Fas-independent mitochondrial damage triggers cardiomyocyte death after ischemia-reperfusion

The Fas/Fas ligand and mitochondria pathways have been involved in cell death in several cell types. We combined the genetic inactivation of the Fas receptor (lpr mice), on the one hand, to the pharmacological inhibition of the mitochondrial permeability transition pore (mPTP), on the other hand, to investigate which of these pathways is predominantly activated during prolonged ischemia-reperfusion. Anesthetized C57BL/6JICO (control) and C57BL/6-lpr mice were pretreated with either saline or cyclosporin A (CsA; 40 mg/kg, 3 times a day), an inhibitor of the mPTP, and underwent 25 min of ischemia and 24 h of reperfusion. After 24 h of reperfusion, hearts were harvested: infarct size was assessed by 2,3,5-triphenyltetrazolium chloride staining, myocardial apoptosis by caspase 3 activity, and mitochondrial permeability transition by Ca2+-induced mPTP opening using a potentiometric approach. Infarct size was comparable in untreated control and lpr mice, ranging from 77 +/- 5% to 83 +/- 3% of the area at risk. CsA significantly reduced infarct size in control and lpr hearts. Control and lpr hearts exhibited comparable increase in caspase 3 activity that averaged 57 +/- 18 and 49 +/- 5 pmol x min(-1) x mg(-1), respectively. CsA treatment significantly reduced caspase 3 activity in control and lpr hearts. The Ca2+ overload required to open the mPTP was decreased to a similar extent in lpr and controls. CsA significantly attenuated Ca2+-induced mPTP opening in both groups. Our results suggest that the Fas pathway likely plays a minor role, whereas mitochondria are preferentially involved in mice cardiomyocyte death after a lethal ischemia-reperfusion injury.

Identification and Characterization of Two Genes (MIP-1β, VE-CADHERIN) Implicated in Acute Rejection in Human Heart Transplantation

Background— Genes and mechanisms of action involved in human acute rejection after allogeneic heart transplantation remain to be elucidated. The use of a murine allograft model in tandem with cDNA arrays and quantitative real-time polymerase chain reaction (Q-PCR) can greatly help in identifying key genes implicated in human heart acute rejection.

Methods and Results— Hearts from Balb/c mice were either not transplanted or transplanted heterotopically in the abdomen of Balb/c (isografts) and C57BL/6 (allografts) mice. Histological analysis showed acute rejection only in allografts. Total RNA was extracted from isografts (n=3), allografts (n=4), and not transplanted hearts (n=4); reverse transcribed; and labeled with P32. Each probe was hybridized to cDNA macroarrays. Eight genes were overexpressed and 7 genes were underexpressed in allografts compared with isografts. Macrophage inflammatory protein-1β (MIP-1β), an overexpressed gene, and VE-cadherin, an underexpressed gene, were validated by immunohistochemistry and Q-PCR in the murine models. Genes of interest, validated in the 3 murine groups, were then investigated in human heart tissues. Immunohistochemistry and Q-PCR performed on endomyocardial biopsies after heart transplantation showing no rejection (n=10) or grade IB (n=10) or IIIA (n=10) rejection, according to International Society of Heart and Lung Transplantation criteria, confirmed the results obtained from the murine model.

Conclusions— We have demonstrated that the upregulation of MIP-1β and downregulation of VE-cadherin may strongly participate in human acute heart rejection.

Pseudotumeur cardiaque révélant une maladie de Behçet

INTRODUCTION

Cardiac thrombosis is a rare complication of Behçet's disease (BD), which may present as a cardiac tumor. Its discovery precedes, in half of the cases, the diagnosis of BD. The high mortality may be associated to postsurgical complications and/or an associated involvement of pulmonary arteries.

CASE REPORT

We present the case of a 31 years old Caucasian French woman, with a history of venous thromboembolic disease, who had surgery after the discovery of a right ventricle tumor. That was an organised thrombus with endomyocardial fibrosis and a diagnosis of Behçet's disease was made after the surgery. The outcome was favourable under medical treatment associating corticosteroids, colchicine and antivitamin K (AVK), without relapse four years later.

CONCLUSION

The discovery of an intracardiac mass in a young patient must evoke the diagnosis of cardiac thrombus and Behçet's disease, even in the absence of predisposing ethnic or geographic factor.

[Evolution of the Fontan operation and results in patients with single ventricles or mixed congenital malformations]

STUDY OBJECTIVES

To examine the results of right heart derivations and clinical outcomes according to preoperative characteristics and operative strategy implemented.

METHODS

Fontan operations were performed in 65 patients (mean age = 10.3 years, 41 males). The majority of cardiopathies were single ventricles (SV) with (49% of patients) or without (26%) tricuspid atresia. A palliative bidirectional cavo-pulmonary (BCP) anastomosis was performed prior to Fontan in 15 patients. Intra-atrial Fontan tunnelling was performed in 43 patients, Kreutzer-type operations in 10, and extracardiac tubes were used in 8 patients. The mean duration of follow-up was 6.1 +/- 0.3 years.

RESULT

The 30-day mortality was 13.8%. Early mortality was higher among patients with SV with than without tricuspid atresia (P < 0.01), and among patients < 4 years old. Early reoperations were required in 5 patients, including dismounting in 1, BCP anastomosis after Kreutzer procedure in 1, and tube thrombosis in 1 patient. A single death occurred past 30 days, and late adverse events included protein-losing enteropathy in 1 patient, complete atrioventricular block in 1, and tube thrombosis treated with heparin in 2 patients. At the end of follow-up, 75% were in New York Heart Association functional class I.

CONCLUSION

Our intermediate-term results of Fontan-type operations were satisfactory, and steadily improving. The prognosis was better in patients operated at age 4 or older. A prior BCP anastomosis improved the results. A higher morbidity was observed with intra- than with extra-atrial Fontan procedures. The merit of fenestration procedures with respect to morbidity remains the be evaluated.

[Replacement of the ascending aorta with conservation of the aortic valve. Results of 50 cases using the Tirone David procedure]

Aortic valve sparing operations are now widely accepted for ascending aortic aneurysm surgery. We herein report our experience of the Tirone David procedure in larger indications. From January 1997 to August 2003, 50 Tirone David procedure have been performed on 36 male and 14 female (mean age: 60 +/- 15). Five patients presented a Marfan disease and 4 acute dissections. Grade III or IV aortic insufficiency was frequent (40%). Aortic diameter was not particularly dilated, ranging from 44 to 78 mm (mean: 57 +/- 10 mm). Mean ejection fraction: 57 +/- 10%. Mean left ventricular end diastolic diameter =63 +/- 7 mm. An associated mitral valve repair and 1 coronary bypass were necessary. Mean cross clamp and bypass times =94 min and 122 +/- 28 min respectively. There was one in-hospital mortality. Secondary mortality affected 2 patients (non-cardiac deaths), for a cumulative follow-up of 946 months. During follow-up continence control was always excellent, only 1 bicuspid valve had an aortic insufficiency >grade II. Tirone David procedure gave satisfactory results as regards both aortic ectasia and aortic regurgitation control. We consider it feasible even in case of aortic dissection but caution is required when facing bicuspid aortic valves.

Mitochondrial permeability transition in cardiomyocyte apoptosis during acute graft rejection

Evidence indicates that acute cardiac graft rejection is associated with cardiomyocyte apoptosis. Mitochondrial permeability transition (MPT) induces apoptotic cell death. We sought to determine whether MPT might play a role in cardiomyocyte apoptosis in the rat model of heterotopic cardiac transplantation. Syngenic and allogenic transplantations were performed, and both native and grafted hearts were harvested 3 or 5 d after transplantation for detection of acute rejection, assessment of Ca(2+)-induced MPT, and myocardial apoptosis by TUNEL staining and caspase 3 activity. Allogenic grafts developed severe acute rejection at day 5 with concomitant cardiomyocyte apoptosis (apoptotic index: 7.1 +/- 1.0% vs. 1.0 +/- 0.2% in syngenic hearts, and caspase 3 activity: 38 +/- 25 vs. 5 +/- 9 nmol/mg, in allogenic vs. syngenic grafts, respectively). At day 5, Ca(2+)-induced MPT was dramatically altered in allogenic when compared with syngenic grafts (mean Ca(2+) overload averaged 0 +/- 20 vs. 280 +/- 30 microM in allogenic and syngenic grafts, respectively). NIM811, a nonimmunosuppressive derivative of cyclosporin A (CsA), that specifically inhibits the MPT pore, did not alter acute rejection, but significantly delayed Ca(2+)-induced MPT pore opening, attenuated caspase 3 activity and cardiomyocyte apoptosis in allogenic grafts. This suggests that mitochondrial permeability transition pore opening may play an important role in cardiomyocyte apoptosis associated with acute cardiac graft rejection.

[Characteristics of infectious endocarditis in ventricular septal defects in children and adults]

The aim of this retrospective study was to analyse cases of infectious endocarditis (IE) of native or repaired ventricular septal defects (VSD) to determine its incidence, the circumstances of its occurrences, the outcome and prognosis of this complication. From 1966 to 2002, 36 IE occurred in 19 boys and 17 girls: the age at diagnosis was 13.4 +/- 11.8 years; 26 had an isolated VSD and 10 had VSD associated with a minor lesion. Eleven of the 36 cases (30.5%) had been previously operated: repair of an isolated VSD with a patch in 5 cases, associated with a Crafoord procedure for coarctation of the aorta in 2 cases, three times with conservative treatment of associated aortic regurgitation (AR) and with ligature of patent ductus arteriosus (PDA) in 1 case. Twenty-five of the 36 cases (69.5%) had not been operated before: 21 isolated type 1 VSD; 2 VSD + AR, 1 VSD with PDA (undiagnosed), 1 VSD with valvular pulmonary stenosis (PS). The portal of entry was post-surgical in 7 out of 36 cases (19.4%): 4 VSD patches, 2 VSD patches + Crafoord and 1 VSD patch with ligature of PDA. The source of infection was dental in 14 out of the 36 cases (38.9%): one isolated VSD repair with residual shunt, 11 native VSDs, and 2 cases of unoperated VSD + AR. The other infectious causes (15 = 41.7%) were ENT (2 cases), skin (2 cases), gastrointestinal (2 cases), pulmonary (1 case) or unknown (8 cases), on operated lesions (3 VSD patches + AR) or native lesions (12 cases: 10 isolated VSDs, 1 VSD with PSD and 1 VSD with PS). Twelve episodes occurred (33.3%) despite antibiotic prophylaxis, 7 out of 7 post-surgical and 5 out of 14 dental cases. The commonest localisation was the tricuspid valve (10 cases, always in isolated VSD). Embolism was observed in 60% of right heart endocarditis (always multiple) and in 55% of IE of the left heart (single embolism). Early surgery was required in 6 patients (16.7%). The risk of early surgery was higher in patients with VSDs associated with other lesions (4 out of 10 = 40%) than in isolated VSD (2 out of 26, 7.7%, p = 0.027). Thirteen patients underwent secondary surgery after an average interval of 2.96 years, median 0.86 years (from 4 months to 22.8 years) for VSD repair (10 cases), aortic valve replacement (2 cases) and aorto-aortic conduit (1 case). The global follow-up period was 7.4 +/- 8.3 years, from 28 days to 27.9 years (median 3.3 years). Five deaths were observed on average 3.7 +/- 6.2 years after the episode of IE (median 6 months): 2 were early, occurring less than 6 months after IE and directly related to the infective episode. The survival was 97.1% at 1 month, 94.3% at 6 months, 91.4% at 1 year and 86.6% at 5 and 10 years after IE. VSD is a benign cardiac lesion, the prognosis of which can be severely compromised by infectious endocarditis: surgical repair reduces the risk but does not totally exclude it because of minor associated abnormalities. Prophylactic antibiotic therapy and the diagnosis of latent infectious problems, particularly dental, remains essential before and after cardiac surgery.

Lupus érythémateux systémique et/ou polychondrite atrophiante compliqué d’un syndrome catastrophique des antiphospholipides

INTRODUCTION

Antiphospholipid syndrome is frequently associated with auto-immune disorders.

EXEGESIS

We report the case of a 59-years-old woman with an antiphospholipid syndrome associated with systemic lupus erythematosus and/or relapsing polychondritis.

CONCLUSION

This fatal evolution as a consequence of a delayed management shows that fast and invasive steps are required for diagnosis and treatment of systemic diseases.

[The risk of maternal venous thromboembolism disease. Synopsis and definition of high-risk groups]

Risk factors for venous thromboembolic disease, during pregnancy and post-partum, can be identified in as much as 75% of pregnant women, who present such an accident. Different risk factors are usually associated in the same women. Risk factors can be attribuated to the pregnant women (age over 35 years, overweight, varicose veins, smoking, previous deep venous thrombosis and/or pulmonary embolism) or to the conditions of the pregnancy (multiparity, immobilisation, hypertension and pre-eclampsia, cesarean delivery). Inherited or acquired biological thrombophilia enhance the risk of thrombosis but the magnitude of this effect in ante-partum, puerperium or post-partum depends on the nature of the abnormality. The analysis of all these risk factors and their cumulative effect enable classifying pregnant women into groups with very high risk, high risk or moderate risk for venous thromboembolism and to propose an adapted strategy to prevent the occurrence of such accidents.

Spontaneous proximal deep vein thrombosis in a patient with severe haemophilia A

Venous thrombosis is a very rare occurrence in patients with haemophilia A. The majority of these cases occurred during or after the administration of clotting factor concentrates. We report the case of a patient with severe haemophilia A, who spontaneously developed a deep venous thrombosis (DVT). The thrombosis occurred in the superficial femoral vein with an extension in the profunda femoris vein. Neither any local anatomic compression nor any predisposing thrombophilic risk factors were identified. Treatment with recombinant factor VIII at prophylactic doses associated with unfractionated heparin led to a successful resolution. This case illustrates the possibility for severe haemophilia patients to develop authentic spontaneous DVT without anti-haemophilic treatment and predisposing risk factors.

[Systemic lupus erythematosus with disease onset after age 65]

OBJECTIVES

Systemic lupus erythematosus with disease-onset in the elderly has rarely been studied (only one report about 21 patients with disease onset at 65 and older). Is the management of this pathology modified in this population?

METHODS

Seventeen hospitalised cases of lupus patients with disease onset at 65 or older are retrospectively reported between 1988 and 2000. The results are compared with those of younger subjects.

RESULTS

The female to male ratio is 1.83. Mean age at disease onset is 71.9 +/- 3.5 years. Mean duration of follow-up is 3.5 +/- 2.4 years. Main initial symptoms are: deterioration of general status (41%), arthritis (35%), cutaneous manifestations (35%), thrombo-embolism (24%) and pleuritis (18%). Malar rash is uncommon (12%). Nephropathy is never a revealing symptom and is rarely serious during the disease's evolution. Like in neurologic manifestations, the etiology has to be discussed in relation to associated co-morbidities. Concerning haematologic features, lymphopenia is found in 82% of the cases with a questionable specificity. Antinuclear antibodies are constant, anti-dsDNA antibodies are found in 82% of the cases, antibodies to extractable nuclear antigens in 50%, and anticoagulant circulating activity in 59%. Prognosis is difficult to assess in such a limited series but 5-years survival probability is 83%. Glucocorticoid lead to 50% of major complications.

CONCLUSIONS

This study focuses on the particular initial manifestations of systemic lupus erythematosus in the elderly (deterioration of general status, thrombosis, unusual cutaneous symptoms), and on the specificity of differential diagnosis and treatment.

[Anticoagulant treatment of thrombo-embolic venous disease]

The curative anticoagulant treatment of venous thromboembolism is non fractionated heparin or low molecular weight heparin, secondly substituted by oral anticoagulant therapy. Early mobilisation and elastic contention should be systematically prescribed. Low molecular weight heparin once or twice a day and early substitution by vitamin K antagonist allow an ambulatory treatment for deep vein thrombosis. It is still recommended a hospital management for patients with symptomatic pulmonary embolism. It is necessary to tailor the duration of anticoagulation individually according to the extension of venous thromboembolism and the presence (or absence) of risk or triggering factors. Bleeding is the major risk of anticoagulant therapy, particularly the vitamin K antagonists, justifying patient's education, adapted and regular biological surveillance, co-ordinated care approach with practical recommendations, patient's self-monitoring.

[Fulminant mediastinitis from Streptococcus pneumoniae following cardiac surgery]

A 62-year-old patient was scheduled for coronary artery bypass surgery because of tritroncular coronary artery disease. The early postoperative period was uncomplicated until the 10th postoperative day when purulent fluid appeared from the sternal wound. Cultures of blood, wound and mediastinal tissues yielded Streptococcus pneumoniae with decreased susceptibility to penicillin G. Despite prompt surgical debridement and appropriate antibiotics, a septic shock with multiorgan failure occurred and the patient died on the 19th postoperative day. Although Streptococcus pneumoniae is uncommonly implicated in postoperative mediatinitis, it frequently leads to multiple organ failure and death.

[Antibiotic prophylaxis in cardiac surgery: practice patterns]

OBJECTIVE

To assess the prescription patterns in French and foreign centres for antibiotic prophylaxis in cardiac surgery.

MATERIAL AND METHODS

Phone and written surveys concerned 64 French and 70 foreign centres. It focused on the first injection, the duration of treatment and the recommended agents.

RESULTS

87% of the French centres and 67% of the foreign centres answered the questionnaire. The first injection took place at anaesthesia induction in all French centres but during administration of premedication in 11% of foreign centres (p < 0.05). The duration of prophylaxis was restricted to the intraoperative period only in 20% and 15% of centres, respectively (ns), as specified by the recommendations. No French centres carried on the antibiotics more than 48 h versus 11% of foreign centres (p < 0.05). Cephalosporines of the second generation were prescribed in 84 and 49% of centres, respectively (p < 0.05). The combination of two antibiotics was less frequent in France than in foreign countries (5 versus 17%, p < 0.01). In absence of betalactamin allergy glycopeptides were not utilized in France versus 8% in foreign countries (p < 0.05). In case of allergy vancomycin was used in 66% of French and 42% of foreign centres.

CONCLUSION

The French recommendations may have influenced favourably the antibiotic choice but the prophylaxis duration was too long in most of the non French European centres.

Clinically and histologically silent Q fever endocarditis accidentally diagnosed by PCR

A case of Q fever endocarditis was diagnosed in a patient with no sign of active endocarditis by performing PCR targeting eubacterial 16S rDNA on the resected mitral valve. The diagnosis was confirmed by detection of high levels of anti-Coxiella burnetti antibodies, positive immunohistologic analysis of the valve tissue with specific antibodies and culture of C. burnetti from the valve tissue. As this patient had an unexplained aggravation of valve dysfunction, we recommended routine serologic testing for C. burnetti to allow the diagnosis of Q fever endocarditis at a very early stage.

[Hypoxemia secondary to inferior vena cava return into left atrium]

The case of a right-to-left shunt-induced hypoxemia with an abnormal return of the inferior vena cava (AIVCR) into the left atrium (LA) is reported in a 30-year-old male with cyanosis and polycythemia. The chest X ray and the lung CT scan was normal. Spirometry was normal but the transfert-CO coefficient (KCO) was lowered. Hypoxemia was observed at rest and worsening during exercise. The alveolo-arterial oxygen tension difference under hyperoxia was increased (56 kPa). Contrast echocardiography (CEch) suggested the presence of an AIVCR with a right-to-left shunt only observed by the inferior route. The inferior vena cava (IVC) angiography and the magnetic resonance imaging demonstrated an AIVCR characterized by a direct drainage of IVC in the left atrium. The good tolerance can be explained by the association of AIVCR with an inter-auricular septal defect resulting in a left-to-right shunt which partially corrected the right-to-left shunt. After surgical treatment, arterial blood gases normalized, KCO remained low and CEch became negative.

Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement

BACKGROUND

Long-term results after composite graft aortic root replacement may depend on the insertion technique. The aim of this study is to assess the influence of the technique of coronary artery implantation on long-term results in composite aortic root replacement.

METHODS

One hundred fifty consecutive patients (mean age, 55 years; 119 men) with different disorders of the ascending aorta who underwent aortic root replacement with a composite graft prosthesis between January 1985 and December 1999 were retrospectively studied. Thirteen patients had previously undergone cardiovascular surgery. The open button technique was performed in 65 patients (43.3%, group 1) and the inclusion technique in 85 patients (56.7%, group 2). Mean follow-up was 70.5 months. Surgery was elective in 110 procedures (73%).

RESULTS

Global actuarial survival was 76.1% +/- 4.3% for group 1 and 73.7% +/- 3.9% for group 2 at 10 years (p = 0.22). Freedom from reoperation excluding early deaths was 81% +/- 3% for group 1 and 86% +/- 2.2% for group 2 at 10 years (p = 0.62). Group 2 demonstrated a statistically significantly higher occurrence of pseudoaneurysm formation versus group 1 (p = 0.04).

CONCLUSIONS

Composite graft aortic root replacement is a safe and effective therapy for proximal aortic aneurysm and dissection, resulting in good early and long-term results irrespective of the anastomotic technique. However, the open button technique seems to avoid late false aneurysm formation at the anastomotic sites.

Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis

BACKGROUND

The optimal duration of oral anticoagulant therapy after a first episode of venous thromboembolism remains controversial.

METHODS AND RESULTS

We performed an open-label, randomized trial comparing a short oral anticoagulant course (3 months for proximal deep vein thrombosis [P-DVT] and/or pulmonary embolism [PE]; 6 weeks for isolated calf DVT [C-DVT]) with a long course of therapy (6 months for P-DVT/PE; 12 weeks for C-DVT). The outcome events were recurrences and major, minor, or fatal bleeding complications. A total of 736 patients were enrolled. There were 23 recurrences of venous thromboembolism in the short treatment group (6.4%) and 26 in the long treatment group (7.4%); the 2 treatment regimens had an equivalent effect. For the hemorrhage end point, the difference between the short and the long treatment groups was not significant: 15.5% versus 18.4% for all events (P=0.302), 1.7% versus 2.8% (P=0.291) for major events, and 13.9% versus 15.3% for minor bleeding. Subgroup analysis demonstrated that the rate of recurrence was lower for C-DVT than for P-DVT or PE.

CONCLUSIONS

After isolated C-DVT, 6 weeks of oral anticoagulation is sufficient. For P-DVT or PE, we demonstrated an equivalence between 3 and 6 months of anticoagulant therapy. For patients with temporary risk factors who have a low risk of recurrence, 3 months of treatment seems to be sufficient. For patients with idiopathic venous thromboembolism or permanent risk factors who have a high risk of recurrence, other trials are necessary to assess prolonged therapy beyond 6 months.

Management of oral anticoagulants in the treatment of venous thromboembolism

Venous thromboembolism still represents a major public health problem. After initial heparin therapy, oral anticoagulants are the treatment most often used. Bleeding is the major risk of such a therapy. This review of the literature emphasises the practical aspects of the clinical management of oral anticoagulant therapy, such as initiation, monitoring, interaction, withdrawal, optimal duration, bleeding complications and non-haemorrhagic adverse reactions.

Optimal duration of anticoagulant therapy after an episode of venous thromboembolism

The optimal duration of oral anticoagulant therapy after a first episode of venous thromboembolism (VTE) is still a matter of debate. It is essential to balance the desired effect of the anticoagulants in reducing recurrences against the risk of major bleeding. The aims of this paper are to describe the current concepts in this field. Recent data, based on randomized controlled trials, suggest that it is necessary to tailor the duration of anticoagulation individually according to the topography of VTE and the presence of risk factors. A 6-week treatment for patients with isolated calf vein thrombosis is sufficient. For proximal thrombosis and/or pulmonary embolism, a short anticoagulant course is sufficient in patients with temporary risk factors (3 months), and a longer anticoagulant course (6 months at least) is recommended for cases with permanent risk factors or idiopathic VTE. For these high-risk of recurrence patients, an assessment of low- or fixed-dose oral anticoagulation is necessary in order to reduce the bleeding risk. It is not possible to precisely determine the optimal duration with the available data. We have already performed a meta-analysis on summary data that suggests a long course of oral anticoagulant therapy is superior to a short course. An individual meta-analytic approach is needed to draw more precise conclusions on an interesting and important clinical topic.

Comparison of long versus short duration of anticoagulant therapy after a first episode of venous thromboembolism: a meta-analysis of randomized, controlled trials

OBJECTIVE

To assess the length of oral anticoagulant therapy (short versus long duration) after a first episode of venous thromboembolism (VTE).

DESIGN

Meta-analysis of randomized controlled trials, comparing two durations of anticoagulation, identified in 1999 by a computerized search of the Cochrane Controlled Trial Register, Medline and Embase, completed by an extensive review of the references of pertinent articles.

SETTING AND SUBJECTS

The meta-analysis was performed on literature data. Seven published controlled trials were included. Relative risks with 95% confidence intervals were computed using the relative risk logarithm method. Statistical significance was set up at 0.01 for the test of association.

MAIN OUTCOME MEASURES

Outcomes are major haemorrhage and recurrence after a 12-month follow-up.

RESULTS

For the recurrence end-point (sample size of 2304 patients), a duration treatment of 12-24 weeks seems preferable to a 3-6 week regimen, with a relative risk (RR) of 0.60 (95% CI: 0.45-0.79, P < 0.001). For the major haemorrhage end-point (1823 patients), the RR is not significantly different from 1 (RR = 1.43, 95% CI: 0.51-4.01, P = 0. 5). The results were similar for the subgroup 'permanent risk factors' or 'idiopathic VTE' (RR for recurrence = 0.48, 95% CI: 0. 34-0.68, P < 0.001). The tendency was similar, although not reaching statistical significance, for the 'temporary risk factors' subgroup (RR for recurrence = 0.34, 95% CI: 0.13-0.93, P = 0.035).

CONCLUSIONS

After a first episode of VTE, a long-term treatment regimen allows a significant reduction in the incidence of recurrences without increasing the incidence of bleeding events.

Thiopurine S-methyltransferase gene polymorphism is predictive of azathioprine-induced myelosuppression in heart transplant recipients

Azathioprine (AZA) is metabolized via the cytosolic enzyme thiopurine S-methyltransferase (TPMT). TPMT activity exhibits genetic polymorphism with four prevalent (75%) mutant alleles TPMT*2 (G238C) and TPMT*3 (A719G and/or G460A) and a wild-type allele TPMT*1. To test the hypothesis that presence of these mutations is associated with greater toxicity of AZA in heart transplant recipients, 30 consecutive patients treated with AZA were followed up for the first month after heart transplant. Mutation of TPMT gene (mutation-specific polymerase chain reaction-based methods) was observed in four patients (A719G: n = 2; A719G plus G460: n = 2). Agranulocytosis did not occur in patients with the wild genotype. It occurred in the two patients with mutation A719G and there was a 40% drop in neutrophils in the two other patients. Discontinuation of AZA in the four mutant patients corrected for the drop. Presence of TPMT mutations is associated with a greater likelihood of agranulocytosis. Determination of these mutations could reduce the risk for hematological side-effects.

[Teaching targets in vascular medicine]

The reference list presented here is a selection of educative objectives performed by the French "Collège des Enseignants de Médecine Vasculaire" for the different levels of the medical initial education course. It was produced through a collective procedure, after selecting the most relevant topics and setting up writing rules based upon docimology, and favoring practical rather than theoretical objectives. The main topics are peripheral obstructive arterial disease, polyatherosclerosis, atherosclerosis risk factors, venous thromboembolic disease, thrombophilia, chronic venous insufficiency, lymphatic insufficiency, leg ulcers, vascular acrosyndromes, cerebrovascular diseases and connective tissue diseases, vascular occupational diseases, vascular adverse effects of drugs, diabetic vascular disease, the vascular consequences of hypertension, vascular malformations and angiodysplasia, inflammatory arterial diseases, and vascular explorations. As a whole they include about 300 objectives for the five teaching levels. We hope that this list will help stimulate production of training courses and documents strongly needed in this field.

[Nasal involvement in atrophic polychondritis. A case report]

Relapsing polychondritis is a rare and little known inflammatory disease. The case of a 29-year-old woman who presented with a one-year history of saddle nose is discussed in this article. After waiting for one year, rhinoplasty was decided, with a good result at the 18th month. We prefer to use a calvarial bone graft for this disease and to only operate under stable and minor conditions.

Biopsy proven and biopsy negative temporal arteritis: differences in clinical spectrum at the onset of the disease. Groupe de Recherche sur l'Artérite à Cellules Géantes

OBJECTIVES

To assess the clinical features of biopsy proven and negative biopsy temporal arteritis at the time of diagnosis and during a three year follow up.

METHODS

Newly diagnosed cases of giant cell arteritis were included in a prospective, multicentre study. Initial clinical and biological features, season of diagnosis, and cardiovascular events occurring during the follow up were recorded. Biopsy proven and negative biopsy cases were compared.

RESULTS

Two hundred and seven biopsy proven, and 85 negative biopsy cases were included from 1991 to 1997. Fifty eight per cent of the biopsy proven cases, compared with 39.29% of the negative biopsy cases, were diagnosed during the autumn or winter (p = 0.003). Visual problems (31.5%, v 19.1%, p = 0.031), blindness (9.7% v 2.38%, p = 0.033), jaw claudication (40.8%, v 28.243%, p = 0.044), and temporal artery palpation abnormalities (61.3% v 29.5%, p = 7.10(-7)) were more frequent in the biopsy proven than in the negative biopsy group. Less specific symptoms, such as headache (82.5% v 92. 9%, p = 0.021), or associated polymyalgia rheumatica (40.1% v 65.9%, p = 9 x 10(-5)) were more prevalent in the negative biopsy cases. Biological markers of inflammation were significantly more increased in the biopsy proven group. All cases of blindness occurring after treatment belonged to the biopsy proven group.

CONCLUSION

Biopsy proven cases seem to be more severe than biopsy negative cases at the time of diagnosis and during follow up. Seasonal difference at diagnosis may suggest a different aetiological pattern.