Bernard Planchon

Endocrine function in 98 HIV-infected patients: a prospective study.

Endocrine function was prospectively evaluated in 98 patients (73 men and 25 women) infected by HIV in various stages of illness: Centers for Disease Control groups II (19), III (20), IVA and IVC2 (27), IVC1 and IVD (32). Testing included baseline and post-stimulation evaluation of gonadal, thyroidal, and adrenal axes. Although adrenal function was within normal values in most cases, with no differences between patient groups, nine out of 98 patients had either a low baseline or post-stimulation serum cortisol, cytomegalovirus adrenalitis being suspected in two cases. Mineralocorticoid response was normal in all individuals. The main abnormalities were sick euthyroid syndrome with low tri-idothyronine and/or thyroxine in 16% of patients and hypotestosteronemia in 29% of men with AIDS. These abnormalities, related to a functional deficiency of the hypothalamic-pituitary axis, were highly correlated with the degree of illness, i.e. weight loss and low CD4+ cell count. It was concluded that endocrine dysfunction in HIV-infected patients is rarely of clinical significance, that it is related more to cachexia and advanced disease than to HIV or opportunistic infections, and that it could serve as a prognostic marker.

Aortic involvement in recent‐onset giant cell (temporal) arteritis: A case–control prospective study using helical aortic computed tomodensitometric scan

OBJECTIVE The prevalence of the involvement of large vessels in giant cell arteritis (GCA) is 3-13%. Aortitis is the most serious complication of GCA. Computed tomodensitometric (CT) scan allows analysis of both the aortic wall and endoluminal part of the aorta. Therefore, we conducted a study using CT scan to analyze aortic abnormalities in patients with recent-onset GCA. METHODS This prospective controlled study compared patients with biopsy-proven GCA with a matched control group based on sex, age, and cardiovascular risk factors. During the 4-week period following diagnosis of GCA, patients underwent an aortic CT scan. The aortic imaging results were blindly compared between both groups. RESULTS From January 5, 1998 to January 11, 1999, 22 patients and 22 controls were screened by CT scan for aortic involvement. Thickening of the aortic wall was more frequent among patients than controls (45.4% versus 13.6%; P = 0.02). Aortic thickening (mean 3.3 mm) was located on the ascending part of the thoracic aorta in 22.7% of the patients, with no evidence of thickening in the controls (P = 0.05). Thickening of the abdominal aortic wall was noted in 27.3% of the patients and none of the controls (P = 0.02). CONCLUSION This study suggests that inflammatory aortic thickening, detected by CT scan, occurs frequently at the time of diagnosis of GCA, and that this condition predominantly occurs on the ascending part of the aorta.

Les manifestations buccofaciales de la sclérodermie systémique : étude de 30 patients consécutifs

INTRODUCTION The face is frequently involved in systemic sclerosis. The main stomatologic manifestations include limited mouth opening, xerostomia, skin atrophy, trigeminal neuralgia. The objective of this study was to describe oral and facial manifestations observed in scleroderma patients from our cohort. METHODS Between March and October 2006, a stomatologic consultation was included in the follow-up of scleroderma patients seen during consultation or daily hospital in internal medicine or dermatology units. Demographic, clinical and biological data were collected. Stomatologic examination comprised measure of the mouth opening, sugars and Schirmers tests, orthopantomogram analysis, and evaluation of the repercussion of symptoms on quality of life using a visual analogical scale (VAS between 0 and 10). RESULTS This study included 30 patients (women 87%, mean age 58.6+/-13.6 years). Mean duration of systemic sclerosis (n=20 limited cutaneous form, n=10 diffuse form) was eight years. Stomatologic manifestations were: skin atrophy (n=28), peribuccal rhagades (n=25), telangiectasia (n=21), decreased mouth opening (n=20), xerostomia (n=20), xerophtalmia (n=16), periodontal ligament space widening (n=10), bone resorptions (n=2), trigeminal neuralgia (n=1). Xerostomia was considered more discomforting (mean VAS=3.8) than decreased mouth opening (mean VAS=2.6). Xerostomia was the second more discomforting sign of scleroderma and was significantly associated to the limited cutaneous form (p=0.045) and to anticentromeres antibodies expression (p=0.002). Decreased mouth opening was correlated to oesophageal involvement (p=0.025). CONCLUSION Oral and facial manifestations are frequently observed in scleroderma patients. These manifestations lead to major functional discomfort, mainly due to decreased mouth opening that seems to be frequently associated to oesophageal involvement. Xerostomia is also frequent and is commonly observed in anticentromere antibodies positive cutaneous limited forms of systemic sclerosis. Evolution of radiographic abnormalities like periodontal ligament space widening (33% of cases), or osteolytic lesions (7%) is poorly known.

Effect of stress on clinical reasoning during simulated ambulatory consultations

Background: The goal of this study was to examine the impact of subjective and physiological stress responses on medical students’ diagnostic reasoning and communication skills. Method: A prospective randomized quantitative study was undertaken, looking at ambulatory consultations in internal medicine. On the first day (baseline day), volunteer year 6 students (n = 41) participated in a simulated ambulatory consultation with standardized patients (SPs). On the second day (study day), one week later, they were randomly assigned to two groups: a low stress (n = 20) and a high stress (n = 21) simulated ambulatory consultation. Stress was measured using validated questionnaires and salivary cortisol. The SPs assessed the students’ reasoning and communication. The students completed assessments of their clinical reasoning after the consultations. Results: Although stress measures were all significantly higher in the high-stress condition (all p < 0.05), no differences were found in diagnostic accuracy and justification scores. However, correlational analyses revealed a negative correlation between multiple-stress measures and the students’ ability to generate arguments for differential diagnoses. Conclusion: Stress was associated with impairments in clinical reasoning, of a nature typically suggestive of premature closure.

Exploring how students think: a new method combining think-aloud and concept mapping protocols.

Medical Education 2010: 44: 926–935

teaching with cognition: Exploring how students think: a new method combining think‐aloud and concept mapping protocols

Medical Education 2010: 44: 926–935

Stress responses in medical students in ambulatory and in‐hospital patient consultations

Medical Education 2011: 45: 678–687

D-Dimers, Thrombin—Antithrombin Complexes, and Risk Factors for Thromboembolism in Hospitalized Patient

Introduction There is lack of data about the correlation between hemostatic markers and the clinical and biological risk factors (RFs) for venous thromboembolism (VTE) in medical inpatients without suspicion of acute VTE. Material and methods To evaluate the coagulation activation status in patients with current known RFs for VTE, the authors measured 2 markers of hypercoagulability, thrombin antithrombin (TAT) complexes and D-dimers, at day 1 in 165 patients hospitalized in internal medicine wards without suspected acute VTE. All known RFs for VTE were systematically assessed at admission and classified in a chronological way as permanent or transient. Results Surprisingly, TAT values followed a multimodal distribution. D-dimers showed a normal distribution after a logarithmic transformation (P = .34, Shapiro—Wilk test). Interestingly, a significant progression in D-dimer levels was found according to the chronological classification of RFs. D-dimer variations on multivariate analysis (not applicable for TAT because of the multimodal distribution) correlated independently with a recent inability to walk and an increase in C reactive protein level more than 10 mg/L. Conclusions (a) this study is the first to describe the variations of hypercoagulability markers according to a systematic screening of RFs for VTE in inpatients without suspicion of acute VTE, (b) TAT appeared as a less relevant marker of hypercoagulability than D-dimers in internal medicine inpatients, (d) the chronological classification of RFs identified clearly groups at risk for the prethrombotic state, and (d) an increased hypercoagulability state was demonstrated in patients with an association between a recent immobility and increased inflammatory markers.

Rémission complète sous imatinib mésylate (Glivec®) d’un syndrome hyperéosinophilique myéloprolifératif associé à une mastocytose cutanée résistant à l’interféron alpha

Resume Introduction. – Le syndrome hypereosinophilique primitif de type myeloproliferatif est une affection hematologique rare de traitement difficile. Nous rapportons l’efficacite de l’imatinib mesylate dans cette pathologie. Exegese. – Un homme de 32 ans presente un syndrome hypereosinophilique primitif a expression pulmonaire, neurologique et hematologique resistant a l’interferon et a l’hydroxy-uree associe par ailleurs a une mastocytose cutanee. L’imatinib mesylate introduit en deuxieme intention apres plus d’un an d’evolution a permis d’obtenir une remission clinique et biologique, complete et durable (recul de 6 mois) en 3 semaines. Conclusions. – L’imatinib mesylate, inhibiteur des tyrosines kinases s’avere particulierement efficace dans ce type d’hypereosinophilie. Son mecanisme d’action bien connu dans la leucemie myeloide chronique reste ici mal elucide (probable inhibition d’oncogenes differents de c-kit et PDGF). L’association d’un syndrome hypereosinophilique primitif a une mastocytose cutanee n’avait quant a elle jamais ete rapportee.

Efficiency of Systematic Thrombophilia Screening in Idiopathic Venous Thrombosis: A Prospective Study in Internal Medicine

In case of unprovoked venous thromboembolism (VTE), the screening of thrombophilia is recommended whatever the age of the patient and the type of risk factors (RF). This prospective study was conducted in patients with unprovoked VTE to detect some predictive factors to have a higher risk of thrombophilia, focusing on age, history of venous thromboembolism, and the existence of a triggering event. From July 2000 to July 2002, in an Internal Medicine Department, unrelated patients with unprovoked VTE were included. Those unprovoked thromboembolic events were defined by the absence of association between permanent and transient RF. The primary outcome measure was the positivity of the thrombophilia screening for any type of abnormality detected (deficit of protein C, S, antithrombin, presence of a lupus anticoagulant, research of V and II mutations). Seventy-four patients were included. Eight died during the follow-up. A higher risk of thrombophilia was found in patients younger than 40 (p=0.03), or with a family but not personal history of VTE (p=0.01) or with transient RF (p=0.02). The most frequent abnormality of coagulation found in patients younger than 40 was the presence of a lupus anticoagulant. As a new strategy for the screening of thrombophilia, one could propose the following attitude: only patients with transient RF or family history of VTE could undergo a complete screening; for all the remaining patients who are younger than 40, a research of a lupus anticoagulant would be only performed. This strategy should now be balanced against the currently recommended systematic attitude in further studies.