Pénétration de l’approche radiale dans le monde et apprentissage de la technique

The transradial approach has been used for the first non selective coronary angiographies but was quickly replaced by the femoral approach until a new birth in 1989 for coronary angiography in 1989 and coronary angioplasty in 1992. Transradial approach use is extremely heterogeneous in the world, dominated by some countries in Europe, Canada, and eastern Asia (India, Taiwan, China, Japan).Risk factors of failure have been well described, allowing two kinds of learning: systematic attempt in all kind of patients when working with a proctor; patient selection when beginning the technique alone in order to get a high and stable success rate from the beginning. Systematic radial approach for coronary angiography is a must to learn the technique.     

Efficacité clinique de l’enzymothérapie dans la maladie de Fabry. Analyse critique

Fabry disease is a X-linked lysosomal storage disorder. Two preparations of the enzyme α-galactosidase A are available in Europe since 2001: agalsidase alpha and agalsidase beta. Clinical evidence of efficacy are mandatory considering the absence of a robust biomarker. A literature review was performed to assess the clinical efficacy of these two enzyme replacement therapies. Only open or randomised controlled trials were considered. No unflawed direct comparison exists between the two drugs. Significant clinical benefits have been demonstrated with enzyme replacement therapy (ERT), mainly at an early phase of the disease, with positive effects on heart, kidneys, pain, and quality of life. Further prospective studies are required to confirm the long term clinical benefits of ERT. More specific studies are also needed in women or with ERT earlier in the course of Fabry disease to assess prevention of organ damage.     

Syndrome de Sweet et abcès aseptiques de la rate

Extra-cutaneous manifestations of neutrophilic dermatosis are exceptional and diverse: they consist of inflammatory infiltrates with neutrophil polymorphonuclears, without evidence of infectious agents. Localisations to the lung are the most frequently observed. A single observation of spleen involvement has been reported in a case of sneddon-Wilkinson 's disease. Herein we report the case of an aseptic splenic abscess during the course of a Sweet's syndrome.     

Y a-t-il une essence de la médecine?

Introduction. — Medical practice has to move from a one-on-one relationship to consensual organization of the overall management of patients. Issues at stakes and potential consequences following such changes are discussed.Exegesis. — The evolution of medical practice is introduced as a necessity resulting from both improvements in medical technology and economical pressure. Utilitarian and procedural doctrines are promoted, taking the place of ethical bases. The one-on-one relationship evidences two essential aspects: there is often more in the request made to the practitioner than just the expression of an immediate need, and the patient is not only an organism. Both aspects reflect the specificity of human beings. There is a danger that they will disappear, as they are not included in the definition of “useful”, which in fact controls current choices.Conclusion. — Medical practice is radically modifying its own basis. Practitioners who acknowledge these changes should be aware of their cost.     

Quelle est la définition du médecin allergologue ?

Here is the translation for the French society of study of allergies of the reference document stemming from the World Organization of the Allergy (WAO) defining the doctor allergist.     

Hypertension artérielle pulmonaire primitive au cours de l’infection par le virus de l’immunodéficience humaine. Étude de neuf observations et revue de la littératurePrimary pulmonary hypertension and human immunodeficiency virus infection. Study of nine cases and review of the literature.

PURPOSE: In medical literature, primary pulmonary hypertension occurs in 0.5% of human immunodeficiency virus (HIV)-infected patients, irrespective of the stage of the HIV disease, and is more frequent in drug users. Plexogenic arteriopathy is the most frequent histological lesion. METHODS: We retrospectively report on nine cases of primary pulmonary hypertension during HIV infection. RESULTS: The subjects were four women and five men, mean age 38 years old. Four of them had been sexually contaminated and five had contracted the disease through intravenous drug use. At the time primary pulmonary hypertension was diagnosed, mean CD4 cell count was 234 +/- 217/mm3 and the viral load was low or undetectable. Primary pulmonary hypertension has been diagnosed an average of 7 months after the first cardiovascular clinical signs had started. Despite anti-coagulant (7/9 cases), vasodilatator (4/9 cases) and/or diuretic (7/9 cases) therapy, the progression of the disease quickly turned out to be negative (seven deaths). CONCLUSION: Diagnosis of primary pulmonary hypertension should be considered when unexplained dyspnea occurs in an HIV-positive patient. At initial evaluation, alterations of hemodynamic parameters are usually less severe than during idiopathic primary pulmonary hypertension, but their progression is quicker and more severe, independent of the patient's immune status. Current data do not allow the determination of whether antiretroviral therapy is active in primary pulmonary hypertension evolution. Therapeutic evaluation with prostacyclin is currently being carried out. While the life expectancy of HIV-infected patients extends, primary pulmonary hypertension occurrence could increase and call for early diagnosis, thus allowing for specific care.     

Hypocholestérolémie du sujet âgé : influence de l’inflammation et de la dénutritionHypocholesterolemia in hospitalized elderly: relations with inflammatory and nutritional status

PURPOSE: Hypocholesterolemia is a common finding in hospitalized elderly people and is associated with increased mortality. Changes in plasma lipid levels are well known in the acute phase response. It has also been suggested that malnutrition is a cause of hypocholesterolemia. However, malnutrition is the reflect of general condition, and the respective roles of malnutrition and inflammation have not yet been clearly established. This research project was undertaken to examine the impact of nutritional and inflammatory status on the hypocholesterolemia. METHODS: In a prospective study, 597 elderly patients (83 +/- 7 years) consecutively admitted in a geriatric acute care unit were included. Clinical and anthropometric data: Body Mass Index (BMI), Tricipital Skinfold Thickness (TSF), Sub-Scapular Skinfold Thickness (SSF), Mid Arm Circumference (MAC) have been collected. The blood samples were obtained within the 72 hours following the admission. Nutritional proteins (albumin, prealbumin, transferrin, retinol binding protein); inflammatory proteins (CRP, alpha-1 acid glycoprotein), and blood lipids (cholesterol, LDL, HDL cholesterol, triglycerides, apoproteins A1 and B) were dosed. RESULTS: The anthropometric and biologic parameters have been compared on the two sexes, significant differences were observed only for blood lipids. The analyses are thus realized and presented by sex separately. Four groups of patients are generated according to the quartile of total cholesterol. Means and standard deviation for all factors are calculated within each group. Both, the trend of means and analyses of correlation show associations with cholesterol in the two sexes. The analysis of variance showed that the cholesterolemia is associated with 1/ decrease in the values of the anthropometrics, and nutritional proteins and 2/ upward trends of the inflammatory parameters. Significant correlations were observed for all transport proteins and CRP with total cholesterol in men and women. The multiple linear regression of the total cholesterol retained albumin, APO A1, APO B and RBP as predictor factors of cholesterolemia for women and APO A1, APO B and tryglicerid for men. When patients with infectious diseases were compared to the others, significant differences have been observed for total cholesterol and all blood lipids, as well as for nutritional and inflammatory proteins. CONCLUSION: The results confirm an association between nutritional status and hypocholesterolemia, and suggest also the responsability of inflammation as a cause of hypocholesterolemia.     

Impact du diamètre et de l’âge du thrombus sur la thromboaspiration. Étude expérimentale

Introduction

Coronary thrombectomy is usually used to treat acute coronary syndrome. Many studies evaluated its benefit in this context however, it is still unknown if coronary characteristics are predictive of success or failure. The aim of our laboratory bench study was to evaluate the impact of angiographic characteristics on the thromboaspiration efficiency.

Methods

Glass tubes of 150 mm in the length were used, with five diameters: 2; 2.6; 3; 3.6 and 4 mm; and for each diameter, three angulations: no angulation; 90° and 120°. Blood sample were taken from healthy subject and thrombi of 3 and 6 hours old were performed, with a constant volume for each test. Thromboaspirations were performed with an Export^® catheter (Medtronic). The primary endpoint was total thrombectomy. A total of 240 thromboaspirations were performed.

Results

A total thrombectomy was obtained for 71.2% of the tests. It was achieved more frequently with the smaller diameter, respectively: 100% for 2 mm, 81.3% for 2.6 mm, 89.6% for 3 mm vs 54.2% for 3.6 mm and 31.3% for 4 mm (P < 0.001). No differences were observed between the 2 thrombi ages (73.3% for the 3 hours old thrombi and 69.2% for the 6 hours old thrombi, P = 0.476), nor between the three tube's angulations (77.5% for no angle, 66.3% for 90° and 70.0% for 120°, P = 0.278). Results and conclusion: This study shows an impact of the coronary diameters on the rate of thromboaspiration success with an Export^® catheter. Beyond 3 mm of diameter, the rate of success is divided by 2: for diameters less or equal to 3 mm, 90.3% of success vs 42.7% for diameters greater than 3 mm (P < 0.001). There is no difference of efficiency between the 3 and 6 hours old thrombi, neither between the tube's angulations. However, this is a preliminary and further works are needed to clarify how to optimize the aspiration and the impact of other catheters.     

Dépistage de l’ischémie myocardique par l’échocardiographie de stress à la dobutamine chez le diabétique de type 2 à haut risque cardiovasculaire au Sénégal

Introduction

Diabetes is a major risk factor for coronary artery disease witch may develop insidiously. Several non-invasive methods are used to detect silent myocardial ischaemia, especially in diabetic patients at high cardiovascular risk. We project to screen, by dobutamine stress echocardiography, silent myocardial ischaemia in type 2 diabetics in Senegal.

Methodology

We randomly recruited in hospital in Senegal type 2 diabetics aged at least 40 years and a dobutamine stress echocardiography was performed in those selected according to the French Society of Cardiology and the French Language Association for the Study of Diabetes and Metabolic Diseases.

Results

Dobutamine stress echocardiography was performed in 79 diabetics at high cardiovascular risk, including 56 women. The average age was 58.8 ± 11.8 years. The exam was positive in 67.1% of cases (53/79), with a predominance of motion abnormalities in anterior territory (83%). Cardiovascular risk factors associated with positivity of test were microalbuminuria (p = 0.0001), inactivity (p = 0.0001), dyslipidemia (p = 0.0002), arterial hypertension (p = 0.001), smoking (0.003) and male sex (p = 0.004).

Conclusion

In Africa, dobutamine stress echocardiography has the advantage of its accessibility and its feasibility. Early detection of silent myocardial ischaemia in diabetics at high risk could optimize their care.