Propos: Le but de cette etude prospective etait d'identifier chez des malades âges de plus de 70 ans hospitalises pour une syncope, a partir d'un questionnaire standardise, les signes cliniques permettant de differencier sur les seules donnees de l'anamnese les syncopes d'origine cardiaque ou neurologique. Methodes: 131 malades âges de plus de 70 ans consecutivement hospitalises pour une syncope ont ete inclus. Chaque malade a ete interroge sur ses symptomes presents avant, durant et apres la syncope. Quand cela a ete possible, un temoin (de l'entourage le plus souvent) ayant assiste a la syncope etait interroge pour comparer ses reponses a celles fournies par le malade. Une comparaison statistique des reponses obtenues entre 3 groupes de malades definis par le mecanisme de leur syncope: cause cardiaque, cause neurologique et perte de connaissance inexpliquee apres explorations complementaires appropriees, ainsi qu'une etude de concordance entre les reponses fournies par les malades et leurs temoins a ete realisee. Resultats: Une sensation imminente de perte de connaissance, une oppression thoracique, le souvenir precis des faits avant la perte de connaissance et un antecedent d'arythmie cardiaque etaient independamment et significativement discriminants entre les 3 groupes. Le souvenir des faits precedant la syncope (OR = 7,5; 95 %; intervalle de confiance IC = 2,2 - 25,3) et un antecedent d'arythmie (OR = 4,8; 95 %; IC = 1,.6-14,2) etaient discriminants entre les syncopes d'origine cardiaque et neurologique, tous deux en faveur d'une origine cardiaque. Une concordance entre les reponses des patients et des temoins etait retrouvee pour les questions se rapportant aux antecedents medicaux et aux circonstances de survenue de la syncope. Conclusion: Une memoire precise des faits precedant la syncope et un antecedent d'arythmie sont dans cette etude, en faveur d'une syncope d'origine cardiaque plutot qu'en faveur d'une syncope de cause neurologique. L'interrogatoire des temoins ayant assiste a la syncope du malade n'est pas contributif pour ameliorer la performance de l'anamnese obtenue directement aupres du malade pour envisager la cause ou le mecanisme de sa syncope.

Background Double stenting of oesophagus and airways may be required in palliative treatment of patients with locally advanced oesophageal cancer.Aim To assess feasibility, efficacy and complications occurring in patients with locally advanced oesophageal cancer receiving both oesophagus and airways stenting.Methods In one single centre between 1997 and 2005, among 180 patients with locally advanced oesophageal cancer treated by the palliative placement of a self-expanding metal stent, patients requiring double stenting of oesophagus and airways were identified. Clinical efficacy, complications and survival were retrospectively collected.Results Fifteen patients (8.3% of 180) required a double stenting at follow-up. Symptomatic efficacy of oesophagus and airways stenting was 86.7% for dysphagia and 100% for dyspnoea. Median survival after the second stent insertion was 99 days. Life-threatening early complications occurred in three patients after double stenting (20%), including two deaths following oesophageal perforation and massive haemoptysis, respectively. Procedure-related mortality was 13.3%.Conclusions Double stenting of oesophagus and airways is feasible in patients with locally advanced oesophageal cancer, with a relevant clinical efficacy. However, early major complications including procedure-related death may occur in as many as 20% of patients. This treatment should be reserved to very selected patients with severe symptoms and end-stage disease.

The investigators undertook a randomized trial of magnesium sulfate (MgSO4) in 573 pregnant women at less than 33 weeks’ gestational age who were expected to deliver within 24 hours. They were seen in the years 1997–2003. Participants were randomly assigned to receive either a single 40-mL infusion of a solution containing 0.1 g/mL of MgSO4, totaling 4 g, or an isotonic saline placebo, over 30 minutes. The primary outcomes were neonatal mortality before discharge and neonatal cranial ultrasound findings of severe white matter injury (WMI) as evidenced by cystic periventricular leukomalacia, periventricular parenchymal hemorrhagic involvement defined as a large unilateral parenchymal hyperdensity, or a large single unilateral porencephalic cyst secondary to ischemic-hemorrhagic infarction. The actively treated and control women were similar in most respects. The median gestational age at entry to the trial was 30 weeks. The trial was stopped after 6 years of enrollment when data from 688 infants were available. Rates of total mortality before discharge from hospital, severe WMI, and the combination of these outcomes all were lower in the MgSO4 group, but none of the differences was statistically significant. Overall neonatal mortality approximated 10%. Rates of neonatal death due to respiratory and/or neurological causes were similar for the actively treated women and placebo recipients. When all degrees of WMI were considered, the rate was lower in the MgSO4 group, as was the rate of nonparenchymal hemorrhage. No major adverse effects were noted in the MgSO4-treated women. These findings suggest that MgSO4 infusion has neuroprotective effects when carried out before very preterm birth. Nevertheless, the evidence is not strong enough to recommend widespread use of MgSO4 in clinical practice at the present time. Treatments combining MgSO4 infusion with other neuroprotective measures should be further evaluated for their potential to further lower the risk of WMI and secondary disorders of brain development.

Objective. To assess the 5-yr course of small-bowel motor disorders, using manometry in patients with systemic sclerosis (SSc), and to investigate for an association between small-bowel motor dysfunction outcome and other clinical manifestations of SSc.Methods. Fasting and post-prandial motor activity of the small-bowel was systematically assessed in eight consecutive patients with SSc, using 24 h manometry: initially and at 5-yr follow-up.Results. At 5-yr follow-up, the eight SSc patients (100%) exhibited deterioration of small-bowel motor activity on manometry as follows: (1) more severe abnormalities of migrating motor complex phase III during the fasting period; (2) decreased median duodenal and duodeno-jejunal index during the post-prandial period; and (3) more frequent alterations of small-bowel motor activity in response to octreotide infusion. Furthermore, an association could be found between the deterioration of small-bowel motor function and pitting scars' onset.Conclusion. Our study underscores the rapid deterioration of small-bowel motor impairment in SSc patients (100%). It also highlights the usefulness of small-bowel manometry in symptomatic SSc patients in objectively defining both the characteristics and degree of motor impairment, which may influence the choice of medical treatment in patients, particularly octreotide therapy.

BACKGROUND:It has been suggested that both anticardiolipin (aCL) and anti-beta(2) glycoprotein I (abeta(2)GPI) antibodies may play a critical role in the pathogenesis of systemic sclerosis (SSc)-related vascular impairment.OBJECTIVES:To evaluate the prevalence of aCL and abeta(2)GPI antibodies and lupus-like anticoagulant (LAC) in patients with SSc and healthy controls. We also investigated a possible relationship between clinical and biological variables of patients with SSc and the presence of aCL/abeta(2)GPI antibodies and/or LAC.METHODS:Measurements of aCL and abeta(2)GPI antibodies, and LAC were performed in 69 consecutive patients with SSc and 69 age- and sex-matched controls. Clinical and biological findings were compared between patients with and without antiphospholipid antibodies.RESULTS:aCL and abeta(2)GPI antibodies and/or LAC were detected in 13 (19%) of 69 consecutive patients with SSc; in the healthy control group, aCL antibody was found in only one (2%) subject (P = 0.0007). None of the healthy controls had abeta(2)GPI antibody and/or LAC. Moreover, pitting scars, pulmonary arterial hypertension, macrovascular involvement as well as severity of capillary impairment (using nailfold videocapillaroscopy) were more frequent in SSc patients with aCL/abeta(2)GPI antibodies and/or LAC compared with those without.CONCLUSIONS:Our findings suggest that antiphospholipid antibodies may have a role in the genesis of vascular involvement related to SSc. Finally, the assessment of antiphospholipid antibodies (aCL and abeta(2)GPI antibodies, as well as LAC) may contribute to a better recognition of clinical features in patients with SSc; in essence, the patients with aCL/abeta(2)GPI antibodies and/or LAC may require close monitoring of vascular changes, including in particular pulmonary arterial hypertension and digital infarcts.

Background. Currently, out-patient care is the traditional approach for the management of patients with psoriasis. However, some patients still require hospitalization. The aim of this study was to assess the main reasons for hospitalization of psoriasis patients.Patients and methods. Data are presented from a retrospective study performed in a single centre over a 15-year period (1990-2005). Hospitalizations of psoriasis patients were identified using the coding L 40.X from the CM10 (out-patients were excluded). For each hospitalization, the following details were recorded: age, sex, associated disorders, mean length of stay, number of re-hospitalizations, clinical type of psoriasis (vulgaris, pustular or erythrodermic), onset factors and treatments.Results. one hundred and twenty-two patients corresponding to 211 hospitalizations were included in this study. Two distinct patient populations could be identified. The first consisted of patients with chronic psoriasis vulgaris (143/211 hospitalizations, 67.8%), chiefly male (n=95, sex-ratio=1.98, p=0.001), alcoholic in 47/95 hospitalizations, 49-5% (P=0.004) and requiring frequent re-hospitalization. The second consisted of patients with acute forms of psoriasis, either pustular (38/211 hospitalizations, 18%) or erythrodermic (30/211 hospitalizations, 14.2%). Most of these patients were female (sex-ratio=0.66) and the onset of their psoriasis was sometimes triggered by an infection (7/38 hospitalizations, 18% of psoriasis pustular, p=0.16) or intake ofa new drug (6/30 hospitalizations, 20% of erythrodermic psoriasis, P=0.007).Discussion. Hospitalization in acute care hospitals is not often used in the management of patients with psoriasis. Hospitalizations concern two different populations: the first with chronic psoriasis vulgaris and commonly associated disorders (alcohol abuse), and the second with acute forms of psoriasis, namely pustular and erythrodermic.

BACKGROUND:It has been reported that increased plasma D-dimer is a reliable marker of systemic prothrombotic state in patients with cardiovascular diseases. OBJECTIVES:To evaluate plasma D-dimer concentration in patients with systemic sclerosis (SSc) and healthy controls. We also investigated a possible relationship between the presence of a high plasma D-dimer concentration and clinical and biological parameters in patients with SSc. METHODS:Measurements of plasma D-dimer concentration were performed in 69 consecutive patients with SSc and 69 age- and sex-matched controls. Clinical and biological findings were compared between patients with and without a high concentration of plasma D-dimer (i.e. >or=500 ng mL(-1)). RESULTS:Median plasma D-dimer concentrations appeared significantly increased in patients with SSc compared with control subjects (506 vs. 211 ng mL(-1); P<0.001). Furthermore, a high concentration of plasma D-dimer (>or=500 ng mL(-1)) was detected more frequently in patients with SSc than in healthy controls (47.8% vs. 4.5%; P<0.0001). Among vascular manifestations related to SSc, macrovascular impairment responsible for peripheral ischaemia was more frequent in patients with SSc with high levels of D-dimer (>or=500 ng mL(-1)), compared with those without (21% vs. 6%; P=0.05). CONCLUSIONS:The association between high levels of plasma D-dimer (>or=500 ng mL(-1)) and macrovascular involvement in patients with SSc is likely to be an innovative issue. We suggest that D-dimer levels may be a helpful additional test to identify patients with SSc at risk to develop thrombotic arterial complications (peripheral arterial disease, stroke and coronary event); such patients with high levels of plasma D-dimer (>or=500 ng mL(-1)) may require close monitoring of vascular parameters, including especially macrovascular impairment.

A recent phase I study showed that weekly cisplatin, irinotecan and concurrent radiotherapy can be administered with moderate toxicity in patients with oesophageal cancer. Patients with no prior treatment and oesophageal cancer stage I to III, performance status <3, caloric intake >1500 kcal day−1 were included. Chemotherapy, with cisplatin 30 mg m−2 and irinotecan 60 mg m−2, was administered at days 1, 8, 22, 29, and concurrently with radiotherapy at days 43, 50, 64 and 71. Radiotherapy was delivered with 50 or 50.4 Gy in 25 fractions/5 weeks. Forty-three patients were included, 10 stage I, 19 stage II and 14 stage III. Mean age was 59.2 years (range 44–79). A total of 30 out of 43 (69.8%) patients underwent all planned treatment. During induction chemotherapy, 14 severe toxicities of grade 3 or 4 in 10 patients (23.3%) were reported with 57.1% due to haematoxicity. During chemoradiotherapy, 31 severe toxicities of grade 3 or 4 with 64.5% due to haematotoxicity were reported in 18 patients. One toxic death occurred (diarrhoea grade 4). The complete clinical response rate was 58.1% (95% CI: 43.4–72.8%). Overall survival rate at 1 and 2 years was 62.8%, (95% CI, 58.3–77.3%) and 27.9% (95% CI, 13.4–41.3%), respectively. In conclusion, cisplatin–irinotecan–radiotherapy is an active and well-tolerated regimen feasible in out-patients.

Aim To assess the prevalence of oesophagitis, Barrett's oesophagus ( BE) and other oesophageal mucosal abnormalities in patients with systemic sclerosis (SSc) without prior selection on digestive clinical presentation. We also investigated the association between oesophageal endoscopic and manometric data with clinical manifestations of SSc.Methods Oesophageal endoscopy and manometry were performed in 133 consecutive patients with SSc, receiving proton pump inhibitor (PPI) therapy since SSc diagnosis.Results Endoscopy revealed oesophagitis in 43 patients (32.3%), BE in 9 patients (6.8%), candidiasis in 7 patients (5.3%) and hyperplastic polyp arising in ectopic gastric mucosa in 1 patient. Patients with severe oesophageal motor impairment further exhibited a higher prevalence of interstitial lung disease (ILD) when compared with those without.Conclusion Our study underlines the high frequency of oesophageal mucosal abnormalities in unselected SSc patients receiving long-term PPI therapy. A relationship between oesophagitis/BE and severe manometric motor disturbances was established; these patients may require a higher regimen of PPI. Finally, our series indicates a correlation between severe oesophageal motor disturbances and evidence for ILD in patients, suggesting that gastro-oesophageal reflux may be one of the contributing factors of ILD in SSc; this subgroup of patients may require close monitoring of lung parameters.

OBJECTIVES:To identify signs and symptoms to differentiate cardiac from neurological syncope in patients over 70 using a standardized questionnaire.DESIGN:Prospective cohort study.SETTING:Five short-stay units in a French university hospital.PARTICIPANTS:One hundred thirty-one in-patients with syncope aged 70 and older.MEASUREMENTS:Patients were interviewed about the signs and symptoms that had been present before, during or after syncope. When possible, a witness who had been present during syncope was also interviewed to compare theirs and the patients' answers. The sensitivity and specificity of 35 questions were calculated among 3 groups defined according to the cause of syncope: cardiac (n = 58), neurological (n = 31) and syncope of unknown origin (n = 42). Statistical analyses were performed to determine discriminating signs and symptoms among the causes and crude agreement was calculated for answers from patients and witnesses.RESULTS:Only 8 and 3 of 35 questions had a sensitivity of at least 0.5 for cardiac and neurological causes respectively. A feeling of impending syncope, thoracic oppression, recall of events preceding syncope and a history of arrhythmia were independently and significantly discriminant among groups. Recall of events preceding syncope (Odds Ratio (OR) = 7.5; 95% confidence interval (CI) = 2.2-25.3) and a personal history of arrhythmia (OR = 4.8; 95% CI = 1.6-14.2) were discriminant between cardiac and neurological causes suggesting mostly a cardiac cause. Agreement between patients and witnesses was only found for questions on the patient's medical history or the circumstances surrounding the onset of syncope.CONCLUSIONS:Recall of events preceding syncope and a history of arrhythmia are strongly suggestive of a cardiac rather than a neurological cause of syncope. Interviews of witnesses are not helpful in suggesting a cause for syncope.

Objective: To determine whether severity and organ failure scores over the first 3 days in an ICU predict in-hospital mortality in oncohematological malignancy patients. Design and setting: Retrospective study in a 22-bed medical ICU. Patients: 92 consecutive patients with onco-hematological malignancies including 20 hematopoietic stem cell transplantation (HSCT) patients (11 with allogenic HSCT). Measurements: Simplified Acute Physiology Score (SAPS) II, Organ Dysfunction and/or Infection (ODIN) score, Logistic Organ Dysfunction System (LODS), and Sequential Organ Failure Assessment (SOFA) score were recorded on admission. The change in each score (Delta score) during the first 3 days in the ICU was calculated as follows: severity or organ failure score on day 3 minus severity or organ failure score on day 1, divided by severity or organ failure score on day 1. Results: In-hospital mortality was 58%. Using multivariate analysis in-hospital mortality was predicted by all scores on day 1 and all Delta scores. Areas under the receiver operating characteristics curves were similar for SAPS II (0.78), ODIN (0.78), LODS (0.83), and SOFA (0.78) scores at day 1. They were also similar for Delta SAPS II, Delta ODIN, Delta LODS, and Delta SOFA. Similar results were observed when excluding patients with allogenic HSCT. Conclusion: Severity and three organ failure scores on day 1 and Delta scores perform similarly in predicting in-hospital mortality in ICU onco-hematological malignancy patients but do not predict individual outcome. Decision to admit such patients to the ICU or to forgo life-sustaining therapies should not be based on these scores.

Introduction. - Proton pump inhibitors (PPIs) are an efficient therapy, being widely used by physicians. In 2004, cost of PPIs' therapy was as high as 748 millions of euros (for The Caisse primaire d'Assurance Maladie) in France. Although validated indications of PPIs are well known, numerous un-necessary prescriptions of PPIs are common. The aim of this prospective study was to evaluate PPIs' prescriptions of patients in a department of internal medicine.Patients and methods. - This is a 12-week assessment of medical charts of patients, receiving PPI therapy in patients in our Department of internal medicine. Data were collected by a standardized questionnaire, with regards to: PPIs' nature and regimen, PPIs' indications as well as duration of therapy.Results. - The medical charts of 729 consecutive patients, with a mean age of 67 years, were collected. Two hundred (and) twenty-four patients (30.7%) received PPI therapy; 157 of these patients were given PPI before admission in our department. Omeprazole was used in 71% of patients. Duration of PPI therapy was over one year in 45% of cases. Thirty-five per cent of family physicians' PPI prescription were validated and 23.8% of those of physicians working in the department of internal medicine. The main non-conform PPI's indications, by family physicians and internists were as follows: prevention of hemorrhagic risk of anti-platelet agent (21 vs 16.4%), anticoagulant (17.8 vs 16.4%), steroids (8.3 vs 13.4%) or non-steroid anti-inflammatory therapy without risk factor (1.9 vs 9%). Finally, in patients receiving PPI therapy before admission, this therapy was maintained in 76% of cases.Conclusion. - This prospective study confirms the frequent prescription of PPI therapy in a department of internal medicine (31% of patients). It also underscores the importance of PPIs' use by family physicians and physicians working in a department of internal medicine; this series further highlights the difficulties to interrupt this well tolerated therapy. To date, PPI therapy should be prescribed with a cautious reweighted costibenefit consideration. (c) 2006 Elsevier Masson SAS. Tous droits reserves.

BACKGROUND:Self-expanding metal stents are used routinely to palliate dysphagia due to oesophageal cancer.STUDY AIM:To compare the frequency of life-threatening complications after self-expanding metal stent insertion, depending on whether patients received prior chemoradiotherapy or no treatment.PATIENTS AND METHODS:During 7 years, 116 consecutive patients were treated at a single centre in a palliative intent by insertion of self-expanding metal stent for dysphagia due to an oesophageal cancer. Patients were retrospectively separated into two groups: patients with chemoradiotherapy before self-expanding metal stent insertion (group 1, n = 56) and patients with no treatment before or after self-expanding metal stent insertion (group 2, n = 60). Life-threatening complications were compared and predictive risk factors of postprocedure complications were identified.RESULTS:Median dysphagia was significantly improved during the first month (grade 3 to grade 1 in the two groups). Early and late major complications occurred more frequently in group 1 (23.2% vs. 3.3%; P < 0.002 and 21.6% vs. 5.1%; P < 0.02 respectively). Prior chemoradiotherapy was the only independent predictive factor of postprocedure major complications, with an odds ratio of 5.59 (CI 95% 1.7-18.1).CONCLUSIONS:Life-threatening complications after palliative self-expanding metal stent placement seem to occur more frequently in patients with prior chemoradiotherapy. Prevention of these severe complications should be considered before stenting.