[Libman-Sachs endocarditis and ischemic stroke: A case report]. / Endocardite de Libman-Sachs et accident vasculaire cérébral ischémique : à propos d'un cas.

Libman-Sacks endocarditis is a rare cardiac manifestation of anti-phospholipid syndromes, in which non-infectious thrombotic vegetations are found on the heart valves. Most patients are asymptomatic whereas the risk of thromboembolism is considerable. Diagnostic work-up is based on questioning and clinical examination data looking for extracardiac signs, biological data and also on imaging, and, above all, echocardiography. We report the case of a 47-year-old female patient with no known history who is admitted to hospital with paresthesia of the right hemi-body associated with dysarthria. Cerebral CT scan confirms a paraventricular ischemic stroke. The etiological work-up for stroke is negative except the transesophageal echocardiogram which reveals mitral valve vegetations. Further investigations lead to the diagnosis of Libman-Sacks endocarditis. Treatment with Coumadin is started, with a target INR of between 2 and 3, as recommended. The clinical course was favourable, with stable lesions on transoesophageal echocardiography carried out later.

[COV IMPACT: Stress exposure analysis among hospital staff in 2 hospitals in France during the COVID-19 pandemic]. / COV IMPACT : analyse des différents facteurs de stress du personnel hospitalier dans 2 centres hospitaliers en France lors de la pandémie COVID-19.

The COVID-19 pandemic has swept through our hospitals which have had to adapt as a matter of urgency. We are aware that a health crisis of this magnitude is likely to generate mental disorders particularly affecting exposed healthcare workers. Being so brutal and global, this one-of the kind pandemic has been impacting the staff in their professional sphere but also within their private circle. The COV IMPACT study is an early assessment survey conducted for 2 weeks in May 2020, of the perception by all hospital workers of the changes induced in their professional activity by the pandemic. The study was carried out by a survey sent to the hospital staff of Béziers and Montfermeil. The readjusted working conditions were source of increased physical fatigue for 62 % of the respondents. Moral exhaustion was reported by 36 %. It was related to the stress of contracting the infection (72 %) but above all of transmitting it to relatives (89 %) with a broad perception of a vital risk (41 %). This stress affected all socio-professional categories (CSP) and was independent of exposure to COVID. Change in organisation, lack of information and protective gear and equipment were major factors of insecurity at the start of the epidemic. Work on supportive measures is necessary. It should focus on the spread of information, particularly towards the youngest, as well as bringing more psychological support and a larger amount of medical equipment, beyond healthcare workers and the COVID sectors.

[Haemostasis. Aspirin and clopidogrel platelet resistances]. / Hémostase. Résistances plaquettaires à l'aspirine et au clopidogrel.

Articles on antiplatelet "resistance" or "nonresponder" subjects now appear in the medical literature or in the media on a regular basis. The clinical consequences of such biological resistances are yet uncertain. In this review, we describe the concepts of specific and non specific resistances according to the tests used and summarize the main studies up to now. If antiplatelet drug resistances are shown to be predictive of cardiovascular events in large prospective studies, tailoring antiplatelet drugs could be beneficial and, therefore, warranted. New compounds with a more potent effect are emerging and might be useful in clinically relevant resistances.

Synthesis, characterization and liquid chromatographic behaviours of a new chemically bonded liquid crystal.

A new bonded liquid crystal stationary phase (2OC12) for high-performance liquid chromatography was studied. It resulted from coupling of LiChrospher Si 100 NH2 and a mesogenic carboxylic acid, 4-(4-(4-(3,4-didoceyloxystyrenyl)phenyl-diazenyl)phenyloxy-methylene) benzoic acid (ILC). ILC was characterized with proton NMR and differential scanning calorimetry, while 2OC12 was characterized by solid state 13C NMR and elemental analysis. 2OC12 surface area was determined by the BET method. The chromatographic behaviour of 2OC12 was investigated under both normal- and reversed-phase conditions. The plots of ln k against 1/T showed transition temperatures at 325 and 337 K. Polyaromatic hydrocarbons (PAHs) were separated using hexane, isooctane or hexane-chloroform. Above the transition temperatures, the bonded material exhibited a liquid crystal-like behaviour: (i) the plate number N was always highest possible, and (ii) the more retained the solute the more elongated it was (anthracene is eluted after phenanthrene, chrysene before tetracene, pentacene after dibenzo-a,h-anthracene). Using acetonitrile/water (60/40), reversed-phase data of aromatic hydrocarbons are similar (highest values of N, better resolution below than during the transitions).

Synthesis and properties of two new liquid crystals: an analytical and thermodynamic study.

Synthesis, analytical performances, thermodynamic and surface properties of two new liquid crystals substituted with poly(ethylene oxide) chains are described. The first of them is N,N'-diphenyl-[4-[2,3,4-tri[2-(2-metoxyethoxy)ethoxy]benzylidene]i mine]piperidine (LC1) and the second is 2-hydroxy-3-methyl-4-[4-[2-(2-butoxyethoxy)ethoxy]] 4'-[4-[2-(2-butoxyethoxy)ethoxy]styryl]azobenzene (LC2). The nematic ranges of the two liquid crystals, determined by differential scanning calorimetry do not interfere. The analytical and thermodynamic studies of LC1 and LC2 in the solid, nematic and liquid state were done using a series of appropriate solutes. Comparison of the analytical performances shows a better efficiency in the nematic state.

[Repolarisation anomalies simulating anterior myocardial infarction during ischemic cerebrovascular accident]. / Anomalies de la repolarisation simulant un infarctus du myocarde antérieur au cours d'un accident vasculaire cérébral ischémique.

The authors report the case of a woman admitted to hospital for minor trauma of the left hip and who presented major ST segment elevation on the second day suggesting an acute anterior wall myocardial infarction at the same time as a cerebrovascular accident. Complementary investigations and follow-up excluded the diagnosis of myocardial infarction with normalisation of the ECG on the 5th day. ECG changes during cerebrovascular accidents may be very variable ranging from extrasystoles to ST elevation mimicking myocardial infarction. They carry a poor prognosis with an increased risk of sudden death necessitating continuous ECG monitoring until the ECG reverts to normal. The cardiac involvement is not ischaemic but due to disease of the insular cortex of the brain which induces myocytolysis (centered around the intra-cardiac nerve endings) due to the sudden liberation of catecholamines. These lesions may be treated by propranolol or phentolamine.

[Bartonella endocarditis on native valves. Apropos of 2 cases]. / Endocardite a Bartonella sur valve native. A propos de 2 cas.

The authors report two cases of Bartonella endocarditis in native valves. The first case was a 15 year old North African Girl who lived in poor social conditions and was admitted to hospital with pyrexia and congestive heart failure. Investigations revealed massive mitral regurgitation due to ruptured chordae tendinae, vegetations on the pulmonary valve with severe pulmonary hypertension due to persistent ductus arteriosus. After antibiotic therapy, the patient underwent surgery for mitral valve replacement, pulmonary valvuloplasty and closure of the patent ductus arteriosus. The second case was a 39 year old man with no fixed abode with a history of alcoholism who presented with a recurrent ischaemic stroke in a context of infection with a murmur of aortic regurgitation. Echocardiography showed a vegetation on the aortic valve with grade III/IV regurgitation requiring aortic valve replacement with a homograft after antibiotic therapy. The aetiological diagnosis was made a posteriori by the finding of high antibody titres and specific genetic amplification of Bartonella. In patients with negative blood cultures, Bartonella infection should be looked for systematically especially in those living under poor social conditions. The practical diagnostic investigation of endocarditis with negative blood cultures is reviewed.

[Chronic obliterative arterial disease of the lower limbs in the coronary patient: prevalence and prognostic incidence. The Monica Toulouse register]. / Artériopathie chronique oblitérante des membres inférieurs chez le patient coronarien: prévalence et incidence pronostique. Registre Monica Toulouse.

PURPOSE: This study was aimed at evaluating the prevalence of peripheral arterial disease of the lower extremities and its prognostic value in a population of patients from the Haute-Garonne department, who were hospitalized for acute coronary artery disease. METHODS: Between 1985 and 1991, four thousands three hundred and sixty-eight patients (3,680 males and 688 females) presenting with acute coronary artery disease were included in the study. RESULTS: The prevalence of peripheral arterial disease of the lower extremities was 13.4%, increasing with age and being higher in male patients. In regard to patients hospitalized for acute myocardial infarction (n = 2,417), independent relationships were observed between the 28-day mortality and the following: patient's age (odds ratio: 1.02; 95% confidence interval: 1.01-1.04; P < 0.0005), female gender (odds ratio: 1.32; 95% confidence interval: 1.17-1.54; P < 0.002), inclusion in the study (odds ratio 0.95; 95% confidence interval: 0.90-0.99; P < 0.02), previous coronary artery disease (odds ratio: 2.88; 95% confidence interval: 2.32-3.48; P < 0.0001), and peripheral arterial disease (odds ratio: 1.61; 95% confidence interval: 1.26-2.06; P < 0.0001). CONCLUSION: The prevalence of peripheral arterial disease of the lower extremities is high in patients with acute coronary artery disease in both genders, whatever the age. This disease is therefore an independent marker of mortality for acute myocardial infarction. Easy diagnosis of peripheral arterial disease of the lower limbs by measurement of the ankle pressure index allows identification of patients prone to death from acute myocardial infarction.

[Distal coronary thrombosis during L-asparaginase treatment for an acute lymphoblastic leukaemia]. / Thrombose coronaire distale compliquant une leucémie aiguë lymphoblastique traitée par asparaginase.

A 53-year-old man is treated by L-asparaginase for an acute lymphoblastic leukaemia. He received anti thrombin infusions. A systematic electrocardiogram showed an asymptomatic subepicardium ischemia without troponin elevation. Echocardiography and heart magnetic resonance imaging showed an apical thrombus facing a zone of myocardial necrosis. A thrombus regression was observed under anticoagulation. Atypical and asymptomatic coronary thrombosis may occur following L-asparaginase treatment. Regular electrocardiogram monitoring is proposed along this treatment. Arterial thrombosis associated with anti tumor chemotherapies are reviewed.

[Practical implementation and usefulness of guidelines for the management of syncope: a professional practice study]. / Application pratique et intérêt des recommandations de prise en charge des syncopes : évaluation de pratiques professionnelles.

AIMS: To assess the practical implementation of international guidelines and their impact on syncope management in a 500-bed general hospital. PATIENTS AND METHODS: Three groups of 63 consecutive patients admitted for syncope to the emergency care unit (ECU) were studied: group 1, before the guidelines delivered to the practitioners, group 2 immediately after the diffusion of guidelines and group 3, one year later. The study evaluates the mean duration of stay (MDS) and the relevance of the diagnostic strategy. RESULTS: In group 1 compared to group 2, MDS were respectively 6.8±5.5 and 5.4±2.8 days (P=0.07) and the unexplained syncope number respectively 22% and 24% (P=0.8). The search of orthostatic hypotension became more systematic (13% versus 86% in group 1 and 2 respectively, P<0.001). The agreement (kappa coefficient) between initial and final diagnostic increased in 0.34 to 0.44. One year later MDS in group 3 was 7.1±4.7 days (P=0.8 versus group 1 and P=0.015 versus group 2) with only 6.3% systematic search for orthostatic hypotension (P<0.001). CONCLUSIONS: Guidelines optimize the syncope management in the ECU and the agreement between the emergency and discharge diagnostic without change of unexplained syncope and. MDS tend to be shorter when guidelines are actively implemented. Nevertheless, the positive impact of guidelines implementation is of limited duration.

Clinical implications of clopidogrel non-response in cardiovascular patients: a systematic review and meta-analysis.

UNLABELLED: BSUMMARY BACKGROUND: Previous studies have shown an important risk of cardiovascular events in patients with clopidogrel biological non-response, and data have shown considerable, unexplored heterogeneity. OBJECTIVES: To evaluate the magnitude of cardiovascular risk associated with clopidogrel non-response and to explore heterogeneity. METHODS: This was a systematic review and meta-analysis of prospective studies of patients treated with clopidogrel for symptomatic atherothrombosis, evaluated by light transmission aggregometry with ADP and monitored prospectively for clinical ischemic events. RESULTS: Fifteen studies were included, totaling 3960 patients, of whom 25% were considered to be clopidogrel non-responders. The global relative risk (RR) for recurrent ischemic events in clopidogrel non-responders was 3.5 [95% confidence interval (CI) 2.4-5.2, P < 0.0001]. The results of the different studies were heterogeneous (Cochran P = 0.01 and I(2) = 52%). The most recent studies yielded lower RRs [global RR = 2.9 (95% CI 2.3-3.8) after 2007, and global RR = 6.6 (95% CI 3.7-11.9) before 2007, P = 0.01]. Heterogeneity was present in the group of studies in which more than 10% of patients took glycoprotein (GP)IIb-IIIa inhibitors [Cochran P = 0.003 and I(2) = 70%; RR = 3.8 (95% CI 2.9-5.1)] and was absent in the other studies [Cochran P = 0.88 and I(2) = 0; RR = 2.5 (95% CI 1.7-3.6)]. The RR was significantly higher in studies using higher ADP maximal aggregation cut-offs (> 65%) for clopidogrel non-response than in studies using lower cut-offs [RR = 5.8 (95% CI 3.2-10.3) and RR = 2.9 (95% CI 2.2-3.7), respectively, P = 0.03]. CONCLUSIONS: The risk of ischemic events associated with clopidogrel non-response is now more precisely defined. The risk is heterogeneous across studies, possibly because of an interaction with GPIIb-IIIa inhibitors and the use of different cut-offs to identify non-responders.

Clinical predictors of dual aspirin and clopidogrel poor responsiveness in stable cardiovascular patients from the ADRIE study.

BACKGROUND: Poor response to both aspirin and clopidogrel (dual poor responsiveness [DPR]) is a major risk factor for recurrent ischemic events. OBJECTIVES: The aim of this study was to identify factors associated with DPR, defined with specific tests, and derive a predictive clinical score. METHODS: We studied 771 consecutive stable cardiovascular patients treated with aspirin (n = 223), clopidogrel (n = 111), or both drugs (n = 37). Aspirin responsiveness was evaluated by serum thromboxane (Tx)B2 assay, and clopidogrel responsiveness by calculating the platelet reactivity index (PRI) on the basis of the phosphorylation status of the vasodilator phosphoprotein. The analysis was focused on patients treated with both drugs, and on independent predictors of DPR. RESULTS: Among patients on dual therapy, there was no relevant correlation between TxB2 levels and PRI values (r = 0.11). Sixty-seven patients (15.4%) had DPR. Diabetes [odds ratio (OR) 1.89, 95% confidence interval (CI) 1.06-3.39], high body weight (> 86 kg vs. < 77 kg, OR 4.74, 95% CI 2.49-9.73), low aspirin dose (75-81 mg vs. ≥ 160 mg, OR 0.12, 95% CI 0.09-0.93) and high C-reactive protein (CRP) level (> 1.6 mg L⁻¹ vs. < 0.6 mg L⁻¹, OR 3.66, 95% CI 1.74-8.72) were independently associated with DPR, via increased TxB(2) levels, increased PRI, or both. These associations with TxB2 and PRI were reproduced across the whole population. With use of a factor-weighed score (c-index = 0.74), the predicted prevalence of DPR was 57% in the highest strata of the score as compared with < 4% for the lowest strata. CONCLUSIONS: Diabetes, body weight, the aspirin dose and CRP levels are readily available independent predictors of DPR, and some are potential targets for reducing its prevalence.

[The concept of aspirin "resistance": mechanisms and clinical relevance]. / Le concept de "résistance" à l'aspirine: mécanismes et pertinence clinique.

Aspirin, a 110-year-old molecule, is a cornerstone in the treatment of atherothrombotic patients. The concept of aspirin "resistance" emerged approximately 15 years ago and is of growing interest. Aspirin resistance, defined as a lack of inhibition of cyclo-oxygenase-1 (COX-1), is a rare phenomenon and its clinical relevance can hardly be studied. On the contrary, residual platelet hyperactivity is more common and affects 20 to 30% of aspirin-treated patients. This latter phenomenon corresponds to sustained platelet reactivity despite a proper inhibition of COX-1 by aspirin. Several meta-analyses suggest that residual platelet hyperactivity could be a risk factor for the recurrence of ischemic events in aspirin-treated patients. Causes of biological non-responsiveness to aspirin are discussed, including the role of compliance, drug-drug interactions, genetic polymorphisms and diabetes mellitus. Ongoing studies are designed to find out the mechanisms of residual platelet hyperactivity, determine its potential clinical relevance and delineate the more appropriate assays in order to identify patients who may benefit of a tailored antiplatelet therapy.