Efficacy of intravenous iron therapy in non-anaemic iron-deficient patients with fatigue.

Iron deficiency, without anaemia, is common in the general population and induces various symptoms. Its management consists of oral and intravenous supplementation for cases of inefficacy of or intolerance to oral iron. We assessed the efficacy of intravenous iron therapy in non-anaemic iron-deficient patients with fatigue. We prospectively evaluated the level of fatigue, using the Fatigue Severity Scale (FSS), in patients suffering from iron deficiency without anaemia, treated by intravenous iron at the moment of the perfusion (W0), after 4 weeks (W4), and 12 weeks (W12). Of 25 patients, at W0, the mean FFS was 49.3+/-13.7. There was a significant improvement in FSS at W4 (44+/-15; p = 0.01) and a sustained response at W12 with an FFS of 35.8+/-17.1 (p < 0,0001). There was no correlation between FSS and serum ferritin level at W12 (p=0.54) or between serum ferritin at W12 and difference between FSS at W0 and W12 (p=0.58). There were six mild adverse events (24%): asthenia (8%), nausea (8%), headache (4%), local pain (4%); and no serious adverse events. Our results suggest the rapid efficacy of intravenous iron in improving fatigue in iron deficiency without anaemia with a good profile of tolerance.

[Duration of seclusion and exit of the seclusion room, study of the impact of anamnestic and institutional factors]. / Durée d'isolement et levée de la mesure ; étude de l'influence des facteurs anamnestiques et institutionnels.

INTRODUCTION: In France, the use of seclusion in psychiatric hospitals is regulated by the Act of January 26th 2016 which enforces a reduction of the use of coercive measures and limiting their duration. Criteria that are unrelated to the patient's symptoms might affect this decision and extend the duration of seclusion. The goal of the current observational study is, firstly, to determine which factors - unrelated to the patient's symptoms - influence the length of stay in seclusion. Secondly, it is to compare the composition of the medical and nursing teams at two times, the beginning and the end of the seclusion time period. METHOD: We conducted this study in a La Rochelle regional hospital from October 2017 to July 2018. There were one hundred and twenty-four episodes of seclusion that occurred in the different psychiatric inpatient wards during this time. The episodes were divided into two groups: short-term and long-term seclusion, defined by the median duration of seclusion. Data were collected using a survey, completed by the nursing teams, based on the recommendations of good clinical practice published in 1998 and revised in 2017 by the French health authority. For each episode of seclusion, we collected the following data: socio-demographic information, history of psychiatric care of the patient and of violent acting-out, admission status, medical indication for seclusion, day of the week and time at the beginning and the end of seclusion, prior administration of a sedative before seclusion, exceptional events that might justify the end of seclusion, transfer to a protected room after seclusion, as well as the composition of the medical and nursing team on duty at the beginning and the end of the seclusion period. We compared the anamnesis between the short-term and the long-term seclusion groups, and we analyzed the composition of the medical and nursing teams at the two time points of seclusion. Statistical analyses were performed using R software (v. 3.5.1). RESULTS: The mean duration of seclusion was 4.7 days and the median was 1.9 days. The average age was 37-years-old, with a ratio of 0.6 for females to males. Variables associated with a long-duration of seclusion were: the male gender (P=0.005), Compulsory Admission at the Request of a State Representative (P=0.008), a prevention measure of any hetero-aggressive action (P=0.007), the lack of psychiatric care (P=0.004), previous medico-legal issues (P=0.006), violent behavior during a previous hospitalization (P=0.022) and the use of seclusion on the weekend (P=0.01). The composition of the medical and nursing teams related to the period of the end of seclusion were: the presence of the physician in charge of the patient (P<0.001), a male caregiver in the team (P<0.001), a specialized psychiatric nurse (P<0.001) and the training of caregivers in the management of violence (P<0.001). The presence of nurses who do not usually work in the psychiatric ward was associated with the period of the beginning of seclusion (P<0.001). CONCLUSION: Our findings showed a strong relationship between several anamnestic factors and the duration of seclusion. Caregivers lacking information about patients, potential violent behaviors and the beginnings of seclusion on weekends are associated with a long-duration of seclusion. Our study also highlights the roles played by the caregivers according to their composition and level of training to determine the ending of patient's seclusion.

[Retinal vein occlusion in a young patient: Where does intraocular hypertension come from?] / Occlusion de la veine centrale de la rétine chez un sujet jeune : chercher d'où vient l'augmentation de pression intraoculaire.

INTRODUCTION: Retinal vein occlusion presents as an acute, painless and unilateral sight loss. We report two cases of retinal vein occlusion (CRVO) in which the etiology was unusual. CASE REPORTS: Case 1. A 54-year-old woman without any significant past medical history presented with an acute loss of vision. Medical history taking revealed the practice of yoga with headstand posture like "Sirsana". Case 2. A 35-year-old woman presented with an acute loss of vision related to a retinal vein occlusion. The investigation found prolonged and repeated vomiting the days before the retinal vein occlusion. CONCLUSION: Cardiovascular assessment is recommended in the investigation of CRVO. Furthermore, especially in young patients, a situation causing an increase of intraocular pressure as the practice of yoga with taking reverse "head down" body positions or even repeated vomiting efforts may be the cause of slower circulation of blood flow in the retinal veins.

[Rituximab-induced acute thrombocytopenia in a patient with chronic lymphocytic leukemia]. / Un cas de thrombopénie aiguë au rituximab dans la leucémie lymphoïde chronique.

INTRODUCTION: Rituximab is a chimeric anti-CD20 monoclonal antibody generally well tolerated. However, a severe but rare rituximab-related immune-toxic syndrome, associating fever, chills and thrombocytopenia can occur shortly after the infusion. CASE REPORT: We report a case of severe acute rituximab-induced thrombocytopenia with favorable outcome in a patient with chronic lymphocytic leukemia and discuss the possible underlying mechanisms. CONCLUSION: Despite the potential initial severity of rituximab-induced thrombocytopenia in CLL, chemotherapy should not be discontinued; tolerance might increase as the hematologic disorder is controlled.

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

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

[Subarachnoid hemorrhages form ruptured aneurysms as the presenting feature of lupus cerebral vasculitis]. / Hémorragies cérébro-méningées sur ruptures d'anévrismes inaugurales d'une vascularite cérébrale lupique.

Cerebral aneurysms secondary to cerebral vasculitis related to systemic lupus erythematosus are rare. We report a 31-year-old woman who presented with a lupus flare associated with inaugural generalized seizures. Computed tomography angiography showed subarachnoid hemorrhage by rupture of a cerebellar artery fusiform aneurysm. Later, despite the initiation of corticosteroids and cyclophosphamide, she presented a second cerebral hemorrhage due to the rupture of a new aneurysm in lenticulostriates arteries. The outcome was fatal. We discuss the frequency and management of this severe complication of systemic lupus erythematosus.

[Severe hypoglycemia induced by tramadol: two new cases of an unlisted side effect]. / Hypoglycémies sévères au tramadol : deux nouvelles observations d'un effet indésirable non référencé

INTRODUCTION: Tramadol is a weak opioid analgesic used as a step two analgesic, approved in France for the treatment of moderate to severe pain in adult patients. The most common side effects are gastrointestinal and neurologic. Hypoglycaemia is an almost unknown side effect. CASE REPORTS: We report two patients who presented with severe hypoglycaemia related to oral administration of tramadol in non diabetic patients. The underlying mechanisms of hypoglycaemia induced by tramadol are unclear. The only weak opioid analgesic drug reported to cause hypoglycaemia is propoxyphene, which has been widely used in France. The recent withdrawal of dextropropoxyphene in France might increase the prescriptions of tramadol and healthcare professionals should be aware of the risk of hypoglycaemia. CONCLUSION: The risk of hypoglycaemia should be added to the summary of product characteristics of tramadol.

Dual mobility design use in preventing total hip replacement dislocation following tumor resection.

INTRODUCTION: Total hip replacement (THR) following hip tumor resection incurs a high risk of dislocation. We assessed the incidence of dislocation associated with use of a dual mobility cup,and the functional results achieved. HYPOTHESIS: Use of a dual mobility cup would reduce the risk of THR instability following hip tumor resection. MATERIAL AND METHODS: We analyzed dislocation rates in a retrospective series of 71 dual mobility cup THRs implanted following the resection of a tumor hip condition: 33 primary bone tumors and 38 bone metastases. The presenting pathology was diagnosed anatomically, and surgery classified in terms of adopted abductor system strategy. Functional results were assessed in terms of pain (analgesia on the World Health Organisation [WHO] scale), assisted walking and Musculoskeletal Tumor Society (MSTS) score. RESULTS: An overall rate of 9.8% dislocation was observed, taking into account all etiologies and contexts together. More precisely, this rate resulted from a compound figure of 5.2% in bone metastasis and 15% in primitive bone tumor. Dislocation risk depended lesson etiology than on the surgical management of the abductor system, being 3.5% in the case of abductor conservation, 9.5% in the case of abductor sectioning/reinsertion, and 18%in case of gluteus medius muscle or nerve resection. Functional improvement was consistently observed, especially in bone metastasis. At the maximal follow-up, 32 patients were not using analgesics, six were taking WHO class III analgesics, 10 class II and 23 class I. Mean MSTS score was 68.1% +/- 23.5% in bone metastasis and 59.6% +/- 17.5% in primary bone tumor.Fourteen patients could walk without assistance, 33 with a single cane, 15 with two canes and eight with a walker; one patient had not been able to resume walking. DISCUSSION: In these indications, dual mobility cups use lead to lower dislocation rates than those reported in the literature. It proved especially effective in the case of bone metastasis and consolidation surgery. In the case of primary bone tumor, it failed to prevent dislocation following acetabular resection, especially when involving the abductor muscles and/or abductor innervation, although it provided lower dislocation rates, comparable to those experienced with other techniques, when applied to limited resection. LEVEL OF EVIDENCE: IV. Retrospective therapeutic study.

Grimontia hollisae, a potential agent of gastroenteritis and bacteraemia in the Mediterranean area.

Vibrio hollisae was first described in 1982 as an agent of diarrhoea and was reclassified in 2003 into a novel genus as Grimontia hollisae. We report the first case of G. hollisae bacteraemia in the Mediterranean area, in an 81-year-old man with a severe gastroenteritis and hepatitis following the consumption of raw oysters. The incidence of this micro-organism as an agent of gastroenteritis may be underestimated because it may not be detected using routine culture conditions.

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

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

[Clinical implications of high cobalamin blood levels for internal medicine]. / Implications cliniques de la découverte d'une hypervitaminémie B12 en médecine interne.

PURPOSE: The high incidence of cobalamin (vitamin B12) deficiency results in frequent dosages of this vitamin in a department of internal medicine may reveal paradoxically high blood levels of cobalamin. The objective of the study was to estimate underlying diseases and potential diagnostic relevance of high cobalamin blood levels in internal medicine. METHODS: A retrospective study was conducted, including in-patients from December 2005 to July 2006 presenting high cobalamin blood levels, as determined with our laboratory normal values (200-950 pg/mL). RESULTS: High cobalamin blood level is not unusual (18.5% of all dosages) and, most of time, it is associated with one or several diseases, among which acute and chronic liver diseases (often of alcoholic origin), various neoplasias, malignant hemopathies (myelodysplasia, myeloproliferative diseases, multiple myeloma), renal insufficiency and transient hematologic abnormalities (neutrophilic hyperleucocytosis, hypereosinophilia). Vitamin B12 supplementation and chronic myeloid leukemia represent less than 5% of all hypervitaminemia. There is no correlation between the level of cobalamin blood level and the number of underlying diseases for each patients. However, very high cobalamin blood levels (>1275 pg/mL) are significantly associated to malignant hemopathies (p<0.05). It is noteworthy that most of diagnosed neoplasia were unknown and at a non-metastatic stage. CONCLUSION: Very high cobalamin blood levels are significantly associated to malignant hemopathies among the population of a department of internal medicine. Referent laboratory should actively advertise the numerous diseases involved with high cobalamin blood levels.

[Dermatomyositis associated with hepatosplenic gamma delta T-cell lymphoma]. / Lymphome T gamma delta avec atteinte méningée exclusive révélé par une dermatomyosite.

INTRODUCTION: Peripheral T cell lymphomas are a heterogeneous group of post-thymic, mature lymphoid malignancies, accounting for approximately 10-15% of all non-Hodgkin's lymphomas. A rare entity within this group is represented by hepatosplenic T cell lymphoma, characterized by primary extranodal disease with infiltration of the liver and the spleen and by expression of the T cell receptor gamma delta chain. EXEGESIS: A 64-year old man with dermatomyositis developed rapid-onset paraparesia and deafness. Cerebrospinal fluid analysis revealed large granular lymphomatous cells with CD3+ CD4- CD8- CD7+ CD16- CD56- surface antigens, expressing the gamma delta T-cell receptor. There was no evidence of skin or bone marrow infiltration by lymphoma or any other involvement. This is the first report of dermatomyositis associated with a gamma delta T-cell lymphoma (GDTL). Moreover, primitive and isolated meningeal involvement of such lymphomas has never been described before. CONCLUSION: GDTL should be added to the differential list of neoplasia associated with dermatomyositis. Physiopathological mechanisms implicated in the neurological involvement of such lymphomas need to be elucidated.

[Auto-immune hepatitis and antiphospholipids]. / Etude de l'association hépatite auto-immune et antiphospholipides.

INTRODUCTION: Only few series have reported the association of autoimmune hepatitis with antiphospholipid antibodies. The aim of our study is to investigate the frequency of these antibodies in a series of autoimmune hepatitis and to search for a correlation with clinical, biological or histological characteristics. MATERIAL AND METHODS: Antiphospholipid were investigated in 24 patients with well defined autoimmune hepatitis. Characteristics were compared between antiphopholipids positive and negative patients. Characteristics of our patients were also compared toward cases collected in a literature review. RESULTS: The frequency of antiphospholipid antibodies is of 70.8% in our series. Four patients had a well defined antiphospholid syndrome. Seven patients had a systemic lupus erythematosus in the antiphospholipid group whereas none in the antiphospholipid negative group. The frequency of the different antiphopholipid antibodies was: IgG ACL (52.9%), IgM APE (52.9%), ACC (43.7%), IgG Abeta2GP1 (41.2%). We found no correlation between hypergammaglobulinemia and the presence or the isotype of antiphospholipid antibodies. Clinical presentation and outcome as biological and histological parameters were similar in both groups. CONCLUSION: Our study report a high frequency of antiphospholipids antibodies in autoimmune hepatitis patients. However we found no clinical, biological or histological correlation with the presence of antiphospholipids. Further longitudinal studies on larger cohorts should clarify the association between antiphospholipid antibodies and autoimmune hepatitis and potential therapeutic issues.

[Central nervous system HIV-associated polyarteritis nodosa: long-term outcome]. / Devenir à long terme d'un cas de périartérite noueuse cérébrale associée au VIH.

INTRODUCTION: HIV-associated vasculitis is an infrequent entity, and only few data about its long-term evolution is available. EXEGESIS: We report the long-term outcome of a patient with central nervous system HIV-associated periarteritis nodosa and then discuss the therapeutic options for this class of vasculitis. CONCLUSION: This observation highlights the role of HAART in the treatment of HIV-associated vasculitis. Persistent remission can be obtained when viral replication is under control.

[Therapeutic intensification and autologous stem cell transplantation in autoimmune diseases]. / Intensification thérapeutique et autogreffe de cellules souches hématopoïétiques pour le traitement des maladies auto-immunes.

THE PATHOPHYSIOLOGY of most autoimmune diseases is often poorly understood. EXPERIMENTAL CONSIDERATIONS and clinical experience suggest that high doses immunoablation followed by stem cell transplantation is a therapeutic option to consider for certain severe autoimmune disorders. THE CONCEPT OF RESTORING NORMAL IMMUNE REACTIVITY must in part br true since current results of 466 transplants (445 autologous, 21 allogeneic) patients suffering from various autoimmune diseases show a beneficial outcome in approximately 2/3 of the patients. TO IMPROVE THE EFFICACY AND SAFETY OF SUCH AN AGGRESSIVE PROCEDURE in patients with potentially affected vital organs by the underlying autoimmune disease, it is especially important to follow international consensus guidelines and to centrally collect clinical data for in depth analysis in the EBMT International Stem Cell Project for Autoimmune Disease in Basel, Switzerland. PHASE III STUDIES ARE RUNNING FOR SYSTEMIC SCLEROSIS (Astis, Autologous Stem cell Transplantation International Rheumatoid Arthritis Trial) started in 2003. A STUDY PROJECT IS PLANNED FOR MULTIPLE SCLEROSIS (Astims, Autologous Stem cell Transplantation International Multiple Sclerosis).

[Avulsion fractures of the greater trochanter in children: two cases, review of the literature and proposition for a classification]. / Décollement épiphysaire du grand trochanter de l'enfant et proposition d'une classification. A propos de deux cas et revue de la littérature.

Avulsion fractures of the greater trochanter are very rare in children. We report two such cases which led to femoral head necrosis. Based on these two cases and an extensive review of the literature, we discuss the pathophysiology of this complication and propose a new classification system. Three types of lesions can be identified as a function of the mechanism causing fracture. Type 1 lesions are avulsion fractures of the greater trochanter secondary to acute contraction of the gluteus muscles. This contraction produces a vertical displacement of the greater trochanter. Femoral head necrosis has never been reported as a complication after this type of fracture mechanism. Type 2 avulsion fractures are associated with fracture of the femoral neck with a subsequent risk of femoral head necrosis. Type 3 associates hip dislocation with apophyseal avulsion with, according to the literature, an inevitable progression to head necrosis. The two cases reported look identical with those described by Linhart and Kawenblum illustrate type 3 avulsion fractures of the greater trochanter.