[Infections in interventional electrophysiology]. / Infections en rythmologie interventionnelle.

The implantation of pacemakers and defibrillators carries the highest risk of infection in interventional electrophysiology. The use of implantable cardiac devices is continually increasing with almost 2 million devices implanted worldwide each year. The recipients' profile may also be associated with an increased risk of infection. Several measures can be implemented to reduce the risk of device-related infection. Systematic antibiotic prophylaxis has proven to be beneficial provided that prescription modalities are respected, especially with respect to the selection of the appropriate molecule and timing of administration prior to the procedure. Despite all the precautions taken during surgery (asepsis, prophylactic antibiotic therapy….) the estimated rate of peri-procedural infection is around 2%. Device related infections are associated with a high rate of morbidity and mortality as well as substantial healthcare costs. Staphylococcus aureus (SA) and epidermidis (SE) are the pathogenic agents involved in most cases. Prevention is crucial given the difficulties in treating such infections because of the near-systematic need to remove the device and antibiotic resistance. Leadless pacemakers and subcutaneous defibrillators are potential alternatives to implantable endocardial devices, albeit with certain limitations. A group of experts has recently issued consensus paper on the prevention, diagnosis and treatment of infections associated with endocardial implantable cardiac devices.

[Screening for familial hypercholesterolemia from low-density lipoprotein cholesterol levels at admission in the coronary care unit]. / Dépistage de l'hypercholestérolémie familiale à partir du LDL cholestérol à l'admission en unité de soins intensifs cardiologiques.

BACKGROUND: Familial hypercholesterolemia (FH) is a frequent genetic disorder that leads to premature atherosclerosis and coronary artery disease. However, knowledge of FH by cardiologists is weak, and FH remains underdiagnosed in France. FH should be suspected when low-density lipoprotein cholesterol (LDLc) levels exceed 1.9g/L (4.9mmol/L) without lipid lowering therapy. PURPOSE: This multicenter retro- and prospective observational study aimed at estimating the prevalence of high LDLc levels in patients admitted in coronary care units, and the impact for the personal and familial follow-up for lipid status. METHODS: Retrospective analysis of all plasma lipid measurements performed at admission in coronary care unit of 4 hospitals in 2017. Retrospective analyses of demographic, clinical, and coronary data of consecutive patients with LDLc levels≥1.9g/L. Prospective 1 year follow-up focused on lipid levels, treatments, and personal and familial screening for FH. RESULTS: Lipid measurement has been performed in 2172 consecutive patients, and 108 (5%) had LDLc level≥1.9g/L (mean age 64±14 years, men 51%). The primary cause of the hospitalisation was acute coronary syndrome (78%), and 22% of patients were free off coronary artery disease. Lipid lowering therapy was present in 9% of patients at admission, and 84% at discharge, with high statins regimen. At 1-year follow-up, control of LDLc level was not performed in 20% of patients, and statin dose was decreased (36%) or withdrawn (7%) in 43%. Lipid measurement has been performed in at least one first degree relative in 37% of patients, and genetic exploration has been done for 3 patients. CONCLUSIONS: Screening of FH in CCU should be routinely performed using the Dutch Score when LDLc is above 1.9g/L. Individual and familial management of patients at high risk for FH screened in CCU should be optimized, both for diagnosis and therapeutic purposes.

Delays in diagnosis and melanoma prognosis (I): the role of patients.

A prospective survey was conducted to assess the role of patients in the melanoma prognosis. Consecutive patients with primary melanoma were interviewed and examined using a comprehensive questionnaire including a psychological instrument. Main outcome measures were the delay before medical intervention and the tumor thickness. Of 590 melanomas, 70.8% were detected by patients and this proportion was higher in females. Relatives were involved in the detection of half of the cases. Median delays before the patient realized he had a suspicious lesion, before this lesion was seen by a doctor, and before the melanoma was removed were 4 months, 2 months, and 1 week, respectively. Delays up to several years were observed in some cases. The rate of self-detection tended to be lower, the delays before seeking medical advice to be longer, and the tumor thickness to be higher in old people, in males, in lower-educated individuals, in those living out of towns, and in people with a low awareness about melanocytic tumors than in other cases. Conversely, individuals with a high number of atypical nevi, those who were aware to be at risk, and those who regularly visited a dermatologist tended to detect their melanoma more rapidly. No specific psychological traits were associated with a late reaction, although negligence and anxiety tended to prolong the delays. Knowledge about melanoma was poor in many patients, especially in males, and wrong beliefs were widespread. This study provides the targets of future education programs.

Delays in diagnosis and melanoma prognosis (II): the role of doctors.

A prospective survey was conducted to assess physician responsibility in melanoma prognosis. Consecutive patients with primary melanoma were interviewed and examined using a standardized questionnaire. Main outcome measures were medical components of the delay before tumor resection and tumor thickness. Of 590 melanomas, 29.1% were coincidentally detected by physicians and their tumor depth was lower than in melanomas detected by patients (p < 0.001). Physician sensitivity for melanoma diagnosis was evaluated at 86%. Median time intervals to propose resection and to perform removal of melanoma were short: 0 (mean 103) and 7 (mean 68) days, respectively. Melanomas were managed in an inappropriate way in 14.2% of cases. Location on acral areas and absence of pigmentation were associated with longer medical delays and more frequent inappropriate medical attitudes. Melanomas located on hardly visible areas were less frequently detected by physicians than those on visible areas. Medical delays were shorter, doctor's attitude was more frequently appropriate, and melanoma thickness was lower (p < 0.001) when the patient visited a dermatologist (54.7%) than when he or she visited a general practitioner (33.4%). Our study shows that doctor responsibility accounts for only a small part of the total delay before melanoma removal. However, systematic total examination and better training of doctors, especially about unusual forms of melanoma, could still improve melanoma detection.

Melanoma and tumor thickness: challenges of early diagnosis.

OBJECTIVE: To test the basic assumption of campaigns for early diagnosis of melanoma, ie, prognosis is correlated with the delay in the diagnosis. DESIGN: Prospective study of the correlation between delays to diagnosis, assessed using a questionnaire, and the Breslow thickness as a prognosis marker. SETTING: Dermatology departments in France. PATIENTS: Five hundred ninety consecutive patients, referred within 12 weeks after resection of cutaneous melanoma. MAIN OUTCOME MEASURES: Assessment of 5 successive time intervals from the first time the patients realized that they had a lesion until the resection of the melanoma, and results of the correlation between each time interval and tumor thickness (Breslow). RESULTS: There is a positive but weak correlation between tumor thickness and the delay to identify a lesion as suspicious (r = 0.17; P = .009). However, this delay tends to be short for the thickest tumors. There is a negative correlation between tumor thickness and the delay to seek medical attention (r = -0.20; P<.001). This delay was shorter for nodular melanoma. No correlation is found between melanoma thickness and physicians' delays. CONCLUSIONS: Poor prognosis can be accounted for by aggressive rapidly growing tumors rather than by delays. In well-informed populations, campaigns for early diagnosis of melanoma may thus no longer have a major impact on prognosis, unless they are focused on subgroups less accessible to information and medical care.

[Delay in diagnosing melanoma. A prospective study in 102 patients]. / Délai de diagnostic du mélanome. Etude prospective chez 102 malades.

INTRODUCTION: Knowledge of the causes of melanoma and reasons for diagnosis delay is essential for early management. PATIENTS AND METHODS: One hundred two patients consulting for melanoma at the Saint-Louis Hospital in Paris from January 1, 1994 to December 31, 1995 were asked to respond to a standardized questionnaire. Time to diagnosis and the different time fractions were analyzed by socio-demographic characteristics and by pathology features. RESULTS: Meantime from the first signs of a new lesion or modification of an old lesion to exeresis of melanoma was 20.4 months. Most of the delay prior to diagnosis was patient-related; lack of knowledge about the early clinical signs of melanoma appeared to be the most important cause of delay. Time to diagnosis was not significantly correlated to the thickness of the melanoma. DISCUSSION: Our results are compared with two similar series reported in other countries during the last ten years. The lack of correlation between the thickness of the melanoma and time to diagnosis appears to be explained, at least in part, by the biological variability of melanomas.

[Multinucleated cell angiohistiocytoma. Report of 6 cases]. / Angiohistiocytome à cellules multinucléées. A propos de six cas.

Multinucleate cell angiohistiocytoma is a recently described entity. It is a benign vascular proliferation. Clinically, it is characterized by violaceous red papules, often mimicking Kaposi's sarcoma. Acral sites and face were the commonest sites. The six patient's age was between 41 and 64 years and sex ratio was equal. Microscopic features were an increased number of blood vessels together with mononucleated and multinucleated histiocyte-like cells with scalloped borders. Staining of mononucleated cells with CD68, anti vimentin and anti factor XIIIa antibodies emphasized a fibrohistiocytic origin. Loss of factor XIIIa expression in multinucleate cells gets clue to think that these cells are dedifferenciated.

[Follicular basaloid hamartoma localized in the sacral region with papular plaque-type]. / Hamartome basaloide folliculaire localisé en plaque papuleuse de la région sacrée.

INTRODUCTION: Basaloid follicular hamartoma is a benign tumor with superficial dermal proliferation of thin basaloid cords in a fibrous stroma. CASE REPORT: A congenital case with sacral plaque-like papules is described. DISCUSSION: Three different forms have been reported: a solitary form (usually an alopecic scalp plaque), a generalized acquired form associated with myasthenia, and a linear form. Histological diagnosis may be difficult and require clinico-pathological evaluation.

[Hypopigmented mycosis fungoides]. / Mycosis fongoïde hypopigmenté.

INTRODUCTION: Isolated areas of hypopigmented skin can be a manifestation of mycosis fungoides. This is a rare clinical form with a particular clinical course and histology which has been described only in black subjects. CASE REPORT: Over a 10-year period, a 28-year-old woman from Mali developed non-infiltrated hypopigmented and discretely squamous macules involving the entire body. The diagnosis of mycosis fungoides was made on pathology evidence of epidermotropic lymphocyte infiltration with a few small nests. PUVA led to rapid regression of the lesions. DISCUSSION: Hypopigmented mycosis fungoides has been described in young black subjects (mean age 19 years). The diagnosis is usually made late because benign skin affection is usually the first diagnosis (pityriasis alba, pityriasis versicolor). The pathogenesis of these hypopigmented lesions is not known. PUVA appears to be effective in most cases.

Plasma thrombomodulin level in malignancy varies according to the tumor type.

Plasma thrombomodulin (TM) level was measured by ELISA in patients with either digestive tract cancers or malignant melanomas. A striking difference was seen between tumor types with an increase in the TM level of the former and a decrease in the latter. This finding is in agreement with the classification of tumors previously proposed by Zacharski et al.

[Intravascular vegetating hemangioendothelioma]. / Hemangioendotelioma vegetante intravascular.

In 1928, P. Masson described in hemorrhoids a peculiar lesions which he called "intravascular vegetating hemangioendothelioma". The possibility of cutaneous location of this lesion was demonstrated only in 1967. Rare if isolated, the intravascular vegetating hemangioendothelioma is often associated with other vascular lesions such as polyps, hemorrhoids, etc. Always benign, this tumor may be misdiagnosed as an angiosarcoma by inexperienced pathologists. In this article, three additional cases are described, the histological differences with an angiosarcoma are stressed and the pathogenesis of this lesion is discussed.