Service de Medecine Interne

Magenta, France

Service de Medecine Interne

Magenta, France
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Haemoglobin transfusion threshold remains debated with a high variability of practice among physicians. Several well-conducted studies revealed that a liberal transfusion policy is not only unnecessary, but can also prove harmful in certain situations. Blood transfusion is a costly act involving risks of infection, allergic and hemodynamic. Optimizing the use of this scarce and expensive resource becomes necessary. This article summarizes the different transfusion thresholds to respect in hospital clinical practice, based on the latest international recommendations, while emphasizing the importance of clinical judgment in each situation.

Acute bacterial skin infections are very common, with various clinical presentations and severity. This review focuses on deep skin infections, separated into purulent and non-purulent infection as in IDSA recommendation in 2014. Bacterial epidemiology of each infection is detailed for France and included in the context of global antimicrobial resistance. Based on the current bacterial epidemiology in France and IDSA recommendations, this review tends to synthesize the antibiotic strategy in the IBPTM in France in 2017. © 2017 Elsevier Masson SAS

Jarrot P.-A.,Service de Medecine Interne | Jarrot P.-A.,Aix - Marseille University | Kaplanski G.,Service de Medecine Interne | Kaplanski G.,Aix - Marseille University
Mediators of Inflammation | Year: 2014

TNF-α is a pleiotropic cytokine, which plays a major role in the pathogenesis of numerous autoimmune and/or inflammatory systemic diseases. Systemic vasculitis constitutes a group of rare diseases, characterized by inflammation of the arterial or venous vessel wall, causing stenosis and thrombosis. Treatment of the different type of vasculitis mainly relies on steroids and immunosuppressive drugs. In case of refractory or relapsing diseases, however, a second line of treatment may be required. Anti-TNF-α drugs have been used in this setting during the last 15 years with inconsistent results. We reviewed herein the use of anti-TNF-α therapy in different kind of vasculitis and concluded that, except for Behcet's disease, this therapeutic option has not demonstrated significant improvement in the treatment of vasculitis. © 2014 Pierre-André Jarrot and Gilles Kaplanski.

Cerebral venous thrombosis associated with protein S deficiency during early pregnancy remains exceptional. We report the case of Mrs. D., a 20 year-old Senegalese woman with no significant medical history, admitted with left hemiparesis, headache, vomiting. All of this took place in a context marked by early pregnancy (12 weeks of amenorrhoea). The diagnosis of cerebral venous thrombosis was made on the basis of CT brain scan results. Etiological research showed protein S deficiency at a rate of about 40% (60-124), three times over quite considerable time intervals. She was treated with enoxaparin sodium. The clinical and radiological outcome was good following two-year follow-up with a successful outcome of pregnancy and delivery. Cerebral venous thrombosis is very rare during the first month of pregnancy. It requires an exhaustive etiological research and the rapid induction of anticoagulation therapy with low molecular weight heparin. © Maouly Fall et al.

Anaphylaxis is the most severe type of food allergy. Factors of risk are advanced age, cardiopathy, asthma, mastocytosis. Age may be linked to an increased consumption of drugs: aspirin, nonsteroidal anti-inflammatory drugs, beta-blockers, inhibitors of angiotensin converting enzyme (ACE). A case-control study comparing anaphylaxis and mild food allergies has shown a sharp increase of consumption of these drugs in patients with anaphylaxis, with odds ratio respectively of 10.8 [Cl 95%: 3.10-41.3], 8.2 [Cl 95%: 1.37-62.51], 6.8 [Cl 95%: 1.78-27.78] and 13 [Cl 95%: 1.34-310.38]. Besides, exercise potentiates the relative risk of drug consumption. Predominant mechanisms could be an increase of gut permeability enhancing the passage of food allergens in the mucosa and in blood, and the inhibition of ACE, so that the angiotensin homeostatic mechanism deteriorates. Main sites of interference may be endothelium and gut epithelium. Preventive measures excluding the intake of aspirin and nonsteroidal anti-inflammatory drugs before the meals can be recommended for food allergic and food sensitized adults. Treatment of hypertension can address to other families of drugs than ACE inhibitors (ACEI) and beta blockers. The benefit-risk ratio of beta blockers and ACEI has to be carefully considered in the case of cardiopathy.

Godeau B.,Service de Medecine Interne
Seminars in Hematology | Year: 2016

During the last two decades, new therapeutic strategies have been developed, particularly anti-CD20 agents and thrombopoietin-receptor (TPO-r) mimetics, for immune thrombocytopenia (ITP). However, although the new efficient drugs have deeply modified the therapeutic strategy and the disease prognosis, there are still unmet needs and challenges. Concerning rituximab, reassuring data concerning its safety have recently been reported. The main limitation of the treatment is its modest long-term efficacy, with frequent disease relapse. Maintenance treatment or association with other immunomodulatory drugs such as dexamethasone may achieve better long-term response. With failure of one of the available TPO-r agonists (ie, romiplostim and eltrombopag), another can be used. Switching may be beneficial, with more than 50% chance of response, and could limit the risk of platelet fluctuation occasionally observed with these treatments. According to the mechanism of action of TPO-r agonists, a rapid relapse of thrombocytopenia should be observed after they are stopped. Several recent observational studies suggested sustained responses in patients achieving complete response with TPO-r agonists and who stopped the treatments. Prospective studies to confirm these unexpected data are needed. Thrombosis in ITP is a concern, particularly with TPO-r agonists, even though the pivotal studies of eltrombopag and romiplostim did not report a higher incidence of thrombosis events with TPO-r agonists than placebo. Despite these reassuring data, the risk of thrombosis with TPO-r agonists remains unanswered, particularly with secondary ITP or in older adults. © 2016 Elsevier Inc..

This purpose of this study was to determine prevalences and risk factors associated with infection by human immunodeficiency virus, hepatitis B Virus, syphilis and bacillary pulmonary tuberculosis in prisons in Burkina Faso. From February 20 to March 20, 2009, 300 prisoners over 18 years of age held in Ouagadougou were selected to take part in this descriptive and analytical cross-sectional study. Sociodemographic data, confinement information (number, motive and prison time), medical history, substance addiction (alcohol, tobacco, drug), and the other risk behaviors (sexual relations, type of partners, sharing of toiletries or razor) were compiled for each prisoner. Serological tests were performed to detect anti-HIV antibodies, Hbs antigen, and anti-treponema antibody. In prisoners presenting signs of tuberculosis, BAAR detection was performed by direct examination of sputum. Men represented 95% of the study population. Median age was of 30.1 +/- 8.9 years (range, 18 and 63). The prevalences of HIV infection, Hbs antigen and positive syphilitic serology were 5%, 27.3% and 5.7% respectively. Four prisoners (1.3%) had bacillary pulmonary tuberculosis. Two prisoners reported homosexual intercourse and 44 reported drug abuse. Sharing of toiletries and razor blades was reported by 18.7% and 20% of the prisoners respectively. Immediate measures are needed reduce the spread of these infections in prisons in Africa.

Dechartres A.,French Institute of Health and Medical Research | Boutron I.,French Institute of Health and Medical Research | Trinquart L.,French Institute of Health and Medical Research | Charles P.,Service de medecine interne | Ravaud P.,French Institute of Health and Medical Research
Annals of Internal Medicine | Year: 2011

Background: A recent study suggested that results of single-center trials are frequently contradicted when similar trials are performed in multicenter settings. Purpose: To perform a meta-epidemiologic study to evaluate whether estimates of treatment effect differ between single-center and multicenter randomized, controlled trials (RCTs). Data Sources: MEDLINE was searched via PubMed for metaanalyses of RCTs with binary outcomes that were published between August 2008 and January 2009 and in the first 6 months of 2010 in the 10 leading journals of each medical specialty. One issue of the Cochrane Database of Systematic Reviews was also searched. Study Selection: All individual RCTs included in the meta-analyses were selected. Data Extraction: Data were extracted and their quality was assessed by use of the risk of bias tool of the Cochrane Collaboration. Data Synthesis: The primary outcome was the ratio of odds ratios (ROR), used to quantify the difference in estimated intervention effect between single-center and multicenter RCTs. An ROR less than 1 would indicate larger estimates of the intervention effect in single-center trials. Sensitivity analyses were performed with adjustment for sample size, risk of bias within RCTs, and variance of the log odds ratio to take publication bias into account. Forty-eight meta-analyses were selected, including 421 RCTs (223 were singlecenter and 198 were multicenter). Single-center RCTs showed a larger intervention effect than did multicenter RCTs (combined ROR, 0.73 [95% CI, 0.64 to 0.83]), with low heterogeneity across individual meta-analyses (I2 = 12.0%; P = 0.24). Adjustment for sample size yielded consistent results (ROR, 0.85 [CI, 0.74 to 0.97]), as did adjustment for risk of bias within RCTs, such as allocation concealment (ROR, 0.76 [CI, 0.67 to 0.86]), and variance of log odds ratio (ROR, 0.83 [CI, 0.72 to 0.96]). Limitation: Despite sensitivity analyses, meta-confounding cannot be fully excluded. Conclusion: Single-center RCTs showed larger treatment effects than did multicenter RCTs, a finding that was consistent in all sensitivity analyses. These results suggest that this item should be considered when the results of RCTs and meta-analyses are interpreted. Primary Funding Source: Academic grant Recherche sur la Recherche from the Délégation Interrégionale à la Recherche Clinique (DIRC), Ile de France, Assistance Publique-Hôpitaux de Paris (APHP). © 2011 American College of Physicians.

M'Bappe P.,Service de Medecine Interne | Grateau G.,Service de Medecine Interne
Best Practice and Research: Clinical Rheumatology | Year: 2012

Whether it is overload disease or mispleated proteins, amyloid is a great pretender. This is especially true for all of the osteo-articular manifestations of amyloid light chain (AL) amyloidosis, which may mimic rheumatoid arthritis, polymyalgia rheumatica, a myeloma or a bone tumour. To improve the prognosis, AL amyloidosis must be considered in front of atypical osteo-articular manifestations. Amyloidosis Ab2 M of chronic haemodialysis (members' arthropathy and destructive spondylitis) is a specific entity that needs to be differentiated from other osteoarthropathies of chronic renal failure. It has become exceptional since the progress of haemodialysis. Finally transthyretin amyloidosis(ATTR) can be responsible for carpal tunnel syndrome(CTS) in its genetic and senile form. Although amyloidosis is rare, it represents one of the aetiologies of CSC, regardless of its type. In the specific context of haemodialysis, this poses no difficulty for the clinician. Yet AL amyloidosis must be considered more often, as must senile amyloidosis ATTR in the elderly. It seems obvious that the anatomo-pathologic analysis with specific staining with Congo red - see typing - should be systematically performed in the case of surgical neurolysis. Amyloidosis is defined by the extracellular deposit of proteins which share common tinctorial affinities, a fibril aspect under electron microscopy and spatial conformation called beta pleated. Once regarded as a mere overload disease, it is currently considered as a disease of misfolded proteins. Indeed, it is certain that abnormalities of spatial pattern play an essential role in the responsibility for the pathology of many proteins whose amyloid fibre is the final common way. They involve both changes in the conformation of proteins and other major in vivo interactions between amyloid protein and the extracellular matrix. In most cases, amyloidosis represents the bulk of histopathological lesions and its pathogenic role is certain. In other cases, it is only one elementary lesion of the disease and its role is controversial. The amyloidosis responsible for osteo-articular manifestations are the AL immunoglobulin amyloidosis, the beta2-microglobulin amyloidosis in patients under haemodialysis and finally the amyloidosis of transthyretin (genetic and senile). Rheumatological manifestations of immunoglobulin amyloidosis are numerous and often indicative of the disease. Deposits affect joint and periarticular structures. The most common presentation is a progressively developing bilateral symmetric polyarthritis with negative immunology and absent specific structural abnormalities. Carpal tunnel syndrome (CTS) is very common and should suggest the aetiology. Other clinical representations are rarer as an isolated bone tumour (amyloidoma) or integrating systemic AL amyloidosis. β 2-Microglobulin amyloidosis occurs in patients under chronic haemodialysis. It is responsible for CTS, arthralgia and above all a specific destructive spondyloarthropathy. The transthyretin amyloidosis also causes CTS. © 2012 Elsevier Ltd. All rights reserved.

The purpose of this report is to describe the first Cameroonian case of disseminated histoplasmosis due to Histoplasma capsulatum capsulatum in association with HIV infection. The patient was a 34-year-old HIV1 infected woman. Diagnosis of histoplamosis was made in post-mortem. The similarity of the clinical symptoms with disseminated tuberculosis makes diagnosis of mycosis difficult. Active and effective care of histoplasmosis is urgently necessary for the HIV infected persons.

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