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OBJECTIVES To investigate the impact of abnormal perinatal loading conditions on cardiac geometry and function in term fetuses and neonates with transposition of the great arteries with intact interventricular septum (simple TGA), and to explore the predictive value of fetal cardiac parameters for an urgent balloon atrial septostomy (BAS) after birth. METHODS This was a prospective longitudinal follow-up study of women delivering at term, including both uncomplicated pregnancies with normal outcome and pregnancies affected by fetal simple TGA. Conventional, spectral-tissue Doppler and speckle-tracking echocardiographic parameters were obtained within 1 week before delivery and within the first few hours after delivery. Neonates with simple TGA that required urgent BAS were assessed after the procedure and before corrective arterial switch surgery. Cardiac parameters were normalized by cardiac cycle length, ventricular end-diastolic length or end-diastolic dimension, as appropriate. Fetal and neonatal cardiac parameters were compared between simple-TGA cases and controls, and perinatal changes in the simple-TGA group were assessed. Receiver-operating-characteristics (ROC)-curve analysis was used to assess the predictive value of fetal cardiac parameters for urgent BAS after birth in the simple-TGA group. RESULTS A total of 67 pregnant women delivering at term were included in the study (54 normal pregnancies and 13 with a diagnosis of fetal simple TGA). Compared with normal term fetuses, term fetuses with simple TGA exhibited more globular hypertrophied ventricles, increased biventricular systolic function and diastolic dysfunction (right ventricular (RV) sphericity index (SI), 0.58 vs 0.54; left ventricular (LV)-SI, 0.55 vs 0.49; combined cardiac output (CCO), 483 vs 406 mL/min/kg; LV torsion, 4.3 vs 3.0 deg/cm; RV isovolumetric relaxation time (IVRT'), 127 vs 102 ms; P

OBJECTIVE To evaluate the effect of diabetes in pregnancy on fetal and neonatal cardiac geometry and function around the time of delivery. METHODS This was a prospective study of 75 pregnant women delivering at term, comprising 54 normal pregnancies and 21 with a diagnosis of pregestational or gestational diabetes mellitus. Fetal and neonatal conventional and spectral tissue Doppler and two-dimensional speckle-tracking echocardiography were performed a few days before and within hours after delivery. Fetal and neonatal cardiac geometry, global myocardial deformation and performance, diastolic and systolic function and left ventricular (LV) torsion were compared between normal pregnancies and those with diabetes, and perinatal changes within the diabetes group were assessed. RESULTS Compared with normal pregnancies, diabetic pregnancies demonstrated significant differences in fetal ventricular geometry, myocardial deformation and cardiac function (right ventricular (RV) sphericity index, 0.56 vs 0.65; LV torsion, 2.1 °/cm vs 5.6 °/cm; LV isovolumetric relaxation time, 101 ms vs 115 ms; and RV isovolumetric contraction time, 107 ms vs 119 ms; P

Abdominal tuberculosis (ATB) is uncommon and not very well known by clinicians. We describe the characteristics, evolution, and treatment of patients with ATB in two large hospitals in the Paris region. We reviewed all records of patients treated for ATB, from January 01, 2010 to December 01, 2016, diagnosed by bacteriological and/or histological methods or highly suspected because of clinical/radiological features. We included 80 patients, with a median (IQR) age of 39 (29–50) years, with 56.2% being males. Among them, 63.7% had African origins, 15% Asian, and 11.2% European. Twenty-nine had a cause of immunosuppression (n = 21 HIV infection). The main abdominal localizations were lymph nodes (72.5%), peritoneum (62.5%), and solid organs (25%). Extra-abdominal localizations were recorded in 65 (81.2%) patients. Tuberculosis was proven bacteriologically in 71%, histologically in 50%, and solely clinical/radiological in 10% of cases. Patients received standard therapy for a median duration of 9 months, with a favorable outcome. Corticosteroid therapy was used in 15 cases, either for paradoxical reaction or to prevent complications. Abdominal TB was mainly represented by lymphatic and peritoneal localizations, proven bacteriologically, and associated with extra-abdominal localizations in most cases. The use of steroids remains controversial, but it does not seem systematically needed in case of abdominal involvement.

Background Lyme borreliosis (LB) diagnosis currently relies mainly on serological tests and sometimes PCR or culture. However, other biological assays are being developed to try to improve Borrelia-infection diagnosis and/or monitoring. Objectives To analyse available data on these unconventional LB diagnostic assays through a systematic literature review. Methods We searched PubMed and Cochrane Library databases according to the PRISMA-DTA method and the Cochrane Handbook for Systematic Reviews of Interventions. We analysed controlled and uncontrolled studies (published 1983–2018) on biological tests for adults to diagnose LB according to the European Study Group for Lyme Borreliosis or the Infectious Diseases Society of America definitions, or identify strongly suspected LB. Two independent readers evaluated study eligibility and extracted data from relevant study reports; a third reader analysed full texts of papers to resolve disagreements. The quality of each included study was assessed with the QUADAS-2 evaluation scale. Results Forty studies were included: two meta-analyses, 25 prospective controlled studies, five prospective uncontrolled studies, six retrospective controlled studies and two case reports. These biological tests assessed can be classified as: (i) proven to be effective at diagnosing LB and already in use (CXCL-13 for neuroborreliosis), but not enough to be standardized; (ii) not yet used routinely, requiring further clinical evaluation (CCL-19, OspA and interferon-α); (iii) uncertain LB diagnostic efficacy because of controversial results and/or poor methodological quality of studies evaluating them (lymphocyte transformation test, interferon-γ, ELISPOT); (iv) unacceptably low sensitivity and/or specificity (CD57+ natural killer cells and rapid diagnostic tests); and (v) possible only for research purposes (microscopy and xenodiagnoses). Discussion QUADAS-2 quality assessment demonstrated high risk of bias in 25/40 studies and uncertainty regarding applicability for 32/40, showing that in addition to PCR and serology, several other LB diagnostic assays have been developed but their sensitivities and specificities are heterogeneous and/or under-evaluated or unassessed. More studies are warranted to evaluate their performance parameters. The development of active infection biomarkers would greatly advance LB diagnosis and monitoring.

Objectives To assess the organization, activity, and funding of transversal infectious diseases (ID) activity in French hospitals. Methods Cross-sectional questionnaire-based survey conducted in 2013–2014. Results The questionnaire was returned by 66 hospitals (response rate: 63%). A transversal ID consultancy activity was present in 65 hospitals (98%) and had existed for a median of 6 years. The median team size for transversal ID activity was equivalent to 0.8 full-time physicians. Among the 16 hospitals (25%) with a full-time physician dedicated to transversal ID activity, only 6 university hospitals received dedicated funding. Teams with a transversal ID activity received a median of 35 calls for advice (IQR = 20–60) per week from other hospital departments, and 14 calls from external structures. They participated in multidisciplinary meetings (75%), dedicated staff meetings (bacteriologists, pharmacists, or infection control physicians – 51%), and promoted antibiotic stewardship (antibiotic usage guidelines (72%) and auditing (62%)). Eleven teams (17%) prepared an annual report of their transversal ID activity, and 30 teams (46%) recorded the number of calls for advice. Twenty-one teams cross-charged their in-hospital transversal ID consultancy, and 5 teams invoiced their external consultancy, with a recovery of the relevant funds by 8 teams. Conclusion Although most French hospitals that responded to this survey had a transversal ID consultancy activity, not all had implemented an antibiotic stewardship program. Few teams conducted standardized data collection or cross-charged their transversal ID activity. Moreover, teams rarely received specific funding for a full-time ID physician dedicated to transversal ID activity.

Objective To compare non-invasive hemodynamic measurements obtained in pregnant and postpartum women using two automated cardiac output monitors against those obtained by two-dimensional (2D) transthoracic echocardiography (TTE). Methods This was a cross-comparison study into which we recruited 114 healthy women, either with normal singleton pregnancy (across all three trimesters) or within 72 hours following delivery. Cardiac output estimations were obtained non-invasively using two different monitors, Ultrasound Cardiac Output Monitor (USCOM®, which uses continuous-wave Doppler analysis of transaortic blood flow) and Non-Invasive Cardiac Output Monitor (NICOM®, which uses thoracic bioreactance), and 2D-TTE. The performance of each monitor was assessed relative to that of TTE by calculating bias, precision, 95% limits of agreement and mean percentage difference (MPD). Intraobserver repeatability was assessed for both monitors and interobserver reproducibility was assessed for USCOM, NICOM being operator-independent. Results Following exclusions due to poor-quality results of a monitor or TTE, or for medical reasons, our analysis included 98 women (29 in the first trimester, 25 in the second and 21 in the third, and 23 postpartum). For cardiac output estimation, when compared with TTE, USCOM had a bias ranging from 0.4 to 0.9 L/min. The MPD of USCOM was 29% in the third-trimester cohort. NICOM had a bias ranging from −1.0 to 0.6 L/min, with a MPD of 32% in the third-trimester group. There was limited agreement between the cardiac output monitors and TTE in the first and second trimesters, with a MPD of 38% for USCOM in both first and second trimesters, and 71% and 61% for NICOM in first and second trimesters, respectively. For cardiac output estimation using USCOM, we found excellent intraobserver repeatability (intraclass correlation coefficient (ICC), 0.97; 95% CI, 0.95–0.98) and interobserver reproducibility (ICC, 0.90; 95% CI, 0.81–0.94), and the repeatability for NICOM was comparable (ICC, 0.95; 95% CI, 0.93–0.97). Conclusions We found good agreement of both USCOM and NICOM when compared with 2D-TTE, specifically in the third trimester of pregnancy. Both devices had good intraobserver repeatability and either had good interobserver reproducibility or were operator-independent. Future studies should take into account the significant differences in the precise maternal hemodynamic values obtained by these devices, and consider developing device-specific reference ranges in pregnancy and the postpartum period. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Preeclampsia is associated with increased cardiovascular long-term risk; however, the underlying functional and structural mechanisms are unknown. We investigated maternal cardiac alterations after preeclampsia. Female rats harboring the human angiotensinogen gene [TGR(hAogen)L1623] develop a preeclamptic phenotype with hypertension and albuminuria during pregnancy when mated with male rats bearing the human renin gene [TGR(hRen)L10J] but behave physiologically normal before and after pregnancy. Furthermore, rats were treated with pravastatin. We tested the hypothesis that statins are a potential therapeutic intervention to reduce cardiovascular alterations due to simulated preeclamptic pregnancy. Although hypertension persists for only 8 days in pregnancy, former preeclampsia rats exhibit significant cardiac hypertrophy 28 days after pregnancy observed in both speckle tracking echocardiography and histological staining. In addition, fibrosis and capillary rarefaction was evident. Pravastatin treatment ameliorated the remodeling and improved cardiac output postpartum. Preeclamptic pregnancy induces irreversible structural changes of cardiac hypertrophy and fibrosis, which can be moderated by pravastatin treatment. This pathological cardiac remodeling might be involved in increased cardiovascular risk in later life.

Background Fetal and neonatal studies report a wide range of cardiac parameters derived by pulsed-wave Doppler tissue imaging (DTI) and two-dimensional speckle-tracking echocardiographic (STE) imaging. The use of different ultrasound systems and their vendor-specific software compromises the ability to compare echocardiographic findings among various studies. The aim of this study was to evaluate intervendor reproducibility as well as intra- and interobserver repeatability of DTI and STE measurements in normal-term fetuses and neonates. Methods A prospective study was conducted of term fetuses (n = 196) from uncomplicated pregnancies assessed days before the onset of labor and a few hours after birth. Fetal and neonatal DTI and STE parameters were obtained and analyzed using vendor-specific software on three ultrasound systems: Toshiba Aplio MX versus GE Vivid E9 and GE Vivid E9 versus Philips EPIQ. A reproducibility study in fetuses and neonates (n = 118) was performed by systematic scanning with head-to-head comparison. Results DTI reproducibility showed moderate to good correlation, with good agreement for fetuses and neonates on Toshiba versus GE (intraclass correlation coefficient [ICC] = 0.4–0.8). Correlation of DTI measurements on GE versus Philips was poor to moderate for fetuses (ICC = 0.1–0.6) and moderate to good for neonates (ICC = 0.5–0.8), with wider limits of agreement. Fetal and neonatal STE parameters revealed very poor correlation (ICC = 0.1–0.3) and agreement among ultrasound vendors. Intra- and interobserver repeatability demonstrated good to excellent correlation of all fetal and neonatal DTI and STE measurements, with good agreement irrespective of the ultrasound platform used. Conclusions These findings demonstrate reliable assessment of fetal and neonatal DTI and STE measurements when performed on the same ultrasound platform, whereas ultrasound machines and software from different vendors give significantly divergent estimates of DTI and STE parameters in fetuses and neonates. These intervendor discrepancies have significant clinical and research implications and should be considered when interpreting and comparing study findings, establishing reference standards, or performing systematic reviews.

Objective Left ventricular (LV) torsion is an important aspect of cardiac mechanics and is fundamental to normal ventricular function. The myocardial mechanics of the fetal heart and the changes that occur during the transition to the neonatal period have not been explored previously. The aim of this study was to evaluate perinatal changes in LV torsion and its relationship with myocardial function. Methods This was a prospective study of 36 women with an uncomplicated term pregnancy. Fetal and neonatal conventional, spectral tissue Doppler and two-dimensional (2D) speckle tracking echocardiography were performed a few days before and within hours after delivery to measure cardiac indices including LV rotational parameters derived from short-axis views at the base and apex of the heart. Linear regression analysis was used to examine the relationship between LV rotational parameters and cardiac geometric and functional indices in term fetuses and neonates. Perinatal changes in LV rotational parameters were assessed. Results There were three patterns of LV twist in term fetuses: those with reversed-apex-type LV twist had the lowest median values of LV torsion (0.1°/cm), with higher values (1.6°/cm) in those with infant-type LV twist and the highest values (4.4°/cm) in those with adult-type LV twist. LV torsion was associated significantly with cardiac geometric and functional indices. Perinatal evaluation revealed a significant increase in LV torsion following delivery in fetuses exhibiting reversed-apex-type LV twist (increase of 2.8°/cm, P = 0.009) and a significant decrease in those with adult-type LV twist (decrease of 3.2°/cm, P = 0.008). Conclusions This study demonstrates the feasibility of 2D speckle tracking imaging for accurate assessment of rotational cardiac parameters in term fetuses. There are unique perinatal patterns of LV twist that demonstrate different values of LV torsion, which was found to correlate with indices of ventricular geometry and myocardial function. Differences in patterns of LV twist may therefore reflect differences in compensatory myocardial adaptation to the physiological environment/loading conditions in late gestation in fetuses and postnatal cardiac adjustment to the acute loading changes that occur at delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

International audience; BACKGROUND: Diphtheria is re-emerging in Europe. A total of 36 cases were reported in Europe in 2015 versus 53 cases between 2000 and 2009.PATIENTS: We report two cases of Corynebacterium diphtheriae infection in a French hospital in 2016: a cutaneous infection with negative toxin testing in a French traveller, and a respiratory diphtheria carriage with positive toxin testing in an Afghan refugee diagnosed with pulmonary tuberculosis. The vaccination history of the Afghan patient could not be retrieved.; Introduction : La diphtérie est une maladie réémergente en Europe. En 2015, 36 cas ont été rapportés contre 53 cas de 2000 à 2009.Patients : Nous rapportons deux cas d’infection à Corynebacterium diphtheriae survenus en 2016 dans un hôpital français : une infection cutanée avec recherche de toxine négative chez un voyageur et un portage respiratoire avec recherche de toxine positive chez un réfugié afghan atteint d’une tuberculose pulmonaire. L’histoire vaccinale était inconnue pour le patient afghan.

Introduction De nombreux patients presentant une suspicion de borreliose de Lyme (BL) experimentent un parcours de soins difficile. Nous avons mis en place un Centre pluridisciplinaire de prise en charge des BL, regroupant infectiologues, rhumatologues, internistes, neurologues, dermatologues, psychiatres, algologues, medecins de readaptation physique. Une ligne telephonique dediee est disponible pour les medecins traitants (MT). L’objectif de ce travail est de presenter l’activite de notre centre de janvier 2018 a janvier 2020. Materiels et methodes Nous avons retrospectivement analyse les caracteristiques de tous les patients adultes ayant consulte, adresses par leur MT ou specialiste, et leur parcours de soins au sein du centre. Tous les cas complexes etaient discutes en reunion de concertation pluridisciplinaire. Les patients ayant des signes cliniques en rapport avec une BL etaient definis selon l’ESGBOR : i)BL confirmee ; ii)BL possible (exposition aux tiques et/ou antecedent d’erytheme migrant, signes cliniques evocateurs, amelioration clinique apres 21–28j d’antibiotiques) ; iii)Syndrome post-Lyme ; iv)Sequelles de BL (signes cliniques objectifs persistants apres traitement bien conduit) ; v)Surveillance post-piqure de tique ; vi)Guerison. Seules les BL prouvees et possibles ont ete traitees (cf.consensus 2019). Resultats Aux 442 patients ayant consulte, 3 orientations ont ete proposees : externe (n = 290 ;65,6 %) ; hospitalisation de jour (n = 87 ;19,7 %) ou semaine (n = 75 ;17 %) ; et 611 consultations de suivi realisees (toutes specialites). 159 patients (36 %) presentaient des signes cliniques en rapport avec une BL : BL confirmee (n = 60 ;13,6 %) ; BL possible (n = 32 ;7,2 %) ; syndrome post-Lyme(n = 29 ;6,6 %) ; sequelles (n = 8 ;1,8 %) ; surveillance post-piqure de tiques (n = 13 ;2,9 %) ; guerison (n = 17 ;3,8 %). Des diagnostics associes ou differentiels etaient identifies chez 376/442 (85,1 %) : infectieux (n = 37 ;8,4 %) ; rhumatologique/auto-immun (n = 115 ;26 %) ; syndromes fonctionnels persistants (n = 44 ;9,6 %) ; neurologique (n = 43 ;9,7 %) ; psychiatrique (n = 32 ;7,2 %) ; effets secondaires des antibiotherapies prolongees (n = 41 ;9,3 %) ; carentiel/metabolique(n = 61 ;13,8 %) ; autres (n = 57 ;12,9 %) ; diagnostic en cours/non faits (n = 43 ;9,7 %). Dix patients ont ete perdus de vue. Un plan personnalise de soins a ete propose a chaque patient dans la filiere de soin adaptee, meme en l’absence de diagnostic. Conclusion Ces resultats concordent avec les precedentes experiences publiees et semblent stable d’une annee a l’autre. Le nombre de diagnostics differentiels ou associes confirment la complexite du diagnostic de BL sans omettre d’autres diagnostics. Une prise en charge pluridisciplinaire permet un diagnostic precis et une prise en charge personnalisee des patients.

Introduction La surprescription d’antibiotiques reste un probleme de sante publique en France. Les services de chirurgie maxillo-faciale (CMF) jouent un role important dans la consommation d’antibiotiques dans les hopitaux publics. Le but de notre observation est d’evaluer l’intervention d’une equipe d’infectiologues dans la prise en charge des patients dans un service de CMF. Materiels et methodes Dans un hopital general d’Ile-de-France, une reunion hebdomadaire entre infectiologues et chirurgiens maxillo-faciaux de fevrier a octobre 2019 a ete mise en place afin de discuter de tous les patients operes et non operes presents dans le service et pour lesquels des antibiotiques etaient prescrits. Les informations sur l’indication de l’antibiotherapie, les doses prescrites, la voie d’administration, la duree prescrite initialement et la duree conseille ont ete collectees. Resultats En 38 seances de 30 minutes, 173 avis ont ete proposes pour des patients d’âge moyen de 40,2 ans et 64 % d’hommes (111/173). La principale indication etait la prophylaxie des fractures aigues de la face (44 %, 77/173) traitees par amoxicilline-acide clavulanique (98 %, 76/77) avec un gramme toutes les 8 heures (96 %, 73/76). La duree moyenne de prescription etait de 5,8 jours (2–7). Nous avons epargne 102 jours d’antibiotherapie avec arret de 23 prescriptions (30 %, 23/77). La deuxieme indication etait le traitement curatif des cellulites faciales (28 %, 48/173), traitees par amoxicilline–acide clavulanique (94 %, 45/48) avec un gramme toutes les 8 heures (91 %, 41/45). L’antibiotique prescrit en cas de doute sur l’allergie a la penicilline etait la clindamycine pour 3 patients (6 %). La voie parenterale etait la plus prescrite (92 %, 44/48) en raison de la difficulte a utiliser la voie orale. Nous avons epargne 5 jours d’antibiotherapie avec arret d’une prescription (2 %), change les antibiotiques pour 3 patients (6 %), avec une reduction du spectre pour un patient. Parmi les autres indications, la duree moyenne de prescription etait de 6,3 jours. Nous avons epargne 49 jours de traitement avec arret de 19 prescriptions (39 %, 19/48) et propose de modifier 7 prescriptions (14 %) reduisant le spectre pour 4 patients (8 %). Conclusion L’antibioprophylaxie en CMF est souvent prescrite de facon prolongee du fait de l’accessibilite du bloc operatoire. L’intervention d’une equipe d’infectiologues chez des patients hospitalises en CMF a permis de reduire la consommation d’antibiotiques, de sensibiliser les chirurgiens et de resserrer les liens entre chirurgiens et infectiologues. Compte tenu du manque de recommandations pour les infections en CMF, nous envisageons de mettre en place des protocoles de traitements dans cette specialite.

Bacteriophages, viruses that are widespread throughout the world, are highly specific for bacteria, usually of a single species and often of a particular strain. After being discovered and isolated 100 years ago, their use, called phage therapy, was instituted in medicine two years later and quickly used around the world to treat various bacterial infections. In the West, phage therapy was overshadowed in the second half of the 20th century by antibiotic therapy, which was then thought to be the definitive solution. But because of the increase in bacterial resistance to antibiotics, the idea of using bacteriophages in medicine has been reawakened. The innumerable observations reported over the years in the literature constitute an invaluable experience. We and some of our colleagues have, in the last decade treated some patients compassionately. With the available documentation and our own experience we discuss the potential indications and limitations of phage therapy. The observation of the increasing number of therapeutic failures in the announced perspective of a post-antibiotic era, we believe, that the introduction of bacteriophages into the therapeutic arsenal seems conceivable today to two preconditions: that their production as biologic drug meets current regulatory standards and that the benefit-risk assessment was conducted in a modern setting. Phage therapy could be applied as a substitution or supplement to antibiotic therapy under multiple circumstances in different modes, precise indications and limits.

OBJECTIVE To evaluate the effect of fetal growth restriction (FGR) at term on fetal and neonatal cardiac geometry and function. METHODS This was a prospective study of 87 pregnant women delivering at term, comprising 54 normally grown and 33 FGR pregnancies. Fetal and neonatal conventional and spectral tissue Doppler and two-dimensional speckle tracking echocardiography were performed a few days before and within hours after birth. Fetal cardiac geometry, global myocardial deformation and performance and systolic and diastolic function were compared between normal and FGR pregnancies before and after birth. RESULTS Compared with normally grown fetuses, FGR fetuses exhibited more globular ventricular geometry and poorer myocardial deformation and cardiac function (left ventricular (LV) sphericity index (SI), 0.54 vs 0.49; right ventricular (RV) SI, 0.60 vs 0.54; LV torsion, 1.2 °/cm vs 3.0 °/cm; LV isovolumetric contraction time normalized by cardiac cycle length, 121 ms vs 104 ms; interventricular septum early diastolic myocardial peak velocity/atrial contraction myocardial diastolic peak velocity ratio, 0.60 vs 0.71; P

Background: Sparing of antiretroviral drug classes could reduce the toxicity and cost of maintenance treatment for HIV infection. Objectives: To evaluate the non-inferiority of efficacy and the safety of lopinavir/ritonavir (r) monotherapy versus a single-tablet regimen of efavirenz, emtricitabine and tenofovir (EFV/FTC/TDF) over 2 years. Methods: Adults on stable ART with plasma HIV-1 RNA viral load

Introduction Le risque de carcinome epidermoide du canal anal est multiplie par 100 dans la population homosexuelle masculine (HSH) vivant avec le VIH, par rapport a la population generale justifiant d’un depistage dont les modalites ne font pas l’objet d’un consensus international. En France, celui-ci repose actuellement sur un examen proctologique seul. Le but de cette etude est de comparer la prevalence des lesions anales intra epitheliales (AIN) detectees en cytologie anale, par un examen clinique et sous anuscopie de haute resolution (AHR). Materiels et methodes Un suivi de 2 ans avec une consultation annuelle par un proctologue avec examen clinique, frottis pour cytologie anale, recherche d’HPV, et AHR etait proposee aux patients HSH vivants avec le VIH et âges de 35 ans et plus suivis dans 6 centres. Le diagnostic de lesion anale de haut grade reposait sur une cytologie de haut grade (HSIL ou ASC-H) et/ou une biopsie de haut grade (AIN 2 ou AIN3). Resultats De decembre 2014 a juin 2016, 513 patients vivants avec le VIH âges de 51,3 [35–82] ans, et suivis depuis 15 [0,2–31] ans ont ete inclus dans 6 centres. A l’inclusion, des symptomes proctologiques etaient retrouves chez 67 (13 %) patients (saignement, prurit, douleur, masse anale ou ecoulement). L’examen clinique etait anormal chez 113 (22 %) patients avec des condylomes dans 60 (12,1 %) cas, une lesion macroscopique evocatrice de maladie de Bowen ou de papulose bowenoide dans 18 (3,6 %) cas et une pathologie proctologique benigne dans 35 (6,8 %) cas. Aucun cancer anal n’etait diagnostique. Une lesion de haut grade en cytologie etait retrouvee chez 37 (7,4 %) patients (31 HSIL et 6 ASC-H). L’analyse histologique des 324 lesions identifiees en AHR chez 210 patients montrait 53 lesions de haut grade (28 AIN2 et 25 AIN3) chez 41 (7,9 %) patients et 186 lesions de bas grade. Ainsi une lesion de haut grade cytologique et/ou histologique etait confirmee chez 82 (16 %) patients. Un HR-HPV etait retrouve dans 343 (70 %) cas et un HPV-16 dans 142 (29 %) cas (sur 490 prelevements analysables). Un antecedent de lesion anale de bas (OR = 2,3–95 %CI 1,0–5,4) ou haut grade (OR = 3,8–95 %CI 1,5–9,9), le tabagisme (ORadj = 2,6–95 %CI 1,3–5,5), ou une infection par un HR HPV (OR = 13,0–95 %CI 1,7–102), ou HPV16 (OR = 46,3–95 %CI 6,1–355) etaient associes au diagnostic de lesion de haut grade (mais pas le nombre de partenaires, le nadir des CD4 et l’anciennete de l’infection par le VIH). Conclusion Ces premiers resultats a l’inclusion confirment la frequence de lesions de haut grade infracliniques non identifiables par le simple examen clinique. Les donnees de suivi longitudinal pourraient permettre de preciser le role respectif de la cytologie, de l’AHR et de la recherche d’HPV16 dans de nouveaux algorithmes de depistage.

Introduction De nombreux patients presentant une suspicion de borreliose de Lyme (BL) experimentent un parcours de soin difficile. Nous avons mis en place un Centre pluridisciplinaire de prise en charge des maladies vectorielles a tique, regroupant infectiologues, rhumatologues, internistes, neurologues, pediatres, dermatologues, microbiologistes, psychiatres, algologues, medecins de readaptation. Une ligne telephonique dediee a ete creee pour les medecins traitants (MT). L’objectif de ce travail est de presenter l’activite de notre centre (janvier-decembre 2018). Materiels et methodes Nous avons retrospectivement analyse les caracteristiques des patients adultes ayant consulte, adresses par leur MT, et leur parcours de soins au sein du centre. Tous etaient presentes en reunion de concertation pluridisciplinaire mensuelle. Les patients ayant des signes cliniques en lien avec une BL etaient definis selon l’ESGBOR : (i)BL confirmee ; (ii)BL possible (piqure de tique ou antecedent d’erytheme migrant, signes cliniques tres evocateurs, amelioration clinique apres 21–28j d’antibiotiques) ; (iii)PTLDS (post-treatment Lyme disease Syndrome) (asthenie/polyalgie/plaintes cognitives persistantes apres traitement bien conduit) ; (iv) sequelles de BL (signes cliniques objectifs persistants apres traitement bien conduit) ; (v) surveillance post-piqure de tique ; (vi) guerison. Seules les BL prouvees et possibles ont recu une antibiotherapie (recommandations HAS 2018). Resultats Nous avons propose 3 orientations aux 180 patients ayant consulte (consultations externes (n = 97 ; 53,9 %) ; hospitalisation (n = 49 ; 27,2 %) et/ou hospitalisation de jour (n = 58 ; 32,2 %)), et realise 370 consultations de suivi (toutes specialites). Un total de 69 patients (38,3 %) presentaient des signes cliniques en lien avec une BL : BL confirmee (n = 28 ; 15,6 %) ; BL possible (n = 12 ;6,7 %) ; PTLDS (n = 11 ; 6,1 %) ; sequelles (n = 5 ; 2,8 %) ; surveillance post-piqure de tique (n = 5 ; 2,8 %) ; guerison (n = 8 ; 4,4 %). Des diagnostics associes ou differentiels ont ete trouves chez 146/180 (81 %) : infectieux (n = 19 ; 10,6 %) ; rhumatologique/auto-immun (n = 45 ; 25 %) ; carentiel/metabolique (n = 25 ; 13,9 %) ; bodily distress syndrome (n = 19 ; 10,6 %) ; neurologique (n = 19 ; 10,6 %) ; psychiatrique (n = 17 ; 9,4 %) ; effets secondaires des antibiotherapies prolongees (n = 15 ; 8,3 %) ; autres (n = 12 ;6,7 %) ; absence de diagnostic (n = 25 ;13,9 %) ; perdus de vue (n = 9 ; 5 %). Un plan personnalise de soins a ete propose a chaque patient dans la filiere adaptee, meme si absence de diagnostic (algologie, readaptation etc.). Les questionnaires de satisfaction (n = 146) montraient 137 patients (93,8 %) satisfaits. Conclusion Ces resultats concordent avec les experiences publiees de centres pluridisciplinaires. Les liens etablis avec les MT facilitent le diagnostic de BL et le parcours de soins. Le nombre de diagnostics differentiels ou associes confirment la complexite du diagnostic de BL sans omettre d’autres diagnostics. Une prise en charge pluridisciplinaire permet un diagnostic plus precis et une prise en charge personnalisee des patients.

Introduction: Several recent studies have identified a potential role for intrauterine Candida albicans in adverse pregnancy outcomes, including preterm birth. There is, however, a limited understanding of the impact of intrauterine candida infection on fetal well-being in early pregnancy. Using a sheep model of early pregnancy, the aims of this study were to determine (1) the ability of experimentally induced intrauterine C albicans to infect the fetus and (2) whether C albicans exposure in early pregnancy is associated with alterations in fetal cardiac function, as measured by spectral tissue Doppler imaging analysis of fetal cardiac function. Methods: Merino ewes carrying singleton pregnancies at 89 days’ gestation (term is ∼150 days) received C albicans (n = 8) via ultrasound-guided intra-amniotic injection. Saline-exposed fetuses served as controls (n = 6). Spectral tissue Doppler imaging echocardiography and amniotic fluid collection were performed at baseline and 24 and 72 hours after intrauterine C albicans injection. Fetal tissues were collected at postmortem for analysis of infection and inflammation. Results: Relative to saline control, intrauterine C albicans infection resulted in pronounced increases in amniotic fluid tumor necrosis factor α (TNF-α; P < .05) and cytokine/chemokine messenger RNA (interleukin [IL] 1β, IL-6, TNF-α, and monocyte chemoattractant protein 1; P < .05) in the fetal myocardium, lung, skin, and liver at 72 and 96 hours postinfection. Spectral tissue Doppler imaging showed diastolic dysfunction at 24 hours and severe biventricular diastolic dysfunction 72 hours postinfection. Conclusion: Intrauterine C albicans infection in a sheep model of early pregnancy causes systemic fetal candidiasis, which is associated with a robust systemic inflammatory response and progressive cardiac dysfunction detectable by spectral tissue Doppler imaging.

The fetal heart at term is exposed to an increase in hemodynamic work as a consequence of fetal growth, increased circulating volume, and alteration in loading patterns due to maturational changes in fetoplacental circulation. The extent to which these cardiovascular changes influence human fetal and neonatal cardiac adaptation has not been fully elucidated. The aim of this study was to evaluate perinatal cardiovascular changes in ventricular geometry and myocardial performance in normal term fetuses.Prospective study of 108 uncomplicated pregnancies delivering at term. M-mode, two-dimensional or B-mode, pulsed wave Doppler, pulsed wave tissue Doppler, and two-dimensional speckle-tracking imaging were performed a few days before and within 24 hours of birth.Analysis of paired fetal and neonatal echoes demonstrated significant perinatal changes (P .0001 for all) in right ventricular (RV) and left ventricular (LV) geometry (RV/LV end-diastolic dimension ratio, 1.2 vs 0.8; RV sphericity index, 0.53 vs 0.40; LV sphericity index, 0.46 vs 0.49). There were corresponding significant (P .001 for all) perinatal changes in global myocardial performance: LV myocardial performance index, 0.60 versus 0.47; RV myocardial performance index, 0.61 versus 0.42; systolic function: LV longitudinal systolic strain rate, -1.4/sec versus -1.0/sec; RV longitudinal systolic strain rate, -1.5/sec versus -1.0/sec; RV S', 5.3 cm/sec versus 6.5 cm/sec; and diastolic function: LV E'/A', 0.8 versus 1.1.The findings support the concept that the perinatal period is associated with major changes in fetal ventricular geometry and cardiac function in response to significant alterations in loading conditions. Improved knowledge of perinatal cardiac changes in normal fetuses could facilitate better understanding of cardiac adaptation in normal and pathological pregnancies.

Introduction L’efficacite virologique de la combinaison sofosbuvir/ledipasvir en fait a ce jour le traitement de premier choix dans l’infection par le VHC bien que sa tolerance reste encore faiblement documentee. L’objectif principal de cette etude est d’evaluer l’efficacite et la tolerance de la combinaison sofosbuvir/ledipasvir chez les patients VHC comparativement a d’autres agents anti-VHC directs. Materiels et methodes Il s’agit d’une etude retrospective utilisant les donnees de la base Nadis des patients infectes par le VIH et le VHC suivis dans l’un des sites hospitaliers de notre Corevih entre 2012 et 2016. Nous avons analyse les evenements cliniques et les anomalies biologiques observes sous sofosbuvir/ledipasvir durant la periode de suivi. Les patients traites par peginterferon/ribavirine ont ete exclus de l’analyse, sauf ceux pour lesquels la ribavirine a ete rajoutee a une combinaison orale anti-VHC. Resultats Parmi les 165 patients VHC inclus, 77 (46,7 %) etaient traites par la combinaison sofosbuvir/ledipasvir. Ils etaient significativement moins âges en moyenne (49 versus 56 ans) que les patients traites par d’autres combinaisons orales anti-VHC. Ces dernieres etaient constituees essentiellement par les combinaisons sofosbuvir/daclatasvir 27 (30,7 %), sofosbuvir/ribavirine 23 (26,1 %) et dasabuvir + ombitasvir/paritaprevir/ritonavir 7 (8,0 %). Les patients co-infectes VIH (99) ont plus souvent ete traites par sofosbuvir/ledipasvir 61 (61,6 %). Le genotype 1 a ete majoritaire chez les patients traites par cette combinaison 55 (71,4 %), suivi du genotype 4, 22 (28,6 %). Ces patients ont ete moins souvent traites au-dela de 12 semaines de traitement 39 (50,7 %) versus 58 (65,9 %) p = 0,003 et ont moins souvent arrete leur traitement durant le suivi 1 (1,3 %) versus 7 (8,0 %) p = 0,047 pour effets indesirables. Douze patients (15,6 %) traites par cette combinaison ont presente une anomalie biologique contre 22 patients (25,0 %) traites par d’autres combinaisons orales anti-VHC. L’efficacite virologique s’est revelee plus marquee chez les patients traites par sofosbuvir/ledipasvir 46/47 (97,9 %) versus 45/51 (88,2 %) 12 semaines apres la fin du traitement (RVS12). Conclusion Dans cette analyse, la combinaison sofosbuvir/ledipasvir est associee a un faible pourcentage d’effets indesirables et presente une efficacite virologique plus marquee par rapport aux autres combinaisons orales anti-VHC. Cependant, certains patients du groupe controle ont recu du sofosbuvir et/ou de la ribavirine. L’evaluation porterait essentiellement sur la comparaison du ledipasvir aux autres molecules. La prise en compte des donnees de l’ensemble des sites hospitaliers de notre Corevih (environ 1000 patients) nous permettra d’approfondir cette analyse.

Summary The second half of the 20th century was what it is necessary to call the gold age of the antibiotherapy, incontestable medical success. For several decades, the treatment of bacterial infectious diseases calls antibiotics which had provoked a huge hope. Today, with the appearance of microbes resistant to almost all antibiotics “superbug”, some infections, notably nosocomial infections, have sometimes dramatic consequences. The treatment of the bacterial infectious diseases with the aid of specific viruses, called bacteriophages, is offered as a possible “alternative”. This treatment, phage therapy, is not new, but it is misread, sometimes condemned by negative prejudices and its possible return will not be able to be made without a reappraisal. This review offers to take stock of the situation of last knowledge on the bacteriophages therapeutic and to introduce the phage therapy as a practical point of view in a modern context. These developments and our personal experience lead us to propose to use both therapies simultaneously.

To compare the management and the virological and serological efficacy of treatments for chronic hepatitis B (CHB) in HIV positive and negative patients.Two hundred and forty-six HIV positive and 205 HIV negative consecutive patients with past or present CHB, seen in October 2008 in participating departments, were included in a multicenter study. All the data were retrospectively collected from the first visit to October 2008 through a standardized questionnaire.Compared to HIV negative patients, HIV positive patients more often presented positive HBeAg (46.4% vs. 32.8%, p=0.01), HBV genotype A (54.8% vs. 17.1%, p0.0001), co-infection with HCV (12.4% vs. 5.9%, p=0.0002) or HDV (12.6% vs. 2.9%, p=0.04). HIV positive patients were more often on HBV therapy (92.7% vs. 57.1%, p0.0001), leading to undetectable serum HBV DNA levels (71.0% vs. 44.1%, p0.0001). In HIV positive patients, multivariate analysis showed that older age, lower initial HBV DNA levels, and longer time on HBV therapy significantly correlated with undetectable HBV DNA. No difference in efficacy was observed between tenofovir used alone or in combination. HBsAg (but not HBe) loss was more often observed in HIV positive patients, sometimes followed by HBsAg re-appearance after withdrawal of HBV treatment. Excluding the 37 HBV-HCV-co-infected patients, the last clinical presentation and liver fibrosis scores were similar in HIV positive and negative patients.The assessment of CHB and the efficacy of HBV therapy have improved in HIV positive patients. HIV infection did not have a negative impact on the likelihood of HBV therapeutic success.

Resume Mycobacterium marinum est responsable d’une infection opportuniste chez l’homme. Si sa presentation clinique la plus frequente est cutanee, les localisations osteoarticulaires ne sont pas rares et doivent etre reconnues rapidement. Le chirurgien orthopediste peut donc etre amene a prendre en charge un patient atteint par cette mycobacterie et doit etre en mesure d’evoquer le diagnostic sur des criteres anamnestiques et cliniques. Les lesions debutent a partir d’une effraction cutanee, par un nodule solitaire ou plaque rouge violacee a surface verruqueuse ou inflammatoire et pouvant s’abceder. Peuvent apparaitre secondairement des lesions d’âge different. Un contact marin est le facteur le plus important a rechercher. Nous rapportons trois patients ayant developpe cette infection avec un delai diagnostic long. L’efficacite du traitement et l’absence de complication etaient correlees a la precocite du diagnostic.

Background More than 10 years after the introduction of combination antiretroviral therapy (cART), we examined the trend in the proportion of deaths caused by end-stage liver disease (ESLD) in HIV-infected adults in France between 1995 and 2005. Design and methods In 2005, 34 departments prospectively recorded all deaths in HIV-infected patients who were followed in those departments (around 24 000). Results were compared with those of four previous cross-sectional surveys conducted since 1995 using the same methodology. Results Among 287 reported deaths in 2005, 100 (35%) were related to AIDS, and 48 (17%) to ESLD. Three out of four patients who died from ESLD-related causes had chronic hepatitis C. Excessive alcohol consumption was reported in approximately half of the patients (48%). At death, 62% of patients had undetectable HIV viral load and the median CD4 count was 237 cells/μL. From 1995 to 2005, the proportion of deaths caused by ESLD increased from 2 to 17% (P

Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by infected ticks. The transmission depends on several factors, especially on the duration of the tick's presence in the host body (the nymph which is smaller than the adults and thus less visible, is in this case the most frequently involved) and on whether the tick is infected or not. The interpretation of results in the few available studies is made difficult by the lack of information obtained (due to difficulty to collect information and examination costs). The comparison is made even more difficult by the difference between Borrelia ticks species in various regions. Today, the best methods are preventive: protective clothing, tick repellents, checking and removal of ticks after a journey in an endemic zone, and in case of tick bite, regular examination of the bite site during the following weeks in order to initiate an early curative treatment if ECM is diagnosed. The currently available data seems to be insufficient to suggest systematic antimicrobial prophylaxis in case of tick bite.

To compare non-invasive hemodynamic measurements obtained in pregnant and postpartum women using two automated cardiac output monitors against those obtained by two-dimensional (2D) transthoracic echocardiography (TTE).This was a cross-comparison study into which we recruited 114 healthy women, either with normal singleton pregnancy (across all three trimesters) or within 72 hours following delivery. Cardiac output estimations were obtained non-invasively using two different monitors, Ultrasound Cardiac Output Monitor (USCOM®, which uses continuous-wave Doppler analysis of transaortic blood flow) and Non-Invasive Cardiac Output Monitor (NICOM®, which uses thoracic bioreactance), and 2D-TTE. The performance of each monitor was assessed relative to that of TTE by calculating bias, precision, 95% limits of agreement and mean percentage difference (MPD). Intraobserver repeatability was assessed for both monitors and interobserver reproducibility was assessed for USCOM, NICOM being operator-independent.Following exclusions due to poor-quality results of a monitor or TTE, or for medical reasons, our analysis included 98 women (29 in the first trimester, 25 in the second and 21 in the third, and 23 postpartum). For cardiac output estimation, when compared with TTE, USCOM had a bias ranging from 0.4 to 0.9 L/min. The MPD of USCOM was 29% in the third-trimester cohort. NICOM had a bias ranging from -1.0 to 0.6 L/min, with a MPD of 32% in the third-trimester group. There was limited agreement between the cardiac output monitors and TTE in the first and second trimesters, with a MPD of 38% for USCOM in both first and second trimesters, and 71% and 61% for NICOM in first and second trimesters, respectively. For cardiac output estimation using USCOM, we found excellent intraobserver repeatability (intraclass correlation coefficient (ICC), 0.97; 95% CI, 0.95-0.98) and interobserver reproducibility (ICC, 0.90; 95% CI, 0.81-0.94), and the repeatability for NICOM was comparable (ICC, 0.95; 95% CI, 0.93-0.97).We found good agreement of both USCOM and NICOM when compared with 2D-TTE, specifically in the third trimester of pregnancy. Both devices had good intraobserver repeatability and either had good interobserver reproducibility or were operator-independent. Future studies should take into account the significant differences in the precise maternal hemodynamic values obtained by these devices, and consider developing device-specific reference ranges in pregnancy and the postpartum period. Copyright © 2016 ISUOG. Published by John WileySons Ltd.

Objectives Disseminated gonococcal infections (DGIs) are rare. We describe the characteristics of DGIs in France. Methods This is a 3-year retrospective analysis of DGI cases collected through two networks of microbiologists and infectious disease specialists in France between 2009 and 2011. DGI was defined either by the isolation of Neisseria gonorrhoeae from blood and synovial fluid or by the existence of a clinical syndrome consistent with DGI and the isolation of N gonorrhoeae from any site. We describe the epidemiological, clinical and microbiological characteristics and outcomes of DGIs. Results 21 patients (9 women, 12 men; 18–62 years old) were diagnosed with DGI. The number of DGI cases increased between 2009 and 2011. Two men who had sex with men were coinfected with HIV. We found 28 extragenital locations, including arthritis (14 cases), tenosynovitis (7), skin lesions (4), endocarditis (1), prostatitis (1) and pelvic inflammatory disease (1). Genital signs were present in five patients. The diagnosis was confirmed by cultures in 20 patients—blood (4), synovial fluid (11), genital (3), throat (1), urine (1)—and by molecular biology on a pharyngeal swab in 1 patient. Seven cases were resistant to fluoroquinolones. The patients were treated with ceftriaxone, associated with corticosteroids (two cases) and surgery (six cases). Four patients had joint sequelae. Conclusions DGIs are increasing. Men seem to be at higher risk than women. Joint involvement was common. Microbiological diagnosis was based on culture, however molecular biology using pharyngeal swabs was helpful when cultures were negative.

We conducted a 12-week, multicenter, randomized, double-blind, placebo-controlled trial of cetirizine to assess the ability of antihistamines to prevent nevirapine-associated rash in patients infected with human immunodeficiency virus type 1. Patients initiating treatment with nevirapine were randomized to receive either cetirizine, 10 mg q.d. (104 patients), or placebo (96 patients) during the first 6 weeks of therapy. Rash occurred in 22 (11%) of 200 patients; 10 (9.6%) were in the cetirizine group and 12 (12.5%) were in the placebo group (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.31-1.81; P=.5). Five of 22 rashes were cases of hypersensitivity syndrome. The rate of nevirapine discontinuation due to rash was similar in the 2 groups (7.7% and 6.25% in the cetirizine and placebo groups, respectively; P=.4). Multivariate analysis showed no treatment-group effect but indicated that age >40 years (OR, 3.83; 95% CI, 1.4-10.46; P=.008) was associated with an increased risk of rash. Cetirizine has no preventive effect on nevirapine-associated rash.

Highly-active antiretroviral therapy (HAART) has lead to a dramatic decrease in the morbidity of patients infected with the human immunodeficiency virus (HIV). However, metabolic side effects, including lipodystrophy-associated (LD-associated) dyslipidemia, have been reported in patients treated with antiretroviral therapy. This study was designed to determine whether successful HAART was responsible for a dysregulation in the homeostasis of tumor necrosis factor- (TNF-), a cytokine involved in lipid metabolism. Cytokine production was assessed at the single cell level by flow cytometry after a short-term stimulation of peripheral blood T cells from HIV-infected (HIV+) patients who were followed during 18 months of HAART. A dramatic polarization to TNF- synthesis of both CD4 and CD8 T cells was observed in all patients. Because it was previously shown that TNF- synthesis by T cells was highly controlled by apoptosis, concomitant synthesis of TNF- and priming for apoptosis were also analyzed. The accumulation of T cells primed for TNF- synthesis is related to their escape from activation-induced apoptosis, partly due to the cosynthesis of interleukin-2 (IL-2) and TNF-. Interestingly, we observed that LD is associated with a more dramatic TNF- dysregulation, and positive correlations were found between the absolute number of TNF- CD8 T-cell precursors and lipid parameters usually altered in LD including cholesterol, triglycerides, and the atherogenic ratio apolipoprotein B (apoB)/apoA1. Observations from the study indicate that HAART dysregulates homeostasis of TNF- synthesis and suggest that this proinflammatory response induced by efficient antiretroviral therapy is a risk factor of LD development in HIV+ patients.

Resume Objectifs Les rickettsioses sont repandues et frequentes dans les pays en developpement. Leur place dans la morbidite et la mortalite hospitalieres reste cependant mal etablie. Materiel et methodes Dans le but de preciser la place des rickettsioses chez les malades febriles hospitalises a Bobo-Dioulasso, une etude prospective a ete menee durant le premier trimestre de 1995: 183 cas dont 102 enfants et 81 adultes ont ete inclus. Resultats L'immunofluorescence indirecte a montre un taux global de prevalence de 45,3 %. La seroprevalence etait respectivement de 35 %, 13,1 % et 10,9 % pour Rickettsia conorii, Coxiella burnetii et Rickettsia typhi . L'incidence de C. burnetii etait de 5 % contre 4 % pour R. conorii et 1 % pour R. typhi . L'incidence de la fievre boutonneuse mediterraneenne est faible et les cas symptomatiques proviennent surtout des quartiers peripheriques. Le typhus murin est frequent en peripherie urbaine, la presentation clinique est classique et l'evolution simple. La fievre Q a une prevalence maximale entre 30 et 60 ans avec une atteinte respiratoire dans 55 % des cas et hepatite biologique dans 75 % des cas. Conclusion Cette etude precise la place de la fievre boutonneuse mediterraneenne, du typhus murin et de la fievre Q chez les patients febriles hospitalises a Bobo-Dioulasso. Des etudes en communaute sont necessaires pour preciser l'epidemiologie.

Resume Introduction. — La diphterie est une maladie reemergente comme le montre bien les deux epidemies survenues recemment a nos portes, en Algerie et dans les etats independants de l'ex-URSS (NIS). Des cas importes ont ete observes dans les pays europeens limitrophes. Actualites et points forts. — L'expression clinique de la diphterie avec angine a fausses membranes fait souvent defaut, rendant le diagnostic plus difficile. La prise en charge therapeutique demeure inchangee, associant au traitement symptomatique, antibiotherapie, serotherapie et vaccination des cas contacts et de l'entourage. Des etudes serologiques recentes tant europeennes (y compris francaises) qu'americaines, ont montre la mauvaise immunoprotection des populations, surtout dans la seconde moitie de la vie, avec un risque permanent d'epidemie. Une surveillance stricte de l'immunite et une revaccination reguliere (tous les 10 ans) devraient permettre d'eviter de telles situations. Les progres lies a la biologie moleculaire ont permis, d'une part, la mise au point d'un test rapide de detection du gene de la toxine par amplification genique (polymerase chain reaction) et, d'autre part, de suivre la circulation mondiale des souches grâce au ribotypage. Cette derniere technique montre que meme si un clone predomine dans les differents pays atteints, une diversite genotypique existe au cours des epidemies. A cote de la diphterie, qui a disparu de France, ont ete decrites des infections liees a des souches non toxinogenes. Il s'agit surtout de bacteriemies, endocardites et arthrites. Perspectives et projets. — Les epidemies recentes ont conduit a developper les techniques diagnostiques et de surveillance epidemiologique, tant au plan national, avec la creation d'un centre national de reference sur la diphterie, qu'au plan europeen et international. Elles ont egalement mis en evidence la faible immunoprotection des populations et la necessite d'une surveillance et d'une revaccination reguliere.

Resume En janvier–fevrier 1997, 985 medecins generalistes (MG) ont participe a une etude visant a evaluer la prevalence du streptocoque A dans les angines aigues de l'adulte par l'utilisation d'un test de diagnostic rapide (TDR) — Abbott test Pack plus with OBC®—et d'evaluer leur impact sur la prescription des MG. Chaque MG devait inclure 3 patients âges de plus de 18 ans presentant une pharyngo-amygdalite aigue et remplir pour chacun d'eux une fiche d'observation precisant le contexte epidemiologique et clinique, la proposition d'antibiotherapie avant et la decision therapeutique finale apres les resultats du TDR. Deux mille sept cent vint sept patients ont ete inclus, 32,2% des tests se sont averes positifs. Aucune difference n'a ete constatee selon le sexe, l'âge et le terrain (angine recidivante, antecedents d'amygdalectomie, antecedents ORL chroniques et milieu socio-economique defavorise). Les patients avec un TDR positif ont plus souvent presente un mode de debut brutal (84,5%/77,8%: p

Resume Dans la Clinique des Maladies Infectieuses, Pediatrie, Colentina, Bucarest, Roumanie, a ete elaboree une etude retrospective ayant pour but de souligner l'utilite d'etablir le diagnostic de la parotidite chronique hypertrophique (PCH), signe revelateur de l'infection par le VIH chez l'enfant. Parmi les 579 enfants infectes par le VIH hospitalises dans cette clinique sur une periode de 3 ans (ler janvier 1990-15 mai 1993), 135 ont presente une PCH Dans 7,40 % des cas, la PCH a ete le seul signe qui a determine la presentation chez le medecin. Le debut de la PCH correle au moment de la detection d'infection a VIH a ete simultane dans 25,18 % des cas, l'a precede de 1 a 25 mois dans 6,7 % des cas (9/135), et l'a suivi dans 68.2 % des cas (92/135). La grande majorite des cas (93,3 %) (126/135) a ete dans la tranche d'âge de 1 a 5 ans. Pres d'un quart des enfants se trouvait dans la tranche d'âge de 3 ans 1/2 a 4 ans. Le enfants infectes par le VIH et ayant une PCH presentaient un etat nutritionnel peu altere dans 2/3 des cas : normo-ponderaux dans 25,93 % des cas, malnutrition proteino-calorique (MPC) I dans 34,1 % des cas. La PCH survenait avant la deterioration marquee des lymphocytes CD4, simultanement a la proliferation des lymphocytes CD8. La PCH se developpait a un stade de l'infection par le VIH ou le pronostic a moyen terme etait considere encore comme favorable.

Diphtheria is a disease with a long history that almost completely disappeared from developed countries. In addition, until 1987, systemic infections involving Corynebacterium diphtheriae were rare. However, in 1990, an epidemic occurred in Russia. These two circumstances have provided the stimulus to gain insight into the situation in France. In fact, between 1987 and 1993, a total of 59 C. diphtheriae strains were isolated. Epidemiological data were collected for patients from whom 40 strains were isolated from normally sterile sites, including 34 from blood cultures, and half of the bacteremic patients developed endocarditis. Osteoarticular involvement was noted in 11 of these 40 patients, including 5 bacteremic patients. The fatality rate following bacteremia was 36%, despite specific antibiotic treatment (beta-lactams and aminoglycosides). The mean age of the participants was 38 years, with half of the patients subsisting under low socioeconomic conditions and suffering from homelessness or alcoholism. Apparently, the skin turned out to be the major route of transmission in this reemerging disease. Eighty-eight percent of the isolates belonged to the C. diphtheriae biotype mitis. These were found predominantly in the Paris area, and most were of the same ribotype. Those isolates originating from the overseas territories (Guyana and New Caledonia) belonged to C. diphtheriae biotype gravis. No strains were positive for the tox gene by PCR. This study attests to the persistent circulation in France of C. diphtheriae in the form of systemic infections. The matter is especially significant since these strains are nontoxigenic and are of a unique ribotype. The strains are, however, sensitive to most antibiotics, although 20% are rifampin resistant.

Resume Une etude epidemiologique a ete menee afin d'apprecier le role pathogene du pneumocoque de sensibilite diminuee a la penicilline dans les meningites purulentes. Cette etude a porte sur 75 patients hospitalises dans 24 centres differents. Les souches dont les CMI etaient superieures a 0,1 mg/l ont represente 20,4 % de l'ensemble des isolements (49 souches etudiees). La mortalite globale etait de 12 %. Un seul deces, non imputable a un echec therapeutique, a ete constate parmi les patients infectes par des souches intermediaires ou resistantes. Le pronostic pejoratif est lie a l'etat neurologique initial, independamment de la CMI du pneumocoque, a condition que la posologie des antibiotiques soit elevee.

Introduction: There is a paucity of data regarding the accuracy, reliability and reproducibility of non-invasive cardiac output monitors in pregnancy. The aim of this study was to compare cardiac output estimations obtained by USCOM® against those obtained by 2-dimensional transthoracic echocardiography (TTE).Methods: Prospective, observational study in which 114 healthy pregnant and postpartum women had haemodynamic indices obtained by USCOM® and TTE. Accuracy and precision statistics (Bland Altman analysis) are presented as bias, precision, 95% limits of agreement (LOA) and mean percentage difference (MPD). Intraobserver repeatability and interobserver reproducibility of USCOM was assessed in 67 and 40 subjects, respectively.Results: USCOM® had a positive bias ranging from 0.4 to 0.9 L/min. The MPD of USCOM® was 28% in the third trimester cohort, which meets the current level of