Pregnancy in women diagnosed with systemic sclerosis is an infrequent situation with a generally favourable outcome according to the most recent studies. Women with systemic sclerosis who wish to become pregnant should obtain preconception counselling in order to withdraw teratogenic drugs and to carefully assess the disease activity. Severe organ impairment, early diffuse systemic sclerosis and pulmonary hypertension ought to discourage patients from pregnancy, as these situations are at high risk of complications for both mother and fetus during pregnancy and puerperium. During pregnancy, the most frequent maternal complication is worsening of gastroesophageal reflux, and the most severe complications are renal crisis and flaring arterial pulmonary hypertension. Angiotensin converting enzyme inhibitors are indicated at any stage of the pregnancy if renal crisis is suspected. Adverse obstetric outcomes are dominated by prematurity which may be the consequence of intra-uterine growth restriction or preeclampsia. Those complications might account for systemic sclerosis-associated vasculopathy, or for the presence of antiphospholipid antibodies. Patients with a previous history of placental insufficiency might benefit from treatment with aspirin, low dose anticoagulants or even nitric oxide donors. During the pregnancy, abnormal bilateral uterine artery Doppler is a predictor of vascular insufficiency and might guide initiation of further preventive treatments. Multicentric prospective cohort studies are warranted to identify more precisely the predictors of pregnancy-related complications and to define the best management of these patients. (C) 2010 Societe nationale francaise de medecine interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.
Placental vascular diseases consist of obstetrical pathologies assumed to be linked to placental ischemia. Preeclampsia, defined as the association of hypertension, proteinuria and edema, occur in 3% of deliveries, in a non-selected population. Eclampsia, defined as the occurrence of convulsions in preeclamptic women, occur in 5 per 10,000 deliveries. Risk factors for preeclampsia are: preeclampsia in the previous pregnancy, maternal age <20 years, multiple pregnancies, and nulliparity. Placenta abruption, defined as premature separation of the placenta before delivery, occur in 5 to 15 per 1,000 deliveries. Risk factors are smoking, infertility, and preeclampsia or placental abruption in the previous pregnancy. Stillbirth, defined as fetal death between 24 weeks of gestation and delivery, occur in 1.5 per 1,000 deliveries, with a higher frequency in case of placental abruption, intrauterine growth restriction or preeclampsia.
Evidence is to date accumulating to suggest that the nucleosome, the fundamental unit of chromatin and ubiquitous product of cell apoptosis, plays a key role in the pathogeny of systemic lupus erythematosus (SLE). Nucleosomes play a central role in the antinuclear antibody response in SLE. Lupus anti-dsDNA and antihistone antibodies are directed towards nucleosomes and belong together with nucleosome-specific antibodies to a broad anti-nucleosome antibody family. Besides anti-dsDNA, nucleosome-specific antibodies have a major role in the pathophysiology of SLE and emphazise the role of nucleosome-antinucleosome immune complexes. Antinucleosome IgG antibodies are a more sensitive marker of SLE than anti-dsDNA. High levels of antinucleosome IgG are almost exclusively found in SLE. Antinucleosome IgG3 are strongly correlated with the SLE disease activity index. Nucleosome can bind to the surface of several cell types and mediate the binding of antinucleosome antibodies. Understanding of the key role of the nucleosome has opened new therapeutic intervention in SLE, such a tolerance induction to the subnucleosomal particles.
Women who were referred with an eating disorder (ED) were compared with a matched normal control group to answer the following questions: What are the frequencies of anxiety disorders in cases of anorexia and bulimia nervosa diagnosed according to DSM-IV criteria? Are anxiety disorders significantly more frequent among women with an eating disorder than among women from the community? We assessed the frequencies of six specific anxiety disorders among 271 women with a current diagnosis of anorexia or bulimia nervosa and 271 controls, using the Mini-International Neuropsychiatric Interview, French DSM-IV version. A lifetime comorbidity with at least one anxiety disorder was found in 71% of both the anorexic and the bulimic subjects, significantly higher than the percentage of controls with an anxiety disorder. The prevalence was significantly higher in the eating disorder groups than in controls for most types of anxiety disorder, and between 41.8 and 53.3% of comorbid cases had an anxiety disorder preceding the onset of the eating disorder. Anxiety disorders are significantly more frequent in subjects with eating disorders than in volunteers from the community, a finding that has important etiological and therapeutic implications.
L'objectif de notre enquete etait double : evaluer la prevalence de la douleur chez l'ensemble des patients d'un meme hopital et rechercher des discordances entre les evaluations faites par les patients, les soignants et les medecins. Cette enquete transversale utilisait trois questionnaires. Ceux destines aux patients et aux medecins portaient sur les multiples aspects de la douleur et de sa prise en charge. Le questionnaire a l'intention des soignants etait l'echelle Doloplus-2. Les trois evaluations etaient jugees concordantes si elles evaluaient de facon homogene un patient comme douloureux ou comme non douloureux. Tous les patients presents (447 patients) ont ete inclus. La prevalence de la douleur est de 57 % pour les soignants et de 53 % pour les medecins. Parmi les patients inclus, 366 sont communicants et acceptent de realiser leur auto-evaluation (82 %) : 66 % d'entre eux s'evaluent douloureux. Les localisations douloureuses principalement citees par les patients et par les medecins sont les membres inferieurs. Les patients s'evaluent dans des niveaux d'intensite plus forts que les medecins. D'autre part, 88 % des malades douloureux recoivent des therapeutiques antalgiques : malgre cela, les patients ne s'estiment pris en charge sur le plan antalgique que pour la moitie de leurs localisations douloureuses ; ils jugent l'efficacite de leur prise en charge antalgique moins favorablement que les medecins. Notre etude montre qu'un grand nombre des patients de Psychiatrie se declare douloureux. Nous retiendrons que le croisement des trois evaluations ne montre une concordance totale qu'une fois sur deux et que plus d'un patient douloureux sur dix n'est reconnu ni par les soignants ni par le medecin.
Cluster headache is characterized by recurrent unilateral attacks of headache of great intensity and brief duration (15180 minutes), accompanied by local signs and symptoms of autonomic dysfunction including conjunctival injection, lacrimation, nasal congestion, rhinnorrhea, forehead and facial sweating, miosis, ptosis or eyelid edema. Attacks occur in so-called cluster periods lasting for weeks or months. About 10% of patients have chronic symptoms with no period of remission. There are only two abortive treatments with proven efficacy: subcutaneous sumatriptan and nasal oxygen inhalation. Prophylactic treatment is often needed to reduce the daily frequency of attacks: verapamil in episodic cluster headache and lithium in chronic cluster headache.
UNLABELLED:The paper presents the health hazards of the major doping substances and raises some questions about the relationship between doping and addictive behavior.AIMS:Current definitions of doping and addictive behavior are examined. The paper's goal is: 1- to assess the risks of neurotoxicity and overall toxicity of doping substances: stimulants, narcotics (seldom used as doping substances), and hormones, and assess their addictive potential; 2- to present available data on drug-dependent patients with a record of early prolonged and intensive physical activity or athletic practice.RESULTS AND DISCUSSION:Some doping substances present high risks for health at large doses, but usually low addictive potential and neurotoxicity. Dependency on doping substances and drift towards dependency to addictive drugs, if any, are therefore determined by genetic and environmental factors. A significant susceptibility to drug dependence has been observed in some cases of very intensive and competitive practice. Over-representation of intensive and competitive athletic antecedents among some drug-dependent patients could be accounted for in either of two ways. On the first account, the causal factor is a sensation-seeking character trait, with a likely genetic component, which predisposes the individual to the use of drugs or doping substances, as the opportunities arise. On the second account, the sudden interruption of intensive practice, and of the associated organic stress and hypersensitization of the hedonic pathway, creates a weaning syndrome and leads to the search for relief through drugs. Further exploration of this hypothesis is called for.
A traumatic event (assault, traffic accident, bomb attack or war, disasters.) is often followed by a reaction of fear and anxiety which can evolve to a posttraumatic stress disorder (PTSD). Its severity and associated handicap justify treatment as early as possible. We present the various PTSD treatments and discuss their respective efficiency and limitations. Most of available treatments (cognitive and behavioral therapies, antidepressants.) are efficient on PTSD and co-morbid disorders. However, the efficiency of some therapies (eye movement desensitization) on the treatment of PTSD are controversial. Studies are necessary to evaluate various treatment strategies, optimal duration of antidepressant treatment and pediatric therapies.
We report two cases of constrictive pericarditis revealing neoplasia. Both patients underwent pericardiotomy with drainage and biopsy that did not disclose malignancy. Likewise, the initial radiologic were not suggestive of cancer.
The objective of this retrospective study was to describe drug maintenance treatments (DMT) in ambulatory care, and to evaluate their impact on social life. A convenience sample of 665 patients on DMT was recruited by 94 general practitioners in three geographic areas (Ile-de-France, Alsace, Aquitaine), and interviewed face to face by independent staff with a standardized questionnaire on three periods (one month before DMT, 6 months after beginning of DMT and 1 month before inclusion within the survey). Among the 665 patients, 76% were on buprenorphine, 20% on methadone, and 4% on morphine sulfate. Consumption of heroin and other psychoactive drugs was lower 6 months after DMT initiation. Patients were more likely to have relationships with people who did not have any problem with alcohol and drugs after DMT initiation than before treatment. They were also more likely to spend their free time alone after having begun DMT than before. All markers of social vulnerability evaluated through standardized questionnaires (employment, housing, social insurance, days of in-patient treatment related to drug consumption and number of condemnations) were improved after a six-month period with DMT. This research contributes to demonstrating the positive impact of DMT both on drug consumption and social life. Health professionals should include social support in their clinical practice.
We report a case of non-metastatic superior sagittal sinus thrombosis complicating a Burkitt's lymphoma of the small bowel, and review similar cases of this cerebrovascular disorder associated with lymphoma.
Takayasu's arteritis and Crohn's colitis are exceptionally associated and characteristics of patients affected with both diseases have not been fully described. In a group of 44 consecutive Takayasu patients, 4 also had Crohn's disease. This 9% prevalence (95% confidence interval=2.5-21.7%) of Crohn's disease in the group is significantly greater than the highest reported prevalence of the disease in the general population. In these 4 patients, fulfilling 5 or more ACR criteria for Takayasu's disease, Crohn's disease was confirmed with colonoscopic examination and biopsies. Takayasu-Crohn patients were younger at diagnosis and tended to have systemic symptoms more frequently. Other clinical, radiological and biological characteristics were not different between the 2 groups. In the literature, 16 cases of this unusual association have been reported. The diagnosis of Takayasu's disease was simultaneous or posterior to Crohn's disease in 87%. Data on vascular lesions was available in 6 out of 16 patients and in the 4 patients of the present study: the distribution of vascular lesions in Takayasu-Crohn patients did not appear to be different from Takayasu patients. Our results and previous reports suggest that this association of rare diseases is not fortuitous. With respect to the indolent course of Takayasu's arteritis, early diagnosis of vascular lesions in Crohn patients is encouraged.
Sjogren's syndrome (SS) is an excellent model for understanding the pathophysiology of autoimmune diseases and the relationships between autoimmunity and lymphoma. Recently discovered new elements probably play a role in the pathogenesis of this multifactorial disease: genetic predisposition remains largely unknown, but there is a link between certain HLA molecules and the type of autoantibodies secreted; sometimes called autoimmune epithelitis, SS is associated with abnormal apoptosis activity in epithelial cells leading to an abnormal accumulation of degradation products of the cytoskeleton proteins such as alpha- and beta-fordrine and also to the presentation of numerous antinuclear autoantigens to the immune system; significant polyclonal activation of B lymphocytes is probably mediated, at least in part, by a major increase in molecules of the TNF family (e.g. BlyS or BAFF) which play an important role in the production of autoantibodies; cytokine inhibition of healthy glands or anti-muscarin receptor antibodies and abnormal function of certain water pumps such as aquaporine could explain the perturbed function of the remaining healthy glands; permanent stimulation of autoreactive B cells favors oncogenic events and could lead to the develoment of B lymphoma with autoantibody activity. The links between these different elements are progressively falling into place. A better understanding of the pathophysiology of SS can be expected to lead to the development of much needed new therapeutic tools.
Immunoglobulin D (IgD) multiple myeloma is rare, accounting for less than 2% of all patients with multiple myeloma. The main presenting features are bone pain in 70% of patients. Extramedullary involvement is less common. We report a case of Ig D lambda multiple myeloma in a 74-year-old man that was revealed by pleural effusion and dyspnea. This effusion was found to be caused by multiple myeloma after electrophoretic and cytologic assays. The patient received a course of chemotherapy with melphalan and prednisone. The patient died one month later with signs of septic shock. Pleural effusion as a first sign of Ig D multiple myeloma is rarely described and the prognosis associated with such a localisation is very poor.
We reviewed the literature on the psychological aspects of MDMA consumption. The present paper examined the characteristics, psychological and psychopathological consequences of synthetic drug use (MDMA). The most frequent features are depression, anxiety, cognitive disorders and sensation seeking. Longer-term, higher dosage, and use of other substances are correlated with higher risk of developing psychopathological disorders. Care should be taken in cross-sectional studies in interpreting signs and symptoms of mental disorder merely as a consequence of MDMA use, because the use of ecstasy may be associated with use of multiple substances from which the mental disorder might be more likely to precede. The consumption pattern of ecstasy and related substances must be carefully analyzed. Knowledge of the MDMA consumption profile is an important for understanding the psychological characteristics of synthetic drug users.
The paper presents the health hazards of the major doping substances and raises some questions about the relationship between doping and addictive behavior. Aims. - Current definitions of doping and addictive behavior are examined. The paper's goal is: 1- to assess the risks of neurotoxicity and overall toxicity of doping substances: stimulants, narcotics (seldom used as doping substances), and hormones, and assess their addictive potential; 2- to present available data on drug-dependent patients with a record of early prolonged and intensive physical activity or athletic practice. Results and discussion. - Some doping substances present high risks for health at large doses, but usually low addictive potential and neurotoxicity. Dependency on doping substances and drift towards dependency to addictive drugs, if any, are therefore determined by genetic and environmental factors. A significant susceptibility to drug dependence has been observed in some cases of very intensive and competitive practice. Over-representation of intensive and competitive athletic antecedents among some drug-dependent patients could be accounted for in either of two ways. On the first account, the causal factor is a sensation-seeking character trait, with a likely genetic component, which predisposes the individual to the use of drugs or doping substances, as the opportunities arise. On the second account, the sudden interruption of intensive practice, and of the associated organic stress and hypersensitization of the hedonic pathway, creates a weaning syndrome and leads to the search for relief through drugs. Further exploration of this hypothesis is called for.
