Efficacité de la nitroglycérine en nébuliseur

The effects of a nitroglycerine spray (Nitrolingual Spray 0,4, G-Pohl-Boskamp) were studied in 14 patients, 6 of whom (Group I) has resting pulmonary capillary pressures (PCP) greater than 18 mm Hg and 8 (Group II) with PCP less than 18 mm Hg. The following parameters were studied before and 5, 10, 30, 60 and 120 minutes after administration : systemic blood pressure (BP), pulmonary artery pressure (PAP), right atrial pressure (RAP), pulmonary capillary pressure, cardiac index (CI) and systolic work index (SWI). In 5 other cases the ejection fraction (EF) was measured by scintigraphy with Technetium 99 labelled red blood cells. In group I, a fall in PCP (p < 0,05) (maximal variation : − 26,6 p. 100) ; RAP (− 30 p. 100) and PAP (− 17,4 p. 100) was recorded after the fifth minute. CI (+ 10,8 p. 100) and SWI (+ 14,6 p. 100) increased up to the 30th minute (p < 0,05).In Group II, no change in CI or SWI was recorded, but PCP (− 37 p. 100) PAP (− 27,9 p. 100), RAP (− 45 p. 100) fell significantly from the 5th up to zhe 30th minute (p < 0,05). The heart rate was unchanged in both groups. The EF increased significantly (+ 17,5 p. 100, p < 0,05) from the 5th minute. In comparison, isosorbide dinitrate (sublingual 5 mg, 5 patients) had no demonstrable effect (RAP − 29 p. 100, PAP − 14,7 p. 100, PCP − 26,9 p. 100) was more delayed (p < 0,05) than the nitroglycerine spray.The action of nitroglycerine spray is marked, rapid and effective. It is limited in time, hardly lasting longer than 30 minutes.     

Auto-anticorps anti-érythrocytaires et anémies hémolytiques auto-immunes. Étude de 80 observations. Aspects particuliers au sujet âgé

The following observations were drawn from the study of 80 patients with anti-erythrocyte auto antibodies (AEAA) :

- The average age was about 62 years with a maximal incidence in the 65–75 year range. There was a female predominance which increased after the age of 65 ;

- In 20 p. 100 cases, the majority being elderly patients, anti-erythrocytic auto immunisation seemed to be idiopathic. The aetiologies in the remaining cases comprised malignant haemoreticulopathies, connective tissue diseases, liver disorders, microorganism infection and treatment with alpha-methyldopa ;

- Anti-erythrocyte auto immunisation does not always cause haemolytic anaemia. In 66 p. 100 of patients with AEAA there were no clinical or biological signs of haemolysis ;

- The association of other immunological abnormalities (anti-organ antibodies, positive rheumatoid factor, hypergammaglobulinaemia…) and AEAA is common and seems to reflect a complex disorder of the immune system. This also applies in patients in whom the immunological type of AEAA changes during the course of the disease ;

- These observations lead to the discussion as to the possible relationship between auto immunity and the ageing process.

Apport de la radiologie au diagnostic étiologique des hypertensions artérielles d'origine surrénalienne

Radiological investigation of adrenal causes of hypertension includes the widely accepted adrenal arteriography and venography, and also the new techniques of echotomography and computerised axial tomography.The choice of investigations is determined by the patients'clinical and biological profiles.In all cases, the initial investigation should be computerised axial tomography or, according to some authors, echotomography.When pheochromocytoma is suspected, adrenal arteriography should be requested as most pheochromocytomas are hypervascular.On the other hand, patients with suspected primary hyperaldosteronism should undergo adrenal venography. It is the only technique currently capable of diagnosing a very small adrenoma by either the angiography or the very selective blood sampling that may be performed at the same time.     

Traitement des accidents vasculaires rétiniens

The treatment of acute retinal vascular occlusions is difficult for two reasons : retina is a fragile tissue, vascular obstruction arterial or venous is very rarely due to a real isolated thrombus.The treatment of retinal arterial occlusions (RAO). It is based on papaverine and xylocaïne i.v., heparine may be added but we must respect its contreindications ; fibrinolytic drugs are not efficient here. Temporal arteritis is a quite special cause of RAO. Its treatment is based on massive steroïd therapy.The treatment of retinal venous occlusions (RVO). It is based chiefly on heparine, streptokinase is not indicated, urokinase may be used on some rare cases, its efficiency is dubious.In the whole it is quite rare that treatment leads to the restauration of a good vascular patency.     

Traitement de la myasthénie grave par échanges plasmatiques et immunosuppresseurs

Twenty one patients ranging from 14 to 71 years with myasthenia gravis (MG) since 3 months to 23 years underwent plasma exchanges (PE). According to Osserman classification, theses patients ranged as followed: 11 grade III ou IV, 10 grade II b. Thymectomy has been performed in 16 patients (10 thymoma).Before PE, all patients received anticholinesterasis drugs, 6 received corticosteroids and 1 received azathioprine. These PE were carried out during the ten first days. They were then repeated according to the clinical evolution. Twenty six courses have been performed for 21 patients. After PE, all patients received prednisone 1 mg/kg/24 h and azathioprine 2 mg/kg/24 h. Clinical improvement has been appreciated from vital capacity, swallowing and muscular strenght.After one course of PE, 18 patients were improved. Four patients relapsed and 2 of them were improved after a second course. One patient was improved only after a third course. Some complications were observed: 4 fever episodes, 2 deep vein thrombosis, 2 hypotension and bradycardia.The patients have been followed up after the PE periodes for a mean period of ten months. The long term results are: 4 complete remissions, 12 improvements, 2 steady states, 3 deaths (2 after intercurrent disease).PE associated with immunosuppressive therapy is valuable for the treatment of acute relapse of MG. The assessment of long term benefits need further studies.     

Benefits of Ophdiat, a telemedical network to screen for diabetic retinopathy: A retrospective study in five reference hospital centres

AimOne objective of Ophdiat^®, a telemedical network using digital non-mydriatic cameras in Île-de-France, is to develop a comprehensive screening programme that provides access to annual fundus examinations to all diabetic patients. The aim of this study was to evaluate the benefits of this programme in a hospital setting.MethodsA retrospective analysis of 500 case reports of diabetic patients hospitalized before and after Ophdiat^® setup was performed in five reference hospital centres. At each centre, 100 case reports (50 before, 50 after) of patients aged greater than 18 years, hospitalized for their annual check-up, with no known diabetic retinopathy (DR) before hospitalization and with the last fundus examination performed greater than 11 months previously, were randomly selected. The primary endpoint was the proportion of patients whose fundus examinations were performed during hospitalization; secondary endpoints were the number of cases of DR found and the time taken by ophthalmologists to make the diagnosis.ResultsThe mean proportion of patients with fundus examinations was 50.4% and 72.4% before and after, respectively, Ophdiat^® (P < 0.01). The prevalence of DR was 11.1% before and 12.7% after (not significant). The mean time taken by an ophthalmologist per diagnosis of DR was 0.90 half-day before and 0.32 half-day after Ophdiat^®.ConclusionThis evaluation shows that Ophdiat^®, combined with the availability of modern and effective devices, has improved DR screening in diabetology departments in hospitals. Additional human resources would certainly ensure more effective use of the system.     

OPHDIAT: quality-assurance programme plan and performance of the network

AIMS: There is a need for evaluation of screening and grading services for diabetic retinopathy (DR) in compliance with quality-assurance (QA) standards. We describe the screening/grading QA programme set up for OPHDIAT over the 2005-2006 period. METHODS: Screening and grading objectives, evaluation criteria and minimum acceptable QA standards were set. To ensure the quality of DR photos, the proportion of nongradable photos in at least one eye had to be less than 10%. To ensure grading accuracy, intergrading agreement had to be greater than 90%. Grader-generated reports had to be available in less than 48 h for more than 80% photos. Readers had to grade 500 to 3000 photos per year. RESULTS: Sixteen screening centres were opened between June 2004 and December 2006, and 14,769 patients were screened. Percentages of nongradable photos were consistently below the QA requirement (less than 10%). Overall, 800 photos were graded a second time by a reader blinded to original grading; agreement between graders ranged from 92 to 99%. More than 90% of grader-generated reports were produced within 48 h. The number of readings by each grader nearly achieved the QA standard. CONCLUSION: QA for DR telescreening should be a continuous process to provide performance feedback, thus guaranteeing a high standard for delivered results. Almost all of the predetermined QA standards in OPHDIAT for screening and grading were met. Besides the quality/sensitivity of the screening/grading modalities, it is important to evaluate at-risk patients so that they can be treated efficiently; this should be addressed in a global QA programme.