Hématome intramural de l’aorte thoracique : traitement médical ou chirurgie ?

Intramural hematoma (IMH) of the aorta is an uncommon entity. This disease shares many characteristics with acute aortic dissection. Treatment of IMH remains controversial. We report the case of a 58 years old man with hypertension disease who was admitted in emergency department with suspicion of acute aortic dissection. Transoesophageal echocardiography showed IMH involving the descending aorta which spred afterwards to the ascending aorta. Patient was treated medically and echocardiographic follow-up showed that aortic hematoma remains stable. Two years later, patient is alive and the last TEE reveals disappearance of hematoma in ascending aorta and decrease of it in descending aorta.     

Quel est l’intérêt de rechercher un hypogonadisme chez un patient présentant des ulcères de jambe récidivant depuis l’âge de 20 ans ?

Androgen replacement therapy has been reported to have a beneficial effect in patients with Klinefelter's syndrome or perforating plantar ulcers. We report the case of a 55-year-old man with a 35-year history of leg ulcers and venous insufficiency. His leg ulcers healed 4 months after a management scheme including vascular rehabilitation (intermittent pressure therapy, ankle mobilization, multiple layer compression bands on the lower limbs), skin grafts and foam sclerotherapy of the great saphenous vein. The ulcers recurred 1 month later. This recurrence and the unusually young age for development of venous leg ulcers led to a search for a rare cause. The diagnosis of anterior pituitary failure was established. Sclerotherapy and androgen replacement therapy led to complete healing without recurrence at the 1-year follow-up visit. A link between androgen deficiency and fibrinolysis, protein synthesis deficiency, inflammation and trophicity is well documented in the literature. A search for hypogonadism may be useful in young patients presenting a longstanding history of leg ulcers or in patients with suspected andropause irrespective of age.     

Transplantation hépatique de l’adulte: qui et quand greffer?

Introduction. -- The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected, or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue.Current knowledge and key points. -- Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease; and secondly, in an acceptable risk taking manner. Major criterias for indication in the most common liver diseases can be summerized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred, is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 μmol/L is generally required; c) apart from «small» hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications; d) acute liver failure requires early referral to a liver transplant center for potential emergency indication.Future prospects and projects. -- In an organ shortage situation which is likely to perdure, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure.

Résumé

Introduction. -- L'augmentation du nombre de transplantations hépatiques est limitée par l'insuffisance des ressources en donneurs. La nécessité impose donc un choix parmi les patients susceptibles de bénéficier de ce traitement -- les cas plus graves? ou ceux qui ont les meilleures chances de guérir? -- et une évaluation optimale du moment de la transplantation dans l'histoire de la maladie: ni trop tôt, ni trop tard.Actualités et points forts. -- La transplantation doit être réservée aux patients souffrant d'une affection hépatique irréversible et symptomatique. Elle doit, en règle générale et par ordre d'importance, d'une part modifier l'histoire naturelle de la maladie et, d'autre part, pour un risque minimal. Les critères majeurs d'indication peuvent être ainsi schématisés pour les hépatopathies les plus fréquentes: 1) pour les cirrhoses non choléstatiques, un score de Pugh-Child de 9-10, ou un score inférieur si des accidents évolutifs se sont déjà produits, est un critère nécessaire et souvent suffisant ; 2) pour les cirrhoses choléstatiques, un taux de bilirubine sérique supérieur à 100-150 μmol/L est un critère admis ; 3) si l'on excepte les «petits» carcinomes hépatocellulaires sur cirrhose (moins de trois nodules de moins de 5 cm), presque tous les cancers sont une contre-indication à la transplantation ; 4) l'insuffisance hépatique aiguë nécessite un transfert précoce en milieu spécialisé pour une éventuelle indication de transplantation en urgence.Perspectives et projets. -- Dans un contexte de pénurie qui risque de perdurer, l'amélioration des conditions d'accès à la transplantation nécessite qu'un avis consultatif puisse être pris précocement dans l'histoire naturelle de la maladie auprès des équipes en charge de la transplantation.     

L’insuline par voie inhalée : un modèle pour l’absorption systémique pulmonaire ?

European Union has recently approved a form of insulin intended to be inhaled. This innovative presentation has the potential to partially or completely replace the injections and thus facilitate starting insulin therapy which is considered with apprehension and too often differed. On this occasion, we reviewed the issues raised by this pulmonary route for systemic absorption (anatomical and cytological limits, cellular mechanisms, relevant physical parameters, facilitating chemical cofactors, role of tobacco smoking and of common respiratory diseases). The pharmacokinetics of inhaled and injectable insulins are comparable, apart from an appreciably faster absorption of the former and both show the same intra-individual variability. The total biodisponibility is definitely lower with the inhaled way but it is notably increased in smokers. These characteristics can vary according to the inhalation system used. A frequent induced cough, the increase in circulating anti-insulin antibodies and a potentially higher cost are not really determining obstacles. The indications will have to be clearly specified and the long-term inocuity of long term inhalation of such a mitogene especially in children and former smokers remains to be formally proven.     

Radiothérapie externe et photothérapie dynamique des cancers de l’œsophage : une association dangereuse ?

A 60-year-old man presented an oesophageal transmural necrosis fistulised in the trachea following curative photodynamic therapy (PDT) for a superficial recurrence of an oesophageal carcinoma, initially treated by radiochemotherapy. Two stents, a tracheal and an oesophageal one, were placed. Eight months later the patient is in complete remission with only mild swallowing problems. This complication, although unusual, has already been described by other teams with the association of radiochemotherapy and PDT. The present case study suggests that illumination dose should be lowered in this indication.