[Sneddon syndrome with anti-mitochondrial type M5 antibodies]. / Syndrome de Sneddon avec anticorps anti-mitochondries de type M5.

INTRODUCTION: Antimitochondrial type M5 antibodies (AMA-M5) are among the immunological abnormalities associated with Sneddon syndrome. CASE: A 45 year-old woman, hospitalized for diplopia and with a 20-year history of obstetrical accidents, internuclear ophthalmoplegia and livedo, was diagnosed with Sneddon syndrome associated with primary antiphospholipid syndrome (APS) aggravated by the presence of AMA-M5. DISCUSSION: AMA-M5 are immunological markers of APS to the same extent as antiphospholipid antibodies. This case demonstrates the interest of screening for AMA-M5 in cases of strong clinical suspicion of APS when the anticoagulant lupus test is normal and no anti-cardiolipin, anti-b2 glycoprotein I or antiprothrombin antibodies are found.

[Digital ischaemia and gemcitabine. Two new cases]. / Ischémie digitale et gemcitabine. A propos de deux nouveaux cas.

Chemotherapy generates numerous adverse effects, but digital ischemia is usually associated with a paraneoplastic mechanism. In addition to thrombotic microangiopathy or hepatic or pulmonary venoocclusive disease gemcitabine appears to induce this type of complication. This study presents two cases of digital ischemia, which are very likely attributable to gemcitabine. The first case involved a 56-year-old female patient with lymph node metastatic squamous cell carcinoma, for which no primitive tumor could be identified. This carcinoma had been treated at a second stage with gemcitabine at a cumulative dose of 14 390 mg. Search for etiology revealed toxic vascularitis. Response was favourable after interruption of gemcitabine and prescription of a suitable medical treatment. The second case was a 74-year-old male patient with an infiltrating bladder urothelium carcinoma with lymph node metastasis. He had been treated by surgery and chemotherapy (gemcitabine and carboplatine). Gemcitabine-induced arterial thrombosis was diagnosed. Nine other cases of digital ischemia were identified in the literature. This rare adverse effect is probably underestimated. The other reported vascular side-effects are thrombotic microangiopathy, with an estimated occurrence of 1 per 6,000 patients and two cases of veno-occlusive disease. The pathogenic mechanisms have still not been fully elucidated. Precautions before use are necessary, especially in case of associated micro or macroangiopathy.

[Chronic meningitis: aetiologies, diagnosis and treatment]. / Méningites chroniques : étiologies, diagnostic et thérapeutique.

PURPOSE: Chronic meningitis are very uncommon and account for less than 10% of all meningitis cases. Their symptoms are uncunth and there outcome is insidious. Therefore, they remain often unknown. There are only a few published reports on this disease, so diagnosis and therapeutic approachs are difficult. CURRENT KNOWLEDGE AND KEY POINTS: Positive chronic meningitis diagnosis is easy. However, determining the cause of chronic meningitis remains dilemma, as many infectious and noninfectious processes (including inflammatory, neoplastic or autoimmune aetiologies or as a result of a chemical exposure) can result in the chronic meningitis syndrome. In order to institute a pertinent treatment, sometimes urgently needed, diagnostic approach must be extremely rigourous and accutely orientated. Nevertheless, although extensive investigations, 30% of the aetiologies remain undetermined. Only two choices are left for the medical physician: an aggressive attitude based on complementary investigations or a contemplated therapy with a close clinical and biological control. On the other hand, when the patient's condition is quickly deterioring without a clear and proved aetiology, it is sometimes necessary to institute an empirical treatment, not always properly determined and sometimes contreversial. Besides, few reports on prognosis and outcome od idiopathic chronic meningitis have been published. FUTURE PROSPECTS AND PROJECTS: After a review of aetiologies and diagnostic investigations chronic meningitis, we propose a practical experience attitude about management and treatment of chronic meningitis. Thus, large-scale studies about the follow up chronic meningitis in long term, in particular those without aetiology, treated or no, should improve the outcome of this chronic syndrome.

High prevalence of hepatitis C virus RNA in the supernatant and the cryoprecipitate of patients with essential and secondary type II mixed cryoglobulinemia.

Detection of hepatitis C virus RNA by polymerase chain reaction was performed in 26 patients with type II mixed cryoglobulinemia, and compared with anti-HCV antibody detection. The patients were divided into two groups according to etiology: 15 had essential type II mixed cryoglobulinemia and 11 had secondary type II mixed cryoglobulinemia. In the essential type II mixed cryoglobulinemia group, the prevalence of hepatitis C virus RNA detected by polymerase chain reaction was 60% in the supernatant and 93% in the cryoprecipitate. In the secondary type II mixed cryoglobulinemia group the prevalence of hepatitis C virus RNA was 45% in the supernatant and 55% in the cryoprecipitate. The differences between the two groups were not statistically significant. In both patient groups, detection of hepatitis C virus RNA in the cryoprecipitate was the most sensitive test for hepatitis C virus infection. These results suggest that hepatitis C virus might be involved in the origin of mixed cryoglobulinemia.

[Evaluation of the importance of ambulatory blood pressure measurement in the diagnostic and therapeutic management of hypertension]. / Evaluation de l'intérêt de la mesure ambulatoire de la pression artérielle dans la conduite diagnostique et thérapeutique des hypertendus.

PURPOSE: evaluate, in a Public Health approach, the contribution of ambulatory blood pressure recordings (ABPR) in the diagnostic and therapeutic management of hypertension. METHODS: a retrospective study is led among 32 physicians who have addressed 473 patients for ABP: 182 for borderline hypertension (B-H) diagnosis, 94 for treatment decision (NT-H) and 197 for a therapy efficiency assessment (T-H). ABPR is performed with the non invasive Spacelabs device on a 24 hour period. The data interpretation is provided by statistical comparison of patient's data with those of a same age and sex 30 normotensive subjects group. RESULTS: The table presents the action of physician according to the ABPR motive and answer: TT = therapy, NT = no therapy, ADJ = adjustment, NADJ = no adjustment. (Table: see text). CONCLUSION: physicians follow drastically ABPR interpretation: a large number of patient avoid a treatment (68 percent of B-H group and 63 percent of NT-H group), the therapy is modified for 40 percent of the T-H patients. Such evidence may have some Public Health implications.

[Does the blood pressure balance obtained in hospitalized hypertensive patients remain satisfactory a month later at home? (Ambulatory measurement)]. / L'équilibre tensionnel obtenu chez les hypertendus à l'hôpital reste-t-il satisfaisant un mois plus tard à domicile? (Mesures en ambulatoire).

Twenty patients with hypertensive heart disease have been hospitalised for adjustment of their antihypertensive medication. The new treatment was left unchanged during a period of forty days, the survey consisted in three blood pressure measurements at rest every day during the first ten days of hospitalisation and an ambulatory blood pressure measurement the 10th and 40th day. The 10th day, there is no significant correlation between blood pressures measured at rest and ambulatory, even if the average BP levels are not significantly different. The 40th day, the average BP levels are equivalent with a correlation coefficient of 0.5 for the systolic and 0.64 for the diastolic blood pressure (p less than 0.01). Thus, a measurement of the ambulatory BP at the 10th day of hospitalisation seems to be a good indicator of the expected long term therapeutic effect. However, absence of greater increase of the ambulatory BP at one month probably corresponds with the majored action of certain treatments as time goes by.

Chronic trichloroethylene intoxication: a new approach by trigeminal-evoked potentials?

Trigeminal nerve impairment is frequently seen in chronic trichlorethylene intoxication (TRI). A total of 104 occupationally exposed subjects were selected for study because they were employed at a highly exposed workplace. They were studied by clinical examination and by trigeminal somatosensory evoked potentials (TSEP). Normal values for TSEP were obtained from the study of 52 healthy nonexposed subjects. Facial hypoesthesia, when present, was global and predominant in the mandibular and maxillary nerve areas, associated or not with absent reflexes. A disturbed TSEP was found in 40 subjects which was predictable from their clinical symptoms. Correlation with exposure parameters (duration of exposure, trichlorethanol, and trichloracetic acid urinary rates) was mainly observed in subjects presenting both clinical and electrical alterations. Electrical alterations alone were less predictive. An abnormal TSEP may thus provide objective determination of risk assessment in the absence of clinical signs.

Determination of beta-endorphin in alcoholic patients in the acute stage of intoxication: relation with naloxone therapy.

beta-Endorphin was measured in the plasma of control subjects and 12 chronic alcoholics in the acute stage of ethanol intoxication. Naloxone was administered and the level of beta-endorphin was compared before and after treatment. The increased level of beta-endorphin in the intoxicated subjects supports the presence of ethanol interactions with the opioid system, since pituitary secretion does not seem to be involved. Furthermore, the coexistence of high levels of beta-endorphin and an effective naloxone response suggest a possible link between the two.

[Can ambulatory blood pressure be assessed using 9 self-measurements?]. / Peut-on évaluer la charge tensionnelle d'activité avec 9 automesures?

This study compares the blood pressure (BP) levels, the variability and the circadian BP variation recorded in ambulatory (AM) and self measurement (SM) conditions. The BP is recorded every 15 min on the day time with an automatic device (Space-labs) in a population of 16 normotensive patients; the same day, each patient performs with an half automatic device (SEB) 9 self measurements between 8 am and 8 pm. The SM method provides significantly lower mean values: -3.9 mmHg and -3.1 mmHg for the Systolic and the Diastolic blood pressure (SBP and DBP) than the AM. The heart rate (HR) also is lower in SM than in AM (-6.5 cy/min). The BP variability is lower for the SBP and the HR in SM. The correlation between AM and SM hours means is poor. This study shows that the self measurement method provides a lower BP level and variability than the full ambulatory method and the hourly means variation are not assessed.

Comparative study of the efficacy of captopril at a single daily dose of 100 mg and at a twice daily dose of 50 mg by measuring ambulatory pressure over 24 hours.

Variations in blood pressure were investigated by an automatic, non-invasive ambulatory method in 9 subjects with essential hypertension. Recordings were made after 6 week periods during which captopril was taken either once or twice daily, in a double-blind cross-over study. Although the effects of captopril administration either once or twice daily were broadly similar, there was a significant decrease in diastolic blood pressure values on the once-daily regimen. These results suggests that treatment once a day can advantageously replace twice-daily treatment.

[Personality characteristics of hypertensive patients. Study of subjects with essential hypertension compared to a control population]. / Recherche de caractéristiques de personnalité chez l'hypertendu. Etude de sujets hypertendus essentiels en référence à une population témoin.

Starting from projective situations--thematic apperception test (TAT) we have researched personality characteristics liable to be found in hypertensive subjects. With reference to a control group of 59 subjects we have studied 41 essential hypertensive subjects. They undergo a preliminary interview structured on the questionnaire type, are classically tested with the TAT, have one or several free interviews. These data are exploited on three levels and contents = manifest, latent, adaptive. It emerges that there are permanent biographical elements (elements of reactivation. Difficulty to put up with aggressiveness, object loss anxiety, use of operative thought back of adaptation = absence of solution to conflicts and possibilities of passage ?), personality patterns in between obsessional pole neurosis and limit state (Bergeret's nosography). These data partly overlap other research, they encompass a wider field than hypertension, given the structures involved (limit state, psychosomatic component). The lack of mentalization justifies the use of therapeutic techniques such as relaxation, biofeedback...

[Ambulatory measurement of arterial pressure. Diagnostic, prognostic and therapeutic value]. / Mesure ambulatoire de la pression artérielle. Intérêt diagnostique, pronostique et thérapeutique.

The invasive and non-invasive techniques now available for automatic monitoring of blood pressure have provided new sets of physiological as well as diagnostic and therapeutic data. Recordings of blood pressure variations over a 24-hour period have shown that it increases during the day and decreases at night, that these physiological changes are more pronounced in the elderly than in young subjects and also that they depend on the degree of physical activity. The clinical applications of these techniques rest on the possibility of recording a blood pressure-activity profile over time, in order to speak, ultimately, in terms of blood pressure load activity. By reference to a normal blood pressure profile, genuinely hypertensive subjects can be differentiated better from those overactive, hyperemotional subjects who are perhaps not suffering from true hypertension. Finally, 24-hour recordings repeated over periods of several days or weeks enable the clinicians to assess therapeutic effectiveness and to envisage an authentic chronotherapy.