La methode mathematique en economie politique

La methode mathematique en economie politique / par Emile Bouvier Paris : Libr. de la Soc. du Recueil Sirey et du Journal du palais, 1901 145 p. ; 26 cm

Imaging in pulmonary hypertension: Focus on the role of echocardiography

SummaryPatients with pulmonary hypertension must be evaluated using a multimodality approach to ensure a correct diagnosis and basal evaluation as well as a prognostic assessment. Beyond the assessment of pulmonary pressures, the echocardiographical examination allows the evaluation of right ventricular adaptation to elevated afterload. Numbers of variables are commonly used in the assessment of the pulmonary hypertension patient in order to detect changes in right heart geometry, right-to-left interaction and right ventricular dysfunction. Whereas an isolated change in one echocardiographical variable is not meaningful, multiple echocardiographical variable modifications together provide accurate information. In this review, we will link pulmonary hypertension pathophysiological changes with echocardiographical indices and describe the clinical implications of echocardiographical findings

0358: Diuretic treatment versus fluid expansion in acute normotensive pulmonary embolism

BackgroundIn submassive pulmonary embolism (PE), when a right ventricular (RV) dysfunction (RVD) is present, the benefit of fluid expansion (FE) is questionable. The Franck-Starling law suggests that the reduction of the RV overload may enhances the RV systolic function.PurposeThe aim of our study was to compare the effects of a diuretic treatment (DT) versus FE in patients hospitalized for normotensive PE with RVD.MethodsWe performed a prospective study. Consecutive patients hospitalized for normotensive PE were treated with diuretic (40mg IV furosemide at admission) or FE (500cc of sodium chloride infusion during four hours at admission). The primary endpoint was the timing for normalization of BNP and troponin Ic values. The secondary endpoints were variations of clinical and RV echographic parameters.ResultsForty five patients were included. Timing for Troponin and BNP normalization was 60,7±28 hours in the DT versus 93,2±42 hours in the FE group (figure 1, p=0.02). Normalization of RV dilatation took 91,7±14,2 hours in the DT group versus 108,4±17,5 hours in the FE group (p=0.01). Normalization of the RVD took 81,2±18 hours in the DT group versus 94,9±13,1 hours in the FE group (p=0.03).ConclusionIn the early management of normotensive PE with RVD, DT may be superior to FE in order to improve the time to normalization of biological and echocardiographic markers.Abstract 0358 – Figure

0337: Prognostic value of reflux of contrast into the inferior vena cava or hepatic veins in pulmonary embolism

BackgroundComputed tomography pulmonary angiography (CTPA) is routinely used to diagnose pulmonary embolism (PE). Reflux of contrast medium into the inferior vena cava or hepatic veins (IVC) on CTPA is a simple sign that could help for PE risk stratification. The purpose of this study was therefore to investigate prognosis significance of contrast reflux into IVC in acute PE.Methods and results141 consecutive patients with acute PE confirmed by CTPA were prospectively included between March 2010 and February 2013. Degree of reflux into the IVC and the hepatic veins was graded from 1 (none) to 6 (severe) by 2 independent observers, blinded to each other. The presence of reflux in IVC was compared with clinical parameters used in the ESC guidelines for PE risk stratification: electrocardiographic signs, Troponine I, BNP and right ventricular dilatation (RV/ LV>0,9) or dysfunction (TAPSE < 17mm, S’<10cm/s) by echocardiography. Composite endpoint was 30-days mortality or clinical deterioration requiring treatment escalation (catecholamine infusion, thrombolytic treatment or cardiopulmonary resuscitation). The composite end-point was observed in 5% of patients with a 30-day mortality rate of 2.1%. Heart rate >110 bpm (OR 5.6, 1.03-30), atrial fibrillation (OR 6.3, 1.05-37.7), negative anterior T waves (OR 6.1, 1.3-29.1), elevated Troponin Ic (OR 5.4, 1.1-25.8), elevated BNP (OR 11.5, 1.3-98.2), right ventricular dysfunction (OR 5.3, 1.1-25.1) were predictors of death or clinical deterioration. Contrast reflux into IVC from grade 4 to 6 was observed in 17% of patients. Interobserver agreement was excellent (Concordance correlation coefficient 0.91). Grade 4 reflux or greater was a strong predictor of events (OR 15.1, 2.8-83.7) and had a 86% specificity and 71% sensitivity to predict adverse outcomes (AUC 0.88).ConclusionA grade 4 or higher contrast reflux into the IVC is a simple and frequent CTPA sign, highly predictive of adverse outcomes in PE patients

Three-dimensional speckle tracking of the right ventricle: implications on survival in pulmonary hypertension

International audienceBackground: Survival in pulmonary hypertension (PH) relates to right ventricular (RV) function. However, the singular anatomy and structure of the right ventricle (RV) limit 2D analysis, and its regional 3D function has not been studied yet.Purpose: We examined the implications of regional 3D RV deformation on clinical condition and survival in adults with PH and healthy.Methods: We performed a prospective longitudinal cohort study recruiting 104 consecutive adult PH patients (58 female, 63±18 years)) and 34 healthy controls (43±14 years) between September 2014 and December 2015. Sixty-four patients (63.4%) were in NYHA functional class ≥III at baseline and 87 (83.7%) were on PH-targeted advanced therapies. 3D transthoracic RV echocardiographic sequences were acquired. Myocardial tracking was performed by a semi-automatic software. Output RV meshes included spatial correspondences. They were post-processed to extract local motion and deformation (area strain) and align the data temporally. Global and local statistics provided representative shape and deformation patterns for each subgroup of subjects.Results: The highest deformation was found in the RV lateral and inferior regions. In PH patients, RV global and regional motion as well as deformation (both area strain, circumferential and longitudinal strain) and global volume patterns were affected in all segments, as compared to healthy controls (p-18% was the most powerful RV function parameter, identifying patients with a 48%-increased risk of death (AUC 0.83 [0.74-0.90], p-18% identifies high-risk PH patients

Speckle-tracking imaging in patients with Eisenmenger syndrome

SummaryBackgroundAdults with Eisenmenger syndrome have a survival advantage over those with idiopathic pulmonary arterial hypertension. Improved survival may result from preservation of right ventricular (RV) function.AimsTo assess left ventricular (LV) and RV remodelling in patients with Eisenmenger syndrome compared to a control population, using speckle-tracking imaging.MethodsAdults with Eisenmenger syndrome and healthy controls were enrolled into this prospective two-centre study. Patients with Eisenmenger syndrome with low acoustic windows, irregular heart rhythm or complex congenital heart disease were excluded. Clinical assessment, B-type natriuretic peptide (BNP), 6-minute walk test and echocardiography (including dedicated views to perform offline two-dimensional-speckle-tracking analysis) were performed on inclusion.ResultsOur patient population (n=37; mean age 42.3±17years) was mostly composed of patients with ventricular septal defect (37.8%) or atrial septal defect (35.1%). Compared with the control population (n=30), patients with Eisenmenger syndrome had reduced global LV longitudinal strain (–17.4±3.5 vs. –22.4±2.3; P<0.001), RV free-wall longitudinal strain (–15.0±4.7 vs. –29.9±6.8; P<0.001) and RV transverse strain (25.8±25.0 vs. 44.5±15.1; P<0.001). Patients with Eisenmenger syndrome also more frequently presented a predominant apical longitudinal and transverse strain profile. Among patients with Eisenmenger syndrome, those with a post-tricuspid shunt presented with reduced global LV longitudinal strain but increased RV transverse strain, compared to patients with pre-tricuspid shunt.ConclusionPatients with Eisenmenger syndrome had impaired longitudinal RV and LV strain, but present a relatively important apical deformation. RV and LV remodelling, as assessed by speckle-tracking imaging, differ between patients with pre- and post-tricuspid shunt

Three-dimensional speckle tracking of the right ventricle : implications on survival

International audienc

Rapport du comité national d'experts sur la mortalité maternelle (CNEMM)

En France, la surveillance de la mortalité maternelle a débuté en 1995 avec le premier « planpérinatalité ».Un Comité national d’experts sur la mortalité maternelle (CNEMM) a été mis en place afind’étudier, par enquête confidentielle, le taux de la mortalité maternelle, ses facteurs de risques etd’évitabilité. Le Comité a également pour mission d’édicter des recommandations auxprofessionnels concernés pour améliorer la situation.En 2001, l’InVS qui a mission de surveiller l’état de santé de la population, est devenu membre dedroit de ce comité.En 2004, la Loi relative à la politique de santé publique a élargi les missions de l’InVS et lui aconfié la responsabilité d’une expérimentation de recueil et d’analyse des événements indésirablesgraves liés aux soins. L’analyse de la mortalité maternelle, qui rentre dans ce cadre a ainsi étéconfiée en 2006 à l’InVS et c’est à ce titre que nous diffusons avec l’Inserm et l’ensemble duCNEMM, les résultats de l’enquête confidentielle concernant la période 1999/2001.Jusqu’alors les travaux du comité étaient fondés sur la base des causes médicales de décèsvalidés par le CépiDC qui est produite avec un certain délai. Ce délai est amplifié par uneprocédure d’enquête rigoureuse mais lourde qui prévoit, pour chaque décès maternel enregistré,que deux assesseurs (un gynécologue-obstétricien et un anesthésiste) se déplacent auprès del’équipe concernée pour recueillir les éléments d’un dossier standardisé important. Ce documentd’enquête revient à l’Inserm qui le rend anonyme et l’adresse au CNEMM, sans possibilité deretour au dossier médical hospitalier. Les experts nationaux analysent chaque dossier et émettentun avis sur la cause de la mort et son évitabilité. L’analyse globale donne lieu à desrecommandations concernant les pratiques.Les résultats présentés concernent les années 1999, 2000 et 2001. Le nombre de mortsmaternelles et le taux d’évitabilité a peu varié par rapport à la période précédente mais l’analysedes causes de décès des facteurs de risques et des pratiques professionnelles est sensiblementdifférente et conforte l’intérêt de poursuivre le travail entrepris depuis dix ans.A la faveur de la certification électronique des causes médicales de décès qui se met en place àpartir de 2007, il sera possible de connaître et d’analyser plus rapidement les décès maternels.C’est pourquoi l’InVS avec le CNEMM et l’Inserm (U149 et CépiDC) se proposent de revoir en2007 le protocole de l’enquête pour en améliorer la réactivité. Les recommandations auxprofessionnels, désormais édictées dans un délai plus court devraient, de ce fait, se révéler plusrapidement opérationnelles