Diagnostic strategies for urinary tract infections in French general practice.

OBJECTIVES: We aimed to describe the diagnostic management procedures for detection of urinary tract infections in general practice and their correlated factors. PATIENTS AND METHODS: We analyzed data from the ECOGEN study on urinary tract infections, collected in France between November 2011 and April 2012. This national cross-sectional study was carried out in general practices. Data was coded according to the International Classification of Primary Care. RESULTS: A total of 340 consultations or home visits were held for urinary tract infections. The five most frequent diagnostic procedures were (in descending order) clinical examination (67.6%), urine cytobacteriological examination (UCBE) (47.9%), urine dipstick test (15.6%), blood test (8.5%), and imaging (6.5%). No urine dipstick test or UCBE was performed in 43% of cases. Factors correlated with diagnostic procedures were age and gender of patients, annual number of consultations held by family physicians, and duration of consultation. CONCLUSION: Family physicians did not comply with guidelines on diagnostic management for detection of urinary tract infections. We hypothesized that this non-compliance could be due to the family physicians' environment and characteristics, and to clinical practice guidelines.

[Endomyocardial biopsy in the monitoring of treatment with anthracyclines. Value of the assay of lactate dehydrogenase and its isoenzymes]. / La biopsie endomyocardique dans la surveillance des traitements par anthracyclines. Intérêt du dosage de la lacticodéshydrogénase et de ses isoenzymes.

Determination of intramyocardial lactate dehydrogenase (LDH) and its isoenzymes (LDH 1 to 5) has been conducted on biopsy material obtained from the right ventricle in 18 patients who had received the theoretical maximal dose of anthracyclines. Total LDH activity, expressed in mU/mg of myocardial protein is higher (852.61 +/- 87.98) than in subjects with good left ventricular function (334 +/- 208), p less than 0.02. The activity of LDH 1 is decreased in the treated group, whereas that of LDH 3,4 and 5 is raised: LDH 1 = 41.95 +/- 7.25 per cent instead of 47.76 +/- 7.93 per cent (p less than 0.03); LDH 3 = 15.34 +/- 5.09 per cent instead of 9.18 +/- 4.56 per cent (p less than 0.05). The H/M ratio (H = fractions of heart isoenzymes; M = fractions of muscle isoenzymes of LDH) is decreased in the treated group: H/M = 4.06 +/- 1.13 instead of 5.30 +/- 1.80 (p less than 0.01). When the histological lesions are minimal (stage 1 or 1.5 of Billingham), the H/M ratio is not altered: 4.92 +/- 1.02. When the lesions attain or exceed stage 2, the H/M ratio is significantly decreased: 3.74 +/- 0.82. These results, which indicate an increase in anaerobic metabolism, add quantitative information to the histological study.

[Hemolysis in patients with heart valve prostheses. Comparison between Björk-Shiley and Saint-Jude Medical valves]. / Hémolyse chez les malades porteurs de prothèse valvulaire cardiaque. Comparaison entre les valves de Björk-Shiley et Saint-Jude Medical.

The problem of haemolysis was studied in 244 patients with one or two prosthetic heart valves: 232 of these patients had normal valve function as assessed by clinical examination, radioscopy and echocardiography; 112 patients had a Bjork-Shiley (BS) prosthesis, 25 in the aortic position (BSA), 71 in the mitral position (BSM) and 16 in both aortic and mitral positions (BSA + M). These patients were operated between July 1979 and January 1981. One hundred and twenty other patients had Saint Jude medical (SJM) prostheses; 48 in the aortic position (SJMA), 44 in the mitral position (SJMM) and 28 in both aortic and mitral positions (SJMM + A). These patients were operated between January 1982 and July 1983. Twelve patients (operated between 1977 and 1984) had prosthetic valve dysfunction confirmed by angiography or anatomically (SJM = 7); BS = 5). The plasma haemoglobin concentration (pHb) was used as the reference: it was measured by spectrophotometry with a sensitivity of 0.5 mg/100 ml. There was no significant difference the SJM and BS groups at surgery (BS: 4.62 mg/100 ml; SJM: 4.31 mg/100 ml). In the absence of prosthetic valve dysfunction, haemolysis was significantly greater (p less than 0.001) in the SJM (8.28 mg/100 ml) than in the BS (3.08 mg/100 ml). No statistical correlation was observed with the severity of cardiac disease, the aortic or mitral position of the prostheses or with the number of prostheses. Haemolysis was subclinical in all cases. When haemodynamically significant prosthetic valve dysfunction was present, haemolysis was inconstant in BS prostheses (2 out of 5 cases) despite major haemodynamic disturbances in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Right intraventricular biopsy. Indications and results. 116 cases]. / Biopsie endoventriculaire droite. Indications et résultats. Cent seize observations.

The indications for endomyocardial biopsy were evaluated from 116 consecutive cases. The diagnostic value of this invasive but well tolerated procedure was in agreement with data from the literature. An accurate diagnosis, unforseeable in 8% of the patients, was established in 12%. The diagnosis of apparently primary myocardiopathy with ventricular dilatation was confirmed in 45 out of 59 cases; there were 3 cases of myocarditis, 3 cases of restrictive cardiopathy (haemochromatosis, fibroplastic endocarditis) and 1 case of hypertrophic cardiopathy. No tissue abnormality was noted in 6 cases. An accurate diagnosis was obtained by biopsy in 1 case of "eosinophilic lung" without overt cardiac involvement. In malignant diseases treated with anthracyclines in doses reaching maximal theoretical total dosage (30 patients), severe tissue lesions were present in 10% of the cases, incipient haemochromatosis in 16.6% and subendocardial fibrosis in 3.3%. However, total doses of up to 600 mg/m2 could be administered to 90% of the patients. Myocardial lesions could be demonstrated in 1 of 2 patients with collagen disease. Endomyocardial biopsy therefore seems to be justified in myocardiopathies with ventricular dilatation, in some collagen diseases with a tendency to cardiac involvement and to monitor treatment with anthracyclines in total doses higher than the theoretical maximum dosage.

[Distribution of lactate dehydrogenase isoenzymes in human myocardium obtained from endomyocardial biopsies]. / Répartition des isoenzymes de la lactico-déshydrogénase du myocarde humain obtenu à partir de biopsies endomyocardiques.

The distribution of lactate dehydrogenase and its isoenzymes in myocardial tissue obtained by biopsies from within the right ventricle can be studied by electrophoresis in a similar manner to that for making serum determinations. Results are comparable to radioimmunologic dosing (Peters) and microelectrophoresis (Schultheiss) and complete the findings obtained from the histological study of biopsied fragments.

[Reinforcement cerclage of dystrophic aortic rings]. / Cerclage de renforcement dans les dystrophies de l'anneau aortique.

Reinforcement of a dystrophic aortic ring with a purse string suture makes it possible to obtain perfect coaptation between prosthesis and ring whilst inducing sclerosis. The technique described here was used by the authors in 30 patients operated upon since June, 1980, and none of these needed reoperation for leakage. These results contrast most favourably with those previously obtained in similar anatomical conditions with conventional prosthesis insertion.

[Histological aspects of congestive cardiomyopathy caused by alcohol. Comparison with so-called primary cardiomyopathies]. / Aspects histologiques de la cardiomyopathie congestive d'origine èthylique. Comparaison avec les cardiomyopathies dites primitives.

The endoventricular biopsies of nine patients with alcoholic congestive cardiomyopathy were studied under the light microscope and under the electron microscope. These were compared with the results of nine cases of primary congestive cardiomyopathy, at a similar clinical stage. In the absence of specific signs, the overall appearance on both light and electron microscopy is sufficiently suggestive to allow differentiation of the two forms of cardiomyopathy. Repeated biopsies revealed disappearance of the nuclear abnormalities after withdrawal of alcohol, which introduces a prognostic element.

[Right endoventricular biopsy using the femoral percutaneous approach: a simple procedure, harmless, reliable and repetitive. Modification of the Konno technic]. / La biopsie endoventriculaire droite par voie percutanée fémorale: un geste simple, anodin, fiable et répétitif. Modification de la technique de Konno.

The technique of right endoventricular biopsy by femoral percutaneous path is described based on 300 incident-free samples. Ability to multiply and then repeat sampling supports a method which can be performed at the same time as examination of the conduction channels. This is of diagnostic, prognostic, therapeutic and research interest.

[Curable asystole in an adult caused by a diffuse and complete arteriovenous aneurysm of the liver. Cure by ligation of the hepatic artery]. / Asystolie curable de l'adulte par anévrysme artérioveineux diffus et total du foie. Guérison par ligature de l'artère hépatique.

A case of cardiac failure in a 54 year old man with a diffuse total arteriovenous aneurysm of the liver is reported. The aneurysm was arteriolarvenous, without a wide bore localised fistula. It occupied the whole hepatic mass, including the territories of the right subphrenic and anterior collateral of the gastroduodenal artery. The cause of cardiac failure was the elevated cardiac output, 15 1/min, which fell to 6 1/min at each peroperative occlusion of the hepatic artery. After ligature of this vessel, the cardiac output stabilised at 9 1/min and remained at this value 4 months after surgical cure. This case is comparable to the neonatal cardiac failure due to multinodular hepatic angioma with respect to the clinical, angiographic and CAT scan characteristics, and the surgical cure of the high cardiac output syndrome. Some of the histological features were suggestive, in places, of the structure of hepatic cavernoma, which makes the exact pathological classification of this diffuse aneurysm difficult; the closest possibility being an involuted from of diffuse capillary hemangioma of childhood allowing such long survival and, occasionally taking on the appearances of a cavernoma. Permanent surgical cure by ligature of the hepatic artery was an additional rare feature of this case.

[Isolated intimal stenosis of the renal artery and curable arterial hypertension in Recklinghausen's disease. Association of hypoplastic stenosis of the aortic and pulmonary trunks and sigmoid aortic regurgitation]. / Sténose intimale isolée d'une artère rénale et hypertension artérielle curable dans la maladie de Recklinghausen.

The case of a patient with Von Recklinghausen's disease with multiple localisations, cardiac, aortic, pulmonary and renal artery is reported. Neurofibromatosis was confirmed by the presence of a "royal" tumour on the left elbow and of many "café au lait" spots of over 15 mm diameter. There was no craniofacial dysmorphism or intellectual impairment. The karyotype was normal. The cardiovascular lesions comprised: - stenosis of the left renal artery resulting in renovascular hypertension. This was due to pure intimal hyperplasia; - supravalvular aortic stenosis with hypoplasia of the ascending aorta. There was no craniofacial dysmorphism or intellectual impairment. The karyotype was normal. The cardiovascular lesions comprised: - stenosis of the left renal artery resulting in renovascular hypertension. This was due to pure intimal hyperplasia; - supravalvular aortic stenosis with hypoplasia of the ascending aorta. There was no craniofacial dysmorphism or intellectual impairment. The karyotype was normal. The cardiovascular lesions comprised: - stenosis of the left renal artery resulting in renovascular hypertension. This was due to pure intimal hyperplasia; - supravalvular aortic stenosis with hypoplasia of the ascending aorta, severe aortic regurgitation with dilatation of the aortic ring without rheumatic valvular thickening; - supra valvular pulmonary stenosis which was atypical in site, extension and in the absence of post stenotic dilatation. The pressure gradient was mild (22 mm Hg). There was a striking similarity between the pulmonary and aortic lesions. This new syndrome may be classified amongst the genetic cardiocutaneous syndromes such as the Gorlin or "leopard" syndrome, Watson's syndrome and Noonan's syndrome. Unusual features are the absence of craniofacial abnormalities, normal intelligence, and the left-sided dominance aggravated by hypertension due to curable intimal stenosis of the renal artery.

[Lymphangioendothelioma. A rare cause of atrioventricular block]. / Lymphangio-endothéliome. Une cause rare de bloc auriculo-ventriculaire.

A new case of lymphangio-endothelioma of the nodal tissue is reported. Complete atrioventricular block had been followed up for 20 years. The histological features are described in detail and the embryological origins of the tumour are discussed. This report underlines the exceptional character of this "smallest benign tumour which can be mortal".

[Automatic activity of the pre-excitation pathways]. / Activité automatique des voies de préexcitation.

The possibility of preexcitation pathways exhibiting automatic activity was demonstrated in 3 cases: in two cases electrophysiological studies supported this diagnosis which was confirmed in the third case by histological examination of the preexcitation pathway. During sinus node dysfunction, spontaneous or induced (by rapid right atrial pacing or by a reciprocating tachycardia), the substitute rhythm arose from the Kent Bundle either transiently or for a longer period: rhythms arising from the Kent Bundle can only be diagnosed after eliminating the possibility of an atrioventricular junctional rhythm conducted to the ventricles by Mahaïm fibres.

[Congenital arteriopathies and Leo Buerger's disease]. / Artériopathies congénitales et maladie de Leo Buerger.

A homogenous series of 7 consecutive cases of Buerger's disease were investigated and the congenital malformations of the upper and lower limb arterial trunks were classified. These malformations constitute the anatomical basis of Buerger's disease and define an autonomous disease entity. Total supra-malleolar interruption of the main lower limb arteries either by triple vessel agenesis or, more rarely, by femoro-popliteal or popliteal and tibio-peronal agenesis was observed. The appearances of the collateral circulation, already established in utero, are characteristic with long axial spiral-shaped arteries and dependant arterioles maintaining a precarious supply to the distal tissues which may be adequate for many years. The nautral history of the disease is directly related to the malformation of the congenital arterial system of the limbs. Proximal arterial malformative occlusion is the cause of early, inevitable trophic lesions; the spiral-shaped arteries and distal arterioles, which represent the maximal embryonic collateral circulation, limit the area of necrosis and favour healing.

[Arterial and renal parenchymal histological data in the areas on polar and truncal arteries in arterial hypertension of adult patients]. / Données histologiques artérielles et parenchymateuses rénales dans les territoires des artères polaires et tronculaires dans l'hypertension artérielle de l'adulte.

The Cardiac Clinic reports its experience of 16 cases having unilateral curative renal surgery for hypertension in the adult, and has found a particularly high incidence (8 per cent of all cases). A study has been made of the lesions in the malformed and dysplastic renal arteries on the one hand, and of the correspondingly ischaemic and atrophic renal parenchyma on the other. Attention is drawn to the cases of unilateral renal atrophy (50 per cent of cases), the commonest involving gross lymphoplasia of congenital arterial origin. The other cases are of stenotic dysplasias, and special points to notice are the spread of the dysplasia towards the parenchyma, the presence of multiple aneurysms which militate towards nephrectomy, and the relative frequency of dysplasia of the intima (2 cases out of 8).

[Congenital defects of the aortic system]. / Artériopathies congénitales du système aortique.

The authors give a basic embriological classification of congenital arterial defects. Congenital abnormalities of the arterial system (arising in an embryo of 12 to 30 mm) affect the primary segments, and comprise excessive involution of the antibrachial trunk, of the popliteal artery, of the tibio-peroneal trunk and peroneal artery, abnormal or persistence of the interosseus artery, of the artery of sciatic nerve, and of the peroneal artery, a high axillary origin of the radial or antecubital artery, renal polar arteries arising directly from the aorta, and agenesis of the palmar or plantar arches. In the second generation arteries, they comprise agenesis or hypogenesis of the radial, antecubital or tibial arteries, and gross hypogenesis of the trunk of the renal artery with an immature kidney. Arrested or mal-development in the foetus can give rise to coarctation and stenosis of the thoracic aorta and large vessels, to segmental agenesis with huge collaterals, to imperforate osita, especially in the mesenteric arteries, to sudden variations in diameter of the renal arteries, and to parietal dyplasia and aneurysms in vessels in the residual undifferentiated mesenchymatous tissue, and diffuse dilatation or stenosis. The authors give their experience for a cardiological clinic, adding arterial hypertension and arterioparenchymatous dysplasia of the kidneys, Raynaud's, Takayasbu's and Burger's disease, and intermittent claudication of the lower limbs; they indicate the areas which they are currently studying.

[Arterial malformations and Takayashu disease]. / Malformations artérielles et maladie de Takayashu.

The authors report a recent series of 5 cases with Takayashu's disease and discuss the common pathological presentation of malformations of the arterial trunk, caused by disorderd development of the arterial system or by later segmental arrested development of the large trunks. The disease, which presents in the young adult as a diffuse inflammatory process, is probably auto-immune, but has its foundations in embryonic and foetal development.

[Pseudotumor of the right atrium caused by hernia of the valve of Vieussens]. / Pseudo-tumeur de l'oreillette droite par hernie de la valvule de Vieussens.

A round swelling was on the substraction films of the right side of the heart taken during angiocardiographic examination of a patient with mitral valve disease; this suggested a mass attached to the inter-atrial septum, and prolapsing into the auricle of the right atrium. Initial diagnsosi was of atrial thrombosis, but this was disproved at operation. An aneurysm of the membrane of the fossa ovalis was found, being caused by overstretching of the auricle of the left atrium under the increased pressure of the valve defect. The aneurysm was resected and the septum simply repositioned as part of the mitral valve replacement. A search of the literature shows how rare this disorder is, and that it should be reclassified with the abnormalities of the inter-atrial septum which are found only rarely in cases of mitral valve disease.