[Management of the elderly in the emergency department: a suitable solution or a second best choice?]. / Prise en charge de la personne âgée aux urgences: solution adéquate ou pis-aller?

The prolongation of life expectancy can only increase the proportion of elderly people in the future. The Emergency Departments being the main gateway to our hospitals, they will often have to admit such patients with their distinct characteristics. These individuals present with a more or less marked geriatric profile; it will be essential to determine their degree of frailty, a factor allowing to predict their survival and future level of autonomy. Evaluation tools have been developed to improve the management of these patients at important moments of their stay in the Emergency Department.

Liver resection for noncolorectal, nonneuroendocrine metastases.

In noncolorectal, nonendocrine liver metastases, the role of surgery is less define than in colorectal or neuroendocrine cancer. This role is marginal as liver is not the primary site of metastases of these cancers. Less than 2 to 5% of the patients with these malignancies might be one day considered as potential candidates for liver resection, as most patients suffer from extra hepatic tumour spread at the time they develop liver involvement. However, in these few cases with liver metastases only, as no other therapeutic option may provide mid- or long-term tumour-free survival, liver resection is indicated in resectable liver metastases. Some prognostic factors have been established in the literature from the few published series: unique versus multiple hepatic metastases, unilobar vs bilobar, metachronous vs synchronous, R0 vs R1 or R2 liver resections. The type of primary tumour is also of great importance, as cutaneous melanoma, pancreatic and gastric adenocarcinoma have a very bad prognosis for liver resection of metastases, even after R0 resection. In these cases, percutaneous or laparoscopic radiofrequency ablation may find its place. In sarcoma, breast carcinoma, uveal melanoma, and genitourinary cancers, liver resection may provide satisfactory long-term results in selected cases, and is the standard of care for isolated, resectable metastasis. However, due to the scarcity of indication of liver resection for noncolorectal, nonneuroendocrine metastases, the decision should be multidisciplinary, and the patients should be informed of the advantages and pitfalls of the surgical procedure.

[Percutaneous transluminal coronary angioplasty (PTCA) in diabetic patients. Part 1: failure due to restenosis after simple PTCA]. / Angioplastie percutanée coronaire chez le patient diabétique Partie 1 : echecs relatifs liés à la resténose après angioplastie simple.

Diabetes mellitus, essentially type 2 diabetes, is markedly associated with a high risk of cardiovascular diseases, especially coronary artery disease (CAD). Revascularization techniques, first coronary artery bypass graft (CABG) and second percutaneous transluminal coronary angioplasty (PTCA), have drastically changed the management of patients with CAD. Unfortunately, overall results of such revascularization procedures are less impressive in diabetic patients than in nondiabetic subjects, because of a worse vascular bed due to a more diffuse disease including small vessels. The diabetic population is indeed characterized by higher rates of both post-CABG thrombosis and post-PTCA restenosis, as compared to the corresponding rates observed in a nondiabetic population. Such vascular complications result in a higher incidence of coronary events leading to greater morbidity and mortality in both the short (weeks-months) and long (years) term. The bad quality of blood glucose control appears to play a crucial role in the risk of restenosis and further complications. The use of endovascular stents, especially new drug-eluting stents reducing the risk of restenosis, may represent a new opportunity for the management of a high-risk population such as diabetic patients.

[Percutaneous coronary angioplasty in diabetic patients. Part II: hopes based on endovascular prosthesis]. / Angioplastie percutanée coronaire chez le patient diabétique. Partie 2: Espoirs apportés par les prothèses endovasculaires.

Coronary artery revascularization procedures provide less favourable results in diabetic patients than in non-diabetic individuals. Especially, percutaneous coronary angioplasty (PTCA) is associated with a higher rate of restenosis and recurrence of cardiac morbidity and death. In diabetic patients, PTCA should, if possible, be combined with a stent. Bare-stents allow to reduce approximately by half the risk of restenosis, but unfortunately their efficacy decreases as the vessel diameter decreases, a common finding among diabetic patients with angiopathy. ARTS ("Arterial Revascularization Therapy Study") recently showed that diabetic patients have a worse prognosis even when bare-stents are combined with PTCA as compared to non-diabetic subjects and as compared to diabetic patients treated with coronary artery bypass graft. These results open new perspectives in favour of the use of drug-eluting stents containing pharmacological agents capable of preventing restenosis. Such new stents might improve the management of diabetic patients with coronary heart disease.

[Percutaneous coronary angioplasty in diabetic patients: new prospects with drug-eluting stents]. / Angioplastie percutanée coronaire chez le patient diabétique. Partie 3: Nouvelles perspectives apportées par les stents enrobés.

Coronary revascularization procedures are associated with less favourable outcomes in diabetic patients as compared to non-diabetic individuals. Especially, percutaneous coronary angioplasty (PTCA) is associated with a high level of restenosis and recurrent cardiac morbidity and mortality. In diabetic patients, PTCA should ideally be combined with stents. Bare-metal stents reduce by almost half the risk of restenosis, but this favourable effect decreases with the vessel calibre, a common finding in diabetic patients. Drug-eluting stents containing pharmacological agents that can reduce the risk of restenosis (sirolimus, paclitaxel) provide better angiographic results, including in small coronary arteries, and this effect has been shown to be accompanied by significant reduction of both morbidity and mortality. Such preliminary results obtained in the general population (including around 20% of diabetic subjects) deserve further confirmation in a large clinical trial specifically devoted to diabetic patients. Drug-eluting stents may represent a major advance in the management of diabetic patients with coronary heart disease in the near future.