La prescription des bêtabloquants (BB) reste insuffisante malgré, en particulier, les recommandations pour le traitement de l'insuffisance cardiaque chronique. Les patients atteints d'une ...bronchopneumopathie obstructive (BPCO) ou de troubles ventilatoires obstructifs sont plus particulièrement affectés par cette faible prescription de BB malgré un fort niveau de preuve en termes de morbidité et de mortalité. Il existe pourtant des données nombreuses laissant présumer de leur sécurité d'emploi même en présence de cette contre-indication relative que constituent les BPCO. Nous proposons donc, une revue de la littérature existante dans le contexte de l'insuffisance cardiaque, des cardiopathies ischémiques et de l'hypertension artérielle pour ensuite proposer une démarche permettant un emploi plus large et rassurant des BB en milieu cardiologique.
The beta-blocker (BB) prescription remains insufficient despite guidelines, especially, for chronic heart failure. Patients suffering chronic obstructive pulmonary disease (COPD) are particularly less treated by BB. The level of evidence for BB prescription is however especially high and as we will focus on, the level of evidence for the safety of BB in the COPD context is convincing enough. We, thus, propose to review the existing literature in regard to this prescription of BB in the chronic heart failure, in the coronary artery disease and for high blood pressure in COPD patients. We then propose our approach to improve the level of prescription of BB in COPD patient really justifying this prescription in cardiology.
After stopping a 3 to 6 months course of oral anticoagulation for a first episode of idiopathic venous thromboembolism (VTE), the risk of recurrent VTE is high (10% per year). In this setting, ...international guidelines recommend at least 6 months treatment. However, this recommendation is not satisfactory for the following reasons: (1) no randomized trial has compared 6 months to extended duration (2 years) anticoagulation; and (2), even though the frequency of recurrent VTE is similar after pulmonary embolism (PE) and deep vein thrombosis (DVT), the fatality rate of recurrent VTE after PE is higher than that after DVT.
A French multicentre double blind randomized trial. The main objective is to demonstrate, after a first episode of symptomatic idiopathic PE treated for 6 months using a vitamin K antagonist, that extended anticoagulation for 18 months (INR between 2 and 3) is associated with an increased benefit / risk ratio (recurrent VTE and severe anticoagulant-related bleeding) compared to placebo. The double blind evaluation is ensured using by active warfarin and placebo, and blinded INR. The protocol was approved by the ethics board of the Brest Hospital on the 7th of March 2006. For an alpha risk of 5% and a beta risk of 20%, the estimated sample size is 374 patients.
This study has the potential to: (1) demonstrate that the benefit / risk ratio of extended anticoagulation for 18 months is higher than that observed with placebo in patients with a first episode of idiopathic PE initially treated for 6 months, during and after the treatment period; and (2) to validate or invalidate the contribution of isotope lung scans, lower limb Doppler ultrasound and D-Dimer at 6 months of treatment as predictors of recurrent VTE (medico-economic analysis included).
Locoregional progression of esophageal cancer can result in respiratory distress aving to tracheoesophageal (T-E) fistula or central airways stenosis. We report our experience of airway stenting in ...51 patients with esophageal carcinoma involving the central airways.
All data were recorded retrospectively. Fifty-one patients (44 men and seven women), with a mean age of 58.6 years, were analyzed. All had an esophageal squamous cell carcinoma. Severe respiratory impairment due to tumor invasion or to a tracheobronchial fistula (n= 14) was present in all patients. Nine of the 14 patients with fistula had dysphagia. Among the 37 patients without fistula, 19 had dysphagia.
Sixty-six tracheobronchial stents were inserted in 51 patients: 65 Dumon stents and one Wallstent. Forty stents were implanted in the trachea, 16 in the left main bronchus and 10 in the right main bronchus. In 47 patients there was a significant improvement of respiratory symptoms. Esophageal intubation, carried out in nine patients, allowed eating and drinking in all cases. Mean survival was 107.7 days, with the longest follow-up 587 days. There was no difference between mean survival in the patients with fistulae (103.3+/-days) and the others (109.3+/-days). In two cases stent placement was responsible for death (massive hemoptysis and pneumonia). The main complications were migration (n=6), granuloma (n=2), pneumonia (n=2) and pneumothorax (n = 2). In 13 patients tumor progression in the airways was noted from one to 11 months after stenting, inducing a relapse of dyspnea.
Complications are easily detected by the appearance of respiratory symptoms and do not necessitate systematic flexible bronchoscopy, but only preventive measures such as regular aerosol therapy, adapted respiratory physiotherapy and regular clinical follow-up.
Among embryonic aortic vascular malformations, persistence of a right aortic arch and aberrant left subclavian artery associated with a diverticulum of Kommerell is rare, and is estimated to occur in ...0.1% of the general population. We report two cases of diverticulum of Kommerell in which tracheal compression due to the vascular ring induced respiratory symptoms such as asthmatic dyspnoea. This reminds us that at least a chest X-ray should be performed in newly diagnosed asthmatic patients, focusing on the trachea and upper mediastinum. In case of vascular abnormality, angiography and magnetic resonance are the best investigations to define the abnormal anatomy and guide surgery.
We report a case of idiopathic aneurysm of the azygos vein associated with lung cancer. This abnormality is exceptional because we could find only 8 previous published cases. Computed tomographic ...scan and especially transesophageal echography were of major importance in identifying the vascular nature of the radiographic abnormality and thus excluding extension of lung cancer.
Étudier la fréquence d’un facteur d’immunodépression chez des patients ayant une tuberculose, et les différences de présentation et de prise en charge diagnostique et thérapeutique selon le statut ...immunitaire.
Étude rétrospective des dossiers des patients hospitalisés au CHU de Rennes en 1998 pour une infection à
Mycobacterium tuberculosis. Comparaison de deux populations, immunodéprimés
versus non immunodéprimés.
Soixante-quinze patients âgés de 20 à 91 ans ont été inclus, 41 patients ont été considérés immunodéprimés et 34 non immunodéprimés. Les causes d’immunodépression étaient : infection par le VIH (n = 2), diabète (n = 4), alcoolisme chronique (n = 12), pathologies respiratoires chroniques sous corticoïdes (n = 6), néoplasie (n = 9), maladies inflammatoires (n = 7).
Les comparaisons entre les 2 populations ont mis en évidence chez les immunodéprimés un antécédent de tuberculose plus fréquent (p = 0,04), un délai diagnostique plus court (p = 0,04), une plus grande fréquence de formes disséminées (p = 0,02) et une mortalité plus importante (p = 0,01). Il n’y avait pas de différence entre les 2 populations en ce qui concerne les signes d’appel cliniques ayant fait évoquer une tuberculose, le mode de diagnostic, les résultats bactériologiques ou les modalités thérapeutiques.
La réactivation fréquente d’une tuberculose chez les patients immunodéprimés et la gravité de l’infection chez ces patients doivent inciter à évoquer la tuberculose et à débuter rapidement un traitement efficace chez ces patients. La réalisation d’un traitement prophylactique en cas d’altération des défenses immunitaires devrait permettre de diminuer le nombre de réactivation de ces tuberculoses.
To study the frequency of a factor of immunodepression in patients with tuberculosis, the differences in presentation, and the diagnosis and therapeutic management according to the immune status.
Retrospective study of the files of patients hospitalised in the University Hospital Centre of Rennes in 1998 for a
Mycobacterium tuberculosis infection. Comparison of two populations, immunodepressed
versus non immunodepressed.
75 patients aged 20 to 91 were included, 41 patients were considered immunodepressed and 34 non immunodepressed. The causes of immunodepression were: HIV infection (n=2), diabetes (n=4), chronic alcoholism (n=12), chronic respiratory diseases treated with corticosteroids (n=6), neoplasia (n=9), and inflammatory diseases (n=7). Comparison between the 2 populations revealed more a frequent history of tuberculosis in the immunodepressed (p= 0.04), shorter delay before diagnosis (p=0.04), greater frequency of disseminated forms (p=0.02) and enhanced mortality (p=0.01). There was no difference in the 2 groups with regard to the clinical signs having evoked tuberculosis, the diagnostic method, the bacteriological results or the modalities of treatment.
The frequent reactivation of tuberculosis in immunodepressed patients and the severity of the infection in these patients should evoke tuberculosis and the rapid initiation of an efficient treatment in such patients. In the case of alteration in immune defences, prophylactic treatment should help to reduce the number of such reactivations.
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