Search

Resume Les infections a Legionella sont causees par une bacterie intracellulaire habitant principalement les environnements aquatiques. La contamination se fait par inhalation d’aerosols. Les facteurs de risques principaux sont le tabac, l’immunodepression et l’âge avance. Les signes extra-respiratoires sont peu specifiques. L’argument clinique le plus solide en faveur d’une legionellose est la resistance aux beta lactamines en cas de pneumopathie. Le diagnostic repose avant tout sur l’antigenurie en cas d’infection a Legionella pneumophila de type 1. L’antigenurie est prise en defaut chez les patients infectes a Legionella non pneumophilia comme les patients immunodeprimes. La culture et la PCR sont alors indispensables au diagnostic. La maladie des legionnaires, forme pulmonaire de l’infection a Legionella, est grave, en particulier chez les sujets âges et/ou les patients immunodeprimes. Le taux de mortalite varie de 10 % dans la population generale, a 50 % en cas d’hospitalisation en reanimation. Le traitement repose sur les macrolides ou les fluoroquinolones. La resistance aux antibiotiques est exceptionnelle.

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

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.Pediatric-onset IBD (17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Legionella-related disease is caused by an intracellular bacteria mainly living in water. Contamination results from inhalation of Legionella sp containing aerosolized water. Main risk factors are tobacco, immunodeficiency, and advanced age. Antigenuria is the cornerstone of the diagnosis. Immunocompromised patients, more commonly infected with non pneumophilaLegionella, present negative antigenuria, and culture and PCR are essential for the diagnosis. Legionnaires' disease may be severe, especially in elderly and/or immunocompromised patients. Mortality rate varies from 10 % in the general population to 50 % in intensive care. Treatment is based on macrolides or fluoroquinolones. Antibiotic resistance is very rare.

A 54-year-old woman was hospitalized for an acute pulmonary oedema revealing a severe aortic stenosis (AS) associated with an aortic aneurysm and a left ventricular hypertrophy (LVH). The coronary angiography found an equivocal left main lesion. Fractional flow reserve (FFR) showed hemodynamic significance (FFR=0.78) and optical coherence tomography confirmed this result with a minimal lumen area of 4.9mm2. FFR-guided percutaneous intervention is reported to improve outcome in patients with stable coronary disease. However, only few data are available in cases of AS. In this condition, secondary LVH is associated with microcirculatory dysfunction, which interferes with optimal hyperemia. An elevated right atrial pressure could also modify FFR measurement. This risk of underestimation of a coronary lesion in patients with severe AS has to be taken into consideration in clinical practice.

A 54-year-old woman was hospitalized for an acute pulmonary oedema revealing a severe aortic stenosis (AS) associated with an aortic aneurysm and a left ventricular hypertrophy (LVH). The coronary angiography found an equivocal left main lesion. Fractional flow reserve (FFR) showed hemodynamic significance (FFR=0.78) and optical coherence tomography confirmed this result with a minimal lumen area of 4.9mm

Aliment Pharmacol Ther 2011; 34: 1193–1201 Summary Background Sorafenib increases median survival and time to radiological progression in patients with advanced hepatocellular carcinoma, but its benefit for Child-Pugh B patients remains uncertain. Aim To evaluate the safety and efficacy of sorafenib in real-life clinical practice conditions and to assess the influence of Child-Pugh class B on safety and efficacy. Methods All patients treated with sorafenib for advanced hepatocellular carcinoma in our institution were included prospectively. Adverse events, overall survival and time to progression were recorded. A case control study was performed to compare outcome of patients with comparable stages of hepatocellular carcinoma, but a different Child-Pugh class. Results From March 2007 to May 2009, 120 patients were included. Overall survival was 11.1 months, Child-Pugh A patients (n = 100) had significantly higher median survival than Child-Pugh B patients (n = 20) (13 vs. 4.5 months, P = 0.0008). In multivariate analysis, Child-Pugh class B, α-fetoprotein level and total size of lesions were independent predictive factors of death. Patients with radiological progression in the first 3 months had shorter median survival (5.4 vs. 17.4 months). In a case control study, time to symptomatic progression (2.5 vs. 3.6 months), frequency of adverse events and discontinuation of sorafenib were not correlated with Child-Pugh class. Conclusions Patients with advanced hepatocellular carcinoma treated with sorafenib had a median survival of 11 months. Sorafenib therapy must be considered with caution in Child-Pugh B patients due to their poor survival. Radiological assessment of tumour progression at an early stage may be advantageous when tailoring sorafenib therapy.

Free-floating thrombi in the right heart chambers is a rare phenomenon. Nearly 99% of detected cases are associated with the presence of proven pulmonary embolism. Its presence is associated with a poor outcome with a mortality between 27 to 44% according to studies. Despite the emergency of treatment, optimal management of free floating right heart thrombus remains controversial with no clear consensus. We present the case of a 84-year-old man hospitalised for acute decompensated heart failure. After an initial favourable evolution, a degradation of respiratory occurred with dyspnea and desaturation. A bedside transthoracic echocardiography showed a mobile serpiginous thrombus, 7cm size, moving to and across the tricuspid valve. A computed tomography of the chest demonstrated massive bilateral pulmonary embolism. After persistence of the thrombus and seven days of heparinotherapy, thrombolysis therapy was initiated. The thrombus disappeared 24h after thrombolysis. Without contra-indication, thrombolysis is a faster, readily available treatment for the management of floating thrombus in the right heart chambers associated with pulmonary embolism.

The publication in 2001 of the first in-man results showing zero restenosis after sirolimus eluting stent implantation produced enormous excitement in the cardiological community. Today, both sirolimus and paclitaxel eluting stents have been shown in randomized trials to reduce restenosis as compared with conventional metallic stents. However, since drug eluting stents become available in Europe very little has changed in the every life of almost all interventional laboratories in Europe. The limitation currently impeding more widespread use of the new technology is nontechnical, nonmedical but economic. The high price of drug eluting stents relative to bare stents has been an obstacle to more widespread utilization of drug eluting stents.

Resume L’annonce du cancer met a l’epreuve la competence technique et les capacites relationnelles du praticien. Notre objectif etait d’evaluer et de restituer aux praticiens la perception que les patients ont eu de l’annonce du cancer. Un entretien semi-directif evaluant le vecu de l’annonce diagnostique a ete propose a 16 patients en cours de traitement de chimiotherapie pour un cancer colorectal. Chaque entretien etait enregistre, retranscrit puis analyse qualitativement. Les transcriptions etaient restituees aux praticiens et examinees en commun au cours de reunions medico-chirurgicales. Douze patients (6H, 6F), âges de 28 a 74 ans, ont participe. Le lieu de l’entretien etait laisse libre et les patients pouvaient etre accompagnes d’un proche. L’analyse a revele quatre determinants de la qualite relationnelle percue lors de l’annonce du cancer : une connaissance mutuelle patient-praticien prealable a l’annonce, la prise en consideration par le praticien de la place des proches dans le soutien du patient, le respect par le praticien du desir d’information du patient et les modalites d’annonce. Les modalites jugees favorables etaient : un praticien empathique et disponible, une annonce progressive faite en termes clairs, la presence des proches pendant l’annonce si le patient le souhaite, et l’absence de mensonge. La restitution aux praticiens a suscite l’expression de leurs propres difficultes lors de l’annonce et une prise de conscience des attentes des patients. Ce travail confirme qu’une meilleure connaissance de l’experience du patient est utile a une reflexion sur nos pratiques lors de l’annonce du cancer.

Aims To determine whether performing a myocardial scintigraphy immediately after a maximal electrocardiogram (ECG) stress test is effective in detecting silent coronary stenoses and predicting cardiovascular events. Methods Asymptomatic patients (n = 262) aged 57.6 ± 8.8 years, with diabetes for 12.0 years (5–39) [median (range)] and no history of a cardiac event, underwent a maximal ECG stress test followed by a myocardial scintigraphy. The patients with an abnormal ECG stress test or abnormal imaging underwent a coronary angiography. Cardiac events were assessed in 250 (95.4%) patients followed for 37.8 months (3–101). Results The ECG stress test was abnormal in 54 patients. Among them, 18 had coronary stenoses and seven had a cardiac event. Despite a normal ECG stress test, the myocardial scintigraphy was abnormal in 42 additional patients, including 16 patients with coronary stenoses. Four of these 42 patients experienced a cardiac event. Follow-up showed a poor prognosis in subjects who were abnormal on the two tests. Univariate predictors of the 15 cardiac events were the ECG stress test [odds ratio (OR) 3.9, 95% confidence interval (CI) 1.3, 11.4, P = 0.008], myocardial scintigraphy (OR 3.8, 95% CI 1.3, 11.0, P = 0.009), coronary stenoses (OR 26.6, 95% CI 7.6, 90.7, P

Background: Intensive intravenous treatment remains the first line therapy of severe, uncomplicated attacks of ulcerative colitis. Aim: To predict the failure of intensive intravenous treatment by combining clinical and laboratory parameters with endoscopy findings. Methods: Retrospective study conducted in a tertiary care referral centre. Failure of intensive intravenous treatment was defined as colectomy before day 30, intravenous cyclosporin, or death. Predictive factors of outcome were assessed using univariate and multivariate prognostic analysis. Results: Between January 1990 and May 1997, 85 consecutive patients were treated with intensive intravenous treatment for non-response to oral corticosteroids (n=59) and/or severe attack of ulcerative colitis (n=26). There were 41 successes and 44 failures (including 1 death, 13 cyclosporin and 30 colectomies before day 30). Multivariate prognostic analysis found that the presence of Truelove and Witts’ criteria (P=0.018), an attack that had lasted more than 6 weeks (P=0.001), and severe endoscopic lesions (P=0.007) were associated with an increased risk of failure. Patients with severe endoscopic lesions and Truelove and Witts’ criteria, or an attack of more than 6 weeks had a failure rate of 85–86%. Conclusion: Clinical, laboratory and endoscopic findings can predict the risk of failure of intensive intravenous treatment. A prospective study is required to confirm these results.

Background : Cigarette smoking is associated with a more severe course of Crohn’s disease, but individual factors determining this effect are poorly known and it is not clear whether smoking cessation is associated with an improvement in the disease activity. Aim : To assess the factors determining the harmful effect of smoking in individuals with Crohn’s disease. Methods : A total of 622 consecutive patients with Crohn’s disease and Crohn’s disease activity index

Resume Une femme de 54 ans a ete hospitalisee pour un œdeme aigu du poumon revelant un retrecissement aortique serre sur bicuspidie, une hypertrophie ventriculaire gauche et un anevrysme de l’aorte ascendante. La coronarographie a montre une lesion intermediaire du tronc commun. Cette lesion etait significative sur les donnees du guide pression (FFR = 0,78) et de la tomographie par coherence optique (surface = 4,9 mm 2 ). L’evaluation des lesions coronaires par guide pression est validee chez le coronarien stable et il y a peu de donnees en cas de retrecissement aortique serre. La mesure risque d’etre faussee par les anomalies de la microcirculation qui perturbent l’hyperhemie optimale et par une pression elevee dans l’oreillette droite en cas de decompensation cardiaque. Ceci peut conduire a un chiffre de FFR plus eleve donc a une sous-estimation de la lesion. Ce risque d’erreur doit etre pris en compte chez ces patients.

Sorafenib increases median survival and time to radiological progression in patients with advanced hepatocellular carcinoma, but its benefit for Child-Pugh B patients remains uncertain.To evaluate the safety and efficacy of sorafenib in real-life clinical practice conditions and to assess the influence of Child-Pugh class B on safety and efficacy.All patients treated with sorafenib for advanced hepatocellular carcinoma in our institution were included prospectively. Adverse events, overall survival and time to progression were recorded. A case control study was performed to compare outcome of patients with comparable stages of hepatocellular carcinoma, but a different Child-Pugh class.From March 2007 to May 2009, 120 patients were included. Overall survival was 11.1 months, Child-Pugh A patients (n=100) had significantly higher median survival than Child-Pugh B patients (n=20) (13 vs. 4.5 months, P=0.0008). In multivariate analysis, Child-Pugh class B, α-fetoprotein level and total size of lesions were independent predictive factors of death. Patients with radiological progression in the first 3 months had shorter median survival (5.4 vs. 17.4 months). In a case control study, time to symptomatic progression (2.5 vs. 3.6 months), frequency of adverse events and discontinuation of sorafenib were not correlated with Child-Pugh class.Patients with advanced hepatocellular carcinoma treated with sorafenib had a median survival of 11 months. Sorafenib therapy must be considered with caution in Child-Pugh B patients due to their poor survival. Radiological assessment of tumour progression at an early stage may be advantageous when tailoring sorafenib therapy.

Extensive coronary dissection is a rare complication of intraluminal angioplasty. We report a retrospective study of 19 patients who consulted in a general hospital without cardiac surgery.After consulting our coronarography and angioplasty database, we included the extensive coronary dissections (type D, E and F) in our study. The medical files of the selected patients were analysed.Between January 2003 and March 2010, 19 coronary angioplasty (total: 2542) were complicated with extensive dissections (incidence 0,75%). For 62,3% of the patients, the dissection was related to the guiding catheter. Eleven patients had type A and B1 lesions. The dissections affected the right coronary artery for 16 patients, the left anterior descending coronary artery for two patients and the left main coronary artery for one patient. After angioplasty, a final TIMI flow 3 was obtained for only 11 patients. In nine cases, we observed a limited extension to the aorta that did not need a chirurgical intervention and had no influence on the prognosis. The complications were common, such as death (n=1), coronary bypass (n=2), myocardial infarction (n=8), cardiogenic shock (n=2) and circulatory assistance (n=2).Extensive coronary dissection is a rare complication of angioplasty. The right coronary is the most frequent vessel concerned and an extension to aorta is usual. The treatment is usually based on sealing the entry with a coronary stent. The complications are common and serious and we did not find any predicting factors to extensive coronary dissections that are unpredictable.

Acute main left coronary artery occlusion is rarely observed during primary angioplasty in myocardial infarction. This retrospective study reports the results of six patients treated by angioplasty in a hospital without cardiac surgery department.From 2002 to 2009, 746 patients were treated by primary angioplasty for acute coronary syndromes with ST elevation. Among those patients, six (0,7%) had acute non protected main left coronary occlusion. We report clinical, angiographical data and follow-up.The population was composed of six patients (five males) with an average age of 64+/-7 years. Five patients were admitted with cardiogenic shock and four were mechanically ventilated. Distal occlusion of main left coronary artery and dominant right coronary artery were noted in all cases. Sub-occluded lesion of right coronary artery was noted in one case. Successful procedure with bare metal stent was achieved in five cases. Mortality rate was 66% (n=4): three patients died in hospital and another 1 or 2 months later of congestive heart failure. Coronary artery bypass grafting was performed at 4 and 12 months later for two patients. They are alive after 12 and 72 months of follow-up.We demonstrate the feasibility of percutaneous coronary intervention of acute main left coronary occlusion. Inspite successful procedure, intrahospital mortality rate is still high and prognosis is related to cardiogenic shock.

an early call to the department of urgent medical assistance--Center 15 (SAMU-centre 15) is associated to shortest delays of reperfusion in case of myocardial infarction. However, patients are not always aware of this.to assess the assimilated counsels by patients after an acute myocardial infarction.from January 1998 to June 2004, patients managed by SAMU 93 and having benefited from thrombolytic therapy prior to hospitalization and/or primary angioplasty for a ST+ acute coronary syndrome with a confirmation of acute myocardial infarction during their hospital stay were prospectively enrolled into this study. A questionnaire was administered by phone from december 2003 to july 2005, assessing the knowledge about the necessity to alert SAMU-center 15 in case of chest pain and availability of medical files data.among the 976 patients: 111 (11%) were lost during follow-up, 162 (19%) were deceased when phone contact and 119 (12%) could not be interrogated. Among the 584 (60%) remaining subjects interrogated with a median follow-up period of 985 days (413-1596), 290 (50%) patients answered they received counseling, including 156 (27%) for taking nitrates, 19 (29%) stated they know that they should call SAMU-center 15. Patients with a high level of education and those treated by thrombolytic therapy prior to hospitalization were better informed; 464 (79%) patients declared having a prescription, 392 (67%) a hospital report, 406 (69%) an electrocardiogram, 227 (39%) a CD with their coronary angiography, and 79(14%) their medical file.the level of knowledge regarding the recommended attitude in case of chest pain is poor. The availability of medical data was better. Arch Mal Cceur

Multidetector computed tomography coronarography is a promising tool, offering a non-invasive anatomic evaluation of coronary arteries. The great majority of studies conducted upon it are single-center studies, and have reported results based upon a highly selected patient population. Our aim was to determine its diagnostic accuracy among an unselected population in multicenter studies.Fifty-two patients were included in a non-randomised, retrospective study. Patients underwent multidetector computed tomography coronarography (16, 40 and 64 slices), in ten different centers (community hospitals or private centres), for clinical suspicion of coronary stenoses. The diagnostic accuracy for detecting significant coronary stenoses (or =50%) was determined in comparison with conventional coronarography.The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were 91.4%, 17.7%, 69.6%, 50.0%, and 67.3%, respectively, in a patient-based analysis, and 55.3%, 85.6%, 30.3%, 94.4% and 82.5% in a segment-based analysis.The results of this study indicate that routine implementation of multidetector computed tomography coronarography is limited by a high false-positive rate, when performed among an unselected population of patients with a high pretest probability of having coronary stenoses, in centres with variable expertises. Its place within the range of diagnostic tools has yet to be determined by large multicenter studies, before being subject to precise recommendations framing its routine clinical application.

Takotsubo is a reversible cardiomyopathy, often triggered by a stressful event. It combines clinical features mimicking a myocardial infarction, transient apical ballooning of the left ventricle, normal coronary arteries and a small rise in troponin level. There is a striking female predominance with mean age ranging from 65 to 76 years among series. Preceding stressful event is documented in 50 to 100% of patients. The most common clinical presentation is an angor-like chest pain with ST-segment elevation on the electrocardiogram (70%). The prognosis is excellent even if serious complications may occur: pulmonary oedema, cardiogenic shock, transient dynamic intraventricular gradient, life-threatening arrhythmias. In-hospital mortality is in the range of 0 to 10%. The recurrence rate is low. The precise physiopathology of the syndrome remains unknown but catecholamine mediated myocardial stunning is the most favored explanation.

Takotsubo cardiomyopathy is a clinical entity mimicking an ST elevation myocardial infarction recently identified. Are associated a chest pain, electrocardiographics abnormalities, minor elevation of enzyme biomarkers in patients who don't have any significant angiographic stenosis on the coronary angiography and where left ventricle angiography shows apical regional wallmotion abnormalities with a characteristic apical ballooning aspect. Between march 2003 and march 2005, we included 11 patients for whom this syndrom was suspected. Mean age was 70, 3 years old. Electrocardiogram was abnormal in all cases. Biological markers show for all patients an elevation of troponin I. All patients had a coronary angiography and coronary arteries were normal. Left ventricle angiography showed in all cases wall-motion abnormalities in the apex with a ballooning aspect. A psychological or physical inducing factor has been found for 8 patients. The evolution was simple for all patients with no complications noted and no recurrence with a mean follow up of 15 months. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrom have a good long-term prognosis even if serious complications sometimes deathly can be seen. The cause of this syndrom is unknown but it must be considered as a possible diagnosis of ST elevation myocardial infarction with normal coronary arteries.

The publication in 2001 of the first in-man results showing zero restenosis after sirolimus eluting stent implantation produced enormous excitement in the cardiological community. Today, both sirolimus and paclitaxel eluting stents have been shown in randomized trials to reduce restenosis as compared with conventional metallic stents. However, since drug eluting stents become available in Europe very little has changed in the every life of almost all interventional laboratories in Europe. The limitation currently impeding more widespread use of the new technology is nontechnical, nonmedical but economic. The high price of drug eluting stents relative to bare stents has been an obstacle to more widespread utilization of drug eluting stents.

When the left anterior descending coronary artery follows an anomalous course between the aorta and pulmonary artery it can cause myocardial ischaemia or sudden death during exercise in young people. Coronary arteriography in a 27 year old man with angina pectoris at rest showed a left anterior descending coronary artery arising from a common right trunk and running from the aorta to the pulmonary artery. Follow up after revascularisation was uneventful.

Background and aims: Obesity is unusual in Crohn's disease and the particularities of the disease in obese patients have not been studied. Methods: 2065 patients were studied retrospectively. Obesity was defined by a BMI value >25.0 at disease onset and >30.0 at any time during the course of the disease. Disease characteristics, therapeutic needs, and year-by-year disease activity were determined in patients with and without obesity. Results : 62 patients (3%) were obese. When compared with non-obese patients, obese patients did not show differences regarding sex, intestinal disease location, and disease behavior, but at diagnosis they were older (32 vs 28 years, P = 0.01) and a larger proportion had anoperineal disease (35 vs 24%, P = 0.03). When the 62 obese patients were paired for sex, location of disease at onset, date of birth, and date of diagnosis with 124 non-obese patients, the disease severity assessed by the importance of medical therapy and excisional surgery did not differ in the two groups but time to development of anoperineal abscess or fistula was shorter in obese patients, and obese patients were more prone to develop an active disease (OR 1.50, 95% CI 1.07–2.11) and to require hospitalization (OR 2.35, 95% CI 1.56–3.52) Conclusion: Obesity in Crohn's disease is associated with more frequent anoperineal complications and a more marked year-by-year disease activity, but does not alter significantly the long-term course of the disease.

Introduction L’interet de la revascularisation est debattu dans la maladie coronaire stable comme dans la coronaropathie silencieuse (CS) chez le diabetique. L’objectif etait de determiner dans une etude retrospective si le pronostic des diabetiques avec CS etait meilleur en cas de revascularisation. Patients et Methodes L’etude porte sur les 93 patients (69 hommes, 61 ± 8 ans, diabetiques depuis 13+8 ans) presentant une CS (stenose coronaire > 70 %) au sein d’une serie de 788 patients asymptomatiques presentant au moins un facteur de risque cardio-vasculaire (nephropathie 43 %, hypertension 76,3 %, dyslipidemie 71,7, tabagisme 35,5 %, autre atteinte arterielle 19,4 %, antecedents familiaux precoces 9,1 %) qui avaient ete depistes pour une ischemie myocardique silencieuse par scintigraphie de stress entre 1992 et 2008 et coronarographie en cas de positivite. Parmi ces 93 patients, 50 avaient des lesions monotronculaires et 16 des lesions tritronculaires. Tous ces patients ont ete suivis pour le premier evenement cardiaque (EC) et l’incidence des EC a ete comparee chez ceux qui avaient eu, sur decision de l’equipe cardiologique, une revascularisation initiale (groupe REVASC : 29 angioplasties, 7 pontages) ou non (groupe MED : n = 57). Resultats La proportion d’hommes etait plus importante dans le groupe REVASC que dans le groupe MED (83,3 vs 53,6 %, p Discussion Ces resultats sont a confirmer par une etude prospective randomisee, testant en particulier les angioplasties avec stent actif. Conclusion Le taux d’EC est tres eleve chez les diabetiques avec CS. Les pontages chez les patients tritronculaires s’accompagnent d’un meilleur pronostic.

Cigarette smoking is associated with a more severe course of Crohn's disease, but individual factors determining this effect are poorly known and it is not clear whether smoking cessation is associated with an improvement in the disease activity.To assess the factors determining the harmful effect of smoking in individuals with Crohn's disease.A total of 622 consecutive patients with Crohn's disease and Crohn's disease activity index200 were enrolled in a prospective 12-18 month cohort study. Patients were classified as current smokers, former smokers, or non-smokers. Alcohol consumption, oral contraceptive use, body mass index, and blood lipid levels were also recorded. The main outcome measure was the rate of flare-up.A total of 139 current smokers (46%) developed a flare-up, vs. 79 non-smokers (30%) and 13 former smokers (23%). The relative risk of flare-up adjusted for confounding factors was 1.35 (1.03-1.76) in current smokers. This risk was increased in patients with previously inactive disease and in those who had no colonic lesions. It became significant above a threshold of 15 cigarettes per day. Former smokers behaved like non-smokers. Obesity, dyslipidaemia, and alcohol consumption had no significant effect.Current smoking, particularly heavy smoking, markedly increases the risk of flare-up in Crohn's disease. Former smokers have a risk similar to that of non-smokers.

The prognosis of patients with coronary artery disease may be threatened by ischaemic mitral regurgitation. Apart from rupture of a papillary muscle which requires rapid valve replacement. Chronic ischaemic papillary muscle dysfunction can often be a severe complication of ischaemic heart disease. The authors report the case of a patient with dyspnoea but no angina of effort. Cardiovascular investigations with right heart catheterisation demonstrated the occurrence of severe mitral regurgitation only during angioplasty of the left marginal artery.

Telemedicine offers new possibilities for multidisciplinary care of cancer patients, allowing direct communications between different, complementary and geographically distant specialists. Thus, it is possible to form oncology committees in small hospitals where all specialties are not represented. The purpose of this study was to evaluate the medical and economic impact of visioconferences in the therapeutic management of cancer patients without access to oncology centers.A telemedicine network was created in Paris between the General Surgery and Gastroenterology services of Rothschild Hospital and the services of Oncology at Saint-Antoine Hospital and Radiotherapy at Tenon Hospital. The three hospitals were connected simultaneously (multipoint) by visioconference and thus constituted a pluridisciplinary oncology committee of radiotherapy, chemotherapy and surgery. Eighty seven cases were evaluated in 27 staff conferences. In 48 cases, this consisted of re-evaluating therapeutic decisions made in surgery or gastroenterology, and in 39 cases opinions were requested by surgery (18), gastroenterology (14) or oncology departments (7).In only 34/87 cases therapeutic agreement was reached directly. The 53 other cases (60.9%) were debated. In fact, all 39 requests for opinion in difficult therapeutic decisions resulted in consensus. Among the 48 re-evaluations, disagreement persisted in one case between the surgeon in charge of the patient and the chemotherapist. Importantly, in 13 of 48 cases (27%), the discussion modified the therapeutic protocol initially proposed. The average cost was 118 French Francs per case and per center. Total initial investment was 334,762 French Francs, but the price of some equipment has already dropped from 30 to 60%.In our study, the visioconference improved management of cancer patients for a weak working cost.

Introduction Nous avons recemment montre que les recommandations francaises ALFEDIAM-SFC definissant les diabetiques de type 2 chez qui rechercher une ischemie myocardique silencieuse (IMS) pouvaient etre ameliorees en considerant le sexe masculin et la presence d’une retinopathie. L’objectif de l’etude etait de determiner si ces criteres etaient egalement valides pour la recherche de stenoses coronaires silencieuses (SC) en vue d’une eventuelle revascularisation. Patients et methodes Entre 1992 et 2006, 731 DT2 consecutifs (384 hommes, 59 ± 9 ans, duree diabete 13 ± 8 ans) asymptomatiques avec ECG de repos normal et au moins un facteur de risque associe (HTA 71 %, dyslipidemie 64 %, tabac 21 %) ont ete explores par scintigraphie myocardique a la recherche d’une IMS, et en cas d’anomalie par coronarographie pour identifier des SC. Resultats Une IMS etait presente chez 215 (29,4 %) patients, dont 79 (10,8 %) avaient des SC (198 coronarographies). Le critere macroproteinurie/arteriopathie peripherique (prevalence chez les patients sans/avec SC 14,5 vs 33,3 %, p Conclusion Prendre en compte les recommandations, le sexe et la presence d’une retinopathie permet de mieux identifier les DT2 avec SC asymptomatiques, avec une tres bonne valeur predictive positive des 3 facteurs combines.

Introduction Le pronostic des diabetiques avec ischemie myocardique silencieuse (IMS), surtout de ceux avec stenoses coronaires (SC), reste altere malgre le controle intensifie des facteurs de risque. Le benefice de la revascularisation dans la maladie coronaire stable est actuellement controverse. Le but de cette etude bicentrique etait de comparer le pronostic de patients diabetiques de type 2 (DT2) avec SC ayant eu ou non une revascularisation coronaire. Patients et methodes Parmi les 1 770 DT2 ayant eu depuis 1991 un depistage de l’IMS par scintigraphie myocardique de stress et des SC par coronarographie si la scintigraphie etait positive, 501 avaient une IMS, 383 d’entre eux ont ete coronarographies et 161 avaient des SC mono, bi ou tritronculaires respectivement dans 58 %, 20 % et 22 % des cas. Resultats Parmi les patients avec SC, 57 ont eu une angioplastie sans stent (n = 15), avec stent nu (n = 13) ou actif (n = 29); 19 des pontages aorto-coronaires; les autres patients ont ete traites medicalement. Les evenements cardiaques majeurs (ECM) ont ete recenses chez 124 patients avec SC depistees depuis plus de 2 ans. Un ECM est survenu chez 29 d’entre eux : 4 deces cardiaques, 22 syndromes coronariens aigus, 5 revascularisations secondaires, 3 insuffisances cardiaques. Chez les patients avec atteinte monotronculaire, aucun des 12 ayant eu une angioplastie avec stent actif n’a eu d’ECM vs 11 des 43 patients traites medicalement (p = 0,08). Chez les patients avec atteinte tritronculaire, un ECM est survenu chez 1 des 13 patients pontes, 2 des 6 patients ayant eu une angioplastie et 4 des 9 patients traites medicalement (log rank 8,64, p Conclusion Ces donnees suggerent que dans la maladie coronaire silencieuse des diabetiques, la revascularisation par pontage est benefique en cas d’atteinte tritronculaire et que l’angioplastie avec stent actif le serait en cas d’atteinte monotronculaire.

The authors report a case of chronic occlusion of the left main coronary associated with occlusion of the second segment of the right coronary artery documented at coronary angiography carried out for effort angina without previous infarction. Myocardial perfusion was preserved mainly by a marginal branch of the right coronary arising immediately before the occluded second segment and by a small branch of the left main coronary artery.

Rationnel Des anomalies glycemiques meconnues seraient tres frequentes chez les coronariens. Le score finlandais de risque de survenue de diabete a 10 ans (Findrisc) a ete valide en population generale vis-a-vis du risque de presenter un diabete meconnu. Le but etait d’apprecier la frequence des dysglycemies meconnues et d’apprecier le risque de diabete futur chez des patients coronariens hospitalises en cardiologie. Patients et Methodes L’etude a porte sur une serie consecutive de 188 patients âges de 67,1 ± 4,2 ans, hospitalises pour syndrome coronarien aigu ou bilan d’une maladie coronaire stable. Tous etaient indemnes d’anomalies glycemiques connues. La glycemie a ete dosee a jeun ainsi que les parametres lipidiques usuels et le Findrisc a ete calcule. Resultats Une anomalie glycemique etait decouverte chez 53 patients (28,2%), en faveur d’une hyperglycemie a jeun chez 29 d’entre eux et d’un diabete chez 24 patients. Le Findrisc etait entre 12 et 14, temoignant d’un risque modere de devenir diabetique (1/6 dans les 10 ans) chez 48 patients, et = 15, temoignant d’un risque eleve ou tres eleve (1/3 a 1/2) chez 27 patients (14,4 %) dont 9 etaient dysglycemiques. Il correlait significativement avec l’âge (p = 0,02), le statut glycemique (normal, hyperglycemie a jeun ou diabete) (p = 0,02), l’IMC (p Conclusion Ces donnees confortent l’importance du depistage des anomalies glycemiques chez les coronariens et l’interet d’evaluer le risque de diabete par un score simple. Un Findrisc eleve doit conduire a evaluer et suivre plus rigoureusement le statut glycemique.

Chez un patient atteint d'hyperparathyroidie primitive, la lesion parathyroidienne n'a pas ete trouvee lors de multiples interventions chirurgicales. Un adenome parathyroidien a ete localise par une arteriographie et traite par embolisation; a propos de cette observation, nous discutons les differents examens qui permettent la localisation des tumeurs parathyroidiennes et l'interet d'un traitement endovasculaire des adenomes parathyroidiens.

The mechanism of coronary spasm is poorly understood. We report a case of coronary artery spasm in a cardiac transplant patient. Pharmacologic testing indicated denervation of the patient's heart. Therefore coronary artery spasm may occur despite cardiac denervation. This case demonstrates that intact autonomic nervous system and cardiac innervation are not essential for coronary artery spasm.

Resume La coronarographie qui affirme seule le diagnostic de stenose du tronc commun de la coronaire gauche (5,2 p. 100 des coronarographies pathologiques) trouve des lesions coronaires associees dans les 54 cas etudies, dont 72,2 p. 100 d'atteintes tritronculaires. La ventriculographie est anormale dans 53 p. 100 des cas avec une fraction d'ejection ventriculaire gauche inferieure a 45 p. 100 dans 37,4 p. 100 des cas. Neuf malades ont ete juges inoperables. Leur evolution, suivie 40 mois, sous traitement medical est severe: 4 deces. 45 malades ont eu une revascularisation myocardique par pontage avec 4 deces operatoires (8,9 p. 100), 8 infarctus postoperatoires (17,8 p. 100) et un deces tardif (2,2 p. 100). La duree du suivi moyen est de 26,4 mois. Les etudes consacrees au sujet s'accordent sur le benefice apporte par la chirurgie, assurant non seulement une amelioration de l'etat fonctionnel, mais surtout une augmentation de la duree de la survie. L'intervention chirurgicale doit etre proposee, malgre les risques operatoires, dans les stenoses du tronc commun de la coronaire gauche superieures a 50 p. 100, chaque fois que le lit d'aval est accessible a la revascularisation.