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Background People living with HIV (PLWH) have a higher risk of CAD. Whether coronary artery calcification (CAC) score could better stratify the CV risk remains debated in this middle age population. Purpose We conducted the French CAC score study to compare the CAC score between PLHIV and HIV− subjects at intermediate risk. Methods 689 subjects (257 PLHIV and 432 HIV−) were consecutively addressed for CV risk evaluation including CAC score assessment in 2 centers between 2013 and 2019. Subjects were included if they were 18 years'old or older, had no known cardiovascular disease and had a CAC score along with cardiometabolic assessment. Results The mean age of the cohort was 59.3 years ± 10.7 and predominantly male (54%). PLHIV were younger (55.8 years ± 9.1 vs 61.3±11.3, p50% was found (13% vs 8%, p=0.16). Concerning, CV risk estimation using 10-year ASCVD and HEART scores, we observed that the median ASCVD score was similar between PLHIV and HIV− group (10.7% vs 9.8, p=0.15) but that PLHIV had a higher HEART score (3.0% vs 2.0%, p Conclusion In this cohort of subjects at intermediate CV risk according to CV risk scores estimation (ASCVD or HEART scores), PLHIV had a similar prevalence of CAC = 0 and median CAC scores as compared to HIV− subjects despite a younger age (6 years). Longitudinal follow up will explore whether this similar CAC score evaluation will be translated into higher CV events. Funding Acknowledgement Type of funding sources: None.

The prognosis of pediatric central nervous system (CNS) malignancies remains dismal due to limited treatment options, resulting in high mortality rates and long-term morbidities. Immunotherapies, including checkpoint inhibition, cancer vaccines, engineered T cell therapies, and oncolytic viruses, have promising results in some hematological and solid malignancies, and are being investigated in clinical trials for various high-grade CNS malignancies. However, the role of the tumor immune microenvironment (TIME) in CNS malignancies is mostly unknown for pediatric cases. In order to successfully implement immunotherapies and to eventually predict which patients would benefit from such treatments, in-depth characterization of the TIME at diagnosis and throughout treatment is essential. In this review, we provide an overview of techniques for immune profiling of CNS malignancies, and detail how they can be utilized for different tissue types and studies. These techniques include immunohistochemistry and flow cytometry for quantifying and phenotyping the infiltrating immune cells, bulk and single-cell transcriptomics for describing the implicated immunological pathways, as well as functional assays. Finally, we aim to describe the potential benefits of evaluating other compartments of the immune system implicated by cancer therapies, such as cerebrospinal fluid and blood, and how such liquid biopsies are informative when designing immune monitoring studies. Understanding and uniformly evaluating the TIME and immune landscape of pediatric CNS malignancies will be essential to eventually integrate immunotherapy into clinical practice.

@DrHulot_PARCC Anti-platelet therapy adjustment guided by CYP2C19 genotyping can be done in

Guidelines recommend to consider excluding non-ST-segment elevation myocardial infarction (NSTEMI) when high-sensitivity cardiac troponin is below the limit of quantification and a single blood sample is taken6 h after the onset of chest pain. The aim of our study was to assess such exclusion when a single blood sample was taken 3-6 h after the onset of permanent chest pain.This observational study included consecutive patients admitted into the emergency room of our hospital with chest pain and suspected NSTEMI, with non-contributive electrocardiograms and a single high-sensitivity cardiac troponin I (hs-cTnI) blood sample taken 3-6 h after the onset of chest pain and hs-cTnI4 ng/l (Abbott Diagnostic). Clinical follow-up was undertaken 1 month after admission.The mean age of the 432 patients was 48.5 ± 5.6 years and 51% were male. Based on a clinical algorithm, the pre-test probability of NSTEMI was low in 70%, and intermediate in 21% of patients. Among 419 patients with available 1-month follow-up data, there were no myocardial infarctions or deaths. Thirty-eight patients (9%) were admitted into hospital but none for cardiac reasons.Our results suggest that exclusion of NSTEMI in patients with a non-contributive electrocardiogram and a single "negative" troponin test in a blood sample taken 3-6 h after the onset of symptoms is valid.

Background With the emergence of coronary computed tomography (CT) angiography, anomalous aortic origin of a coronary artery (ANOCOR) is more frequently diagnosed. Fractional flow reserve derived from CT (FFRCT) is a noninvasive functional test providing anatomical and functional evaluation of the overall coronary tree. These unique features of anatomical and functional evaluation derived from CT could help for the management of patients with ANOCOR. We aimed to retrospectively evaluate the physiological and clinical impact of FFRCT analysis in the ANOCOR registry population. Methods and Results The ANOCOR registry included patients with ANOCOR detected during invasive coronary angiography or coronary CT angiography between January 2010 and January 2013, with a planned 5‐year follow‐up. We retrospectively performed FFRCT analysis in patients with coronary CT angiography of adequate quality. Follow‐up was performed with a clinical composite end point (cardiac death, myocardial infarction, and unplanned revascularization). We obtained successful FFRCT analyses and 5‐year clinical follow‐up in 54 patients (average age, 60±13 years). Thirty‐eight (70%) patients had conservative treatment, and 16 (30%) patients had coronary revascularization after coronary CT angiography. The presence of an ANOCOR course was associated with a moderate reduction of FFRCT value from 1.0 at the ostium to 0.90±0.10 downstream the ectopic course and 0.82±0.11 distally. No significant difference in FFRCT values was identified between at‐risk and not at‐risk ANOCOR. After a 5‐year follow‐up, only one unplanned percutaneous revascularization was reported. Conclusions The presence of ANOCOR was associated with a moderate hemodynamic decrease of FFRCT values and associated with a low risk of cardiovascular events after a 5‐year follow‐up in this middle‐aged population.

To assess the diagnostic delay (between first hospital medical contact and diagnosis) and the surgical delay (between diagnosis and incision) of type A acute aortic syndromes (AAAS) within the RENAU (REseau Nord Alpin des Urgences), organizing the management of emergency medicine care in the French North Alpine Arc.Multicenter retrospective study between 2012 and 2016 on the AAAS operated in the RENAU heart surgical centers (Annecy, Grenoble). Post-traumatic, iatrogenic or chronic lesions, incidental discoveries and deaths before surgery were excluded.One hundred and ninety-seven patients were included with a median age [IQR] of 65 years [58; 73] of which 67% were men. The median diagnosis delay was 88min [46;241] and the median surgical delay was 193min [146;249]. Initial management was performed by the SMUR for 102 patients (52%), 7% of whom received a pre-hospital transthoracic ultrasound. 52 patients (26%) presented themselves spontaneously to the emergency department. Patients were initially admitted in a center without cardiac surgery in 65% of cases. The CT scan was the diagnostic test in 81% of cases. The postoperative hospital mortality was 16%.Referring to IRAD data reporting a median diagnostic and surgical delay of 258min each, our study suggests that the RENAU organization may be associated with reduced diagnostic and surgical delays for patients with SAAA.

The percutaneous coronary interventions use large doses of ionizing radiation, particularly when treating complex lesions. The incidence of radio-induced skin lesions is poorly known. Our goal was to evaluate the frequency of occurrence of such lesions, as well as the factors that may contribute to a high radiation dose. The recommended DAP (dose-area product) cutoff for skin monitoring after percutaneous coronary interventions is 500Gy cmWe prospectively studied the incidence of acute (after 5-7 days) and subacute (after 7 days to 6 months) skin lesions following angioplasty with a dose-area product (DAP) ≥200Gy cmNine hundred and thirty three consecutive procedures were analyzed, of which 102 with a DAP ≥200Gy cmRadiodermatitis lesions occur for 4.82% of patients benefiting from procedures with a DAP ≥200Gy cm

Familial hypercholesterolemia (FH) is a frequent genetic disorder that leads to premature atherosclerosis and coronary artery disease. However, knowledge of FH by cardiologists is weak, and FH remains underdiagnosed in France. FH should be suspected when low-density lipoprotein cholesterol (LDLc) levels exceed 1.9g/L (4.9mmol/L) without lipid lowering therapy.This multicenter retro- and prospective observational study aimed at estimating the prevalence of high LDLc levels in patients admitted in coronary care units, and the impact for the personal and familial follow-up for lipid status.Retrospective analysis of all plasma lipid measurements performed at admission in coronary care unit of 4 hospitals in 2017. Retrospective analyses of demographic, clinical, and coronary data of consecutive patients with LDLc levels≥1.9g/L. Prospective 1 year follow-up focused on lipid levels, treatments, and personal and familial screening for FH.Lipid measurement has been performed in 2172 consecutive patients, and 108 (5%) had LDLc level≥1.9g/L (mean age 64±14 years, men 51%). The primary cause of the hospitalisation was acute coronary syndrome (78%), and 22% of patients were free off coronary artery disease. Lipid lowering therapy was present in 9% of patients at admission, and 84% at discharge, with high statins regimen. At 1-year follow-up, control of LDLc level was not performed in 20% of patients, and statin dose was decreased (36%) or withdrawn (7%) in 43%. Lipid measurement has been performed in at least one first degree relative in 37% of patients, and genetic exploration has been done for 3 patients.Screening of FH in CCU should be routinely performed using the Dutch Score when LDLc is above 1.9g/L. Individual and familial management of patients at high risk for FH screened in CCU should be optimized, both for diagnosis and therapeutic purposes.

Risk stratification allows outpatient management of low-risk pulmonary embolism (PE). Here, we carry out an evaluation of the professional practices on the emergency management of low-risk PE, after selection with the sPESI score.All patients admitted to the emergency department of Chambéry hospital, with a final diagnosis of PE are analyzed. The PE of score sPESI at 0 are included, in the absence of contraindications. Ninety-day follow-up is done. The objective is to evaluate the proportion of ambulatory care for low-risk patients.Eighty PE were diagnosed in 2016, 28 with sPESI score at 0 and 3 patients excluded. Of the 25 inclusions, 6 patients had signs of right ventricular dysfunction and were therefore hospitalized. The remaining 19 were eligible for outpatient care but only 8 of them stayed less than 24hours in the hospital.The sPESI score is a decision support tool for outpatient management but should not be used alone. The search for right ventricular dysfunction seems important here.

A large thrombus burden is not uncommon in primary percutaneous coronary intervention, and is associated with more frequent complications. The role of intracoronary thrombolysis and glycoprotein IIb/IIIa inhibitors in the management of a large thrombus burden is discussed. The use of thromboaspiration must follow a particular logic and used with rigorous manipulations; the capacities of the protective filters are often exceeded. Stents dedicated to thrombus management can be used. Interest and limits of these stents are developed. Direct stenting should be encouraged, and delayed stenting probably considered for the most important thrombotic burden despite "negative" results in studies.

Carotid atherosclerosis is a powerful predictive factor of vascular risk at the individual patient level. Ultrasonography is a reference technique for the evaluation of this condition. However, its use in common practice remains difficult due to a lack of standardization and inter-operator variability. We present a new and simple technique for the assessment of carotid atherosclerosis; and evaluate the ability of vascular neurologists to obtain results consistent with those of an expert in vascular ultrasound.The TIMMA scale is an acronym for the five classes of carotid atherosclerosis in French, VIMMA in English: very important, important, moderate, minimal and absent. Combined, the first two classes make up the group "significant atheroma" and the last three classes make up the group "no significant atheroma". This scale was evaluated in 38 patients (76 carotid arteries) suffering from ischemic stroke or transient ischemic attack by five operators who are competent in carotid echocardiography: one TIMMA-trained (40 hours of training) vascular neurologist physician (VNP), three VNPs informed on the measurement method (1 hour of information) and one specialized vascular physician (SVP) who was considered to be the reference examiner. We evaluated the concordance between the VNPs and the SVP in classifying patients, firstly into the significant or not atheroma group and, secondly, into the five TIMMA classes.The evaluation of the two-group clustering scale found a concordance between the informed VNPs and the SVP on 76 carotid arteries of 86% (kappa=0.7) and between the trained VNP and the SVP on 58 carotid arteries of 90% (kappa=0.8). The positive and negative predictive values for significant atheroma diagnosis were 100% and 81%, respectively, for the informed VNPs, and 100% and 80% for the trained VNP. The evaluation of the Five-Class Scale showed a concordance between the informed VNPs and the SVP of 46% (kappa=0.3), and between the trained VNP and the SVP of 74% (kappa=0.7).TIMMA allows VNPs who are competent in carotid ultrasonography to reproducibly identify subjects with significant carotid atheroma. The contribution of this scale to the determination of cardiovascular risk should be evaluated.

Introduction: Pain is a significant driver of demand in emergency care and 65% of adult patients with trauma also report moderate to severe pain. Inhaled low dose methoxyflurane (MEOF) a rapid-acting patient administered inhalational analgesic was recently approved in Canada for the short-term relief of moderate to severe acute pain associated with trauma or interventional medical procedures in conscious adult patients. This study will generate real-world evidence to complement the global clinical development program through evaluation of the effectiveness of MEOF in Canadian emergency departments. Methods: This is a phase IV, prospective open label, multi-centre study. Approximately 100 adult (≥18 yrs) patients with moderate to severe acute pain (NRS0-10≥4) associated with single system trauma will be enrolled at 5-10 EDs across Canada. Patients will receive a single treatment of up to 2 x 3 mL MEOF (2nd 3 mL to be provided only upon request), self-administered by the patient under medical supervision. Rescue medication will be permitted at any time, if required. Results: Planned Assessments and Outcome Measures: Pain will be assessed using the NRS0-10 at 4 time points: screening/triage, 5 minutes and 20 minutes post-start of administration (STA) of MEOF, and when ready for discharge. Secondary assessments will include the speed of action of analgesia (from STA of MEOF); patient and physician satisfaction with treatment (as assessed through Global Medical Performance (GMP) at 20 minutes post-STA and when ready for discharge); patient and physician fulfilment of pain relief expectations (assessed when ready for discharge); use of rescue medication and treatment-emergent adverse events. Exploratory outcomes will include the time to disposition, time to readiness for discharge and responder analysis. The primary outcome measure will be the change in pain intensity over 20 minutes from the start of administration of MEOF as measured on the NRS0-10. Conclusion: We report on the methodology of a phase IV, prospective open label, multi-centre study, evaluating the use of MEOF for the management of acute traumatic pain in Canadian Emergency Departments.

l s’agit d’un patient de 53 ans presentant comme principaux antecedents, un diabete non insu-linodependant et une coronaropa-thie decouverte dans le cadre de la surveillance de son diabete, avec probable antecedent d’infarctus silencieux antero-septal, constatation d’une atteinte monotronculaire avec angioplastie de l’artere interventri-culaire anterieure et de la premiere diagonale en 2009 (Italie). Il est seden-taire, sans activite sportive reguliere ni autre facteur de risque cardiovascu-laire notable, notamment tabagique.Dans la prevision d’un projet de des-cente de la Vallee Blanche a ski (mas-sif du Mont-Blanc, France), il revoit son cardiologue traitant qui rea-lise un examen clinique et un elec-trocardiogramme (ECG) de repos, normaux. Il preconise la realisation d’un test non invasif de la reserve coronaire : realisation d’une echo-graphie de stress, sous dobutamine, sans anomalie retenue de la cine-tique segmentaire en dehors d’une hypokinesie antero-septale connue ne s’aggravant pas durant le test. Dans ces conditions, il est autorise a realiser ce projet.En cette fin mars 2013, la descente s’effectue par beau temps dans une neige lourde et profonde. Des le debut de la descente, le patient a des difficultes pour suivre le groupe ; il est asthenique, avec une sensa-tion de mal-etre, sans douleur thora-cique exprimee a l’entourage ou au guide. Il s’effondre a proximite du refuge du Requin (2516 m) lors de la remontee vers celui-ci. Un guide present, assiste de la gardienne du refuge debute les gestes qui sauvent et apporte le defibrillateur automa-tise externe (DAE) installe a l’annee dans ce refuge (programme d’equi-pement avec un financement de la Federation francaise de cardiologie, en collaboration avec l’Ifremmont et Pharefuge) (

In the emergency department, the management of patients with pulmonary embolism depends on the early mortality risk. Outpatient care is possible in low-risk patients. We present the existing scores and the strategy proposed by the North Alps Emergency Network, which uses the simplified PESI score (Pulmonary Embolism Severity Index) to select those low-risk patients, candidates for early discharge.

Resume Introduction Le reseau nord-alpin des urgences (RENAU) federe les acteurs des urgences de 3 departements des Alpes francaises. Le but de notre etude etait de decrire l’activite extra-hospitaliere pediatrique des services mobiles d’urgence et de reanimation (SMUR) au sein de ce reseau. Methode Il s’est agi d’une etude retrospective des interventions pediatriques de 7 SMUR, au sein d’hopitaux dotes de plateaux techniques varies (reanimation, chirurgie, urgences, pediatrie). Tous les patients âges de 1 mois a 18 ans pris en charge par un SMUR entre le 1 er janvier et le 31 decembre 2012 ont ete inclus. Resultats Sur la periode etudiee, les SMUR avaient effectue 15 038 interventions (11 951 primaires et 3087 secondaires) dont 1325 (8,8 %) repondaient aux criteres d’inclusion : 1087 patients pris en charge en intervention primaire et 238 patients en intervention secondaire. Parmi les interventions primaires, 531 (48,9 %) patients avaient ete pris en charge pour un traumatisme, 118 (11 %) avaient ete laisses a domicile, 427 (39,9 %) avaient ete perfuses, et 27 (2,5 %) avaient ete intubes. Un pediatre avait assure la medicalisation de 64 (26,9 %) interventions secondaires. Parmi les 1649 interventions de secours en montagne, 296 (18,7 %) concernaient des enfants. Conclusion L’activite pediatrique des SMUR polyvalents est incontournable et justifie un materiel et une formation adaptes.

International guidelines have recommendations for selecting the type of reperfusion (fibrinolysis or angioplasty) in the setting of ST-segment elevation myocardial infarction (STEMI), and suggest that emergency-care networks adapt these recommendations according to the local environment.To assess the proportions of STEMI patients treated with fibrinolysis or angioplasty in accordance with regional guidelines.Observational study based on a permanent registry of patients with STEMI of12h duration in an emergency network in the French North Alps (Isère, Savoie, Haute-Savoie) from January 2009 to December 2012.The registry included 2620 patients. Reperfusion was given in 2425/2620 (93%) of patients. Reperfusion type was in accordance with recommendations in 1567/2620 (60%) patients. Guideline-recommended fibrinolysis and angioplasty were performed in 47% (656/1385) and 79% (911/1149) respectively, of patients. In multivariable analysis, variables independently associated with guideline-recommended reperfusion were: an age65 years (OR 1.60; 95%CI 1.33-1.90), being managed in Haute-Savoie versus Isère or Savoie (OR 1.38; 95%CI 1.12-1.71), an arterial tension100mmHg (OR 1.73; 95%CI 1.27-2.35), a cardiogenic shock (OR 0.50; 95%CI 0.30-0.84), a pacemaker or left bundle branch block (OR 0.49; 95%CI 0.28-0.88), and an initial management outside the network (followed by treatment in an interventional centre in the network) (OR 0.62; 95%CI 0.40-0.94). Patients initially treated by mobile intensive care units were more often reperfused in accordance with recommendations when admitted3 (versus ≥ 3) h following symptom onset (adjusted OR 2.05; 95% CI 1.61-2.59), while those initially treated by in-hospital emergency units were less often reperfused in accordance with recommendation when treated3h following symptom onset (adjusted OR 0.67; 95% CI 0.46-0.97). In-hospital major adverse cardiac events (9.1% vs. 8.5%) and in-hospital mortality (6.4% vs. 5.1%) were not significantly different between patients reperfused in accordance with (versus not) recommendations.Forty percent of patients with STEMI were not reperfused with fibrinolysis or angioplasty in accordance with regional guidelines. Characterization of this population should allow us to improve guideline adherence.

The northern French Alps emergency network (RENAU) manages emergent care and patient treatment pathways in a three-county area in the French Alps. The aim of the study was to describe the pediatric activity in mobile intensive care units (MICUs).This retrospective observational study was conducted from 1 January to 31 December 2012. Data were obtained from patients' medical records in seven representative MICUs of the RENAU. Consecutive patients between 1 month and 18 years of age were enrolled.During the study period, MICUs carried out 11,951 primary transports and 3087 secondary transfers. A total of 1325 patients were enrolled: 1087 primary transports and 238 secondary transfers. In primary interventions, 531 (48.9%) patients were managed for a trauma, 118 (11%) children were discharged and stayed home, 427 (39.9%) underwent an intravenous cannulation and 27 (2.5%) on-scene intubation. A pediatrician was in charge of 64 (26.9%) secondary transfers. Among 1649 (18%) mountain rescues, 296 (18.7%) involved a child.Emergency physicians in MICUs are involved with children's prehospital care and need dedicated materiel and special training.

The prevalence of hypertension in the Sub-Saharan Africa region is increasing as a manifestation of the epidemiological transition, and this fact will oblige these countries to mobilize significant resources. World Bank estimates cheaper to prevent cardiovascular disease than to treat people once these diseases are established suggesting the need to know the prevalence of hypertension in order to allow prevention programs in our population. However, data in Togolese populations are rare. The purpose of the present study was to determine the prevalence of high blood pressure and its risk factors in Lomé.We performed a cross-sectional survey among 2002 unselected respondents of the municipality of Lomé in May 2011. A questionnaire has been filled about family history of hypertension, habits and practices that affect hypertension on behalf of each respondent and anthropometric data and blood pressure has been measured.The prevalence of high blood pressure was 36.7% (34.6% of male vs. 38.4% of female, OR=0.85; 95%CI=0.7-1.02; P=0.08); 42.4% of the hypertensive respondents have been diagnosed at the screening. Blood pressure was positively correlated to the age (SBP: r=+0.46; P=0.001; DBP: r=+0.36; P0.001), the body mass index (SBP: r=+0.7; P0.001; DBP: r=+0.89; P0.001) and waist circumference (SBP: r=+0.28; P0.001; DBP: r=+0.3; P0.001). There was a significant relationship between arterial hypertension and obesity (OR=1.65; 95%CI=1.47-1.84; P=0.003), salt consumption (OR=1.4; 95%CI=1.13-1.72; P0.001) and oral contraception (OR=2.1; 95%CI=1.29-3.43; P=0.002).There was a high prevalence and low awareness of arterial hypertension in the municipality of Lomé with a female prevalence. This affection was correlated to age, salt consumption and obesity. This study raises the need for accentuating the prevention in our poor populations which are unable to face adverse outcomes which can occur.

Objective: To identify predictors of early TIMI 3 flow patency of the infarct-related artery after prehospital thrombolysis in patients with ST-segment elevation myocardial infarction (STEMI) using data from a “real-world” population, and to develop a nomogram for triaging patients to emergency angiography. Design: Multicentre, observational, prospective, cohort study. Setting: 79 Hospitals in France with a prehospital mobile intensive care unit and a coronary care unit with 24 h access to coronary angiography. Patients: 997 Patients with STEMI. Interventions: All patients received prehospital thrombolysis within 6 h of symptom onset and angiography was performed within 6 h of thrombolysis. Main outcome measures: Coronary patency (TIMI flow). Results: The median age of the population was 59 years and the sample comprised 18% women. After multivariable logistic regression analysis, predictors of TIMI 3 flow in the infarct-related artery were current/previous smoking (odds ratio (OR) = 1.60, 95% confidence interval 1.15 to 2.22), ⩽5 leads with ST-segment elevation before thrombolysis (OR = 1.59, 1.12 to 2.25), Killip class I (OR = 1.96, 1.05 to 3.67), chest pain relief (OR = 1.62, 1.17 to 2.25) and ST-segment resolution ⩾70% (OR = 1.76, 1.29 to 2.38). A nomogram was developed to assess the probability of TIMI 3 flow, according to smoking status, number of leads with ST elevation before thrombolysis, Killip class, chest pain relief and ST-segment resolution. Conclusions: This study provides quantitative data for predicting success of prehospital thrombolysis. The nomogram is a simple tool for predicting likelihood of coronary patency, based on clinical and electrocardiographic data. It may help to identify patients who require emergency angiography and rescue percutaneous coronary intervention.

The prognostic impact of a myocardial ischemia-based therapeutic program in asymptomatic diabetic patients remains controversial. We prospectively assessed the benefit of a stratification algorithm based upon clinical and myocardial perfusion imaging (MPI) data on cardiovascular events in such patients in a non-randomized register.701 consecutive asymptomatic diabetic patients were classified to be at low or intermediate-to-high cardiac risk according to 13 simple boil-clinical parameters. Intermediate-to-high risk patients were scheduled for MPI and underwent either a conventional (Group 1, n=180) or an intensive multifactorial (Group 2, n=245) therapeutic program. Low risk patients (Group 3, n=276) underwent no specific management.At the end of the survey and as a consequence of intensive management, lipid lowering therapy, antiplatelet drugs, and beta-blockers were more often prescribed in Group 2 than in Group 1 (55, 31 and 17% versus 36, 23, and 8% respectively, p0.01). Planned coronary angiography in case of severe ischemia on MPI and revascularization were more frequent in Group 2 (16.2 and 8.9%) than in Group 1 (8.0 and 2.8% - p0.01). At 19-month follow-up (96.7% completed), major event rate in Group 2 was significantly lower than in Group 1 (3.9 versus 9.8%, p0.01) and similar to that of Group 3 (2.2%, NS).Easy-to-perform risk stratification is able to select diabetic patients with good medium-term prognosis. In clinically selected higher risk patients, an intensive medical therapy combined with coronary angiography +/- revascularization in case of large ischemia on MPI is effective to improve prognosis.

North American studies suggest that as many as one-third of people living with HIV/AIDS self-medicate with cannabis for relief of physical and stress-related symptoms. Although cannabis remains a controlled substance in Canada, legal access has been granted to people with HIV/AIDS and other serious illness under the Marihuana Medical Access Regulations (MMAR) since 2001. Several years into the programme, however, few Canadians ( approximately 1400) have obtained MMAR approval, suggesting that substantial obstacles remain. This paper reports findings from a 2005 survey (n=197) and focus groups conducted to identify barriers to access to medical cannabis among people living with HIV/AIDS. Most (86%) respondents who reported using cannabis as medicine continue to rely on illegal sources for their supply. They cited lack of information, product quality concerns, and an onerous, confusing application process among other problems mentioned with the MMAR. The findings are discussed in terms of policy suggestions for facilitating access to a legal source of cannabis for medical users.

Blood measurements of BNP and NT-proBNP, its catabolite, improve diagnosis for patients admitted to emergency departments with dyspnoea. In this paper, we have compared the BNP to the NT-proBNP for 119 dyspnoeic patients using at random clear clinical status. Among the test group of 119 patients, 57 showed coherent biological results for the 2 markers. These results confirm the final clinical diagnosis. Nine patients with congestive heart failure had abnormally low BNP and NT-proBNP rates. Six of these patients experienced long delays (longer than 48 hours and less than 72 hours) between their admission in emergency and the biological measurement of the natriuretic biomarkers. Three of the other patients could be not only flash OAP cases with a fast growth and a fast normalisation of BNP but also could have existing genetical factors. These genetical factors leading to high variability in BNP synthesis are not related to physiological or cardiac factors. 43 patients showed a mismatch between BNP and NT-proBNP. BNP appeared to be unstable in vitro. The lack of stability in whole blood or plasma samples is increased by sampling in a glass EDTA collection tube and too long delays in transferring the samples from the emergency area and the laboratory in a big hospital. Ten patients showed a mismatch with abnormally high NT-proBNP or false positive results. Among these 10 patients, 5 had renal dysfunction with a high level of creatinine concentration. It is clear that all Diagnostics Manufacturers should now propose different cut-off for natriuretic peptides tests according to the degree of patients' renal impairment.

To compare processes of care for acute myocardial infarction among patients admitted to alpine vs other French hospitals.Prospective observational study of patients with ST-elevation and non ST-elevation myocardial infarction of less than 48 hours hospitalized in 369 intensive care units in November 2000.Fifty-five patients were enrolled in nine alpine hospitals and 2265 patients in 360 other French hospitals. Patients baseline characteristics did not differ between the two groups with the exception of ST-elevation myocardial infarction which was less frequent in patients admitted to alpine hospitals (71 vs. 83%, P = 0.02). Patients living in the alpine area were less likely to be admitted to hospitals with on-site cardiac catheterization facilities (42 vs. 60%, P0.01) although the use of primary (20%) and rescue (24%) percutaneous coronary intervention did not differ significantly between the two groups. There were no differences in the use of medical treatments between the two groups with the exception of low-molecular-weight heparin. The risk of in-hospital death and complications did not differ significantly between the two groups while the risk of death at one year was lower in patients admitted to alpine hospitals (5 vs. 16%, P = 0.04).In 2000, a lower proportion of patients living in the alpine area had access to hospitals with cardiac catheterization facilities compared to other French patients. This finding supports the creation of an additional cardiac catheterization laboratory with experienced operators performing percutaneous coronary interventions 24 hours/7 days and the implementation of an emergency medical care network for acute coronary syndromes in the alpine area.

Aim To assess the prognostic impact of a therapeutic program based on bioclinical risk-stratification and myocardial-perfusion-imaging (MPI) data on survival and the occurrence of coronary events (CE=death+myocardial infarction) in asymptomatic patients with diabetes. Method Five hundred twenty one consecutive asymptomatic diabetic outpatients were prospectively enrolled and clinically classified as being at either low or high cardiac risk. All high-risk patients ( n =245, age 61±9 years) underwent MPI and an intensive multifactorial medical therapeutic program, including anti-ischaemic agents in cases of moderate ischemia; a coronary angiography was performed in all high-risk patients with severe ischaemia ( n =38), followed by immediate revascularization if necessary ( n =21). Low-risk patients ( n =276, age 57±9 years) underwent medical management of their risk factors. Results At the 19-month (median) follow-up (range, 12–36 months), both high- and low-risk patients showed similarly low CE rates (2.3% and 1.5% per year, respectively; age- and gender-adjusted log-rank P =NS). None of the patients who underwent myocardial revascularization experienced any CEs, and none of the low-risk patients died during follow-up. The negative predictive value of first-line bioclinical stratification was 0.98 for the occurrence of CEs, and 0.95 when low-risk patients were combined with high-risk patients who had normal MPI findings. Conclusions Bioclinical first-line stratification allows identification of diabetic patients who have a good medium-term cardiac prognosis. The CE rate is similar in selected high-risk asymptomatic patients with diabetes using an intensive MPI-guided program that combines medical therapy, coronary angiography in the 16% of cases with severe ischemia and, if appropriate, revascularization.

The effectiveness of thrombolytics has been clearly demonstrated in more than half the cases in the large cohorts of patients selected for trials during the acute phase of myocardial infarction. At individual level, thrombolysis will clinically either succeed or fail so, for the medical team managing the patient, choice of treatment may be likened to a gamble which in the best of cases (most often) leads to an uncomplicated success and, in the worst of cases, failure worsened by a severe complication. OPTIMAL is a multidisciplinary and multicentre, prospective cohort study associating mobile medical teams and interventional cardiology units to test the hypothesis that the outcome of prehospital thrombolysis does not depend on chance alone but also varies according to demographic, etiological, clinical and logistic factors involved in the occurrence and management of myocardial infarction. The primary objective of this French study, conducted over one year on more than 800 subjects, is to identify the predictors of the results of prehospital thrombolysis from a very early angiographic evaluation. The results for this cohort may be useful for setting up appropriate management strategies for acute myocardial infarction, from the prehospital phase (thrombolysis or not) up to in-hospital orientation of the patients (angiography room or Intensive Care Unit) and to determine the most judicious time for coronary angiography. OPTIMAL is to date the largest prospective serie of prehospital thrombolysis evaluated by an early angiographic control.

National audience; OBJECTIVES: To identify the factors associated with early cardiac catheterization in patients with a non ST-segment elevation acute coronary syndrome. METHODS: We analyzed data collected by retrospective chart review for 208 patients presenting at seven French hospitals with an acute coronary syndrome (chest pain at rest within 24 h prior to presentation with positive cardiac markers and/or electrocardiographic changes) between January and March 2005. RESULTS: Eighty-seven patients (42%) were first admitted to hospitals with cardiac catheterization facilities. One hundred ten patients (53%, 95% confidence interval [95% CI], 46-60) underwent early cardiac catheterization less than 48 h following presentation. In addition to presentation at hospitals with catheterization facilities, factors independently associated with early catheterization included positive cardiac markers in patients first admitted to hospitals without catheterization facilities (adjusted odds ratio [aOR] 34.5, 95% CI, 4.4-268.0) and diabetes mellitus (aOR, 0.4, 95%CI, 0.2-0.9). With the exception of positive cardiac markers, no risk factors comprising the TIMI risk score were associated with increased odds of early cardiac catheterization. During the index hospital stay, six patients (3%) died, seven patients (3%) had pulmonary edema, three patients (1%) had major or minor bleeding, and none had ST segment elevation myocardial infarction. CONCLUSION: Despite the dissemination of international guidelines, the use of early cardiac catheterization remains related to initial presentation at hospitals with catheterization facilities rather than risk assessment in patients with a non ST-segment elevation acute coronary syndrome.

To evaluate the therapeutic impact of an education program on patients undergoing oral anticoagulation treatment, within the hospital of Annecy (France).Groups of 10 patients were invited to participate to two meetings. The education was carried out by two nurses. Thanks to this prospective study, we compare the population before and after education in terms of treatment knowledge and stability.Within 9 months 88 patients have been included, amongst which 55 have attended the two meetings. The average of correct answers to the knowledge evaluation questionnaire distributed before and after 6 months of education were, respectively, 6.63/12, 10.09/12 (P0.0001). Through INR controls within the 6 months preceding (424 controls) and the 6 months following the education (619 controls), we observe: an increase of the total INR average in therapeutic zone, from 45% to 61% (P0.0001); a decrease of the difference average per patient between the INR value observed and the one targeted: 0.54 before education, 0.40 after education (P = 0.0016); at last, the average phasing per patient under the therapeutic zone increases after education, from 49% to 65% (P0.001).The education improves objectively the knowledge of patient undergoing AVK. If the size of patient sample is not large enough to prove any consequence on hemorrhagic or thrombotic complications, the education program still improves significantly the treatment stability.

To assess the generalizability of the medico-economic analysis comparing primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction.A systematic analysis of published studies was performed by two independent reviewers, in accordance with guidelines promulgated by health economic experts.Eleven articles, which concerned seven studies, were selected. Respectively, four evaluations were carried out in U.S. and three other in European countries (France, Netherland and Austria). There were three randomized trials, two observational studies and two decision trees. The costs were respectively ranged 2042 to 83,708 1999 US dollars for thrombolytic therapy and 3289 to 83,477 1999 US dollars for angioplasty. In two randomized trials and one decisional tree, the primary coronary angioplasty was both more effective and less costly than the thrombolysis therapy. One observational study concluded that thrombolytic therapy was less costly than primary angioplasty despite comparable effectiveness. Two analysis could not conclude of a difference between the alternatives, because of lack of statistical power.Published medico-economic analysis remain of a little interest for the French health care system because of lack of transparency in presentation of results. The dominance of the primary angioplasty was sensitive to time required for patient's transfer (ideally less than an hour), to the presence of redundant laboratories in an area and to the presence of an experienced staff for 24 h a day.

We have evaluated the sensitivity of a diagnostic algorithm for all patients suspected of pulmonary embolism using: D-Dimer, lower limb venous ultrasonography and helical computed tomography. To validate this approach, a lung scan is systematically carried out if the pulmonary embolism diagnosis is not withheld as a result of the algorithm. Clinical tests are organised between the 3rd and 6th month.Two hundred patients were involved between January 1998 and October 1999. One hundred and six pulmonary embolisms were diagnosed. Out of the 200 ultrasonography tests carried out we found: 71 proximal deep-vein thrombosis (popliteal or supra-popliteal), 33 distal thrombosis (infra-popliteal). Ninety-two cases were negative (4 tests non conclusive). We have deduced that a deep-vein thrombosis permits the diagnosis of thrombo-embolic illness without any further diagnostic approach (no computed tomography). Out of the 129 computed tomographies carried out we found: 35 pulmonary embolisms and 23 other diagnoses. Seventy-one lung scans were therefore carried out. We recorded 7 discordances (scans showed high and very high probability for pulmonary embolism whilst computed tomographies did not): pulmonary angiography was negative 4 times and diagnosed pulmonary embolism once and two patients refused to take the test (Table 2). There are two recurrences in the follow-up: proximal thrombosis and a pulmonary embolism. This involved two patients who had refused to undergo pulmonary angiography.This diagnostic approach therefore seems satisfactory but would require further investigation on a wider scale.

Provides a comprehensive profile of the program, including participant and school demographics, services offered, and performance outcomes, using 1998-1999 performance reports submitted by 355 projects serving over 300,000 participants. Notes that 52 percent of participants continued from a previous year; 48 percent were new to the program. Seventy-four percent met both the low-income and first generation college eligibility requirements. To obtain copies, write to: Office of Federal TRIO Programs, U.S. Department of Education, 1990 K Street, NW, Suite 7000, Washington, DC, 2006-8510; or fax yoru request to 202-502-7857; or e-mail your request to: TRIO@ed.gov.

Provides a comprehensive profile of the program, including grantees and participants, services provided, and performance objectives and outcomes, using data from 1998-1999, 1997-1998, and 1996-1997. The data, submitted by almost all funded projects, represent over 9,000 participants. Notes that 75 percent of grantees were public institutions, and almost 80 percent had 5,000 or more full-time students. Historically Black Colleges and Universities made up 10 percent of grantees; Hispanic-Serving Institutions made up another 11 percent. To obtain copies, write to Office of Federal TRIO Programs, U.S. Department of Education, 1990 K Street, NW, Suite 7000, Washington, DC 20006-8510; or fax your request to 202-502-7857; or e-mail your request to TRIO@ed.gov

Program In 2002, the regional agency of health in Rhone-alps area set up a health care network with the goal to optimise patient management, by a better coordination of existing facilities in the northern Alps. The ‘RESeau des URgences CORonariennes’ (RESURCOR), a subgroup of this network, is in charge of urgent cardiac care. The RESURCOR involves three French departments: Isere, Haute-Savoie and Savoie, which includes 1.8 million people with wide seasonal variations related to tourism. It coordinates urgent care between one university hospital, 12 general and three private hospitals, three emergency medical aid departments (SAMU), 12 mobile intensive care units (SMUR) and four cardiac interventional units. Emergency physicians and interventional and non-interventional cardiologists meet regularly to set up regional procedures for the management of patients suffering from acute myocardial infarction. It highlights the importance of reperfusion techniques, delays to have reperfusion and where the patient has to be admitted. A permanent regional registry monitors the management of these patients, the types of management and time. Results Since 2002, 3940 patients have been included in this registry. The accuracy was assessed at 84%. During the studying period, the number of primary percuntaneous interventions (PCI) gradually increased (33% in 2002 to 53% in 2008). The average time from the first medical contact to intravenous thrombolysis (62 mn in 2002 to 24 mn in 2008) and to arterial puncture of primary PCI (101 mn in 2002 to 78 mn in 2008) significantly decreased. Prehospital management by air increased from 3% in 2002 to 12% in 2008. According to the regional recommendations, 92% of the patients were directly admitted to an interventional coronary center in 2008. Discussion RESURCOR submit recommendations for patient management and assess through a registry if the recommendations have been followed by physicians. Myocardial infarction was the first condition which the network took care of. Since this approach succeeded, we have followed the same pattern for the other diseases requiring cooperations between hospitals without the same technical equipment: Unstable angina, stroke (fibrinolysis sometimes required), cardiac arrest (urgent coronary angiography or extra corporeal membrane oxygenation sometimes required) and severe traumatology (trauma-system). Conclusion RESURCOR is a network for patient management which needs urgent care. It allows coordination of care between different institutions in a large area. Objectif Amelioration des prises en charge des infarctus du myocarde. Programme En 2002, le RENAU (REseau Nord Alpin des urgences), reseau de prise en charge des urgences a ete mis en place sur le Nord des Alpes, a l`initiative de l`Agence Regionale d`Hospitalisation. Au sein de ce reseau, la filiere cardiologique s`est organisee autour du RESURCOR. Le RESURCOR couvre les departements de l`Isere, la Haute-Savoie et la Savoie, soit un total de 1.8 million d`individus, avec de larges variation saisonnieres. Il concerne un CHU, 12 hopitaux generaux, 3 cliniques privees, 3 SAMU, 12 SMUR et 4 centres de cardiologies interventionnelles. Le financement du reseau a permis de recruter 2 medecins responsables a temps partiels, une coordinatrice et 4 techniciennes de recherche cliniques a temps plein. Un site internet permet de faire circuler l`information et aux acteurs de communiquer (http://www.renau.org). Urgentistes, cardiologues interventionnels et non interventionnels se reunissent regulierement pour mettre a jour les recommandations regionales de prise en charge des infarctus du myocarde. Elles insistent sur l`importance des techniques de reperfusion, des delais de prise en charge et des parcours de soins des patients. Un registre regional a ete mis en place en 2002 pour evaluer sur le terrain la qualite des prises en charges. Le registre definit pour tous les patients victimes d`infarctus aigu du myocarde, les techniques de reperfusions, les delais de prise en charge et les parcours des patients. Resultats Depuis 2002, 3940 patients ont ete inclus avec une exhaustivite mesuree a 84%. Le nombre annuel des inclusions est stable depuis 2002. On assiste dans le temps a une augmentation du nombre d`angioplasties primaires (33% en 2002 a 53% en 2008). Les delais de reperfusion diminuent significativement dans le temps avec un delai median de thrombolyse passant de 62 mn en 2002 a 24 min en 2008 et un delai median de ponction en angioplatsie primaire passant de 101 mn en 2002 a 78 min en 2008. Le nombre des prises en charges heliportees a significativement augmente avec le temps (3% en 2002 et 12% en 2008). Selon les recommandations, 92% des patients sont adresses directement a un centre de cardiologie interventionnelle en 2008. Discussion Le RESURCOR emet des propositions de prise en charge, definit des referentiels de bonne pratique et verifie les modalites de prise en charge de ces urgence dans la pratique, a l`aide d`un registre continu, dedie a l`evaluation des pratiques professionnelles. L`infarctus du myocarde a ete la premiere pathologie concernee par cette demarche et devant le succes obtenu, nous avons developpe le meme concept aux principales urgences pouvant necessiter une collaboration entre les etablissements de sante: L`angor instable (angioplastie coronaire), l`AVC (Thrombolyse), l`arret cardiaque (angioplastie coronaire, ECMO) et la traumatologie grave (Trauma-system). Conclusion Le RESURCOR est un reseau de prise en charge, issu du terrain et finance par l`agence regionale d`hospitalisation. Il permet de coordonner et d`organiser la prise en charge des urgences a l`echelle d`un bassin important de population en faisant travailler ensemble des etablissements avec des plateaux techniques heterogenes.

Over a period of 24 years, 23 women who had undergone renal transplantation gave birth to 26 children whose gestational ages were above 28 weeks. The average duration of stable kidney function tests before the onset of pregnancy was 34.5 months (6 to 109 months). Immunosuppressive treatment consisted mostly of azathioprine and steroids (20/26), steroids and cyclosporin A (CyA) in one case, and azathioprine, steroids and CyA in 5 cases. Average gestational age at birth was 35.2 weeks (30-40 weeks), average birth weight was 2,330 g (1,160-3,700 g). Caesarean section was performed in 73% of cases. The most frequent neonatal pathological condition was the occurrence of respiratory distress, most often related to prematurity and the mode of delivery. No child presented with any lethal congenital malformation. Children born to mothers who were given CyA did not present with more congenital malformations or renal function impairment.

The association of arteriopathy and Coxiella burnetii infection was described in the sixties. We deal with the reality of this association about four cases of peripheral arteriopathy of lower limbs and chronic infection by Coxiella burnetii .