Bulletin de la Societe des sciences medicales du Grand-Duche de Luxembourg最新文献

An Antiphospholipid syndrome (APS) was diagnosed in a patient who had massive pulmonary embolisation from a right atrial thrombus. The (APS) is an autoimmune disease defined by the presence in the serum of at least one type of autoantibody known as antiphospholipid antibody (aPL) and the occurrence of at least one clinical feature from a list of potential disease manifestations, the most common of which are venous or arterial thrombosis, recurrent fetal loss and thrombocytopenia. The prevalence of APS in a series of patients from internal medicine is 2 percent. The mean age at diagnosis is 42 years. The pathogenesis of APS associated with clinical manifestations seems to result from a variety of effects of aPL on coagulation pathways,but the exact mechanism of action of aPL on these pathways is not completely understood. The APS can be primary or secondary to a disease. Thrombosis is the most frequent clinical manifestation of APS. It involves many organs, resulting on multiorgan failure: this is the catastrophic APS. The treatment is the same whether the APS is primary or secondary. It is mainly symptomatic and consists in the prevention of thrombosis at short and long-term by using aspirin and/or anticoagulants. Immunomodulating treatment can be offered but its efficiency at long-term is unproven. The mortality varies according to the etiology and the clinical manifestations. The mortality rate is 50 percent in catastrophic APS, despite treatment.

Background and study aims: The aim of this observational study was to perform the first epidemiology study in a primary care patient population with GERD in the Grand Duchy of Luxembourg and to evaluate the added value of the GERD Impact Scale (GIS) patient questionnaire.

Patients and methods: 152 Patients with symptoms of GERD from 20 study centers were included. At visit 1, demographic data including lifestyle factors and the patients' symptoms were recorded. GERD symptoms and their severity, treatment changes and the GIS were all assessed at baseline (visit 1), visit 2 (4-6 weeks) and visit 3 (8-14 weeks). Analyses were performed on an intent-to-treat basis.

Results: 142 patients were included in the analysis, which comprised 50% men and 50% women with a mean BMI of 27 kg/m2. Documented lifestyle factors included consumption of caffeine-containing beverages (87% of patients), stress (62%) and alcohol consumption (53%); 44% of patients were smokers or ex-smokers. The median duration of GERD was 2.0 years. Upon inclusion, 46% were receiving, or had received, proton pump inhibitors (PPIs), antacids (44%), H2-receptor antagonists (21%) or no treatment (21%). PPIs were prescribed at the first visit in the majority of cases (94%) with 75% of patients being prescribed esomeprazole with a median daily dose of 40 mg. The GIS score correlated well with the clinician's judgment of symptom severity and was reported to help determine the appropriate treatment and evaluate the patient's response in approximately 80% of patients.

Conclusions: In this, the first epidemiological study on GERD patients in the Grand Duchy of Luxembourg, data was obtained as planned. The novel patient questionnaire was judged to be helpful by the physician and data shows that the GIS may have an added value over current assessments.

Introduction: Left Ventricular twist (LV twist) is defined as the apical counter-clockwise rotation relative to the clockwise basal rotation. It has been shown that LV twist decreases after myocardial infarction (MI) and that it is well correlated with left ventricular ejection fraction. Most studies have only evaluated anterior wall MI. The aim of our study was to determine whether LV twist is dependent on the infarct territory (anterior vs. inferior) and whether there is a correlation between LV twist and matrix metalloproteinase-9, a marker of LV remodeling.

Methods: We measured LV twist using echocardiography with 2D speckle tracking in patients with acute MI and in a control group.

Results: We evaluated 27 controls and 35 patients with acute MI, 15 with anterior wall and 20 with inferior wall MI. LV twist was significantly decreased after MI, compared to the control group (10.93 +/- 2.05 vs 15.5 +/- 2.29; p = 0.003). There was no difference between anterior and inferior MI. LV rotation was decreased in the infarct area. We did not observe a correlation between LV twist and MMP-9, or creatine phosphokinase.

Conclusion: With this study we confirm that LV twist decreases after acute MI. Moreover, we show that LV apical rotation is mostly decreased after large anterior MI. As apical rotation is important for ejection and aspiration (untwisting), this could be a possible mechanism of LV dysfunction after MI.

Herpes encephalitis can be a life-threatening condition, despite early instauration of acyclovir treatment. In particular patients may succumb to rapidly progressive cerebral oedema. We report a 66-year patient with a Glasgow Coma Score (GCS) of 6 and incipient uncus herniation of the right temporal lobe on the third day. Decompressive hemicraniectomy was immediately performed. The long-term outcome was satisfactory with unassisted gait and a Barthel Index score of 70 after 9 months.

Background: There is a discrepancy between the incidence of viral pathogens and the frequency of prescribing antibiotics for acute respiratory tract infections (ARTIs). Typically, primary care physicians have few possibilities to order sophisticated laboratory tests to help distinguish viral pathogens from bacterial pathogens. C-Reactive Protein (CRP) measurement could help the primary care physician to discriminate more easily between these two conditions, and should contribute to reducing unnecessary prescribing of antibiotics during the first patient consultation.

Methods: A literature review was performed in order to see what is known and tested about CRP measurement in ARTIs in adult patients in the primary care setting, to assist GPs in their decision whether or not to prescribe antibiotics.

Results: Out of 54 entered articles reviewed from 109 abstracts, we could identify 8 articles which correspond to our selection criteria. Overall the methodological quality of the studies is heterogeneous. Specificity and sensibility of CRP measurement in ARTIs in adults vary widely from as low as 10% to as high as 99%.

Discussion and conclusion: Current literature is insufficient and too heterogeneous to allow conclusions about the value of CRP measurement to support the decision of prescribing antibiotics for ARTIs in adults, in primary care. Most studies tested CRP in view of an aetiological diagnosis of ARTIs, whereas common practice in primary care is oriented pragmatically towards risk management and watchful waiting when 'dangerous' symptoms are absent. We found sufficient evidence that CRP would be a useful biomarker in this perspective, but thorough and rigorous studies are needed to test this hypothesis.

Posttraumatic stress disorder (PTSD) is a prevalent and disabling condition. The patients suffering from PTSD often consult primary care clinician for non-specific symptoms. The aim of this work is to find out useful clinical guidelines for diagnosis and therapy in primary care, starting from a literature review (1981-2009) and a preliminary observational study. 20 patients with PTSD had a specific trauma-focused psychotherapy, called "Trauma and Reintegration Psychotherapy (TRP)". This is a psychodynamic eclectic treatment combining Ericksonian Hypnosis and EMDR techniques. The results show a more important decrease of PTSD symptoms in patient's beneficiating of the TRP, than the average of the usual clinical studies. This could be linked to an early diagnosis made by the primary care general practitioners.

The entire subject of abuse can be compared to a gigantic puzzle were patients as well as their physicians get lost. The goal of this article is first to find a common definition to all acts of abuse and then to subdivide them into three distinct categories: sexual, physical, and emotional abuse. The treating physician should realize that victims of abuse, after the passage of time, will eventually fall sick and consult a doctor for physical or/and psychological symptoms which are the result of the past abuse. Most of the time, these patients will not speak spontaneously of the abuse, either because they have not understood the cause/effect relation, or because the abuse feels unspeakable. It is therefore necessary for the doctor to know how to detect abuse through symptomatology, how to help these patients reveal their secret, how to listen with a non-judgemental ear, and how to propose appropriate treatment.

Posterior ankle and heel pain is common among athletes. The most common injury in this region is that of the Achilles tendon. However, besides the Achilles tendon, pain can originate from a retrocalcaneal bursitis, posterior impingement syndrome, os trigonum syndrome, or flexor hallucis longus tenosynovitis. These pathologies often caused by overuse, but can also occur after trauma. With careful examination, and the help of MRI imaging, the distinction can be made among these pathologies and the more common Achilles tendon problems. Like most overuse injuries, the majority of cases of retrocalcaneal bursitis, posterior impingement, flexor hallucis longus tenosynovitis respond to conservative treatment. However, when this fails, open or arthroscopic surgery can be proposed. Arthroscopy is less aggressive than open surgery, with the added advantage of less patient morbidity, less post-operative pain, and early functional rehabilitation. It is becoming the surgery of choice, especially among athletes.

Objectives: The aim of this work is to measure the inter-judge concordance in thirteen psychiatric expertises for invalidity insurance.

Method: We analyzed thirteen interdisciplinary (somatic and psychiatric) expertise files, blinded for the patient identity. The patients had a first opinion of a "classic" psychiatric expertise and then a second opinion of other experts, from a center specialized for interdisciplinary expertises in Switzerland. The inter-experts' judgments were compared according to the complexity of every file, due to the intervention of four foreign independent experts with regard to the expertise process (France, Belgium, United States, Switzerland, Romania).

Results: A satisfactory inter-judge concordance in terms of diagnoses and to incapacities was observed in nine files out of thirteen, with a better consensus for the male patients (chi2 = 4.95; p = 0.026). Divergent opinions seem to be in relation with the lack of explicit expertise guidelines used by the first psychiatric experts. We highlight some general principles issued from guidelines of the Swiss Insurance Psychiatric Society for medical expertise of psychiatric disorders. In our opinion these principles would have been able to improve the inter-judge concordance in the thirteen analyzed expertises.

Discussion: In spite of his methodological limits, especially the reduced number of analyzed expertises, this work underlines the interest to use of certain guidelines for the realization of psychiatric expertises in terms of invalidity insurance.

Conclusion: The use of guidelines could improve the inter-judge concordance for the realization of psychiatric expertises about invalidity insurance.

We report the case of a 78-year-old man diagnosed with metastatic renal cell carcinoma developping acute haemolysis under Sunitinib as well as under Sorafenib. This side effect induced a definitive withdrawal from the drugs. As these drugs are used more widely, rare side effects are bound to appear.