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[Recommendations for best practice in the management of venous thromboembolic disease in adults. Long version]. Rev Mal Respir 2021; 38 Suppl 1:e1-e6. [PMID: 31280989 DOI: 10.1016/j.rmr.2019.05.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Multidisciplinary management of locally advanced and metastatic cutaneous squamous cell carcinoma. Curr Oncol 2020; 27:e399-e407. [PMID: 32905333 PMCID: PMC7467796 DOI: 10.3747/co.27.6015] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Non-melanoma skin cancers are the most prevalent form of cancer, with cutaneous squamous cell carcinoma (cscc) being the 2nd most common type. Patients presenting with high-risk lesions associated with locally advanced or metastatic cscc face high rates of recurrence and mortality. Accurate staging and risk stratification for patients can be challenging because no system is universally accepted, and no Canadian guidelines currently exist. Patients with advanced cscc are often deemed ineligible for either or both of curative surgery and radiation therapy (rt) and, until recently, were limited to off-label systemic cisplatin-fluorouracil or cetuximab therapy, which offers modest clinical benefits and potentially severe toxicity. A new systemic therapy, cemiplimab, has been approved for the treatment of locally advanced and metastatic cscc. In the present review, we provide recommendations for patient classification and staging based on current guidelines, direction for determining patient eligibility for surgery and rt, and an overview of the available systemic treatment options for advanced cscc and of the benefits of a multidisciplinary approach to patient management.
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4d cardiac magnetic resonance flow in patients with pulmonary arterial hypertension associated with congenital heart disease. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2020. [DOI: 10.1016/j.acvdsp.2019.09.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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5
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[When and how to investigate chronic thrombo-embolic pulmonary hypertension after a pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e125-e130. [PMID: 31611022 DOI: 10.1016/j.rmr.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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[Recommendations of good practice for the management of thromboembolic venous disease in adults. Short version]. Rev Mal Respir 2019; 36:249-283. [PMID: 30799126 DOI: 10.1016/j.rmr.2019.01.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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P2614Factors associated with survival in patients with not-operated chronic thromboembolic pulmonary hypertension (CTEPH) in the modern management era. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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8
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Évaluation des échanges érythrocytaires dans la prise en charge de l’hypertension pulmonaire précapillaire chronique associée à la drépanocytose. Rev Mal Respir 2018. [DOI: 10.1016/j.rmr.2017.10.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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5022Clinical phenotypes and outcomes of heritable and sporadic pulmonary veno-occlusive disease. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.5022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Reproducibility of clinical events adjudications in a trial of venous thromboembolism prevention. J Thromb Haemost 2017; 15:662-669. [PMID: 28092428 DOI: 10.1111/jth.13626] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/31/2016] [Indexed: 12/14/2022]
Abstract
Essentials The reproducibility of Clinical Events Committee (CEC) adjudications is almost unexplored. A random selection of events from a venous thromboembolism trial was blindly re-adjudicated. 'Unexplained sudden deaths' (possible fatal embolism) explained most discordant adjudications. A precise definition for CEC adjudication of this type of events is needed and proposed. SUMMARY Background When clinical trials use clinical endpoints, establishing independent Clinical Events Committees (CECs) is recommended to homogenize the interpretation of investigators' data. However, the reproducibility of CEC adjudications is almost unexplored. Objectives To assess the reproducibility of CEC adjudications in a trial of venous thromboembolism (VTE) prevention. Methods The PREVENU trial, a multicenter trial of VTE prevention, included 15 351 hospitalized medical patients. The primary endpoint was the composite of symptomatic VTE, major bleeding or unexplained sudden death (interpreted as possible fatal pulmonary embolism [PE]) at 3 months. The CEC comprised a chairman and four pairs of adjudicators. Of 2970 adjudicated clinical events, a random selection of 179 events (121 deaths, 40 bleeding events, and 18 VTE events) was blindly resubmitted to the CEC. Kappa values and their 95% confidence intervals (CIs) were calculated to measure adjudication agreement. Results Overall, 18 of 179 (10.1%, 95% CI 6.5-15.3%) adjudications proved discordant. Agreement for the PREVENU composite primary endpoint was good (kappa = 0.73, 95% CI 0.61-0.85). When analyzed separately, agreements were very good for non-fatal VTE events (1, 95% CI not applicable), moderate for all (fatal and non-fatal) VTE events (0.58, 95% CI 0.34-0.82), good for fatal and non-fatal major bleeding events (0.71, 95% CI 0.55-0.88), and moderate for all fatal events (0.60, 95% CI 0.40-0.81). Unexplained sudden death interpreted as possible fatal PE was responsible for nine of 18 (50%) discordant adjudications. Conclusion The reproducibility of CEC adjudications was good or very good for non-fatal VTE and bleeding events, but insufficient for VTE-related deaths, for which more precise and widely accepted definitions are needed.
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Le conseil génétique dans le centre de référence de l’hypertension pulmonaire sévère. Rev Mal Respir 2016. [DOI: 10.1016/j.rmr.2015.10.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Caractéristiques des patients atteints de maladie veino-occlusive porteurs de mutations du gène EIF2AK4. Rev Mal Respir 2016. [DOI: 10.1016/j.rmr.2015.10.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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L’hypertension pulmonaire associée aux fibroses médiastinales. Rev Mal Respir 2016. [DOI: 10.1016/j.rmr.2015.10.702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Facteurs de risque de séquelles perfusionnelles pulmonaires après un premier épisode d’embolie pulmonaire non provoquée : résultats d’un essai multicentrique, double insu, randomisé : PADIS EP. Rev Mal Respir 2016. [DOI: 10.1016/j.rmr.2015.10.706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Demographic changes in the world population will cause a significant increase in the number of new cases of cancer. To handle this challenge, societies will need to adapt how they approach cancer prevention and treatment, with changes to the development and uptake of innovative anticancer drugs playing an important role. However, there are obstacles to implementing innovative drugs in clinical practice. Prior to being incorporated into daily practice, the drug must obtain regulatory and reimbursement approval, succeed in changing the prescription habits of physicians, and ultimately gain the compliance of individual patients. Developing an anticancer drug and bringing it into clinical practice is, therefore, a lengthy and complex process involving multiple partners in several areas. To optimize patient treatment and increase the likelihood of implementing health innovation, it is essential to have an overview of the full process. This review aims to describe the process and discuss the hurdles arising at each step.
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Are Life-Saving Anticancer Drugs Reaching All Patients? Patterns and Discrepancies of Trastuzumab Use in the European Union and the Usa. Ann Oncol 2014. [DOI: 10.1093/annonc/mdu438.56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Discrepancies in cancer incidence and mortality and its relationship to health expenditure in the 27 European Union member states. Ann Oncol 2013; 24:2897-902. [DOI: 10.1093/annonc/mdt352] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Drainage péricardique des tamponnades des patients atteints d’une hypertension pulmonaire précapillaire : une étude monocentrique. Rev Mal Respir 2013. [DOI: 10.1016/j.rmr.2012.10.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pulmonary hypertension in patients with sickle cell disease: not so frequent but so different. Eur Respir J 2012; 39:3-4. [PMID: 22210808 DOI: 10.1183/09031936.00119811] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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La scintigraphie pulmonaire dans la maladie veno-occlusive. Rev Mal Respir 2012. [DOI: 10.1016/j.rmr.2011.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
The mean pulmonary artery pressure (P(pa)) achieved on mild-to-moderate exercise is age related and its haemodynamic correlates remain to be documented in patients free of pulmonary hypertension (PH). Our retrospective study involved patients free of PH investigated in our centre for possible pulmonary vascular disease between January 1, 2007 and October 31, 2009 who underwent right heart catheterisation at rest and during supine exercise up to 60 W. The 38 out of 99 patients aged <50 yrs were included and a P(pa) of 30 mmHg was considered the upper limit of normal on exercise. The 24 subjects who developed P(pa)>30 mmHg on exercise had higher resting P(pa) (19±3 versus 15±4 mmHg) and indexed pulmonary vascular resistance (PVRi; 3.4±1.5 versus 2.2±1.1 WU·m(2); p<0.05) than the remaining 14 subjects. Resting P(pa) >15 mmHg predicted exercise P(pa) >30 mmHg with 88% sensitivity and 57% specificity. The eight patients with resting P(pa) 22-24 mmHg all had exercise P(pa) >30 mmHg. In subjects aged <50 yrs investigated for possible pulmonary vascular disease and free of PH, patients with mild-to-moderate exercise P(pa) >30 mmHg had higher resting PVRi and higher resting P(pa), although there was no resting P(pa) threshold value that could predict normal response on mild-to-moderate exercise. The clinical relevance of such findings deserves further long-term follow-up studies.
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Complications pulmonaires des syndromes drépanocytaires majeurs chez l’adulte. Rev Mal Respir 2011; 28:129-37. [DOI: 10.1016/j.rmr.2010.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 08/30/2010] [Indexed: 10/18/2022]
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Durable responses to Erlotinib despite KRAS mutations in two patients with metastatic lung adenocarcinoma. Ann Oncol 2010; 21:1385-1387. [PMID: 20501506 DOI: 10.1093/annonc/mdq153] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Survival in incident and prevalent cohorts of patients with pulmonary arterial hypertension. Eur Respir J 2010; 36:549-55. [PMID: 20562126 DOI: 10.1183/09031936.00057010] [Citation(s) in RCA: 439] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive, fatal disease. We studied 674 consecutive adult patients who were prospectively enrolled in the French PAH registry (121 incident and 553 prevalent cases). Two survival analyses were performed. First, the cohort of 674 patients was followed for 3 yrs after study entry and survival rates described. Then, we focused on the subset with incident idiopathic, familial and anorexigen-associated PAH (n = 56) combined with prevalent patients who were diagnosed <3 yrs prior to study entry (n = 134). In the cohort of 674 patients, 1-, 2-, and 3-yr survival rates were 87% (95% CI 84-90), 76% (95% CI 73-80), and 67% (95% CI 63-71), respectively. In prevalent idiopathic, familial and anorexigen-associated PAH, 1-, 2-, and 3-yr survival rates were higher than in incident patients (p = 0.037). In the combined cohort of patients with idiopathic, familial and anorexigen-associated PAH, multivariable analysis showed that survival could be estimated by means of a novel risk-prediction equation using patient sex, 6-min walk distance, and cardiac output at diagnosis. This study highlights survivor bias in prevalent cohorts of PAH patients. Survival of idiopathic, familial and anorexigen-associated PAH can be characterised by means of a novel risk-prediction equation using patients' characteristics at diagnosis.
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Recommandations de bonne pratique : prévention et traitement de la maladie thrombo-embolique veineuse en médecine. ACTA ACUST UNITED AC 2010; 35:127-36. [DOI: 10.1016/j.jmv.2009.12.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 12/07/2009] [Indexed: 10/19/2022]
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Implementing the ESC/ERS pulmonary hypertension guidelines: real-life cases from a national referral centre. Eur Respir Rev 2009; 18:272-90. [DOI: 10.1183/09059180.00005909] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Tracing of recently assimilated carbon in respiration at high temporal resolution in the field with a tuneable diode laser absorption spectrometer after in situ 13CO2 pulse labelling of 20-year-old beech trees. TREE PHYSIOLOGY 2009; 29:1433-45. [PMID: 19797042 DOI: 10.1093/treephys/tpp072] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The study of the fate of assimilated carbon in respiratory fluxes in the field is needed to resolve the residence and transfer times of carbon in the atmosphere-plant-soil system in forest ecosystems, but it requires high frequency measurements of the isotopic composition of evolved CO2. We developed a closed transparent chamber to label the whole crown of a tree and a labelling system capable of delivering a 3-h pulse of 99% 13CO2 in the field. The isotopic compositions of trunk and soil CO2 effluxes were recorded continuously on two labelled and one control trees by a tuneable diode laser absorption spectrometer during a 2-month chase period following the late summer labelling. The lag times for trunk CO2 effluxes are consistent with a phloem sap velocity of about 1 m h(-1). The isotopic composition (delta13C) of CO2 efflux from the trunk was maximal 2-3 days after labelling and declined thereafter following two exponential decays with a half-life of 2-8 days for the first and a half-life of 15-16 days for the second. The isotopic composition of the soil CO2 efflux was maximal 3-4 days after labelling and the decline was also well fitted with a sum of two exponential functions with a half-life of 3-5 days for the first exponential and a half-life of 16-18 days for the second. The amount of label recovered in CO2 efflux was around 10-15% of the assimilated 13CO2 for soil and 5-13% for trunks. As labelling occurred late in the growing season, substantial allocation to storage is expected.
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P16 Treatment of VTE during pregnancy with a once-daily regimen of LMWH. Thromb Res 2009. [DOI: 10.1016/s0049-3848(09)70061-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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[Prolongation of anti vitamin K treatment for 18 months versus placebo after 6 months treatment of a first episode of ideopathic pulmonary embolism: a mutlicentre, randomised double blind trail. The PADIS-EP Trial]. Rev Mal Respir 2008; 25:885-93. [PMID: 18946418 DOI: 10.1016/s0761-8425(08)74358-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND After stopping a 3 to 6 months course of oral anticoagulation for a first episode of idiopathic venous thromboembolism (VTE), the risk of recurrent VTE is high (10% per year). In this setting, international guidelines recommend at least 6 months treatment. However, this recommendation is not satisfactory for the following reasons: (1) no randomized trial has compared 6 months to extended duration (2 years) anticoagulation; and (2), even though the frequency of recurrent VTE is similar after pulmonary embolism (PE) and deep vein thrombosis (DVT), the fatality rate of recurrent VTE after PE is higher than that after DVT. METHODS A French multicentre double blind randomized trial. The main objective is to demonstrate, after a first episode of symptomatic idiopathic PE treated for 6 months using a vitamin K antagonist, that extended anticoagulation for 18 months (INR between 2 and 3) is associated with an increased benefit / risk ratio (recurrent VTE and severe anticoagulant-related bleeding) compared to placebo. The double blind evaluation is ensured using by active warfarin and placebo, and blinded INR. The protocol was approved by the ethics board of the Brest Hospital on the 7th of March 2006. For an alpha risk of 5% and a beta risk of 20%, the estimated sample size is 374 patients. EXPECTED RESULTS This study has the potential to: (1) demonstrate that the benefit / risk ratio of extended anticoagulation for 18 months is higher than that observed with placebo in patients with a first episode of idiopathic PE initially treated for 6 months, during and after the treatment period; and (2) to validate or invalidate the contribution of isotope lung scans, lower limb Doppler ultrasound and D-Dimer at 6 months of treatment as predictors of recurrent VTE (medico-economic analysis included).
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[Pulmonary embolism: the extent of computerized tomography]. REVUE DE PNEUMOLOGIE CLINIQUE 2008; 64:276-281. [PMID: 19084206 DOI: 10.1016/j.pneumo.2008.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 09/19/2008] [Indexed: 05/27/2023]
Abstract
The use of computerised tomography in the diagnosis of pulmonary embolism has been the subject of clinical research while, at the same time, technical progress has provided the current multidetector-row spiral equipment. Computerised tomography has been assessed both with respect to reference strategies as well as in extensive pragmatic trials. The preliminary evaluation of the clinical probability and the assay of d-dimers has progressively become imperative. The value of the venous doppler ultrasound of the legs, in particular in the elderly, is limited by the variable accessibility according to the centre. In rare cases, uncertainty persists, for example with a good quality negative multidetector-row spiral computerised tomography associated with a high clinical probability, leaving room for complementary explorations. The confrontation between clinicians and radiologists is then all the more pertinent.
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[Seventeenth century French universities and health science education]. REVUE MEDICALE DE BRUXELLES 2008; 29:495-496. [PMID: 19055124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Abstract
This relation is sometimes described as a double association: venous thromboembolism (VTE) can reveal cancer (so-called Trousseau syndrome), but cancer and its treatment are also risk factors for VTE. Lung cancer, frequent and serious, is one of the greatest purveyors of VTE, a disease that pneumologists and oncologists must often confront in diagnosis, prevention, and treatment. This article investigates the epidemiological, prevention, and treatment aspects of VTE in cancer patients, particularly those with lung cancer, but also discusses diagnostic specificities and, briefly, the possible antitumor effect of heparins.
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Pulmonary arterial hypertension associated with fenfluramine exposure: report of 109 cases. Eur Respir J 2008; 31:343-8. [DOI: 10.1183/09031936.00104807] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
BACKGROUND In view of recent substantial changes in the management of orthopedic surgery patients, a study was performed in order to update data on the epidemiology of venous thromboembolism (VTE) in patients undergoing lower limb arthroplasty according to contemporary practise. METHODS We performed a prospective observational study of a cohort of consecutive patients hospitalized for total hip or knee replacement in June 2003. The primary study outcome was the incidence of symptomatic VTE at 3 months. All events were adjudicated by an independent critical event committee. RESULTS Data from 1080 patients (mean age 68.0 years) were available; 63.2% were undergoing total hip replacement and 36.8% total knee replacement. Pharmacological thromboprophylaxis was administered for a mean time of 36 days. Injectable antithrombotics were used in more than 99% of patients, irrespective of the type of surgery. The incidence of the primary study outcome was 1.8% (20 events; 95% CI: 1.0-2.6%). The incidences were 1.3% and 2.8% in hip and knee surgery patients, respectively. There were two pulmonary embolisms, both in knee surgery patients; neither was fatal. Thirty-five per cent of VTEs occurred after hospital discharge. An age of at least 75 years and the absence of ambulation before hospital discharge were the only significant (P < 0.05) predictors of VTE. The rate of clinically significant bleeding was 1.0% and the rate of death was 0.9%. CONCLUSIONS The incidence of symptomatic VTE after lower limb arthroplasty is low, even if there is still a need to improve thromboprophylaxis, notably in patients undergoing knee arthroplasty.
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[A report on the 4th International Forum of Medical Education]. REVUE MEDICALE DE BRUXELLES 2007; 28:199-200. [PMID: 17708478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease characterized by the persistence of thromboemboli obstructing the pulmonary arteries as an organized tissue. The consequence is an increase in pulmonary vascular resistance resulting in pulmonary hypertension (PH) and progressive right heart failure. BACKGROUND It is difficult to recognize the postembolic nature of PH because there is no known history of thromboembolic disease in more than 50% of cases. Diagnosis is based on the presence of mismatched segmental defects in the ventilation-perfusion scanning. When CTEPH is suspected, pulmonary angiography and high-resolution CT scan are required to establish the diagnosis and to assess the operability. Pulmonary angiography is always performed in conjunction with a diagnostic right heart catheterization, which is required to confirm the diagnosis of PH and to determine the degree of hemodynamic impairement. If there is a good correlation between the pulmonary vascular resistance and the anatomical obstruction, pulmonary endarterectomy (PEA) must be proposed. Otherwise, vasodilator and antiproliferative treatments and lung transplantation represent interesting alternatives. VIEWPOINT AND CONCLUSION PEA remains the treatment of choice for eligible patients. Nevertheless, there is a need to conduct randomized trials to assess the efficacy of novel medical therapies in some situations: (1) in inoperable CTEPH due to distal lesions, (2) before PEA (therapeutic bridge) in patients who are considered "high risk" due to extremely poor hemodynamics, (3) in patients with persistent pulmonary hypertension after surgery.
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Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is rare in the presence of malignancy and tumour embolisation is one of several possible pathological mechanisms. CASE REPORTS We report our experience of 5 clinical cases and undertake a literature revue of the pathophysiological mechanisms and of the possible diagnostic and therapeutic approaches. CONCLUSIONS Neoplastic PAH due to tumour micro-emboli is rare and the diagnosis difficult to establish. Cytological examination of pulmonary arterial blood could allow early institution of appropriate chemotherapy and lead to an improvement in the grave prognosis of this condition.
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511 Évaluation hémodynamique de patients drépanocytaires ayant une suspicion d’HTAP à l’échocardiographie. Rev Mal Respir 2007. [DOI: 10.1016/s0761-8425(07)72888-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
INTRODUCTION Although the advent of multi-detector row computed tomography (CT) has enabled better visualization of subsegmental pulmonary (SSP) arteries, SSP embolism is of uncertain clinical significance. We aimed at answering the following questions: Is spiral CT an accurate method to detect SSP embolism? How are subsegmental perfusion defects managed in outcome studies including spiral CT? What are the main characteristics and outcomes of patients in whom CT detects isolated subsegmental defects? METHODS We performed a Medline search on July 1, 2004, using the keywords 'pulmonary embolism' and 'computed tomography'. We limited our search to English language prospective studies comparing CT to pulmonary angiography, and to prospective outcome studies including CT in a diagnostic strategy, with at least a 3-month follow-up. RESULTS Fourteen studies comparing CT to pulmonary angiography, and five prospective management studies using CT were retrieved. The sensitivity of single-detector CT for detecting subsegmental defects compared with pulmonary angiography was low (25%). The proportion of isolated SSP images was significantly higher in management studies using multi-detector CT (17 of 770 scans, 2.2%) compared with those using single-detector CT (22 of 2232, 1.0%; P = 0.01). No straightforward attitude regarding anticoagulation therapy for isolated subsegmental defects emerged from the available literature. Finally, important clinical differences were found between patients having subsegmental and segmental or more proximal defects. CONCLUSIONS These findings underline the uncertainty regarding the clinical significance of SSP embolism, and the management of patients with such findings.
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Caractéristiques des patients atteints d’hypertension artérielle pulmonaire selon la découverte d’une mutation du gène BMPR2. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)72447-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary arterial hypertension that affects predominantly post-capillary pulmonary vessels. A major concern with PVOD is the poor response to available therapies and the risk of pulmonary oedema with continuous intravenous epoprostenol. The present authors hypothesised that alveolar haemorrhage may be a characteristic feature of pulmonary veno-occlusive disease, as compared with other forms of pulmonary arterial hypertension that predominantly involve pre-capillary pulmonary arteries. This paper reports a series of 19 patients with either PVOD (n = 8) or idiopathic pulmonary arterial hypertension (IPAH; n = 11) who underwent bronchoalveolar lavage. Cytological analyses were performed and differential counts were made on Perls-stained preparations. The Golde score was used to assess alveolar haemorrhage. As compared with IPAH, PVOD was characterised by a higher percentage of haemosiderin-laden macrophages (40+/-37 versus 3+/-6%), resulting in elevated Golde scores (81+/-88 versus 4+/-10). It was concluded that occult alveolar haemorrhage is a common feature of pulmonary veno-occlusive disease. Detecting occult alveolar haemorrhage may be of interest in the diagnostic approach of pulmonary veno-occlusive disease.
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Traitement de l’HTAP thrombo-embolique chronique inopérable par le Bosentan. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)72445-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Référentiel de compétences infirmières en RD du Congo dans le cadre du renforcement des ressources humaines en santé. SANTE PUBLIQUE 2006; 18:459-73. [PMID: 17094685 DOI: 10.3917/spub.063.0459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This article describes the results of a participatory process aiming to design and develop a referential of competencies for nurses to be used in secondary professional training within the context of the global South, and more specifically in the Democratic Republic of Congo (DRC). Priority focus is given to the presentation of the final validated product. The competencies' referential is accompanied by a training referential as a pre-requisite guide, which outlines the course of study. Only the referential of competencies is described in this article. The result documents, in the first instance, the shape which this referential of competencies takes in reality, from which a school nurse can be brought to mobilise while practicing his/her profession. The referential's basis and presentation is founded on four key skill sets as a starting point. Each of the four key skills were further broken down and divided according to levels of competencies and minimal criteria for perfecting these skills per year of study. The presentation of the referential of competencies ends by regrouping "families of situations" for each year as well as with an adapted glossary. The discussion focuses on the results of the referential of competencies in its context but also on the use which should be made of this tool within the framework of the implementation of the education and training reform for nurses in DRC. Another point is the interest of this approach by skills for various types of professional training in the health sciences.
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Abstract
Chronic thromboembolic pulmonary hypertension is a condition that has long remained in the shadows, a kind of orphan disease, because of the lack of any curative treatment. The renewal of interest by pulmonary specialists, cardiologists and thoracic surgeon is due to the development over the past 20 years of major new treatments: lung transplantation, continuous prostacyclin infusion, and pulmonary endarterectomy, in chronological order. Most patients with postembolic pulmonary arterial hypertension (PEPAH) in a sufficiently proximal location can benefit from curative surgical treatment by bilateral endarterectomy of the pulmonary arteries. This complex surgery, performed under deep hypothermic circulatory arrest, clears out the pulmonary vascular bed down through its subsegmental branches and results in a frank reduction in pulmonary vascular resistance and normalization of cardiopulmonary function. It is a curative procedure with a perioperative mortality rate less than 7% and a definitive result, unlike pulmonary and cardiopulmonary transplantation, which have a postoperative mortality rate of 20% and a 5-year survival rate of 50%. It is difficult to recognize the postembolic nature of pulmonary hypertension because there is no known history of venous thrombosis or embolic phenomena in more than 50% of cases. Diagnosis is based on the presence of mismatched segmental defects in the radioisotopic ventilation-perfusion scanning. To be accessible to endarterectomy, lesions must involve the main, lobar, or segmental arteries. When conducted by experienced operators according to specific protocols, pulmonary (frontal and lateral views of each lung) and multislice CT angiography optimize assessment of the lesion site. When the pulmonary vascular resistance evaluated by catheterization is correlated with the anatomical obstruction visible on the images, pulmonary endarterectomy has a mortality rate below 4% and offers the patient a substantial chance to regain normal cardiorespiratory function. In cases of pulmonary arterial hypertension due to older embolisms, major arteriolitis occurs in the nonobstructed areas and aggravates the pulmonary hypertension, which may become suprasystemic. The endarterectomy mortality rate is then higher, and in specific cases justifies preoperative medical treatment. Pulmonary or cardiopulmonary transplantation is indicated in this disease only when the lesions are too distal and thus inaccessible to endarterectomy.
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Le traitement antithrombotique de la maladie thromboembolique veineuse. Rev Mal Respir 2005; 22:833-5. [PMID: 16272990 DOI: 10.1016/s0761-8425(05)85645-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
BACKGROUND An increased prevalence of splenectomy has been reported in patients with idiopathic pulmonary arterial hypertension. Examination of small pulmonary arteries from these subjects has revealed multiple thrombotic lesions, suggesting that thrombosis may contribute to this condition. Based on these findings, we hypothesised that splenectomy could be a risk factor for chronic thromboembolic pulmonary hypertension (CTEPH), a condition defined by the absence of thrombus resolution after acute pulmonary embolism that causes sustained obstruction of the pulmonary arteries and subsequent pulmonary hypertension. METHODS The medical history, clinical characteristics, thrombotic risk factors and haemodynamics of 257 patients referred for CTEPH between 1989 and 1999 were reviewed. In a case-control study the prevalence of splenectomy in patients with CTEPH was compared with that of patients evaluated during the same period for idiopathic pulmonary hypertension (n=276) or for lung transplantation in other chronic pulmonary conditions (n=180). RESULTS In patients with CTEPH, 8.6% (95% CI 5.2 to 12.0) had a history of splenectomy compared with 2.5% (95% CI 0.7 to 4.4) and 0.56% (95% CI 0 to 1.6) in cases of idiopathic pulmonary arterial hypertension and other chronic pulmonary conditions, respectively (p<0.01). CONCLUSION Splenectomy may be a risk factor for chronic thromboembolic pulmonary hypertension.
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