Diagnostic strategies for urinary tract infections in French general practice.

OBJECTIVES: We aimed to describe the diagnostic management procedures for detection of urinary tract infections in general practice and their correlated factors. PATIENTS AND METHODS: We analyzed data from the ECOGEN study on urinary tract infections, collected in France between November 2011 and April 2012. This national cross-sectional study was carried out in general practices. Data was coded according to the International Classification of Primary Care. RESULTS: A total of 340 consultations or home visits were held for urinary tract infections. The five most frequent diagnostic procedures were (in descending order) clinical examination (67.6%), urine cytobacteriological examination (UCBE) (47.9%), urine dipstick test (15.6%), blood test (8.5%), and imaging (6.5%). No urine dipstick test or UCBE was performed in 43% of cases. Factors correlated with diagnostic procedures were age and gender of patients, annual number of consultations held by family physicians, and duration of consultation. CONCLUSION: Family physicians did not comply with guidelines on diagnostic management for detection of urinary tract infections. We hypothesized that this non-compliance could be due to the family physicians' environment and characteristics, and to clinical practice guidelines.

[1st and 2d degree atrio-ventricular blocks caused by disorders of intra-auricular conduction]. / Blocs auriculo-ventriculaires du premier et deuxième degré par trouble de conduction intra-auriculaire

In three cases collected among subjects with atrial anatomical lesions (two cases of "sinus disease" with partial atrial paralysis and one traumatic lesion of the right atrium in a WPW syndrome), atrial pacing demonstrated a considerable increase of the interval between stimulus and atrial response or intra-atrial Luciani-Wenckebach periods, for slightly increased pacing rates. Conduction changes into the right atrium explain apparently paradoxical variations of the degree of pre-excitation under pacing, in the case of Wolff-Parkinson-White syndrome.

[Ischemic lesions of the left branch of the bundle of His. Their relation of left hemiblock]. / Lésions ischémiques de la branche gauche du faisceau de His. Leur rapport avec les hémiblocs gauches

The term "hemiblock of the left branch of the bundle of His" seems to a histologist to be too precise to be accepted without reservation. Ten cases with septal infarction, with or without left intraventricular conduction problems, were studied by serial sectioning of the heart; these are used as a basis for a discussion of the concepts of electrocardiography, and its implications in the prognosis of patients with myocardial necrosis.

[Arterial and renal parenchymal histological data in the areas on polar and truncal arteries in arterial hypertension of adult patients]. / Données histologiques artérielles et parenchymateuses rénales dans les territoires des artères polaires et tronculaires dans l'hypertension artérielle de l'adulte.

The Cardiac Clinic reports its experience of 16 cases having unilateral curative renal surgery for hypertension in the adult, and has found a particularly high incidence (8 per cent of all cases). A study has been made of the lesions in the malformed and dysplastic renal arteries on the one hand, and of the correspondingly ischaemic and atrophic renal parenchyma on the other. Attention is drawn to the cases of unilateral renal atrophy (50 per cent of cases), the commonest involving gross lymphoplasia of congenital arterial origin. The other cases are of stenotic dysplasias, and special points to notice are the spread of the dysplasia towards the parenchyma, the presence of multiple aneurysms which militate towards nephrectomy, and the relative frequency of dysplasia of the intima (2 cases out of 8).

[Right branch of the bundle of His. From morphology to its function]. / Branche droite du faisceau de His. De sa morphologie à sa fonction

A histological study of serial sections of 71 right branches of the bundle of His has enabled us to confirm the classical findings, but also lay emphasis on certain facts which are not so well known: --the presence or early collateral branches; --the concept of a septal nerve ending; --variations in its course associated with abnormalities in the relationship of the conus with the inferior part of the septum. Certain embryological and functional implications of these facts are noted.

[Renal arteries and renal parenchyma in arterial hypertension in pregnancy]. / Artères rénales et parenchyme rénal dans l'hypertension artérielle gravidique

Hypertensives in pregnancy are not so grossly distinct and different from adult hypertensives if reference is made to the underlying arterial anomalies and malformations of the parenchyma and their incidence. It is, however, in this group that the limited way in which the active remnant of parenchyma, once constrained by these anomalies, can compensate for the changes in pressure and volume sensitivity imposed by pregnancy is most evident; these changes may be caused by pyelonephritis of pregnancy (genuine but rare), eclampsia of the primigravida, progressive hypertension in the multigravida, or certain cases of late hypertension, menopausal hypertension, or hypertension as a late result of a simple juvenile eclampsia. This series contains a particularly high percentage (21%) of cases of hypertension due to unilateral renal arterial ischaemia which are curable.

[Automatic activity of the pre-excitation pathways]. / Activité automatique des voies de préexcitation.

The possibility of preexcitation pathways exhibiting automatic activity was demonstrated in 3 cases: in two cases electrophysiological studies supported this diagnosis which was confirmed in the third case by histological examination of the preexcitation pathway. During sinus node dysfunction, spontaneous or induced (by rapid right atrial pacing or by a reciprocating tachycardia), the substitute rhythm arose from the Kent Bundle either transiently or for a longer period: rhythms arising from the Kent Bundle can only be diagnosed after eliminating the possibility of an atrioventricular junctional rhythm conducted to the ventricles by Mahaïm fibres.

[Embryological duplications of the node-bundle of His : its pathological rôle]. / Dualité embryologique des voies nodo-hisiennes : son rôle en pathologie

A histological study by the method of seriated sections in one case of "double-outlet left ventricle" made it possible to confirm and to describe the embryology of the nodal-His junction: not only the atrio-ventricular node (AV N) but also the His bundle (H) have a double origin, atrial and ventricular. Fusion of these two buds, inexistant in the "lone ventricle" is certainly imperfect. Two macroscopically normal hearts provided examples of nodal buds in one case, of a persisting cleft between the two His buds in the other.

[Complete atrio-ventricular block caused by tuberculoma of the inter-atrial septum. Histological analysis]. / Bloc auriculo-ventriculaire complet par tuberculome du septum inter-auriculaire. Analyse histologique

A syndrome of obstacle to the outflow of the left ventricle was found in a woman with atrio-ventricular block with narrow ventricular complexes. A tuberculoma of the intar-atrial septum was responsible both for the obstacle to left ventricular ejection and for the block which was found to be proximal on microscopic examination.

[Pseudotumor of the right atrium caused by hernia of the valve of Vieussens]. / Pseudo-tumeur de l'oreillette droite par hernie de la valvule de Vieussens.

A round swelling was on the substraction films of the right side of the heart taken during angiocardiographic examination of a patient with mitral valve disease; this suggested a mass attached to the inter-atrial septum, and prolapsing into the auricle of the right atrium. Initial diagnsosi was of atrial thrombosis, but this was disproved at operation. An aneurysm of the membrane of the fossa ovalis was found, being caused by overstretching of the auricle of the left atrium under the increased pressure of the valve defect. The aneurysm was resected and the septum simply repositioned as part of the mitral valve replacement. A search of the literature shows how rare this disorder is, and that it should be reclassified with the abnormalities of the inter-atrial septum which are found only rarely in cases of mitral valve disease.

[Atrioventricular block and localized reentry into the trunk of the bundle of His]. / Bloc auriculo-Ventriculaire et ré-entrée localisés au tronc du faisceau de His

In a patient with an AV block and a resulting variable rhythm, the coupled ventricular complexes with dissociated P waves on the standard tracing suggested a reentry into the atrioventricular area. Intracavitary investigation revealed: 1) a complete bidirectional AV block in the upper portion of the bundle of His (there being a proximal His potential with a fixed relationship with the dissociated atrial activity shown on the ventriculogram); 2) escape of the bundle of His low down, or of the beginnings of the branches, preceded by a distal Hispotential; 3) re-entry echos preceded by a third variety of potential in the bundle of His.

[Lesions of immature renal parenchyma in the region of an abnormal aortic polar artery during arterial hypertension in the young adult. anatomo-clinical example]. / Lésions du parenchyme rénal immature dans le territoire d'une artère polaire aortique anormale au cours de l'hypertension artérielle de l'adulte jeune. Exemple anatomo-clinique

A female patient of 22 with major hypertension was operated upon for a dyspalastic diaphragm stenosis of the right renal artery; she had otherwise a left lower polar aortic artery. The histological study was under-taken on four comparative biopsy specimens. In the aortic polar artery territory, the signs of atrophic dysgenesis were demonstrated: rarefaction and sclerosis of the glomeruli, sclerosing intretitial infiltration. They reproduce exactly the lesions of immature kidneys described by Marshall.

[Isolated intimal stenosis of the renal artery and curable arterial hypertension in Recklinghausen's disease. Association of hypoplastic stenosis of the aortic and pulmonary trunks and sigmoid aortic regurgitation]. / Sténose intimale isolée d'une artère rénale et hypertension artérielle curable dans la maladie de Recklinghausen.

The case of a patient with Von Recklinghausen's disease with multiple localisations, cardiac, aortic, pulmonary and renal artery is reported. Neurofibromatosis was confirmed by the presence of a "royal" tumour on the left elbow and of many "café au lait" spots of over 15 mm diameter. There was no craniofacial dysmorphism or intellectual impairment. The karyotype was normal. The cardiovascular lesions comprised: - stenosis of the left renal artery resulting in renovascular hypertension. This was due to pure intimal hyperplasia; - supravalvular aortic stenosis with hypoplasia of the ascending aorta. There was no craniofacial dysmorphism or intellectual impairment. The karyotype was normal. The cardiovascular lesions comprised: - stenosis of the left renal artery resulting in renovascular hypertension. This was due to pure intimal hyperplasia; - supravalvular aortic stenosis with hypoplasia of the ascending aorta. There was no craniofacial dysmorphism or intellectual impairment. The karyotype was normal. The cardiovascular lesions comprised: - stenosis of the left renal artery resulting in renovascular hypertension. This was due to pure intimal hyperplasia; - supravalvular aortic stenosis with hypoplasia of the ascending aorta, severe aortic regurgitation with dilatation of the aortic ring without rheumatic valvular thickening; - supra valvular pulmonary stenosis which was atypical in site, extension and in the absence of post stenotic dilatation. The pressure gradient was mild (22 mm Hg). There was a striking similarity between the pulmonary and aortic lesions. This new syndrome may be classified amongst the genetic cardiocutaneous syndromes such as the Gorlin or "leopard" syndrome, Watson's syndrome and Noonan's syndrome. Unusual features are the absence of craniofacial abnormalities, normal intelligence, and the left-sided dominance aggravated by hypertension due to curable intimal stenosis of the renal artery.

[Congenital arteriopathies and Leo Buerger's disease]. / Artériopathies congénitales et maladie de Leo Buerger.

A homogenous series of 7 consecutive cases of Buerger's disease were investigated and the congenital malformations of the upper and lower limb arterial trunks were classified. These malformations constitute the anatomical basis of Buerger's disease and define an autonomous disease entity. Total supra-malleolar interruption of the main lower limb arteries either by triple vessel agenesis or, more rarely, by femoro-popliteal or popliteal and tibio-peronal agenesis was observed. The appearances of the collateral circulation, already established in utero, are characteristic with long axial spiral-shaped arteries and dependant arterioles maintaining a precarious supply to the distal tissues which may be adequate for many years. The nautral history of the disease is directly related to the malformation of the congenital arterial system of the limbs. Proximal arterial malformative occlusion is the cause of early, inevitable trophic lesions; the spiral-shaped arteries and distal arterioles, which represent the maximal embryonic collateral circulation, limit the area of necrosis and favour healing.

[Hemolysis in patients with heart valve prostheses. Comparison between Björk-Shiley and Saint-Jude Medical valves]. / Hémolyse chez les malades porteurs de prothèse valvulaire cardiaque. Comparaison entre les valves de Björk-Shiley et Saint-Jude Medical.

The problem of haemolysis was studied in 244 patients with one or two prosthetic heart valves: 232 of these patients had normal valve function as assessed by clinical examination, radioscopy and echocardiography; 112 patients had a Bjork-Shiley (BS) prosthesis, 25 in the aortic position (BSA), 71 in the mitral position (BSM) and 16 in both aortic and mitral positions (BSA + M). These patients were operated between July 1979 and January 1981. One hundred and twenty other patients had Saint Jude medical (SJM) prostheses; 48 in the aortic position (SJMA), 44 in the mitral position (SJMM) and 28 in both aortic and mitral positions (SJMM + A). These patients were operated between January 1982 and July 1983. Twelve patients (operated between 1977 and 1984) had prosthetic valve dysfunction confirmed by angiography or anatomically (SJM = 7); BS = 5). The plasma haemoglobin concentration (pHb) was used as the reference: it was measured by spectrophotometry with a sensitivity of 0.5 mg/100 ml. There was no significant difference the SJM and BS groups at surgery (BS: 4.62 mg/100 ml; SJM: 4.31 mg/100 ml). In the absence of prosthetic valve dysfunction, haemolysis was significantly greater (p less than 0.001) in the SJM (8.28 mg/100 ml) than in the BS (3.08 mg/100 ml). No statistical correlation was observed with the severity of cardiac disease, the aortic or mitral position of the prostheses or with the number of prostheses. Haemolysis was subclinical in all cases. When haemodynamically significant prosthetic valve dysfunction was present, haemolysis was inconstant in BS prostheses (2 out of 5 cases) despite major haemodynamic disturbances in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Kidney parenchymatous hypoplasia and arterial dysplasia in adult arterial hypertension. Data of selective renal arteriography]. / Les hypoplasies parenchymateuses et les dysplasies artérielles des reins dans l'hypertension artérielle de l'adulte. Données de l'artériographie rénale sélective

Analysis of a further series of 125 consecutive unselected adults who were admitted to hospital with hypertension has advanced the study of arterial abnormalities and parenchymal hypoplasia, as demonstrated by selective renal arteriography, further in the direction of the parenchyma. An index of arterioparenchymal thinning is described. The authors list the features and incidence of polar arteries arising from the aorta (46%), polar arteries of non-aortic origin (31%), stenosing dysplasia (26%) and other arterial malformations, as well as biapical hypoplasia (67%), monofocal hypoplasia (37%), and the main types of renal dysgenesis (30%) which they found. The incidence of these abnormalities confirms the previous study of polar arteries arising from the aorta, and gives much more extensive information on the topic of parenchymal hypoplasia in so-called essential hypertension in the adult.

[Abnormalities of the renal arteries in arterial hypertension in adults]. / Les anomalies des artères rénales dans l'hypertension artérielle de l'adulte

Results of arterial surveys on the basis of renal arteriograms in 100 consecutive unselected and hospitalized cases of lone arterial hypertension of the adult. Abnormal polar arteries with direct branching from the aorta were observed in 52 cases, combined with a stenosing or parnechymatous arterial anomaly in 7, quite isolated in 45 cases (61.8 percent of 73 cases). The very great incidence of abnormal polar arteries is a fundamental epidemiological datum of lone arterial hypertension of the adult.

[Study of monophasic action potentials of the myocardium by endocavitary approach. Methodology]. / Etude des potentiels daction monophasiques du myocarde par voie endocavitaire. Méthodologie

The suction electrode makes it possible to record the monophasic action potentials (MAP) of the heart in situ. The technical characteristics of the tripolar electrode which we use are described. The O phase of the MAP is more prolonged than that of the intracellular action potential, but makes it possible to demonstrate the time of arrival of the activation wave in front of the exploring electrode. The phase 1-2 and the phase 3 have their characteristic contour in the right atrium and ventricle. The duration of repolarization makes it possible to assess the refractory period of different parts of the atrial and ventricular myocardium. The relatively simple and harmless method of recording of the monophasic action potentials by the endocardial route, both in the animal and in man, widens our investigation field of electrophysiology applied to the study of arrhythmias, of the repolarization disturbances and of the drug influences on the cell activity.

[Curable asystole in an adult caused by a diffuse and complete arteriovenous aneurysm of the liver. Cure by ligation of the hepatic artery]. / Asystolie curable de l'adulte par anévrysme artérioveineux diffus et total du foie. Guérison par ligature de l'artère hépatique.

A case of cardiac failure in a 54 year old man with a diffuse total arteriovenous aneurysm of the liver is reported. The aneurysm was arteriolarvenous, without a wide bore localised fistula. It occupied the whole hepatic mass, including the territories of the right subphrenic and anterior collateral of the gastroduodenal artery. The cause of cardiac failure was the elevated cardiac output, 15 1/min, which fell to 6 1/min at each peroperative occlusion of the hepatic artery. After ligature of this vessel, the cardiac output stabilised at 9 1/min and remained at this value 4 months after surgical cure. This case is comparable to the neonatal cardiac failure due to multinodular hepatic angioma with respect to the clinical, angiographic and CAT scan characteristics, and the surgical cure of the high cardiac output syndrome. Some of the histological features were suggestive, in places, of the structure of hepatic cavernoma, which makes the exact pathological classification of this diffuse aneurysm difficult; the closest possibility being an involuted from of diffuse capillary hemangioma of childhood allowing such long survival and, occasionally taking on the appearances of a cavernoma. Permanent surgical cure by ligature of the hepatic artery was an additional rare feature of this case.

[Lymphangioendothelioma. A rare cause of atrioventricular block]. / Lymphangio-endothéliome. Une cause rare de bloc auriculo-ventriculaire.

A new case of lymphangio-endothelioma of the nodal tissue is reported. Complete atrioventricular block had been followed up for 20 years. The histological features are described in detail and the embryological origins of the tumour are discussed. This report underlines the exceptional character of this "smallest benign tumour which can be mortal".