A rare localization in right-sided endocarditis diagnosed by echocardiography: A case report

BACKGROUND: Right-sided endocarditis occurs predominantly in intravenous drug users, patients with pacemakers or central venous lines and with congenital heart diseases. The vast majority of cases involve the tricuspid valve. CASE PRESENTATION: A case of a 31-year-old woman with intravenous drug abuse who had a right-sided vegetation attached to the muscular bundle of the right ventricle is presented. Transthoracic echocardiography revealed a vegetation in the right ventricular outflow tract. Transesophageal echocardiography clearly showed that the 1.8 cm vegetation was not adherent to the pulmonary valve but attached to a muscular bundle. CONCLUSIONS: Our case points to an unusual location of right-sided endocarditis in intravenous drug users. It confirms that TTE remains an easy and highly sensitive first-line examination for the diagnosis of right-sided endocarditis

PLACE DE L'EMBOLISATION DES FISTULES ARTERIO-VEINEUSES HEPATIQUES DANS LE TRAITEMENT DE L'INSUFFISANCE CARDIAQUE PAR HYPERDEBIT AU COURS DE LA MALADIE DE RENDU-OSLER-WEBER

PARIS7-Villemin (751102101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Cinétique des D-dimères au cours de la maladie thromboembolique veineuse (implication dans la stratification du risque de récidive)

Après un premier épisode de thrombose veineuse profonde, le risque de récidive est élevé mais pas inéluctable : 17.5% à 2 ans, 24.6% à 5 ans et 30.3% à 8 ans. En l'absence de marqueur pronostique objectif de récidive, la durée optimale de traitement par anticoagulant, après un premier épisode de TVP idiopathique notamment, chez un patient porteur ou non d'une thrombophilie congénitale, reste encore controversée. Les D-dimères sont des marqueurs biologiques indirects de l'activation de la coagulation, facteur déterminant dans la maladie thromboembolique veineuse. Des études récentes mettent en évidence l'intérêt des D-dimères, sur la base de dosages ponctuels pendant ou après l'arrêt du traitement anticoagulant, pour prédire le risque de récidive thromboembolique veineuse après un premier épisode. Les D-dimères pourraient servir d'outil de stratification du risque individuel de récidive thromboembolique veineuse pour adapter la durée du traitement anticoagulant. Plus que des dosages ponctuels, la cinétique précise des D-dimères, pendant et après arrêt du traitement anticoagulant, devrait permettre de mieux comprendre l'évolution de la coagulation au cours de la maladie thromboembolique veineuse et définir les conditions d'évaluation et la place exacte de ce marqueur biologique à titre pronostique. Dans la littérature, ces évaluations sont très rares. À partir d'une cinétique précise, prospective et prolongée de D-dimères au cours de trois accidents thromboemboliques veineux idiopathiques chez un patient jeune, porteur d'une thrombophilie multiple, nous illustrons ce qu'on peut attendre des D-dimères au titre du pronostique individuel de la maladie thromboembolique veineuse. Les résultats de cette observation unique et d'études récentes devraient inciter à intégrer la surveillance des D-dimères dans le traitement et le suivi de la maladie thromboembolique veineuse. Après un premier épisode de thrombose veineuse profonde, le risque de récidive est élevé mais pas inéluctable : 17.5% à 2 ans, 24.6% à 5 ans et 30.3% à 8 ans. En l'absence de marqueur pronostique objectif de récidive, la durée optimale de traitement par anticoagulant, après un premier épisode de TVP idiopathique notamment, chez un patient porteur ou non d'une thrombophilie congénitale, reste encore controversée. Les D-dimères sont des marqueurs biologiques indirects de l'activation de la coagulation, facteur déterminant dans la maladie thromboembolique veineuse. Des études récentes mettent en évidence l'intérêt des D-dimères, sur la base de dosages ponctuels pendant ou après l'arrêt du traitement anticoagulant, pour prédire le risque de récidive thromboembolique veineuse après un premier épisode. Les D-dimères pourraient servir d'outil de stratification du risque individuel de récidive thromboembolique veineuse pour adapter la durée du traitement anticoagulant. Plus que des dosages ponctuels, la cinétique précise des D-dimères, pendant et après arrêt du traitement anticoagulant, devrait permettre de mieux comprendre l'évolution de la coagulation au cours de la maladie thromboembolique veineuse et définir les conditions d'évaluation et la place exacte de ce marqueur biologique à titre pronostique. Dans la littérature, ces évaluations sont très rares. À partir d'une cinétique précise, prospective et prolongée de D-dimères au cours de trois accidents thromboemboliques veineux idiopathiques chez un patient jeune, porteur d'une thrombophilie multiple, nous illustrons ce qu'on peut attendre des D-dimères au titre du pronostique individuel de la maladie thromboembolique veineuse. Les résultats de cette observation unique et d'études récentes devraient inciter à intégrer la surveillance des D-dimères dans le traitement et le suivi de la maladie thromboembolique veineuseAfter a first episode of deep venous thrombosis (DVT), recurrence is common but not inevitable: 17.5% within two years, 24.6% within five years, and 30.8% within eight years. In the absence of any reliable objective predictive marker for recurrence, the ideal duration of the course of anticoagulant therapy following a first episode of idiopathic DVT (whether or not the patient is congenitally thrombophilic) remains a controversial subject. D-dimers are indirect biological markers for activation of the coagulation factor which is key in DVT. Recent studies have pointed to the value of the D-dimers when measured regularly during and after the withdrawal of anticoagulant therapy after a first episode of DVT: D-dimer testing could be used as a way of assessing the risk of recurrent venous thromboembolism and defining the length of the course of treatment to be administered to a given patient. In addition to isolated quantitative measurements, changes in D-dimer kinetics during and after the withdrawal of anticoagulant therapy should provide information about how coagulation patterns change in venous thromboembolic disease. Such kinetic studies should also make it possible to establish the optimal evaluation conditions and to define the prognostic value of this biological marker. Such evaluations are rare in the literature. On the basis of precise, prospective and prolonged kinetic profiles of D-dimers in the course of three idiopathic venous thromboembolic episodes in a young patient with multiple thrombophilia, we show their potential as a prognostic marker for thromboembolism. The results of this one-off case history, together with those of other recent studies, should lead to the integration of D-dimer monitoring into the surveillance and treatment of venous thromboembolic diseasePARIS12-CRETEIL BU Médecine (940282101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Intensité du traitement anticoagulant dans la prévention secondaire de la maladie thrombo-embolique veineuse (intérêt des D-dimères dans trois cas)

PARIS6-Bibl. St Antoine CHU (751122104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

PAX4 gene variations predispose to ketosis-prone diabetes.

Ketosis-prone diabetes (KPD) is a rare form of type 2 diabetes, mostly observed in subjects of west African origin (west Africans and African-Americans), characterized by fulminant and phasic insulin dependence, but lacking markers of autoimmunity observed in type 1 diabetes. PAX4 is a transcription factor essential for the development of insulin-producing pancreatic beta-cells. Recently, a missense mutation (Arg121Trp) of PAX4 has been implicated in early and insulin deficient type 2 diabetes in Japanese subjects. The phenotype similarities between KPD and Japanese carriers of Arg121Trp have prompted us to investigate the role of PAX4 in KPD. We have screened 101 KPD subjects and we have found a new variant in the PAX4 gene (Arg133Trp), specific to the population of west African ancestry, and which predisposes to KPD under a recessive model. Homozygous Arg133Trp PAX4 carriers were found in 4% of subjects with KPD but not in 355 controls or 147 subjects with common type 2 or type 1 diabetes. In vitro, the Arg133Trp variant showed a decreased transcriptional repression of target gene promoters in an alpha-TC1.6 cell line. In addition, one KPD patient was heterozygous for a rare PAX4 variant (Arg37Trp) that was not found in controls and that showed a more severe biochemical phenotype than Arg133Trp. Clinical investigation of the homozygous Arg133Trp carriers and of the Arg37Trp carrier demonstrated a more severe alteration in insulin secretory reserve, during a glucagon-stimulation test, compared to other KPD subjects. Together these data provide the first evidence that ethnic-specific gene variants may contribute to the predisposition to this particular form of diabetes and suggest that KPD, like maturity onset diabetes of the young, is a rare, phenotypically defined but genetically heterogeneous form of type 2 diabetes

Intentionality in adherence to long-term therapies. Results from an online survey of 3,001 patients with cardio-metabolic pathologies in France

International audiencePurpose: Some patients make a rational choice not to follow medical prescriptions; others fail to take their medications for reasons beyond their control, such as mere forgetfulness or a weak medication routine. The aim of this study was to elucidate the functioning of patient intentionality in medication adherence.Patients and Methods: This online study was conducted in metropolitan France in 2019. A cross-sectional survey of 50 questions was conducted with 3001 respondents diagnosed with diabetes, hypertension, and/or hypercholesterolemia identified from a panel of 54,000 people. These questions included a validated six-item questionnaire to detect nonadherence, two questions to detect intentional nonadherence by patients, and three questions on the effects of habit. Our questionnaire also included questions on the feelings of respondents regarding their doctor’s attitude to their problems and needs, their trust in general practitioners (GP) and specialists, their sense of being involved in treatment decisions, and the influence of side effects and habits on patients’ adherence. This study used the strategy of focusing on strictly adherent patients in the hope of finding ways to improve adherence. For this reason, we defined adherence as the absence of a positive response to the 6-item nonadherence screening questionnaire.Results: Of 3001 respondents, 1804 were diagnosed with hypertension, 1458 with hypercholesterolemia, and 774 with diabetes. Of the total number of patients, 72% were afflicted with one disease, 21% with two ailments, and 7% with three simultaneous illnesses. One-third (33%) of the patients did not tender a positive answer to the adherence questionnaire and were deemed adherent. 1) Thirty-two percent of the patients reported occasionally omitting their medication deliberately, and 84% said they had a reason for missing doses. These statements suggesting intentional nonadherence were negatively associated with adherence as identified via multivariate analysis (P = 0.0012 and P < 0.0001, for the first and second statement, respectively). 2) Univariate analyses revealed strong associations (P < 0.0001) between strict adherence on one hand and lack of intentional nonadherence, patient age, absence of drug side effects, taking drugs by habit, feeling involved in treatment decisions, getting information about treatment, and disease, and trust in doctors, on the other hand. 3) Specifically, univariate analysis of the absence of reported side effects revealed strong associations (P < 0.0001) with adequate information about medicines and diseases and trust in GP. These original data were consistent with the concept of the nocebo effect. 4) We observed a strong association between the absence of intentional nonadherence (statement of never deliberately missing medication) and respondent statements about generally sticking to the routine (P < 0.0001), ie, “I take my medication because I am used to taking it.” This important result suggests that patients are strictly adherent in two ways: the absence of intentional nonadherence and reliance on habit, which we term as “unintentional adherence.” 5) Finally, a multiple correspondence analysis illustrated all statistically significant relationships found in this study.Conclusion: We present a new global model of adherence in which patient adherence was improved both by reducing intentional nonadherence and by promoting the abovementioned unintentional adherence by habit. This model highlights the role of shared decision-making and the trust felt by patients in their doctors. These results could exert a major impact on medical practice and education by demonstrating the importance of physicians’ attitudes, involving the patient in decisions (shared decision-making), offering information about medicines and diseases (patient education), understanding the problems of patients, and taking their needs into account (empathy). The development of these attitudes should be an important aspect of the medical curricula

Early short-course corticosteroids and furosemide combination to treat non-critically ill COVID-19 patients: An observational cohort study

International audienc

Oral corticoid, aspirin, anticoagulant, colchicine, and furosemide to improve the outcome of hospitalized COVID-19 patients - the COCAA-COLA cohort study

International audienc

No VTE Recurrence After 1-Year Follow-Up of Hospitalized Patients With COVID-19 and a VTE Event

International audienc

Early and short-term intensive management after discharge for patients hospitalized with acute heart failure: a randomized study (ECAD-HF)

International audienceAims Hospitalization for acute heart failure (HF) is followed by a vulnerable time with increased risk of readmission or death, thus requiring particular attention after discharge. In this study, we examined the impact of intensive, early follow-up among patients at high readmission risk at discharge after treatment for acute HF. Methods and results Hospitalized acute HF patients were included with at least one of the following: previous acute HF &lt; 6 months, systolic blood pressure &lt;= 110 mmHg, creatininaemia &gt;= 180 mu mol/L, or B-type natriuretic peptide &gt;= 350 pg/mL or N-terminal pro B-type natriuretic peptide &gt;= 2200 pg/mL. Patients were randomized to either optimized care and education with serial consultations with HF specialist and dietician during the first 2-3 weeks, or to standard post-discharge care according to guidelines. The primary endpoint was all-cause death or first unplanned hospitalization during 6-month follow-up. Among 482 randomized patients (median age 77 and median left ventricular ejection fraction 35%), 224 were hospitalized or died. In the intensive group, loop diuretics (46%), beta-blockers (49%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (39%) and mineralocorticoid receptor antagonists (47%) were titrated. No difference was observed between groups for the primary endpoint (hazard ratio 0.97; 95% confidence interval 0.74-1.26), nor for mortality at 6 or 12 months or unplanned HF rehospitalization. Additionally, no difference between groups according to age, previous HF and left ventricular ejection fraction was found. Conclusions In high-risk HF, intensive follow-up early post-discharge did not improve outcomes. This vulnerable post-discharge time requires further studies to clarify useful transitional care services