To the Editor: We appreciate the comments of Hiyama and colleagues on our article in CHEST (August 2000).1Boulay F Berthier F Sisteron O et al.Seasonal variation in cryptogenic and noncryptogenic hemoptysis hospitalizations in France.Chest. 2000; 118: 440-444Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar They stated that the percentage of cryptogenic hemoptysis (42%) was particularly high in our study compared with other previously published studies and with their own results (12%). The distribution of causes of hemoptysis differed greatly in different studies,2Hirshberg B Biran I Glazer M et al.Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital.Chest. 1997; 112: 440-444Abstract Full Text Full Text PDF PubMed Scopus (330) Google Scholar depending on geographic setting, time, and design of the study, and patient inclusion (or exclusion) criteria. Hiyama and colleagues studied a clinical series of 51 patients hospitalized for hemoptysis during a 6-year period, with detailed information and prospective follow-up. In contrast, we performed a retrospective epidemiologic study, covering a broad population (6,349 subjects who had, during a 3-year period, received a discharge diagnosis of spontaneous hemoptysis, with less detailed information collected from a large electronic discharge data file. This also explains why we had no information on smoking history or on the amount of expectorated blood. Furthermore, in our study, patients were not selected, and our data file included all kinds of patients, regardless of their age, the completeness of the etiologic investigation, and the amount and/or duration of bleeding. It is possible that a small number of the cases could have been erroneously classified as cryptogenic hemoptysis, but it is noteworthy that, in the study by Adelman et al,3Adelman M Haponik EF Bleecker ER et al.Cryptogenic hemoptysis: clinical features, bronchoscopic findings, and natural history in 67 patients.Ann Intern Med. 1985; 102: 829-834Crossref PubMed Scopus (66) Google Scholar cryptogenic hemoptysis was identified in approximately 30% of all patients. In the second part of their letter, Hiyama and colleagues commented about smoking, but they did not specify whether they considered tobacco an etiologic factor or a triggering factor of cryptogenic hemoptysis. Indeed, as with coronary atherosclerosis,4Goldberg RJ Epidemiologic aspects of circadian patterns of cardiovascular disease and triggers of acute cardiac events.Cardiol Clin. 1996; 14: 175-184Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar tobacco use could, with a long latent period, lead to the creation of an underlying lesion, or it could transform this underlying lesion to clinically detectable bleeding. Due to the small number of patients with cryptogenic hemoptysis (only six patients), any conclusions about the etiologic factors should be drawn very cautiously. Furthermore, among the 51 hospitalized patients described by Hiyama and colleagues, the percentage of patients with hemoptysis who smoked was low, and the status of smokers (history of smoking or current smoking) was not precisely specified. So it is possible that some of the nonsmoking patients may have stopped smoking in reaction to the respiratory disease that caused their hemoptysis (lung cancer, chronic bronchitis, bronchiectasis). An argument for the role of tobacco as a triggering factor of hemoptysis would be that active smoking follows a seasonal pattern identical to cryptogenic hemoptysis. As a matter of fact, in contrast with respiratory infections, seasonal variations have never been described for active smoking. So we agree with Aldelman et al3Adelman M Haponik EF Bleecker ER et al.Cryptogenic hemoptysis: clinical features, bronchoscopic findings, and natural history in 67 patients.Ann Intern Med. 1985; 102: 829-834Crossref PubMed Scopus (66) Google Scholar that the hypothesis of infection is the most likely explanation of the seasonal pattern of cryptogenic hemoptysis. Cryptogenic Hemoptysis and SmokingCHESTVol. 121Issue 4PreviewTo the Editor: Full-Text PDF

OBJECTIVES: The circadian variation in portal blood pressure and in the diurnal incidence of variceal bleeding is well known, but the seasonal variation in variceal bleeding is still controversial. This report analyzes the seasonal variations in mortality and hospitalizations due to variceal bleeding in the French population.METHODS: All the deaths due to variceal bleeding that occurred from 1987 to 1996 (N = 13,514) and all adults discharged from French public hospitals for variceal bleeding from 1995 to 1997 (N = 17,026) were examined retrospectively. Cumulated monthly averages were expressed as the percentage above or below the average monthly value during the entire study period.RESULTS: Deaths due to variceal bleeding in France occurred with a clear annual periodicity and peaked in winter (December/January), both in the overall population and in subgroups defined by age and sex, except for women. The distribution of cumulative monthly deaths differed by 24%, with a peak (14% above average) in December and a trough (10% below average) in July (Roger's test: p < 0.001). Hospitalizations for variceal bleeding in French public hospitals followed a similar seasonal pattern (p < 0.001) with a winter-spring predominance (4% to 7% from December through April), except in patients aged 15-49 yr. There was a short sharp peak of mortality in early winter in French public hospitals. The seasonality of hospitalization and death increased markedly with age.CONCLUSIONS: A better understanding of these age- and sex-specific seasonal patterns would allow to improve pharmacological protection measures, disease management, and educational strategies. (C) 2001 by Am. Cell. of Gastroenterology.

OBJECTIVES:Seasonal and circadian rhythms are observed in cardiovascular diseases. Seasonal variation in acute intestinal vasculopathy has never been investigated. This report describes the seasonal variation of acute intestinal vasculopathy mortality in the French population.METHODS:All deaths that occurred among French adults over the period 1987–1996 (N = 20,830) for acute intestinal vasculopathy (International Classification of Diseases, Ninth Revision code 557.0) were examined retrospectively. Cumulated monthly averages were expressed as the percentage above or below the average monthly value during the entire study period.RESULTS:Deaths for acute intestinal vasculopathy peaked in January (15% above the trend), and were lowest in July (11% below the trend), both in the overall population (Roger's test: p < 0.001) and in subgroups defined by age (>69 yr old) and sex. Compared to other subgroups, the >90 yr old individuals had a higher incidence of acute intestinal vasculopathy with a greater amplitude of seasonal variation (p < 0.001).CONCLUSIONS:Awareness of higher risk during winter would help to reduce the high mortality from acute intestinal vasculopathy. A better understanding of this seasonal pattern would allow practitioners to improve early diagnosis and treatment.

found no difference in the proportion of surgical or nephrology centres that provided skin cancer surveillance, full skin examination, or specific training for clinicians performing surveillance (table), regardless of the size of the unit (data not shown).

STUDY OBJECTIVE:To determine the potential role of seasonality in hospitalizations for cryptogenic and noncryptogenic hemoptysis in the French population.DESIGN:Retrospective analysis of hospital discharge data from a National Register.SETTING:All 29 French university hospitals, between July 1, 1994, and June 30, 1997.PATIENTS:Two thousand six hundred seventy-seven and 3,672 adult hospitalizations for cryptogenic and other hemoptysis, respectively.MEASUREMENTS:Cumulative monthly averages were determined, expressed as the percentage above or below the average monthly value during the entire study period.RESULTS:The distribution of cumulative monthly hospitalizations for cryptogenic hemoptysis peaked in March (32% above the average) and was lowest in summer (30% below the average; p < 0.001). Hospitalizations for noncryptogenic hemoptysis followed a similar seasonal pattern (p < 0. 001). In the 16- to 34-year-old individuals, cryptogenic hemoptysis, compared with noncryptogenic hemoptysis, showed a higher incidence with a larger seasonal amplitude (p < 0.001).CONCLUSIONS:A better understanding of the fundamental pathophysiologic mechanisms underlying this respiratory and hemorrhagic condition may be helpful in developing preventive measures, especially in patients with a risk of recurrence.

BACKGROUND Circannual variation in blood pressure and in the incidence of acute myocardial infarction is well known but has not been investigated in chronic heart failure. This report describes and compares the seasonal variation of chronic heart failure hospitalizations and mortality in the French population. METHODS AND RESULTS All deaths that occurred among French adults over the period 1992 to 1996 (n=138 602) and all discharges by adults in French public hospitals for chronic heart failure over the period 1995 to 1997 (n=324 013) were examined retrospectively. First, chronic heart failure deaths in France occurred with a striking annual periodicity and peaked in winter (December through January), both in the overall population and in subgroups defined by age (>44 years old) and sex. The distribution of cumulative monthly deaths differed by nearly 35%, ranging from a peak of 20% above average in January to 15% below average in August (Roger's test: P<0.001). Second, hospitalizations for chronic heart failure in French public hospitals followed a similar seasonal pattern (P<0.001), with a winter-spring predominance (+7% to +10% from December through April). Third, for persons >/=85 years old, excess hospitalizations occurred earlier in the year, with marked synchronized peaks in January for both mortality and hospitalizations (P<0.001). CONCLUSIONS Clear seasonal variations in adult chronic heart failure hospitalizations and deaths were identified. The considerable economic impact on health care services warrants further epidemiological investigations and a more comprehensive approach to disease management.

The clinical and echocardiographic features of six patients in whom a right atrial thrombus was detected using two-dimensional echocardiography are reported. In four patients with acute cor pulmonale, the thrombus appeared as a coiled mass moving freely within the right atrium and prolapsing through the tricuspid valve. In another patient referred for syncope, a large coiled mass attached to the lateral wall of the right atrium was seen prolapsing regularly through the tricuspid valve, simulating an atrial myxoma. In the remaining patient who presented with chronic cor pulmonale, two-dimensional echocardiography demonstrated a motionless ovoid mass with a broad base of attachment to the interatrial septum.

The clinical and echocardiographic features of right atrial thrombi were examined in 9 patients, 5 men and 4 women aged 16 to 86 years. The 2D echocardiographic diagnosis was confirmed at autopsy (4 cases) or by the association of severe recurrent pulmonary embolism (5 cases). Three patients had associated ischaemic heart disease and on patient had dilated cardiomyopathy. The clinical presentation was: acute cor pulmonale (5 cases including 2 patients which biventricular myocardial infarction), chronic post-embolic cor pulmonale (1 case), tricuspid valve obstruction (1 case), general ill health with pyrexia (1 case) and heparin-induced thrombocytopenia (1 case). Predisposing factors included: absence of anticoagulent therapy (7 cases), previous supraventricular arrhythmias (2 cases) and right ventricular failure (6 cases, including 2 of right ventricular infarction). In 2 patients the thrombi were relatively immobile and had a wide base of implantation on the interatrial septum; in 1 patient, multiple thrombi were observed lining the right heart cavities from the inferior vena cava to the pulmonary infundibulum. In the other 6 patients, the thrombi were very mobile with a visible pedicule of implantation (2 cases) or totally free (4 cases). The variable polylobulated appearances, completely irregular whirling motion and intermittent prolapse into the tricuspid valve were characteristic features of the latter 4 cases. They disappeared spontaneously (2 cases) or after fibrinolytic therapy (2 cases) in under 36 hours. Three patients were operated with one postoperative death. The global hospital mortality was 22%. The present occasional detection of right atrial thrombosis will certainly become more common if patients with pulmonary embolism, right ventricular infarction or deep venous thrombosis are systematically examined by 2D echocardiography in the acute phase of their illness.

A vectorcardiogram (VCG) was recorded in 22 patients in the acute phase of a right ventricular infarct in order to investigate any characteristic signs of this diagnosis. The RV infarct had been proven by at least two investigations: 2D echo, isotopes and right ventricular catheterisation. 17 patients had ST depression in V4R. The QRS complex presented two features: there was a reduced refractory period in every case, associated with septal extension in 3 cases and true posterior infarction in 11 cases, and, in the frontal plane, the QRS which was in clockwise rotation had showed an abnormal left axial lead in 18 cases with a maximal vectorial axis of between - 10 degrees and - 60 degrees. These modifications are similar to those seen in experimental infarcts of the RV. In conclusion, repeated VCGs in the acute phase of inferior infarction should suggest the diagnosis of right ventricular extension if it shows the appearance of more marked left axis deviation than that seen with isolated inferior infarcts. However, this sign is no constant and is not specific.