[Clinical characteristics and follow-up of 60 patients with recent diagnosis of giant cell arteritis, NEWTON study]. / Caractéristiques et profils évolutifs des patients avec un diagnostic récent d'artérite à cellules géantes, étude NEWTON.

INTRODUCTION: The management of giant cell arteritis (GCA) has evolved with the arrival of tocilizumab (TCZ) and the use of PET/CT. Our objective is to describe the characteristics and followup of patients with recent diagnosis of GCA in current care. PATIENTS AND METHODS: The NEWTON cohort is a monocentric retrospective cohort based on data collected from 60 GCA patients diagnosed between 2017 and 2022 according to the ACR/EULAR 2022 criteria. RESULTS: The median age at diagnosis was 73 [68.75; 81] years old. At diagnosis, the main manifestations were unusual temporal headaches in 48 (80 %) and an inflammatory syndrome in 50 (83 %) patients. Temporal artery biopsy confirmed the diagnosis in 49/58 (84 %) patients. Doppler of the temporal arteries found a halo in 12/23 (52 %) patients. The PET/CT found hypermetabolism in 19/43 (44 %) patients. Prednisone was stopped in 17.5 [12.75; 24.25] months. During follow-up, 22 (37 %) patients received TCZ. At least one complication of corticosteroid therapy was observed in 22 (37 %) patients. After a median follow-up of 24 [12; 42] months, 25 (42 %) patients relapsed. At the end of the follow-up, 29 (48.3 %) patients were weaned from corticosteroid therapy and 15 (25 %) were on TCZ. CONCLUSION: Despite the increasing use of TCZ in the therapeutic arsenal and of the PET/CT in the imaging tools of GCA patients, relapses and complications of corticosteroid therapy remain frequent, observed in more than a third of patients.

Depression, Anxiety and Stress among the Students and Their Academic Performance in Selected Medical Colleges of Bangladesh.

Medical education is associated with a great psychological distress that affects many aspects of students' lives, including their academic performance and professional development. The objective of the study was to determine the level of depression, anxiety and stress and their academic performance among fifth year medical students. This was a cross-sectional descriptive study conducted in Dhaka Medical College, Mymensingh Medical College, Anwar Khan Modern Medical College and Community Based Medical College of Bangladesh. For this purpose, 359 students were taken as sample and self-administered semi-structured questionnaire was used to collect data. Depression, anxiety and stress were assessed by using short form DASS-21 BV score. The results showed that, the mean age of students was 22.74 years with female predominance 230(64.0%). Majority 319(88.9%) of the respondents' parents monthly income was ≤100000 taka and one third 126(35.1%) respondents' monthly study expenditure was in between 5001 to 10000 taka. Four fifth 317(88.0%) of the respondents came from nuclear type of family and two third 245(68.2%) lived in hostel. Half 178(50.0%) of the respondents were eldest in birth order. Majority 221(61.6%) of the students were admitted to medical college by their own motivation and interest. Symptoms of depression, anxiety and stress were present in 179(49.9%), 215(59.9%) and 161(44.8%) respectively. No significant association was found between academic performance with depression or anxiety or stress, except class attendance of Gynaecology and Obstetrics which was significantly associated with stress (p=0.016); the students who suffered from more stress, their class attendance were very poor. Students who reappeared in MBBS professional examination were significantly associated with depression (p=0.032) and stress (p=0.036). There was significant difference between students of public and private medical colleges in terms of anxiety (p=0.031) that is students of public medical colleges more suffered from depression, anxiety and stress in comparison to private medical colleges. Depression (p=0.001) and anxiety (p=0.010) were significantly associated with motivation to study MBBS. No significant difference of depression, anxiety or stress was found with sex difference. This study revealed that fifth year MBBS students suffered more from depression, anxiety and stress. The causes of depression, anxiety and stress should be identified and resolved to improve their mental health and academic performance.

Prospective study comparing the conventional and same-day strategies to diagnose pulmonary tuberculosis.

OBJECTIVE: The WHO recommends same-day sputum smear microscopy for the diagnosis of smear-positive tuberculosis (TB) in countries with high TB burden for earlier diagnosis and treatment, a cornerstone to prevent air-borne transmission. We aimed to compare the conventional strategy (sputum collection on three consecutive days) and the same-day strategy (hour h, h+1, h+2) in France, a country with low TB burden. PATIENTS AND METHODS: Over a six-month period, all adult individuals presenting with presumptive smear-positive TB were eligible for the study, registered in https://clinicaltrials.gov/ ID (NCT02961569). Sputum specimens were collected three times the first day, then once on the second day and once on the third day. The concordance between the two strategies regarding smears and cultures were assessed. RESULTS: Of the 131 eligible individuals, 34 were given a TB treatment. Smears from hour h, h+1, h+2, day two and three were negative in 19 of these 34 patients. Positive smears were obtained in 15, 14, 15, 14, and 14 patients at hour h, h+1, h+2, on day two and three, respectively. Concordance regarding smear or culture was good, with Kappa 0.69 and 0.64, respectively. CONCLUSION: The same-day strategy seems to be a good alternative to the conventional strategy.

Gender-specific study of recurrent suicide attempts in outpatients with multiple substance use disorders.

BACKGROUND: people suffering from substance use disorders (SUD) often die by suicide, so that the prevention of suicide attempts (SA) remains a top priority in this population. SA recurrence is common and is associated with suicide death, but this phenotype has been overlooked in SUD populations. Thus, we aimed at identifying the risk factors of SA recurrence in SUD, controlling for both gender and levels of exposure to addictive substances, including tobacco. METHODS: we consecutively recruited 433 treatment-seeking outpatients with either opiate or cocaine use disorder and assessed their lifetime history of addictive and suicidal symptoms by standardized questionnaires. They were reliably classified as never, single or recurrent (≥ 2) suicide attempters, whose characteristics were identified by multinomial regression, stratified by gender; and compared to our previous work on serious SA in order to identify common or different risk profiles. RESULTS: 86/140 (61%) suicide attempters reported recurrence. The mean number of SA was 3.1. Recurrence was independently associated with psychiatric hospitalization in both genders, with nicotine dependence in men and with sedative use disorders in women. LIMITATIONS: psychiatric diagnoses were derived from the current medication regimen. CONCLUSION: specific and possibly avoidable/treatable risk factors for the recurrence of SA in SUD have been identified for the first time, opening new avenues for research and prevention in this high-risk population. Apart from nicotine dependence, these risk factors were very similar to those of serious SA. Although this comparison is indirect for now, it suggests a common liability towards suicidal behavior.

[Prospective study of the factors associated with the acceptance of generics substitution by patients and their liberal doctors]. / Étude prospective des facteurs associés à l'acceptation de la substitution des génériques par les patients et leurs médecins libéraux.

BACKGROUND: Many prescribers and patients remain reluctant to substitution to generics. METHODS: We conducted a prospective observational study, using semi-structured interviews adapted to identify factors independently associated with the acceptance of alternative to a generic drug by doctors and patients. RESULTS: Between December 2014 and August 2015, 108 patients and 73 private doctors from Île-de-France and Nord-Pas-de-Calais were enrolled. Only 48 % of patients thought that the effectiveness and safety of generic were identical to the brand-name, 50 % had a favorable opinion and 36 % said they routinely accept substitution, especially when substitution was proposed by the general practitioner (68 % of patients). Age, gender, occupational status and the presence of a chronic condition were not associated to acceptance of substitution (P>0, 1), unlike the opinion (P<0.001), perception of efficacy (P<0.001) and side effects (P=0.0005). Two thirds of physicians substituted more than 50 % of their brand name prescription to generics. This low figure was due to patient request not to substitute (63.9 %). CONCLUSION: The acceptance of substitution was independently associated to patient' opinion about generic drugs, further emphasizing the need for information campaigns dedicated to patients.

[Central nervous system lymphoma revealed by lymphocytic meningitis in a patient with systemic lupus erythematosus: An unusual association]. / Méningite lymphocytaire chez une patiente lupique révélant un lymphome cérébral primitif : une association rare.

INTRODUCTION: We report an unusual observation of central nervous system (CNS) lymphoma in a 60-year-old woman with systemic lupus erythematosus and fatal outcome. OBSERVATION: The patient had systemic erythematosus lupus for 7 years, treated with mycophenolate mofetil and developed lymphocytic meningitis in 2015 associated to the presence of EBV in the cerebrospinal fluid and a necrotic vermis' lesion. Diagnosis of large B-cell lymphoma was histologically confirmed from stereotaxic biopsy, shortly before she died from neurological complications. CONCLUSION: Even though the current association is unusual, lymphocytic meningitis with hypoglycorrachia in patients with systemic lupus erythematosus may reveal CNS lymphoma and diagnosis confirmation requires stereotaxic biopsy in order not to delay specific therapeutic management.

[Prevalence of granulomatous lesions in minor salivary gland biopsy in a case series of 65 patients with tuberculosis]. / Étude de la prévalence des granulomes à la biopsie des glandes salivaires accessoires chez 65 patients atteints de tuberculose.

PURPOSE: The distinction between tuberculosis (TB), a worldwide infectious granulomatosis requiring specific antibiotic therapy, and sarcoidosis, a rare granulomatous disease that may require corticosteroids is not straightforward and may result in diagnostic and therapeutic delay. METHODS: We prospectively and consecutively evaluated the presence of epithelioid granulomas in minor salivary gland biopsy of 65 consecutive patients with TB. RESULTS: In our study, 10.8 % of our TB patients had epithelioid granulomas without caseous necrosis identified in their minor salivary gland biopsy, regardless of the location of TB, HIV status and whether or not the sputum examination was positive for tuberculous bacilli. CONCLUSION: The presence of epithelioid granulomas in minor salivary gland biopsy may not be helpful to the clinician to rule out TB in a patient with suspected sarcoidosis.

[Drug-food interactions in internal medicine: What physicians should know?]. / Interactions médicaments-aliments en médecine interne: quels messages pour le clinicien?

Orally administered medications may interact with various fruits, vegetables, herbal medicines, functional foods or dietary supplements. Drug-food interactions, which are mostly unknown from prescribers, including internists, may be responsible for changes in drug plasma concentrations, which may decrease efficacy or led to sometimes life-threatening toxicity. Aging, concomitant medications, transplant recipients, patients with cancer, malnutrition, HIV infection and those receiving enteral or parenteral feeding are at increased risk of drug-food interactions. This review focused on the most clinically relevant drug-food interactions, including those with grapefruit juice, Saint-John's Wort, enteral or parenteral nutrition, their respective consequences in the clinical setting in order to provide thoughtful information for internists in their routine clinical practice. Specific clinical settings are also detailed, such as the Ramadan or multiple medications especially in elderly patients. Drug-food interactions are also presented with respect to the main therapeutic families, including the non-steroidal anti-inflammatory drugs, analgesics, cardiovascular medications, warfarin as well as new oral anticoagulants, anticancer drugs and immunosuppressant medications. Considerable effort has been achieved to a better understanding of food-drug interactions and increase clinicians' ability to anticipate their occurrence and consequences in clinical practice. Describing the frequency of relevant food-drug interactions in internal medicine is paramount in order to optimize patient care and drug dosing on an individual basis as well as to increase patients and doctors information.

[What happens to therapeutic changes decided during hospitalization in an internal medicine ward? A two-month single-centre prospective study in France]. / Que deviennent les modifications thérapeutiques décidées au cours d'une hospitalisation en médecine interne ? Étude prospective française monocentrique sur 2 mois.

PURPOSE: During a hospitalization in an internal medicine department, drug prescriptions are frequently modified. We studied the course of these therapeutic changes after patients' discharge. METHODS: Eighty-four patients with a long-term drug prescription and a registered general practitioner were included on the day of their discharge from an internal medicine department in Paris. Their medications before and after the hospitalization were established according to the discharge letter, and patients were contacted two months after discharge in order to assess the modifications that could have occurred during these two months after discharge. RESULTS: Medications prescribed before the admission were often preserved, 17.7% were withdrawn, and 7% were switched to another medication. Two months after discharge, 85% of the modifications were maintained, the discharge drug prescription was renewed without a change for 77% of the patients. The drug classes that were the more frequently modified during the hospital stay were the antihypertensive therapies, with 65% of sustained modifications at two months, and analgesics, with 75% of sustained modifications. Therapeutic changes that were explained in the discharge letter were more frequently preserved at two months than those that were not explained (100% versus 79%, 95%CI of the difference [0.09-0.27]; P<0.0001). CONCLUSION: Therapeutic changes decided during a hospitalization in an internal medicine unit and prescribed at discharge are mostly preserved in outpatients two months after discharge, especially when the modifications are explained in the discharge letter.

Challenges in the optimisation of post-operative pain management with opioids in obese patients: a literature review.

An increasing number of obese patients are undergoing surgery, particularly bariatric and orthopaedic surgery. The physiological differences between obese and normal-weight subjects may modify not only anaesthetic requirements during surgery but also post-operative analgesic management, raising a number of challenges in a critical period. In this review, we analyse studies of post-operative pain management with opioids in obese subjects. We discuss the genetic factors common to pain and obesity and the factors potentially modifying opioid pharmacokinetics and pharmacodynamics in obese patients, and we analyse the overall efficacy and safety of opioids for pain management during the post-operative period in obese patients. Both modifications to surgical methods and additional analgesic treatments to decrease the requirement for opioids may improve early rehabilitation and quality of care and reduce adverse effects in obese patients.

[An atypical presentation of Kikuchi-Fujimoto disease]. / Maladie de Kikuchi-Fujimoto: une présentation atypique.

INTRODUCTION: Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease) is a rare clinical entity characterized by the association of enlarged lymph nodes in the posterior cervical region and fever. The disease is more frequent in young women. CASE REPORT: We report a 41-year-old African patient who presented with atypical features of Kikuchi's disease including cutaneous lupus, haemophagocytosis, and lymphocytic meningitis. The ethnic origin and the clinical presentation were initially suggestive of tuberculous meningitis. However, microbiological analyses remained negative, histological findings were suggestive of Kikuchi's disease and HHV6 DNA integration was documented in our patient. CONCLUSION: Kikuchi's disease should be suspected in an African patient when lymphocytic meningitis is associated with enlarged cervical lymph nodes, hemophagocytosis and HHV6 DNA integration.

Could the inter-individual variability in cocaine-induced psychotic effects influence the development of cocaine addiction? Towards a new pharmacogenetic approach to addictions.

Cocaine addiction is a chronic disease marked by relapses, co-morbidities and the importance of psychosocial consequences. The etiology of cocaine addiction is complex and involves three types of factors: environmental factors, factors linked to the specific effects of cocaine and genetic factors. The latter could explain 40-60% of the risk for developing an addiction. Several studies have looked for a link between cocaine addiction and the genes of the dopaminergic system: the genes DRD2, COMT, SLC6A3 (coding for the dopamine transporter DAT) and DBH (coding for the dopamine beta hydroxylase) but unfortunately very few well established results. Pharmacogenetic approach could be an interesting opportunity for the future. The gene DBH has particularly been linked with the psychotic effects caused by cocaine. This so-called cocaine-induced psychosis (CIP) or cocaine-induced paranoia may influence the development of cocaine addiction. Indeed, these psychotic symptoms during cocaine exposure could cause an aversive effect limiting the development of an addiction. Several functional alterations caused by different mutations of the genes involved in dopaminergic transmission (principally-1021C>T of the gene DBH, but also Val158Met of the gene COMT, TaqI A of the gene DRD2 and VNTR 9 repeat of the DAT) could result in a cocaine-induced psychosis prone phenotype. We are hypothesising that the appearance of CIP during the first contact with cocaine is associated with a lower risk of developing cocaine addiction. This protective effect could be associated with the presence of one or more polymorphisms associated with CIP. A pharmacogenetic approach studying combination of polymorphism could isolate a sub-group of patients at risk for CIPs but more favorably protected from developing an addiction. This theory could enable a better understanding of the protective factors against cocaine addiction and offer new therapeutic or preventive targets in vulnerable sub-groups exposed to cocaine.

[Assessment and impact of intrathoracic disease in advanced ovarian cancer]. / Evaluation et impact de l'extension sus-diaphragmatique dans les cancers avancés de l'ovaire.

As seventy-five percent of patients with ovarian cancer are diagnosed at an advanced stage (FIGO stage III/IV), optimal surgery is then difficult to perform. The aim of our study is to assess the interest of thoracoscopy in the management of ovarian carcinoma with pleural effusion.

[Evaluation of the efficacy of a drug: from discovery to market]. / Evaluation de l'efficacité d'un médicament: de la découverte à la mise sur le marché.

To move from a chemical entity to a real drug, preclinical trials have to be followed by phase I human studies to evaluate human toxicity, phase II studies to demonstrate the pharmacological activity in healthy volunteers and patients, followed by phase III studies to evaluate the real therapeutic efficacy. Then new drug authorization is granted for a product that shows good pharmaceutical quality and a positive risk-benefit ratio. However, full knowledge of a new drug is available only after several years of clinical use.

Muscle infarction in a young woman with brittle type 1 diabetes.

We present the first case of muscle infarction in a 30-year-old woman who had a 5-year history of type 1 diabetes mellitus that was not complicated by nephropathy, retinopathy or neuropathy. All common causes of muscle infarction were excluded, particularly microangiopathy and a hypercoagulable state. The differential diagnosis included infection (pyomyositis, necrotic fasciitis), focal inflammatory myositis, vascular events, trauma, tumor and diabetic amyotrophy, all of which were excluded. In spite of good glycaemic control, her diabetes remained brittle; alternating states of transient acute hypoglycaemia and hyperglycaemia may have been responsible for the infarction. Brittleness resumed after treatment with subcutaneous insulin infusion using a portable pump. No recurrence of muscle infarction was observed during a 18-month follow-up.

Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most frequent sustained arrhythmia. After restoration of normal sinus rhythm, the recurrence rate of AF is high. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. OBJECTIVES: To determine, in patients who recovered sinus rhythm after AF, the effect of long-term treatment with antiarrhythmic drugs on death, stroke and embolism, adverse effects, pro-arrhythmia and recurrence of AF. If several antiarrhythmics were effective our secondary aim was to compare them. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Libary (Issue 2, 2005), MEDLINE (1950 to May 2005) and EMBASE (1966 to May 2005) were searched. The reference lists of retrieved articles, recent reviews and meta-analyses were checked. No language restrictions were applied. SELECTION CRITERIA: Two independent reviewers selected randomised controlled trials comparing any antiarrhythmic with a control (no treatment, placebo or drugs for rate control) or with another antiarrhythmic, in adults who had AF and in whom sinus rhythm was restored. Post-operative AF was excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed quality and extracted data, on an intention-to-treat basis. Disagreements were resolved by discussion. Studies were pooled, if appropriate, using Peto odds ratio (OR). MAIN RESULTS: 45 studies met inclusion criteria, comprising 12,559 patients. All results were calculated at 1 year of follow-up. Class IA drugs (disopyramide, quinidine) were associated with increased mortality compared with controls (OR 2.39, 95% confidence interval (CI) 1.03 to 5.59, P = 0.04, number needed to harm (NNH) 109, 95% CI 34 to 4985). Other antiarrhythmics did not modify mortality. Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of AF (OR 0.19 to 0.60, number needed to treat 2 to 9), but all increased withdrawals due to adverse affects (NNH 17 to 36) and all but amiodarone and propafenone increased pro-arrhythmia (NNH 17 to 119). AUTHORS' CONCLUSIONS: Several class IA, IC and III drugs are effective in maintaining sinus rhythm but increase adverse events, including pro-arrhythmia, and disopyramide and quinidine are associated with increased mortality. Any benefit on clinically relevant outcomes (embolisms, heart failure, mortality) remains to be established.