Epidemiology and course of acute upper gastro-intestinal haemorrhage in four French geographical areas.

OBJECTIVE: To compare incidence rates and epidemiological characteristics of acute upper gastrointestinal haemorrhage (AUGIH) in France with those of other European studies. DESIGN: Population-based multi-centre prospective survey. SETTING: 29 public hospitals and 96 private specialists in gastroenterology in four administrative areas in France during 1996. SUBJECTS: A total of 2133 AUGIH patients 18 years and over were included in the six-month study. OUTCOME MEASURES: Incidence and mortality. RESULTS: The overall incidence in France was 143 cases per 100000 persons per year, classified as out-patients (16%), emergency admissions (59%) and in-patients (25%). The incidence rates increased with age except for in-patients, and were higher in males. Peptic ulcer (36.6%), varices (13.7%) and erosive disease (12.3%) were the most frequent diagnoses. In 677 patients (31.7%), aspirin, antiinflammatory drugs or corticosteroids were taken on the 7 days before bleeding. The overall mortality (out-patients excluded) was 14.3% (10.7% for emergency patients and 23% for in-patients). Mortality was associated with comorbidities (especially malignancies, cirrhosis, asthma or respiratory deficiency), was lower in emergency patients using non-steroid anti-inflammatory drugs, and higher in in-patients using corticosteroids. CONCLUSIONS: In France, patients with AUGIH are frequently managed as out-patients. Gastrotoxic drug use is frequently associated with AUGIH and constitutes a strategic opportunity for preventive treatment. Discrepancies between countries are not clearly explained either by demographic factors or by drug use, but this may be related to the emphasis on AUGIH in in-patients.

Mammographic patterns of inflammatory breast carcinoma: a retrospective study of 92 cases.

OBJECTIVE: To quantitate initial mammographic signs and to describe post-therapeutic patterns of inflammatory breast cancer. MATERIAL AND METHODS: Two radiologists retrospectively analyzed the initial clinical and mammographic findings of 92 patients with inflammatory breast carcinoma. The post-therapeutic mammogram (n = 75) was considered abnormal when focal opacity and or malignant-type microcalcifications were still visible. RESULTS: Redness of the skin, "peau d'orange' and increased temperature were the most common findings. A palpable mass was noted in 97% with axillary lymph node involvement in 83% of cases. All initial mammograms were abnormal. Isolated inflammatory signs were observed in 14% and malignant signs in 86% of patients (opacity = 77% and/or malignant-type microcalcifications = 47%). Skin thickening was seen in 93.5%, nipple inversion in 56.5%, increased breast density in 93.5%, stromal coarsening in 85% and hypervascularisation in 32.5% of mammograms. On post-therapeutic mammograms, 35 patients (46.5%) were suspected of having residual disease. During follow-up, 19 patients (25.3%) relapsed locally: 75% had abnormal post-therapeutic mammograms. CONCLUSION: The presence of isolated inflammatory signs on the mammogram is sufficient to suspect inflammatory breast carcinoma and biopsy must be performed in doubtful cases. Radical surgery is indicated when persistent malignant signs are still visible on mammogram after conservative treatment.

[Helicobacter pylori and gastroduodenal lesions in 547 symptomatic young adults]. / Helicobacter pylori et lésions gastro-duodénales chez 547 jeunes adultes symptomatiques.

OBJECTIVES: Helicobacter pylori (H. pylori) is involved in the pathogenesis of gastric inflammatory disorders. Both antral chronic gastritis and H. pylori infection prevalence increase with age. The aim of the study was to assess the prevalence of H. pylori infection in young adults and to study the relationship between endoscopical and histological features and H. pylori infection. METHODS: The study concerned 547 young patients (age: 18-25 years), undergoing endoscopy for upper gastrointestinal symptoms. The severity and the activity of chronic gastritis was graded by histological examination of antral biopsies. The diagnosis of H. pylori infection was based on histology and culture or urease test. RESULTS: Fifty-three percent of the patients had a normal endoscopy; 44 ulcers were found: 34 duodenal ulcers and 10 gastric ulcers. H. pylori infection was detected in 34% of cases. The prevalence of H. pylori infection was 29.8% in non-ulcer patients, 50% in gastric ulcers and 91% in duodenal ulcers (P < 0.01). Duodenal ulcer, aspect of antral mosaic mucosa and nodular gastritis, were closely related to the presence of H. pylori. There was a significant relationship between H. pylori infection and both the severity (P < 0.01) and the activity (P < 0.01) of the antral chronic gastritis. The prevalence of follicular gastritis was 22% : it was present in 60% of H. pylori positive patients and 2.4% of H. pylori negative patients. H. pylori infection was more frequent in patients from Africa than in Europeans (P < 0.01). There was no significant association between H. pylori infection and different types of diets, settlements (rural vs urban) or symptoms. CONCLUSION: These results show that in the young population studied, duodenal ulcer, nodular gastritis, antral mosaic mucosa, active chronic gastric and follicular gastritis are closely related to H. pylori infection. They suggest that in the subgroup of non ulcer symptomatic patients, H. pylori prevalence is higher than in the general population.

[Follicular gastritis in adults. Relations with Helicobacter pylori, histological and endoscopic aspects]. / Les gastrites folliculaires de l'adulte. Relations avec Helicobacter pylori, aspects histologiques et endoscopiques.

Follicular gastritis (FG) is characterized by lymphoid follicle hyperplasia in the gastric mucosa. The aim of this prospective study was to determine the prevalence of FG in adults, their relation to Helicobacter pylori infection, and their histological and endoscopic features. Of 445 patients (379 men, 66 women), 36.4 years old (range: 18-86), FG was detected in 63 patients (14.2%). This was highly significantly associated with H. pylori infection: 49/138 infected patients (35.5%) versus 14/307 non infected patients (4.6%) (P < 0.001). None of the histological features of the antral mucosa were correlated with FG. The prevalence of FG in patients less than 20 years old (in 45.4%) and between 20 and 40 years (in 41.3%) was higher than in patients aged from 40 to 60 years (in 33%) and older than 60 years (in 23%) (no significant difference). No one endoscopic feature of the gastric mucosa was predictive of the presence of FG. We conclude that FG is highly correlated with H. pylori infection and represents a local immune response to bacterial antigens. Their occurrence is probably multifactorial and related to age, duration of infection, bacterial strains, host immune status.

[Management of upper digestive hemorrhage occurring in the community: patterns of patient care in 4 French administrative areas]. / Prise en charge des hémorragies digestives hautes communautaires. Trajectoires des malades dans 4 départements français.

AIMS: To describe patterns of health care management in patients with upper gastrointestinal hemorrhage and to identify factors linked to the different patterns. PATIENTS AND METHODS: We conducted a prospective study of patients over 18 with upper gastrointestinal hemorrhage (inpatients excluded) among all public hospitals and private practice gastroenterologists in 4 French administrative areas (3 in Northern France and one in the South West). RESULTS: One thousand six hundred and two patients were included over a six-month period (1996). An endoscopic procedure was performed in 1532 patients in public (70%) or private (20.5%) hospitals, or at private office (9.5%). Hospitalization was necessary in 78.8% of the patients in university, non university public or private hospitals (38.9, 45.5 and 15.6%, respectively) with a median duration of 6.5 days. Admission was associated to old age, short delay between hemorrhage and endoscopic procedure, previous gastrointestinal bleeding, cirrhosis or cancer, bleeding from peptic ulcer or esogastric varices. Endoscopic hemostasis was performed in 21.4% of the patients, more often in university and no university public hospitals. Surgery was necessary in 4% of the patients. Death rate was 10.7%. Important geographical variations were observed concerning referral patterns. Patients' characteristics did not differ between the 4 areas. On the other hand, health care supply provided in the management of upper gastrointestinal hemorrhage was different in the four French geographical areas. CONCLUSION: a) An initial endoscopic procedure is nearly always performed in patients with an upper gastrointestinal hemorrhage in France; in 1 patient out of 10, endoscopy was performed in a private gastroenterologist office; b) hospital admission was strongly related to epidemiological and clinical criteria of severity; c) the geographical variations observed in referral patterns depend in part on health care supply; d) upper gastrointestinal haemorrhage status could be used as an indicator of the quality of health care organizations.

[Hemorrhaging eso-gastro-duodenal ulcers: epidemiology and management. A multicenter prospective study]. / Les ulcères oeso-gastro-duodénaux hémorragiques: épidémiologie et prise en charge. Etude prospective multicentrique.

UNLABELLED: The aim of this study was to estimate the incidence, and to describe the characteristics and medical care in patients with bleeding upper gastrointestinal ulcers in the general population. PATIENTS AND METHODS: A study was performed over six months in 1996 in 4 French geographical areas: Finistère, Gironde, Seine-Maritime, and the Somme (3 million people minimum 18 years). All public or private hospitals, and specialist gastroenterologists in private practice participated in the study, based on a standardized questionnaire. RESULTS: Over 6 months 793 patients with bleeding ulcers were identified, corresponding to 27 per 100,000 inh./year or 24,000 cases in France. Most patients were men (60%) and 40.1% were 75 years and older. The ulcer was oesophageal (6%), gastric (47%), or duodenal (69%). In 406 patients (51.2%) a chronic disease was present (cancer, cirrhosis, circulatory, respiratory or cardiac disease). In 237 cases (29.9%) the ulcer occurred in patients, 453 patients (57.1%) were admitted and 103 patients (13%) were managed as outpatients. Gastrotoxic drugs were taken by 349 patients (44%): non steroidal anti-inflammatory drugs (18.7%), aspirin (21.2%, including 2/3 with doses under 330 mg/day), corticosteroids (7.8%) and 24.3% had anticoagulant therapy. Patients were managed in university hospitals (39.3%), other public or non profit hospitals (44.2%) or private hospital (16.5%) with geographical differences between the 4 areas. Therapeutic endoscopy was performed in 16.9% and a surgical procedure was performed in 5.9%. The mortality rate (outpatients excluded) was 13.5% (n = 93), but only 2% (n = 16) of death were associated with a bleeding ulcer: mortality was higher in inpatients (24.1%) than in out patients (8.1%). A chronic disease was also associated with higher mortality (17.9% versus 8.1%). CONCLUSION: Bleeding ulcers are frequent and severe, especially in inpatients or associated with chronic conditions. A gastrotoxic drug used is found in about fifty percent of the cases.

Osteochondritis dissecans of the trochlea of the humerus.

Osteochondritis dissecans is a transchondral fracture. Localization to the elbow is rare when it is usually located in the capitellum of the humerus or the radial head. Osteochondritis of the trochlea of the humerus is described in a 12 year old X-ray and MRI.

Blount's disease: magnetic resonance imaging.

To evaluate the information obtained by magnetic resonance (MR) imaging, the radiographic and MR investigations of nine patients treated for idiopathic tibia vara were reviewed in retrospect. There were six unilateral and three bilateral cases (12 tibiae). Initial radiographs of each patient were assigned a stage according to Catonné's classification. MR imaging was performed with a 0.5- or 1.5-T apparatus. Bony epiphyses were poorly developed in all cases. The cartilaginous component of the epiphyses compensated partially (6/12 cases) or completely (6/12 cases) for the collapse of the physes. In two cases an abnormal area was found between the medial meniscus and the cartilaginous portion of the epiphysis. An abnormally large medial meniscus was noted in four cases; an abnormal signal in the medial meniscus was seen in two cases. MR imaging has several advantages over plain film: it uses no ionizing radiation, it shows the shape of the ossified and cartilaginous epiphysis, and it demonstrates meniscal and physeal abnormalities. MR imaging may influence the choice of treatment.

Spontaneous portal venous gas in a patient with Crohn's ileocolitis.

In a 70-year-old man with Crohn's ileocolitis who presented with a sudden fever, ultrasound and computed tomographic (CT) examinations showed hepatic portal venous gas (HPVG). Abdominal plain film was normal. The course was benign with medical management. The authors review previous cases of portal vein gas in intestinal inflammatory diseases.

[Fine-needle biopsy and core biopsy in nonpalpable breast lesions. How does one judge with mammography?]. / Cytoponctions et ponctions biopsiques des lésions mammaires non palpables. Comment prélever en mammographie?

Techniques for localizing and sampling subclinical lesions seen on mammograms are reviewed. Localization of the lesion, the equipment used (fine-needle aspiration or core biopsy), and harvesting techniques are discussed, with special emphasis on quality criteria that should be satisfied to ensure optimal histologic performance.

Padronização da rotina operacional em banco de ossos realizada por um serviço hemoterápico: propostas de elaboração de normas / Guidelines to standardize an operation routine manual of a bone bank at Sírio-Libanês Hospital

Desde 1970 vem ocorrendo crescimento na utilização de ossos alogênicos em vários procedimentos ortopédicos, resultando na criação de bancos de ossos no mundo todo. Com o propósito de minimizar a morbidade nos receptores de ossos e padronizar procedimento operacionais para banco de ossos, os autores consideram necessário e fundamental estabelecer normas e critérios para regulamentar a doação de ossos. Seu objetivo é propor uma padronização para procedimentos operacionais em banco de ossos no Brasil. Com a finalidade de padronizar um manual operacional, vários manuais de padronização provenientes de instituições internacionais foram consultados, juntamente com a Portaria 1.376 do Ministério da Saúde (1993), por ser esta a referência concernente à doação de sangue no Brasil. Dessa maneira, parece ser plausível a adaptação de regulamentos internacionais para banco de ossos à legislação brasileira. Um manual de procedimentos operacionais em banco de ossos foi desenvolvido com o objetivo de padronizar os critérios para a retirada, identificação, processamento, estoque e liberação do material doado. Nesse manual também estão contidos os testes sorológicos mínimos para a investigação de doenças infecciosas e testes microbiológicos para o descarte de material contaminado. O banco de ossos necessita de um programa de controle de qualidade similar ao do banco de sangue. É recomendado que o banco de ossos seja gerenciado pelo banco de sangue, por sua experiência gerencial e sua estrutura operacional adequada para o manuseio do material doado.