Particularités cliniques de l’embolie pulmonaire chez la personne âgée : étude comparative de 64 patients

Purpose

To date only a few studies regarding pulmonary embolism (PE) in elderly have been published. The aim of this study was to determine the clinical features of PE in elderly patients (≥ 75 years).

Methods

All patients hospitalized for PE in our internal medicine department from January 2005 to December 2010 were included in the study. The aim was to compare the features of PE in elderly patients (≥ 75 years) to those of patients younger than 75 years. The following data were recorded: past medical history, risk factors for venous thrombo-embolism (VTE), clinical features, and PE etiologies.

Results

The population was composed of 64 patients (women 56%) with a median age of 82 years (IQR: 13.5). There was no statistical difference for risk factors of VTE. Syncope was more frequent in elderly patients (33% versus 7%, P = 0.04) whereas thoracic pain predominated in younger patients (36,5% versus 7%, P = 0.005). Chronic obstructive pulmonary disease was more frequent in the past medical history of elderly patients. The diagnostic of PE was less suspected in elderly patients (47% versus 72%, P = 0.035). The etiologies were similar between the two groups.

Conclusion

Our study highlights the frequency of syncope as the presenting feature of PE in elderly, whereas thoracic pain is uncommon. We confirmed the difficulty to diagnose PE in elderly population.     

Étude électrophysiologique par voie transœsophagienne chez des enfants de moins de 11 ans, non sédatés, ayant un syndrome de Wolff-Parkinson-White

The electrophysiological evaluation of Wolff-Parkinson-White syndrome (WPW) is recommended in children aged more than five years to detect a risk of life-threatening arrhythmia. The purposes of the study were to determine the feasibility of transesophageal EPS in a child between six and 10 years in out-patient clinic.

Methods

Electrophysiological study (EPS) was indicated in 22 children, aged six to 10 years, with a manifest WPW either for no documented tachycardia (n = 7), unexplained dizziness (n = 2) or for a sportive authorization in 10 asymptomatic children. Two of the last children had a history of permanent tachycardia after the birth but were asymptomatic since the age of one year without drugs.

Results

EPS was performed in all children. The main difficulty lied in passing the catheter through the mouth. Programmed stimulation at cycle length of 380 ms was performed in all children to avoid high rates of pacing when the conduction through the accessory pathway (AP) and normal AV system was evaluated. Isoproterenol was not required in five children, because they developed a catecholaminergic sinus tachycardia. The AP refractory period was determined in all children between 200 and 270 ms. Orthodromic reentrant tachycardia (RT) was induced in 11 children, three asymptomatic children (27%), seven complaining of tachycardia and one with syncope. Rapid antidromic tachycardia was induced in this last child with dizziness. Atrial fibrillation was never induced.

Conclusions

Esophageal EPS can be performed without sedation in a young child six to 10-year-old with a shortened protocol of stimulation, which was capable to clearly evaluate the WPW-related risks.     

Caractéristiques cliniques,paracliniques et profil évolutif de l’atteinte aortique de la maladie de Horton : à propos de 26 cas d’aortite parmi 63 cas de maladie de Horton

Purpose

Aortic involvement that occurs in temporal arteritis is probably underestimated because it is usually asymptomatic. The characteristics of giant cell arteritis with aortic involvement are still poorly described and the relationship between aortitis and vascular outcome of the disease has not been clearly delineated. The objective of this retrospective study of 63 patients with giant cell arteritis, including 26 with aortic involvement, was to compare the features of patients with and without aortitis, and to assess the contribution of CT-scan and FDG-PET-scan in screening for vascular disease, monitoring, and therapeutic management of patients.

Methods

This retrospective study was conducted in the internal medicine department of the university hospital in Marseille, France, from January 1, 2005 to September 30, 2011. Patients had at least three out of the five American College of Rheumatology criteria for temporal arteritis and aortic involvement was investigated in all patients using CT-scan. Aortic wall thickness greater or equal to 3 mm was considered to be abnormal.

Results

Of 63 patients diagnosed with giant cell arteritis, 26 (41.3%) had aortic involvement diagnosed by aortic CT-scan. Age at diagnosis was significantly younger (66.8 vs 73.8 years; P = 0.002) in the group with aortitis. Inflammatory dorsal and low back pain, signs of vascular disease of the upper limbs (P = 0.009), and higher level of acute phase reactants were associated with aortitis. Aneurysmal lesions of the aorta were significantly more frequent in the group with aortitis. Twenty patients had both aortic CT-scan and FDG-PET-scan. For patients in whom aortic involvement was not demonstrated with CT-scan, FDG-PET-scan was always non-contributive. With corticosteroids, aortitis resolved within 6 months in all patients as evaluated by aortic CT-scan. However, aortitis persisted in 80% of cases at 6 months when evaluated with FDG-PET-scan, and in 66% of cases at 12 months, without influencing the treatment.

Conclusion

This case series shows no specific features of aorta and its main roots involvement in giant cell arteritis, justifying a systematic screening by CT-scan. The high frequency of this arterial involvement could help physicians in the diagnosis of giant cell arteritis. Aortitis seems to be associated with vascular complications as highlighted by the frequency of aortic aneurysm and a case of early aortic dissection. Finally, the role of PET-CT-scan for screening vascular disease and therapeutic monitoring remains to be clarified.     

Évaluations clinique et économique de la bivalirudine au cours des procédures d’angioplasties coronaires

Bivalirudin, with provisional GP IIb/IIIa inhibitor use allows the same protection against ischemic complications while reducing the hemorrhagic complications compared with the systematic association of a GP IIb/IIIa inhibitor plus heparin (The Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events-2 [Replace-2]). In clinical practice, the use of heparin is not systematically associated with a GP IIb/IIIa inhibitor. That's why we studied the clinical and economic interest of bivalirudin only versus heparin (UFH) only. Opened pragmatic monocentric study carried out in 2007. We made a chronological matching: for each patient treated with bivalirudin, we included the next patient with the same clinical presentation treated with unfractionated heparin. Ninety-two patients were included (46 in each group). The need for a GP IIb/IIIa inhibitor during the PCI was not significantly different between the two groups (p = 0.11). No major hemorrhagic complications were observed in the two groups. Prevalence of ecchymosis was not significantly different: 22 % in the UFH group versus 13 % in the bivalirudin group (p = 0.27). The average troponin level the next day was significantly higher in the bivalirudin group (p = 0,049), although the change in troponin levels before and after the procedure was similar in the two groups. The average cost by patient of anticoagulation by bivalirudin and HNF is very different, respectively 473 ± 150 and 51 ± 146 € (p = 0.0001). Bivalirudin can be an interesting alternative for patients with a high risk of having complications. But considering its cost this therapy must be used only for selected patients.     

Gastroentérite à éosinophiles

Purpose

Eosinophilic gastroenteritis is a rare and heterogeneous disorder characterized by eosinophilic infiltration of one or more layers of the gastrointestinal tract. Although it can involve any part of the gastrointestinal tract, the stomach and the proximal small bowel are the most common sites of involvement. Clinical features depend on which layer and site are involved. We report eight cases of eosinophilic gastroenteritis.

Methods

We conducted a retrospective review of consecutive adult cases diagnosed with eosinophilic gastroenteritis from 1990 to 2010. The diagnosis was established by histologic examination of endoscopic biopsy or operative specimen or by the presence of eosinophilic ascites.

Results

Eight patients (three men, five women) were diagnosed with eosinophilic gastroenteritis during the study period. Three out of the eight patients had a history of allergy. All patients had gastrointestinal symptoms. The most common symptoms were abdominal pain, vomiting, weight loss and ascites. Seven patients (87.5%) had hypereosinophilia. Seven patients had involvement of the subserosa and one of the mucosa. Four patients were treated with oral prednisolone. The symptoms in all the patients subsided within one month. The remaining four patients improved spontaneously. Four of our patients were followed-up for at least 2 months (11 to 68 months). A single patient presented a relapse.

Conclusion

Eosinophilic gastroenteritis should be suspected in patients having gastrointestinal discomfort along with peripheral eosinophilia. Definitive diagnosis requires histological demonstrations of eosinophilic infiltration of the gastrointestinal wall or high eosinophilic count in ascites fluid.     

Observance médicamenteuse chez un échantillon d’hypertendus dans la région de Sfax (Tunisie)

The aim of the study

Medication noncompliance is one of the daily problems of the physician. Improving the medication adherence allows better management of hypertension. The aim of this work was to determine the level of compliance for patients with hypertension and to identify factors that determine compliance.

Methods

A cross-sectional study was carried out among a sample of hypertensive patients attending general and specialist practitioners in public or private clinics of Sfax. Two hundred and seventy-three participants had accepted to be interviewed. Patients were identified as noncompliants using a questionnaire developed by the Comité de lutte contre l’hypertension artérielle (CFLHTA).

Results

Non-compliance rate was 63.4%. The low level of education was associated with a lower adherence. The monotherapy, the once-daily regimen with fewer number of tablets were associated with a better adherence (p < 10⁻⁶). The welcome and the availability of drugs in the public clinic affect positively the adherence of patients (p < 0.0002). A patient very satisfied with his consultation and the explanation given by the doctor about his illness and its treatment had a better adherence (p < 0.00003).

Conclusion

Our study had demonstrated a low compliance with antihypertensive drug therapy. Tunisian health care system should elaborate a management plan which takes into account our particular predictors of compliance to improve adherence to antihypertensive medication.     

Validation de la reproductibilité de la mesure de la surface de l’orifice régurgitant par planimétrie dans l’insuffisance aortique : une étude préliminaire d’échocardiographie trans-œsophagienne tridimensionnelle

Background

Aortic regurgitation is mainly evaluated by trans-thoracic echocardiography using multi-parametric qualitative and semi quantitative tools. All those parameters can fail to meet expectations, resulting in an imperfect diagnostic reliability and assessment of aortic regurgitation severity can be challenging.

Objectives

We sought to evaluate feasibility and intra- and inter-observer reproducibility of aortic regurgitant orifice area measured by planimetry with tridimensional trans-esophageal echocardiography on patients with at least grade 2/4 aortic regurgitation.

Patients and methods

Consecutive patients with at least grade 2/4 aortic regurgitation measured by trans-thoracic echocardiography and referred for trans-esophageal echocardiography for any reason were included. Planimetric reconstructions of regurgitant orifice area were studied and reproducibility indexes between senior and junior observers were calculated.

Results

Twenty-three patients were included in this study. Intra- and inter-observer reproducibility were excellent with an ICC of 0.95 [0.88–0.98], P < 0.0001 and 0.91 [0.79–0.96], P < 0.0001, respectively. Mean length of the measurement was 6.6 ± 0.9 min [CI95% 6.23–7.01].

Conclusion

Planimetric measurement of the aortic regurgitant orifice using tridimensional trans-esophageal echocardiography seems to be feasible and has great intra- and inter-observer reproducibility. Reconstruction durations were compatible with a daily use. There is a need now to investigate the reliability of this measurement as compared with the reference technique.     

Séjour éducatif pour enfants asthmatiques en Ardèche : un programme innovant

Asthma is children's foremost chronic disease. If the medicinal progress is unambiguous, therapeutic education as well as rehabilitation efforts are integral parts of asthmatic children's global care. Initiated and proposed by the Association asthme et allergies, a protocol that defines place, dates, purposes and means, received the agreement of the French ministry for Youth and Sports. Thirteen children (eight boys, five girls, with an average age of eleven) who suffer from persistent asthma, from moderate to severe and/or exercise-induced asthma, were selected by two Parisian hospitals. The children spent fourteen days on vacation in Ardèche (altitude, 1400 m) during the month of July and were supervised by a medical and an animation team. Motivating children to engage in sports activities and strengthening therapeutic education trained in asthma's schools (écoles de l’asthme) were the dual purpose of the stay. An educational diagnosis and an evaluation of the knowledge of each child were realized at the beginning and at the end of the stay. A flexible program was set up and combined outdoor games, role-playing, educational workshops on breathing, techniques of inhalation and measurement of breath… associated with tests and coupled with physical or sportive activities practiced individually or collectively. Climatic conditions did not provoke any asthma attack or intercurrent affection. The questionnaire dispensed at the end of the stay reveals the children's global satisfaction. In terms of health, preliminary results are promising, particularly regarding their aerobic capacity and physical performances. A medium-term evaluation is in progress, but consequences of this experience - shared by children coming from different social milieus and in a less polluted environment - seem to confirm the interest for promoting educational and sportive stays supervised by health professionals specialized in therapeutic education and spent in specific places which correspond to the standards of allergens’ eviction.     

Complications de la gastroentérite à éosinophiles : une observation et revue de la littérature

Introduction

Eosinophilic gastroenteritis is an unusual disease characterized by an eosinophilic infiltration of the gastrointestinal tract. The esophageal location of this disorder is uncommon and is usually revealed by dysphagia. Diagnosis is obtained by histology during endoscopy after exclusion of differential diagnosis. Treatment is based on systemic corticosteroids, which improve dramatically symptoms and endoscopic lesions.

Case report

We report an 88-year-old man who presented eosinophilic gastroenteritis with esophageal injury complicated by gastrointestinal haemorrhage and fistule.

Conclusion

Eosinophilic gastroenteritis may have a potentially unfavourable outcome. The treatment of complicated forms is not codified and often empirical.     

L’éducation nutritionnelle du patient coronarien en pratique

Background

The Mediterranean diet is one of the food models which showed its ability at the patient at high cardiovascular risk in numerous cohort studies and two major interventional studies: Lyon Heart Study in 1999 and PREDIMED in 2013.

Aim of the study

Propose a practical assistance in the analysis of the dietary habits of the coronary patient with a simplified food frequency questionnaire.

Patients and methods

Hundred coronary patients followed a program of cardiac rehabilitation and benefited from a nutritional education. The analysis of their dietary habits was made with the questionnaire of frequency of consumption of Rennes upon their arrival and 6 months later. We have coded again these data by means of a simplified questionnaire with 15 items and compared the results and their evolution in 6 months.

Results

On studied 200 questionnaires, the score of Rennes was 10.6 ± 4.5 and the simplified score 8.2 ± 3.4 with a coefficient of correlation of Pearson r = 0.94 (0.91–0.95) at risk P < 0.0001. Initial scores were respectively 8.0 ± 4.4 and 6.3 ± 3.4 (r = 0.93) and the scores at 6 months 13.1 ± 2.9 and 10.1 ± 2.2 (r = 0.86). The evolution of the scores of 100 patients were respectively 14.2 ± 11.7% and 12.6 ± 11% (P < 0.26).

Conclusion

The use of a simplified questionnaire allows to analyze the dietary habits of the coronary patient and to estimate their evolution during a therapeutic educational program.     

Caractéristiques clinicobiologiques des méningites à Enterovirus de l’adulte : étude de 59 cas

Purpose

To describe the epidemiological and clinical features of enteroviral meningitis as well as the biological profile of the cerebrospinal fluid (CSF).

Methods

A retrospective study conducted in a single centre between 2004 and 2008. All aseptic meningitis due to Enterovirus were included.

Results

Fifty-nine patients were included. The triad including fever, headache and neck stiffness was reported in 62% of patients. Twelve patients (20%) had a neutrophilic leukocytosis and 23 (39%) an elevated CRP level. Twenty-eight patients (47%) had a prominent neutrophilic reaction in the CSF and nine (15.2%) had a low glucose concentration. A presumptive anti-bacterial treatment was initiated in 47 patients (80%) for an average of 3.2 days.

Conclusion

Due to the lack of specificity of clinical features and biological manifestations of Enterovirus meningitis, the widespread use of real-time Enterovirus PCR is a priority for reducing the number of unnecessary anti-bacterial treatment. Guidelines based on clinical and biological features may be associated to help physicians in the differential diagnosis between bacterial and viral meningitides.     

Manifestations vasculaires des infections à Campylobacter fetus subsp. fetus : à propos de deux cas

Introduction

Campylobacter fetus is a rare Gram-negative bacteria affecting especially elderly and immunocompromised patients, and that is responsible of vascular and cutaneous involvement.

Observations

We report two cases of C. fetus infection in two diabetic male patients, aged 75 and 85 years. The first patient was admitted for chronic fever. First-line examinations were inconclusive. Combined positron emission tomography and computed imaging tomography (PET-CT) diagnosed an infection of a previously operated popliteal aneurysm. The patient underwent surgery, and per-operative samples were positive for C. fetus. The second patient was admitted for a leg cellulitis. Blood cultures were positive for C. fetus. PET-CT found a septic superficial thrombophlebitis. The outcome was favorable for both patients with prolonged antibiotic therapy.

Conclusion

Vascular involvement should be suspected in the presence of C. fetus infections. PET-CT may be useful, as other imaging modalities are not always contributive.     

Lichen plan buccal érosif associé à un syndrome de Good

Introduction

Good syndrome is characterized by thymoma, hypogammaglobulinemia, low number of peripheral B cells, and variably, peripheral CD4 T cell lymphopenia and inverted CD4/CD8 T cell ratio, associated with infections and autoimmune diseases.

Case report

We report an 85-year-old woman who presented with oral erosive lichen planus and thymic tumor. Improvement of oral erosive lichen planus was observed after resection of a benign thymoma, but was ineffective on the immunodeficiency syndrome. Only 11 patients with Good syndrome and lichen planus have been previously reported and are reviewed.

Conclusion

The association of oral erosive lichen planus with Good syndrome is rare, but does not seem to be fortuitous.     

Granulomatoses rénales : étude rétrospective de 44 observations

Purpose

Granulomatous interstitial nephritis (GIN) are identified in 0.5 to 1,3% of all renal biopsies. Renal outcome and treatment modalities are not clearly established in the literature.

Methods

We retrospectively analyzed a case series of 44 GIN identified among all renal biopsies performed between 1984 and 2005 in the Rhône-Alpes area.

Results

The study population included 25 men and 19 women with a mean age of 56 years, and mean diagnostic delay was 11 months. Renal function was severely impaired (mean creatinine clearance 24 mL/min). Proteinuria was observed in 77% (mean value 0,9 g/24 h) of the patients and associated with microscopic hematuria and leukocyturia in 30% and 25%, respectively. The most common diagnosis was sarcoidosis (25%, n = 11), followed by drug-induced GIN (9%, n = 4), tuberculosis (6,8%, n=3), hemopathy-related paraneoplastic GIN (6,8%, n = 3), HIV infection (n = 1) and chronic renal allograft rejection (n = 1). In other patients, no aetiology was found (48%, n = 21). Severity of renal failure justified hemodialysis in 34% (n = 15) of the patients. Three patients underwent renal transplantation. Nonetheless, renal outcome was generally favorable: renal function improved in 41% (n = 18) and stabilized in 34% (n = 15) of patients.

Conclusions

Sarcoidosis, drug-induced and infections represent the main causes of GIN. Histologic features are not specific enough to determine the aetiology. Corticosteroids is the gold standard in sarcoidosis, drug-induced, and idiopathic GIN. Treatment is etiologic in the other cases.     

Intérêt de l’échocardiographie trans-œsophagienne dans l’optimisation de la stratégie thérapeutique après un accident vasculaire cérébral ischémique

Aim of the study

In the setting of ischemic stroke, the place of transesophageal echocardiography (TEE) is still matter of debate. The aim of the study is to evaluate the therapeutic impact provided by TEE and to characterize patients in whom TEE is warranted.

Patients and method

Three hundred and fifty-nine consecutive patients were included in the study. “Decisive TEE” (DTEE) was defined by echographic findings resulting in a change of treatment, whereas “informative TEE” (ITEE) was defined by TEE revealing a potential cardiac or aortic source of embolism.

Results

Three hundred and forty-one patients underwent TEE. Twenty-eight patients (8.2%) had DTEE and 184 (53.9%) had ITEE. DTEE were as follows: thrombus in the left atrial appendage in 6 patients, complex aortic plaques in 10 patients, patent foramen ovale (PFO) associated with atrial septal aneurism (ASA) and an important right to left shunt (3 patients), FOP associated with ASA and lower limb phlebitis (1 patient), 4 cases of endocarditis and 4 patients with intense spontaneous echo contrast in the left atrium. In most cases of DTEE (67.8%), the patient was given anticoagulation drugs. Left atrial dilatation (P = 0.005) and multivessel territory stroke (P = 0.018) were statistically predictive of DTEE.

Conclusions

In the setting of ischemic stroke, TEE provides important additional informations, but modifies therapeutic strategy in less than 10% of cases. Multivessel territory stroke, and left atrial dilatation were predictive of DTEE.     

Facteurs de risque cardiovasculaire chez les travailleurs postés d’une centrale de production d’électricité au centre tunisien

The purpose of the study

The aim of the present study was to investigate relationship between shift work and the cardiovascular risk factors.

Methods

A cross-sectional study was included 330 subjects worked in a company of electricity production in the Centre of Tunisia. The collection of data was based on a questionnaire, a clinical exam and biomarkers.

Results

A total of 290 workers was participated in our study (128 shift workers and 162 daytime workers). A raised prevalence but not statistically significant of some factors of cardiovascular risks was found in the shift workers: obesity (25.8 % versus 17.9 %), smoking (44.5 % versus 39.5 %), impaired fasting glucose (11.7 % versus 9.9 %), hypertriglyceridemia (28.1 % versus 25.9 %) and hypercholesterolemia (14.8 % versus 12.4 %). Whereas the prevalence of the alcohol consumption (25.8 % versus 16.0 %) was significantly higher in the shift workers (p = 0.04).

Conclusion

The high prevalence of the cardiovascular risk factors, observed in our shift workers, justify the adoption of measures to protect this category of workers.