by the combination of recurrent burning pain, warmth and redness of the extremities. It is considered in its primary form as an autosomal dominant neuropathy related to mutations of SCN9A, the encoding gene of a voltage-gated sodium channel subtype Nav1.7. Secondary erythromelalgia is associated with myeloproliferative disorders, drugs (bromocriptine, calcium channel blockers), or clinical conditions such as rheumatic diseases or viral infection. Primary familial erythromelalgia include genetics and sporadic forms associated with small fibers neuropathy. Aspirin is a useful treatment of erythromelagia associated with myeloproliferative disorders. Treatment of primary erythromelalgia is difficult, individualized, with sodium channel blockers such as lidocaine, carbamazepine and mexiletine.

Resume Propos L’echographie de compression est aujourd’hui l’examen de reference pour le diagnostic de la thrombose veineuse profonde distale des membres inferieurs. Cependant, les conditions de realisation de cet examen sont extremement differentes selon les pays. Il en decoule une importante heterogeneite de prise en charge therapeutique. Actualites et points forts Aux Etats-Unis, au Canada et aux Pays-Bas, l’examen echographique est proximal et n’explore pas les veines distales, considerant que les performances de l’echographie y sont insuffisantes. Associee a une demarche clinique qui inclut la probabilite clinique et/ou la repetition d’un examen echographique, une telle attitude a fait la preuve de son efficacite et de sa securite pour les malades (taux d’extension aux veines proximales de 1,2 % a trois mois en l’absence de risque d’embolie pulmonaire mortelle). En France, en Italie et en Espagne, l’examen echographique inclut l’exploration des veines distales et realise un examen dit « complet », amenant a decouvrir un grande nombre de thromboses sous-poplites (45–56 %) au sein des 14 a 36 % de thromboses veineuses profondes diagnostiquees en cas de suspicion clinique. Les etudes de strategie diagnostique recentes montrent que ces deux attitudes ont une efficacite clinique identique au prix de deux fois plus de traitements anticoagulants en cas d’examen complet. La justification de cet exces de prescription n’est pas evidente du fait d’un risque d’extension proximale relativement faible a comparer au risque d’hemorragies graves a trois mois et au surcout induit. Perspectives et projets Des etudes prospectives therapeutiques comparatives sont de fait indispensables au cours des thromboses sous-poplitees et l’etude Cactus, actuellement en cours, est construite pour repondre a cette problematique.

The association between thrombosis and cancer, initially evidenced in metastatic patients is well recognized and now described in patients with occult cancer where venous thrombosis may be the first clinical manifestation (Trousseau's syndrome). In this review, clinical and epidemiological interactions between thrombosis and cancer are described in five distinct step: venous thrombosis during malignancy and occult cancer, period of large increased in the risk for diagnosis of cancer, patients or venous thrombosis with increased risk for occult cancer, extensive or not extensive screening for occult cancer, earlier occult cancer detection associated or not with improved treatment possibilities and thus prognosis.

While in most countries warfarin is the preferred anti-vitamin K, fluindione, a molecule with a prolonged half-life remains largely prescribed in France. Some of its side effects, including immuno-allergic complications, remain poorly understood.A 77-year-old woman presented with a febrile severe neutropenia of immunoallergic mechanism with a favourable outcome associated with fluindione, introduced 25 days earlier for the treatment of atrial fibrillation.This rare side effect is a reminder of the importance of biological monitoring in the first weeks following the introduction of fluindione and key diagnostic elements and therapeutic aspects of iatrogenic agranulocytosis.

Resume Objectif Evaluer a partir des resultats de l’etude ATTEST les modalites de prise en charge de l’arteriopathie obliterante des membres inferieurs (AOMI) en medecine generale par reference aux « bonnes pratiques » qui suggerent notamment la mesure de l’index de pression systolique (IPS), la recherche d’autres localisations atherothrombotiques, le traitement des facteurs de risque et en particulier l’arret du tabac, l’entrainement a la marche et un traitement au long cours par anti-agregant plaquettaire. Methode ATTEST est une etude epidemiologique observationnelle transversale et multicentrique realisee en France metropolitaine. Elle a permis de recruter 8 475 patients analysables souffrant d’une AOMI symptomatique isolee (3 811 patients) ou associee a d’autres localisations atherothrombotiques (2 416 patients) ou souffrant d’autres pathologies cardiovasculaires (2 248 patients) sans AOMI suivis chez 3 020 medecins. Six mille deux cent vingt-sept patients arteritiques ont ainsi ete inclus (homme 81,2 %, femme 18,8 % ; âge moyen : 67,2 ans) parmi lesquels 78,8 % au stade de claudication intermittente. Les facteurs de risque etaient representes par le tabagisme actuel ou passe (61 %), l’hypercholesterolemie (66,3 %), l’HTA (63,1 %) et le diabete (26 %). Resultats Tandis que 91,2% des patients ont beneficie d’un echo-doppler arteriel des membres inferieurs, l’IPS, a visee diagnostique, n’a ete mesure que chez 170’entre eux. Les patients ayant ou pas une atteinte coronaire ou cervico-encephalique authentifiee ont beneficie d’un ECG dans 85,8% des cas et d’un echo-doppler des troncs supra-aortiques dans 69,3% des cas. Alors que 39% des patients fumaient encore, une aide a la desintoxication n’etait prescrite que dans 7% des cas, chez les non fumeurs depuis moins d’un an. Pres de deux tiers des patients de cette etude avaient recu des conseils concernant l’activite physique. Enfin, 92,2% d’entre eux recevaient un traitement anti-agregant plaquettaire. Conclusion Le medecin generaliste joue un role cle dans la prise en charge diagnostique et therapeutique de l’AOMI. Bien que la mesure de l’IPS soit la methode recommandee pour le depistage precoce de l’AOMI et l’evaluation de sa severite, moins d’un tiers des arteritiques en beneficie. La recherche d’une autre localisation atherothrombotique concerne en revanche plus de la moitie des patients. D’un point de vue therapeutique, l’exercice physique est souvent recommande et les anti-agregants plaquettaires largement prescrits. En revanche, la lutte contre le tabagisme est manifestement insuffisante. Les resultats de cette etude justifient d’optimiser la collaboration entre medecins generalistes et specialistes des maladies vasculaires. (J Mal Vasc 2004 ; 29 : 249-256).

Summary Background The aim of this study was to assess the tolerance and report obtained results with a stable prostacyclin analogue (iloprost) in diabetic patients with severe forms of permanent lower limb ischaemia. Methods Sixty-four consecutive unselected patients, in stage III and IV of Leriche and Fontaine, turned down for vascular surgery after angiography and treated with iloprost during 28 days, were enrolled in this study. Patients were followed-up clinically (ischemic pain, trophic change, walking distance) and with transcutaneous oxymetry (D28). Long-term assessment (6 and 12 months) was expressed as rate of death, major amputation and of live patients with viable limbs and walking. There was no manifestation of intolerance to iloprost. Were considered as responders patients offering a lack or significant decrease in pain, a reduction of trophic lesions and improvement or recovery of walking. Results Response at two months is lasting: 29 responders (45.3%) and 35 non-responders (54.7%). At 6 months and one year, we observed that 8 (12.5%) and 15 (24.1%) patients respectively had died; 19 (29.6%) and 22 (34.3%) patients underwent major amputation, but 41 (64%) and 34 (53.1%) patients were still alive with their limb and conservative walking. In responder group, at 6 months, 28 (96.5%) patients were alive without amputation for only 13 (37.1%) among non-responders. At one year, 79.3% of the responders and 31.4% of the non-responders were alive without amputation. A total loss of walking, a segmental amputation and a previous amputation of opposite limb were more often noted in no responder group. But no predictive factor was referred to TcPO 2 in particular. Results ware similar in the group of 136 non diabetic patients treated during the same period (67.9% alive with limb at 6 months). Conclusions This retrospective study, despite its limitations, underlines the clinical particularities of critical ischaemia in diabetics and the good tolerance to iloprost. This point allowed patients, in non-surgical chronic critical ischaemia, to avoid being confined to bed and to access to benefits of a early physiotherapy, in association with local treatment. However, no predictive criterion of long-term results could be established, except initial clinical severity and clinical change one month after treatment.

The use of a red blood cell transfusion in a patient with major sickle cell disease is sometimes necessary. The occurrence of delayed haemolytic transfusion reaction is a rare but potentially serious complication. This event can occur at any age. It is probably under diagnosed due to the difficulty in diagnosis with few specific signs.We describe in this article the clinical, biological, and hazards of therapeutic management of three cases of delayed haemolytic transfusion reaction in sickle cell disease patients. The high performance chromatography, which evaluates the percentage of HbA1, is the biological investigation used to establish the diagnosis of this event. The pathophysiology of this event remains still poorly understood. Several treatments have been used during this event. However, the therapeutic management remains controversial.Transfusion in any patient likely to suffer from delayed haemolytic transfusion reaction is not recommended because of the risk of worsening this reaction. Prevention of recurrence is essential.

Multi-component compression, inelastic, short stretched or coated strips bandages, and class 4 stockings have been recommended since 2010 by the French Superior Health Authority as first- and second-line treatment for venous leg ulcers.Assess the prescribing habits and knowledge of general practitioners about compression therapy and determine factors predictive of prescriptions consistent with recommendations.Evaluation study of professional practices conducted during a six-week period. A questionnaire was sent to 210 general practitioners asking them to report their prescribing practices and the last prescription written for a patient with venous ulcers.The response rate was 36.2% (76 responses). For the last patient seen, long stretched bands were prescribed by 50.8% of responders, stockings by 40% and multi-component compression by 7.7%. Stockings were class 2 for 87.7% of the prescriptions. Knowledge of short stretched bands and multi-component compression was reported by 45.8% and 38.9% of general practitioners respectively. Guidelines were followed by 10.8% of the physicians. No factor related to the general practitioner (age, sex, modalities of exercise, experience and education), to the patients (age, sex, under-nutrition, autonomy) or to the leg ulcer (size, exudates, course, complexity of care), was associated with compliance or not with the guidelines. General practitioner training enabled a non-significant improvement of prescriptions (14.3% vs 4%, P=0.24).Compliance with the guidelines for compression therapy is insufficient in general medicine. Better training and knowledge of modalities for compression therapy could be useful to improve prescription practices and encourage use of multi-component compression and short stretched bandages, known to be more effective and better tolerated.

Venous thromboembolism and dehydration are frequent conditions in elderly. The objective of this study was to assess the prevalence of dehydration in patients aged over 70 years suspected of deep vein thrombosis (DVT).This is a prospective observational study that included patients aged over 70 years and suspected of deep vein thrombosis. Clinical and biological dehydration was diagnosed on the presence of a skin fold, a weight loss≥5%, a thirst, a plasmatic osmolality295 mOsm/L or blood urea nitrogen/creatinine ratio20.One hundred and forty-four patients (mean age 81.8±5.8 years) were included. A diagnosis of DVT was retained in 97 patients. Clinical dehydration was not more frequent in the DVT+ group (37.2% vs 35.1%). At baseline, 69.1% of DVT+ patients and 53.2% of DVT- patients had a plasma osmolality greater than 295 mosm/L (NS). BUN/creatinine ratio greater than 20 was found in 58.8% of DVT+ patients and 72.3% of DVT- patients (NS). Clinical and biological dehydration was present in 28.6% of DVT+ patients and in 33.3% of DVT- patients (NS). The positive predictive value of the Wells score≥3 was 86.5%, and negative predictive value of a Wells score≤0 was 85%.The presence of dehydration does not appear predictive of the occurrence of DVT and does not influence the statistical performance of the Wells score in elderly patients.

Rituximab is a monoclonal antibody targeting the CD20 molecule of the B lymphocyte. Its efficacy has been recently reported in ANCA-associated vasculitis. We report a case of psoriatic arthritis that occurs during a treatment with rituximab in granulomatosis with polyangiitis.A 66-year-old woman, without past history of psoriasis, presented with a relapsing granulomatosis with polyangiitis in July 2010 with sinus and lung involvement. Treatment with rituximab was started, allowing a complete remission in 6 months. Two months after the first two infusions of rituximab she developed asymmetric arthritis of 3 distal interphalangeal joints. A few months later, the clinical presentation showed asymmetrical arthritis of the hands and wrists and dactylitis. Standard radiographs and MRI showed an inflammatory impairment according with psoriatic arthritis.Accountability of rituximab was retained in the development of the disease given the chronology of psoriatic arthritis development. It may be a paradoxical reaction, by analogy to those observed in anti-TNFα.

Resume L'aspirine, ou acide acetylsalicylique, est le chef de file des salicylates et fait partie de la famille des anti-inflammatoires non steroidiens. En depit de sa large utilisation depuis plus de 100 ans, les connaissances concernant ses mecanismes d'action et ses utilisations therapeutiques continuent d'evoluer. Le mecanisme d'action principal est l'inhibition de la synthese des prostaglandines a partir de l'acide arachidonique. Celle-ci s'exerce par l'intermediaire de l'inhibition de la prostaglandine endoperoxyde synthetase (PGHS) ou cyclo-oxygenase (COX), enzyme cle de la cascade enzymatique aboutissant a la formation des prostaglandines. La majorite de ses indications therapeutiques en decoulent. Cependant, celles-ci evoluent au cours du temps; si l'aspirine a ete utilisee uniquement pour ses proprietes analgesiques, anti-inflammatoires et antipyretiques pendant de tres nombreuses annees, ses proprietes antiagregantes plaquettaires, initialement considerees comme un effet indesirable, ont permis son developpement dans la prevention primaire et surtout secondaire des complications atherothrombotiques des maladies cardiovasculaires. La meilleure connaissance de ses mecanismes d'action oriente aujourd'hui vers, d'une part, le developpement de molecules a action plus selective et de fait mieux tolerees et, d'autre part, vers des indications potentielles, comme la prevention primaire de certaines affections malignes ou neurodegeneratives.

Resume A l'aube du troisieme millenaire, l'aspirine ne cesse de nous etonner. Si l'histoire pharmaceutique de l'acide acetylsalicylique est relativement recente, l'utilisation de plantes qui secondairement s'avereront contenir des salicylates remonte a l'Antiquite. I nitialement utilisee sous forme de decoctions a base de feuilles ou d'ecorce de saule par les Egyptiens et les Sumeriens puis par Hippocrate, pour prevenir les douleurs de l'enfantement, et plus tard par le reverend Edward Stone (premier auteur a montrer scientifiquement son efficacite) pour traiter les fievres, il fallut attendre le XIXe siecle pour decouvrir le principe actif, et les caracteristiques de la salicine. Si Charles-Frederic Gerhardt, chimiste francais, fut le premier a obtenir l'acide acetylsalicylique, sans toutefois le reconnaitre, c'est Felix Hoffmann qui redecouvrant la molecule et l'utilisant chez son pere rhumatisant, laissa son nom a la posterite en tant que decouvreur de l'aspirine permettant, du meme coup, le developpement international des laboratoires Bayer. Connu dans un premier temps pour ses proprietes antalgiques, anti-inflammatoires et antipyretiques, l'acide acetylsalicylique fut secondairement employe comme antithrombotique, dont la comprehension du mecanisme d'action sur l'inhibition de la synthese des prostaglandines valut a sir John Vane le prix Nobel de medecine en 1982. La decouverte recente de deux formes de cyclo-oxygenase (COX-1 etant present de maniere constitutive alors que COX-2 n'est synthetisee que sous l'action de stimuli chimiques inflammatoires) ouvre de nouvelles voies de recherche therapeutique, COX-2 devenant une veritable cible therapeutique pour les molecules du futur. Apres plus de deux siecles d'evaluation chez l'homme, l'aspirine est toujours d'actualite, ce d'autant qu'il n'est pas exclu que de nouvelles indications potentielles soient envisagees.

Resume Les estrogenes etant susceptibles de favoriser la survenue de complications thrombotiques notamment veineuses, ce travail analyse les resultats des etudes epiemiologiques recentes evaluant le risque thrombotique veineux des differents estroprogestatifs utilises lors de la contraception orale ou lors du traitement hormonal substitutif de la menopause. Quatre etudes epiedmiologiques ont montre que la prise d'une contraception estroprogestative etait associee a un risque, certes modere, mais indiscutablement accru de complications thrombotiques veineuses. Ce risque est superieur chez les femmes employant une pilule de 3 e generation (risque passant de 3,8 pour 100 000 annees-femmes en l'absence de contraception estroprogestative a 16 pour 100 000 annees-femmes avec les pilules de 2 e generation contenant du levonorgestrel et a 29 pour 100 000 annees-femmes avec celles de 3 e generation contenant du gestodene ou du desogestrel). Ce risque accru est secondaire a l'induction par les estroprogestatifs, et notamment par les pilules de 3 e generation, d'une resistance acquise a la proteine C activee, dont le risque thrombotique apparait similaire 3 celui induit par la mutation du facteur V. Avec des composes et des posologies bien distincts, les estrogenes utilises lors d'une hormonotherapie substitutive apets la menopause semblent induire une majoration du risque thrombotique veineux (risque relatif multiplie par 2). Cependant, celui-ci reste non significatif par rapport a l'indiscutable diminution des facteurs de risque vasculaire arteriel et son corollaire la reduction de la morbidite cardiovasculaire.