Les sténoses artérielles rénales post-dénervation – une problématique préoccupante ?

Renal denervation, an invasive technique indicated in resistant hypertension patients insufficiently controlled by antihypertensive drugs, has a good safety profile. However, an increasing number of post-denervation renal artery stenosis cases has recently been reported. We describe the case of a 49-year-old woman with resistant hypertension who was referred to our university hypertension center for renal sympathetic denervation. Her daily treatment included six antihypertensive drugs. CT angiography prior to denervation showed no renal artery stenosis or vessel wall lesions. A standard renal denervation procedure using the St Jude protocol was performed. After an initial improvement in blood pressure profile, she presented with a blood pressure impairment at 3 months after renal denervation leading to the diagnosis of a severe right renal artery stenosis.     

Bébés siffleurs : qui traiter ?

Wheezing in babies is an important clinical problem. Differential diagnosis and prognosis are uncertain as there are no reliable markers for separating non-atopic wheezing from atopic “asthmatic” wheezing. Bronchial hyperresponsiveness cannot be ascertained easily in this age group and, moreover, it is not a reliable predictor of persistence of asthma. Serum markers that will forecast the development of asthma are not sufficiently sensitive. Allergic sensitisation, family history and evidence of atopy in the child are at present the most reliable indicators of future asthma. In babies where these factors exist, long-term treatment with an inhaled steroid is warranted. The possibility of dose-dependent systemic side effects, for which babies are particularly vulnerable, must be taken into account.     

Syndrome des antiphospholipides « séronégatif » : mythe ou réalité ?

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by thrombosis and/or obstetrical manifestations and the persistent presence, at least 12 weeks apart, of antiphospholipid antibodies (aPL) such as lupus anticoagulant (LA) and/or anticardiolipin antibodies (ACL) and/or anti-β2 glycoprotein I antibodies (aβ2GPI). The finding of patients with clinical profile highly suggestive of APS but who are negative for conventional biological criteria has led to the concept of seronegative APS. In the last few years, new antigen targets and methodological approaches have been employed to more clearly identify this syndrome in patients with thrombosis or obstetrical complications without conventional aPL. Although seronegative APS is still controversial, there is increasing recognition of the existence of this subgroup. However, clinical relevance of non conventional aPL need to be confirmed by efforts toward standardizing new biological tools and longitudinal studies involving large cohort of patients.     

Embolie paradoxale : mythe ou réalité ?

Paradoxical embolism should be suspected in front of a clinical phenomenon of thromboembolism associated with an anatomical right-to-left shunt. Others potential cardiac sources of thromboembolism must be ruled out. Strokes constitute the most frequent clinical manifestations of paradoxical embolism. Right-to-left left shunts are in connection with intracardiac defects (atrial septal defect and patent foramen ovale) or pulmonary arteriovenous malformations. The probability that a discovered PFO is stroke-related can be evaluated by a score. Therapeutic approaches for secondary prevention of recurrent stroke include antithrombotic and/or percutaneous treatments. The choice strategy begins to be clearer with the recent results of randomized controlled studies.     

Dermatite atopique : données génétiques actuelles

The genetic approach has allowed identification of chromosomal loci and candidate genes involved in predisposition to atopic dermatitis. Some are skin-specific, while others are common with other atopic disorders. However, results may be discordant because of genetic heterogeneity and uncertainties about the relative importance of environmental and genetic factors in phenotype expression. The relative risk for atopic dermatitis in relatives of affected patients may be defined, and a better understanding of the pathogeny of atopic dermatitis is expected.     

Les anémies hémolytiques immunologiques médicamenteuses : étude rétrospective de 10 observations

PurposeDrug-induced immune haemolytic anemia occurs in one case per million and can be fatal. Our aim was to describe the main characteristics and the type of drug involved.MethodsCases were retrospectively identified using spontaneous notifications collected by our pharmacovigilance centre and the results of immuno-hematological investigations performed by the laboratory of French blood establishment of Lyon between 2000 and 2012. Inclusion criteria were: an immune (positive direct antiglobuline test), hemolytic, anemia (haemoglobin < 100 g/L), with at least a plausible causal relationship with drug exposure according to the French method of imputability or the presence of drug-dependent antibodies, and exclusion of other causes of hemolysis.ResultsTen cases (5 men and 5 women, median age 54.4 years) were identified. Causal drugs were ambroxol, beta-interferon, cefotetan, ceftriaxone, loratadine, oxacilline, oxaliplatine, piperacilline-tazobactam, pristinamycine, and quinine. The median time to onset of anemia after starting the culprit drug was 6 days (2 hours to 16 days). The median nadir of hemoglobin was 57.9 g/L (range: 34–78). The direct antiglobulin test was positive in 8 patients: IgG only (n = 4), IgG and complement (n = 3), and IgA (n = 1). Drug-induced immune haemolytic anemia was considered as definite in 5 cases with positive drug-induced antibodies, probable in 4 cases negative for the detection of drug-induced antibodies but with plausible or likely causal relationship with drug exposure, and probable with an autoimmune mechanism in 1 case.ConclusionThe diagnosis of DIIHA is often difficult because of the similarities with autoimmune haemolytic anemia and the inconstant sensitivity of immunologic tests that sometimes required repetitive assessment.     

Toxidermies médicamenteuses : quelques nouveautés

Some recent advances regarding drug eruptions will be presented in this short review. An improved definition of ‘drug hypersensitivity syndrome’ has been proposed. New insights on the role of the immune response to drugs will be discussed that challenge the current dogma that reactive metabolites are pivotal to allergic drug reactions. Several randomised controlled trials have shown that a progressive increase in drug dosage decreased the rate of drug eruptions with some ‘high-risk’ medications.     

Nécrose hémorragique bilatérale des surrénales sous apixaban : penser au syndrome des antiphospholipides ?

IntroductionAdrenal hemorrhage is a classical but rare complication of antiphospholipid syndrome, revealing diagnosis in one third of the cases. Anti-vitamin K therapy is the standard treatment but direct oral anticoagulants are discussed as an alternative. In the latest recommendations, it is advised not to use direct oral anticoagulants in the setting of antiphospholipid syndrome.Case reportWe present a case of bilateral adrenal hemorrhage revealing primary antiphospholipid syndrome with triple positive antibody profile, in a 47-year-old man treated by apixaban for previous venous thromboembolism.ConclusionTo our knowledge, it is the first case of adrenal hemorrhage occurring during apixaban treatment in a patient with antiphospholipid syndrome. This case illustrates the inefficacy of direct oral anticoagulants to prevent thrombotic events in antiphospholipid syndrome, in accordance with the latest recommendations.     

Réhabilitation précoce après tumorectomie rénale robot-assistée : quelle satisfaction des patients ?

IntroductionSeveral enhanced recovery protocols after surgery showed a benefit for postoperative recovery and reduction of hospital lengths of stay. Very few studies evaluated patient's satisfaction about these enhanced recovery protocols. The aim of this study was to evaluate patient's satisfaction about our enhanced recovery protocol for robotic-assisted partial nephrectomy (RAPN).MethodsA validated survey EORTC In PATSAT32 with a specific questionnaire about protocol was sent to the first patients included in the enhanced recovery protocol for RAPN. The survey was sent after the postoperative consultation at postoperative day 30. Responses were anonymous. Satisfaction's scores for EORTC questionnaire were calculated for each dimension with Likert's method. Scores were transformed linearly into a scale ranging from 0 to 100, where 100 represent the highest level of care satisfaction (EORTC method).ResultsA total of 21 patients (50%) returned the completed questionnaire. The overall satisfaction score was 75.1% (37.3; 100) in the EORTC survey. In total, 71.4% of patients (n = 15) were satisfied with the discharge at postoperative day 2 (POD2) and 5 patients (23.8%) found this premature. None of the patients had a negative impression on the clinical pathway. The average overall evaluation on the protocol by patients, on a satisfaction scale of 1 to 10 was 8.9/10.ConclusionIn this study, patients included in the enhanced recovery protocol after RAPN were very satisfied with their pre-, per- and postoperative care. Given patients satisfaction, reduction of LOS, patient's safety and the medicoeconomic advantage, these enhanced recovery protocol have become a priority to develop and evaluate. More large studies are needed to assess the patient's experience with these clinical pathways.Level of evidence4.     

Rétrécissement aortique : mise au point

Aortic stenosis remains one of the most frequent valvulopathy worldwide, burdened with great mortality and morbidity, and for which there is not yet an effective preventive approach, although the pathophysiological mechanisms involved in its development are better understood nowadays. Its cure, however, has been revolutionized in the last decade by the advent of transcatheter aortic valve implantation, or TAVI (also named transcatheter aortic valve replacement or TAVR). The technique of TAVI has been refined and its indications has been extended, following the publication of large randomized controlled trials where it was compared to surgical aortic valve replacement with favorable results. Consequently, transfemoral TAVR has become the first line of treatment in case of symptomatic severe aortic valve stenosis. In this review, we describe the pathophysiological mechanisms leading to severe aortic stenosis and the main ongoing randomized controlled trials targeting them. We describe the indication for surgical or percutaneous aortic valve replacement and the main complications following the procedure.     

Notre ennemi : le caillot. Thrombose coronaire : stratégie et arsenal thérapeutique

Intra coronary thrombus is  frequently encountered during acute coronary syndromes revascularisation procedures. It can also be encountered during angioplasty procedures in a stable angina context, although at a much lesser frequency.In both situations, it harbors a risk of poor angiographic result and poor prognosis. Intracoronnary thrombus may cause coronary occlusion at the angioplasty site or distal embolic  flow obstruction. Per procedure thrombus prevention rests on an prior optimal anti thrombotic treatment and in some circumstances the choice to defer the revascularisation procedure in the complex high risk setting. Treating the initiated thrombus remains controversial concerning thrombectomy and GPIIBIIIa inhibitors which are still in use in common practice. No reflow phenomenon is a particularly complex setting during cornary angioplasties, partially but not solely related to a thrombotic complication. It's treatment remains unclear in the absence of related oriented studies.The current mechanical and pharmacological antithrombotic therapies must remain common practice and used appropriately as of the clinical and angiographic setting, until further scientific outbrakes.