[The practice of telemedicine by French internal medicine physicians in 2019]. / La pratique de la télémédecine par les médecins internistes français en 2019.

INTRODUCTION: Telemedicine has been developing in France since 2018. The objective of this survey was to assess the knowledge, attitudes, practices and training of internal physicians regarding telemedicine. MATERIAL AND METHODS: A national descriptive observational study carried out between July and October 2019, via an online self-questionnaire with members of the National Society of Internal Medicine and the Association of Young Internists, included a descriptive and comparative analysis by subgroups of age. RESULTS: Analysis of 309 responses from physicians qualified in internal medicine or practicing in an internal medicine service (61,8%) and residents in internal medicine (38%) showed that 34.6% had notions or a good knowledge of regulation of telemedicine. For 62,1%, 72.5% and 74.1% respectively, it could improve patient care, access to care and exchanges between internists and other doctors. The main obstacles to this practice were the absence of face-to-face with the patient (57.3%) and computer dysfunctions (55%). Only 23.3% practiced it, including 88.9% tele-expertise. Telemedicine was performed informally (telephone and email) in 70.8% of the cases. Doctors over the age of 50 were better acquainted with the regulations and more practiced official telemedicine. In total, 54% wanted to practice telemedicine and 72.8% wanted to train there. CONCLUSION: Attitudes towards telemedicine were positive, but few internists knew about it and practiced it formally, warranting appropriate training.

[E-cigarette use in university students and its relationship to cigarette smoking]. / Vapotage chez les étudiants à l'université et relation avec le tabagisme.

INTRODUCTION: There is concern that e-cigarette use could be a risk factor for subsequent cigarette smoking. METHODS: This survey included a group of 1220 students at Aix-Marseille University who attended a check-up visit and volunteered to participate to the survey. They answered a standardized questionnaire relating to e-cigarette use, smoking habits and the relationship between both habits. Mean age of participants was 19.9 years and 56% of them were female. RESULTS: All students invited to the check-up examination attended and agreed to participate in the survey. 13.3% of students answered they had already used e-cigarettes, a higher proportion of boys (17.5%) than girls (10.0%), starting at a mean age equal to 19.2 years. Forty-six percent of them had already smoked cigarettes, more girls (55.0%) than boys (45.0%). Among current cigarette smokers, e-cigarette use had induced giving up smoking in 12.6% and a decrease in the number of cigarettes smoked in 30.1%. Twenty percent said they begun to smoke cigarettes after using e-cigarettes. DISCUSSION: E-cigarette use is much less prevalent than smoking conventional tobacco cigarettes. There is a strong link between both. E-cigarette use had allowed a cessation or reduction in tobacco smoking in half of users. E-cigarette users may go on to start tobacco smoking but prospective surveys are needed to know how this will evolve over time. E-cigarette use could also be a means to prevent or postpone cigarette smoking.

[Clinical, laboratory, radiological features, and outcome in 26 patients with aortic involvement amongst a case series of 63 patients with giant cell arteritis]. / Caractéristiques cliniques, paracliniques et profil évolutif de l'atteinte aortique de la maladie de Horton : à propos de 26 cas d'aortite parmi 63 cas de maladie de Horton.

PURPOSE: Aortic involvement that occurs in temporal arteritis is probably underestimated because it is usually asymptomatic. The characteristics of giant cell arteritis with aortic involvement are still poorly described and the relationship between aortitis and vascular outcome of the disease has not been clearly delineated. The objective of this retrospective study of 63 patients with giant cell arteritis, including 26 with aortic involvement, was to compare the features of patients with and without aortitis, and to assess the contribution of CT-scan and FDG-PET-scan in screening for vascular disease, monitoring, and therapeutic management of patients. METHODS: This retrospective study was conducted in the internal medicine department of the university hospital in Marseille, France, from January 1, 2005 to September 30, 2011. Patients had at least three out of the five American College of Rheumatology criteria for temporal arteritis and aortic involvement was investigated in all patients using CT-scan. Aortic wall thickness greater or equal to 3mm was considered to be abnormal. RESULTS: Of 63 patients diagnosed with giant cell arteritis, 26 (41.3%) had aortic involvement diagnosed by aortic CT-scan. Age at diagnosis was significantly younger (66.8 vs 73.8 years; P=0.002) in the group with aortitis. Inflammatory dorsal and low back pain, signs of vascular disease of the upper limbs (P=0.009), and higher level of acute phase reactants were associated with aortitis. Aneurysmal lesions of the aorta were significantly more frequent in the group with aortitis. Twenty patients had both aortic CT-scan and FDG-PET-scan. For patients in whom aortic involvement was not demonstrated with CT-scan, FDG-PET-scan was always non-contributive. With corticosteroids, aortitis resolved within 6 months in all patients as evaluated by aortic CT-scan. However, aortitis persisted in 80% of cases at 6 months when evaluated with FDG-PET-scan, and in 66% of cases at 12 months, without influencing the treatment. CONCLUSION: This case series shows no specific features of aorta and its main roots involvement in giant cell arteritis, justifying a systematic screening by CT-scan. The high frequency of this arterial involvement could help physicians in the diagnosis of giant cell arteritis. Aortitis seems to be associated with vascular complications as highlighted by the frequency of aortic aneurysm and a case of early aortic dissection. Finally, the role of PET-CT-scan for screening vascular disease and therapeutic monitoring remains to be clarified.

[Occupational exposure and systemic sclerosis. Literature review and result of a self-reported questionnaire]. / Evaluation de l'exposition toxique professionnelle de patients atteints de sclérodermie systémique. Revue de la littérature et résultat d'un auto-questionnaire.

Systemic sclerosis (scleroderma) is a rare auto immune disease. Its physiopathology, based on various mechanisms, involves a predisposing genetic background and some exogenous factors. Among them, the role of toxic products is highly suggested according to several case-control studies. The aim of this study is to review the literature concerning occupational exposure associated with scleroderma. This review is completed by the results of a self-reported questionnaire on occupational exposures sent to 82 scleroderma patients followed in Marseille. Scleroderma associated with silica exposure should be declared as occupational disease. Moreover, the role of other toxic agents such as solvents is highly suspected and scleroderma occurring in case of high exposure should also be declared. Our study performed in Marseilles showed a occupational exposure in 10% of cases (five patients having an occupational exposure that could be involved in the genesis of the disease). One had an occupational silica exposure and was declared as occupational silica disease. Other cases had various toxic exposures including solvents and two were declared as disease of occupational nature. Occupational exposure (labour and leisure) must be searched for when faced with a scleroderma patient for two reasons: the possible declaration of an occupational disease and a better knowledge on toxics involved in scleroderma.

Overlap syndrome between FMF and TRAPS in a patient carrying MEFV and TNFRSF1A mutations.

OBJECTIVE: Familial Mediterranean Fever (FMF) and TNF-Receptor Associated Periodic Syndrome (TRAPS) are two inheritable inflammatory disorders. They share some clinical manifestations but their treatments are different. We present here the case of an overlap syndrome of FMF and TRAPS in a patient carrying a mutation in both the MEFV and TNFRSF1A genes. CASE REPORT: A 20-year-old woman of Mediterranean origin had suffered since childhood from attacks of fever and arthritis, with skin and ophthalmic manifestations. The initial diagnosis was FMF. The symptoms responded poorly to colchicine but regressed with steroids. Genetic analysis revealed a homozygous M694V mutation in MEFV and a heterozygous R92Q mutation in TNFRSF1A. We discuss the complexity of this combined FMF-TRAPS phenotype. CONCLUSION: This case shows that mutations in MEFV and TNFRSF1A can occur together in a single patient, a condition that may modify its response to treatment. It would be interesting to evaluate the role of the R92Q mutation in TNFRSF1A in patients of Mediterranean origin with FMF unresponsive to colchicine.

Urticarial vasculitis revealing relapsing polychondritis.

We report a case of hypocomplementemic urticarial vasculitis heralding a relapsing polychondritis in a 63-year-old woman. The patient, who had suffered in the past from polymyalgia rheumatica, suddenly experienced a generalized urticarial eruption with a dramatic decrease in C4 complement fraction and the presence of anti-C1q antibodies. Two months later, an ear chondritis occurred and the patient rapidly responded to steroids and dapsone. To our knowledge, this association has never been reported.

Severe lower limbs lymphedema following breast carcinoma treatment revealing radiation-induced constrictive pericarditis--a case report.

In patients treated for breast carcinoma, unilateral lymphedema of the upper limb is usual. However, to the authors' knowledge, lower limb lymphedema has never been reported as a complication of breast carcinoma therapy. They report here the first case of a radiation-induced constrictive pericarditis revealed by severe lower limbs lymphedema. A 60-year-old woman was treated for left breast carcinoma with quadrantectomy, axillary lymphadenectomy, and combined radio chemotherapy (60 grays). Three and a half years later she suffered from a diffuse and increasing lower limbs lymphedema, which became huge and disabling. Radiation-induced constrictive pericarditis was evidenced by right cardiac cavities catheterization. A dramatic improvement was rapidly obtained after pericardectomy. Histopathologic analysis of the pericardium did not reveal neoplastic cells. Radiation-induced constrictive pericarditis is usually responsible for lower limbs edema, but lymphedema is exceptional. This case highlights the need to search for a constrictive pericarditis also in the case of lower limbs lymphedema, particularly in a patient treated with mediastinal radiotherapy or combined radio chemotherapy.

[A group fever: safari's fever]. / Une fièvre collective: la fièvre des safaris.

INTRODUCTION: Acute schistosomiasis, called safari's fever in Africa and Katayama fever in Japan, is an immunoallergic reaction due to transcutaneous penetration of infective cercaria. We report the collective case of seven young adults spending holidays in Mali. EXEGESIS: An eighteen years-old girl presents fever, headache, diarrhoea and abdominal pains at return from Dogon country (south of Mali). After turned down malaria and with the notion of bathing in fresh water followed by pruritus, we think to safari's fever. So we alarm all other members of the group. All can be treated to avoid chronic schistosomiasis. CONCLUSION: These observations recall that acute schistosomiasis is a real danger for tourists when bathing in fresh water in endemic areas of Africa. Education of travellers is necessary. Occurrence of safari's fever should alert physicians to prevent chronic schistosomiasis.

[Asymptomatic gastric phytobezoar and anaemia due to iron deficiency revealing an autoimmune gastritis]. / Phytobézoar gastrique asymptomatique et anémie par carence martiale révélant une gastrite autoimmune.

UNLABELLED: This observation recalls that gastric phytobezoar should lead to a search for an underlying disease and that a iron deficiency can be associated and hide macrocytosis related to a vitamin B12 deficiency. CASE REPORT: A 19 year-old woman consulted for asthenia. Microcyte anaemia associated with iron deficiency was diagnosed. Upper digestive endoscopy revealed severe, totally asymptomatic phytobezoar. Biological investigations revealed a vitamin B12 deficiency, high serum gastrin level and strong positivity for gastric antiparietal anti-cell antibodies, suggestive of an autoimmune gastritis. Total immunoglobulin A deficiency was also noted. DISCUSSION: Autoimmune gastritis is responsible for megaloblastic anaemia (vitamin B12 deficiency) but can also provoke microcytic (iron-deficiency) anaemia due to insufficient absorption of the latter and related to gastric achlorhydria. Phytobezoar might also be related to achlorhydria and/or gastroparesia associated with autoimmune gastritis. Hence, autoimmune gastritis should be searched for when confronted with unexplained gastric bezoar or iron-deficiency anaemia.

[Icteric Fort Bragg fever: a case report with nosological discussion]. / Fièvre de Fort Bragg ictérique: discussion nosologique à propos d'un cas.

INTRODUCTION: Ictero-hemorrhagic leptospirosis is an endemic disease in France. Weil's disease, a form of leptospirosis, is well known. Fort Bragg fever is characterized by a constant pretibial papular lesion. First described in the USA, this non icteric form of leptospirosis is usually benign. We report the first French case of a mixed form of leptospirosis. EXEGESIS: A 52-year-old man living in South East France suffered from fever and myalgias associated with a pretibial papular lesion. A severe icterus appeared and permitted a diagnosis of leptospirosis. CONCLUSION: Our case recalls the clinical presentation of Fort Bragg fever, which is recognized through its inflammatory pretibial lesion associated or not with icterus.

Cryoglobulinemia vasculitis following intravesical instillations of bacillus Calmette-Guerin.

Infections and/or immune-mediated reactions may occur after intravesical instillation of bacillus Calmette-Guérin for the treatment of bladder carcinoma. We report herein a cryoglobulinemia vasculitis occurring after intravesical BCG instillation for a superficial papillary transitional cell bladder carcinoma. The patient, an 80-year-old man, presented peripheral ischemia 10 days after the second course of intravesical BCG instillation. Biological evaluation revealed autoimmune thrombocytopenia, hypergammaglobulinemia, low C3 and C4 complement fraction levels related to mixed cryoglobulinemia and lupus anticoagulant. The patient was treated with heparin and prostacyclins with a good outcome. All of the immune anomalies spontaneously regressed within 3 months. To our knowledge, cryoglobulinemia has only been reported once in the literature and lupus anti-coagulant has never been reported as a complication of intravesical BCG instillation.

Neuromuscular diseases associated with antigliadin antibodies. A contentious concept.

Many neurological syndromes associated with antigliadin antibodies have been published. The most frequent are cerebellar ataxia and peripheral neuropathy. Such cases are reported under the title of gluten ataxia or of coeliac neuropathy. However, associations do not prove cause. Herein, a short review is made of the literature and the author's personal experience. Many unsolved questions remain. Gluten sensitivity is probably an immunological response in genetically susceptible individuals with or without enteropathy. Antigliadin antibodies are present in healthy adults, in some idiopathic ataxias and neuropathies. A gluten-free diet is effective on gastrointestinal but not on neurological symptoms. Whether antigliadin antibodies are elevated is more of a waiting classification than a definite diagnosis. Finally, the relationship between antigliadin antibodies and neurological diseases is very weak.