Laurent Davin

Tumour necrosis factor (TNF) gene polymorphism in Crohn's disease (CD): influence on disease behaviour?

Crohns disease (CD) is a multifactorial disease with genetic heterogeneity. TNF‐α plays a key role in the development of the mucosal lesions. The aim of our work was to study a single base pair polymorphism located in the promoter region of TNF gene, in a large population of CD patients with well defined phenotypes. One hundred and ninety‐three patients with CD and 98 ethnically matched controls were studied. The −308 single base pair polymorphism of TNF gene was studied using an allele‐specific polymerase chain reaction. Genotype and allelic frequencies were compared between patients and controls and between subgroups of patients defined by sex, age at diagnosis, familial history, location of disease, type of disease, extra‐intestinal manifestations, and response to steroid treatment. In 29 patients a measure of TNF‐α production by colonic biopsies was performed. The frequency of the allele TNF2 as well as the proportion of carriers of the allele TNF2 were slightly but not significantly lower in CD than in controls (11.9% versus 14.8% and 21.5% versus 27.6%, respectively). A more prominent difference in frequencies of allele TNF2 and in proportions of TNF2 carriers was found when comparing subgroups of patients. The frequency of allele TNF2 was significantly higher in steroid‐dependent than in non‐steroid‐dependent disease (28.1% versus 10.3%; Δu2003=u200317.8%, 95% confidence interval (CI)u2003=u20036.3–29.5%, Pu2003=u20030.0027) and tended to be higher in colonic than in small bowel disease and in fistulizing than in stricturing disease. Furthermore, TNF2 carriers tended to be more frequent in patients with steroid‐dependent than non‐steroid‐dependent disease (43.8% versus 19.3%; Δu2003=u200324.5%, 95% CIu2003=u20033.6–45.4%, Pu2003=u20030.022), in patients with fistulizing than stricturing disease (26.5% versus 9.6%; Δu2003=u200316.9%, 95% CIu2003=u20031.1–32.6%, Pu2003=u20030.036), and in patients with colonic than small bowel disease (26.5% versus 11.1%; Δu2003=u200315.4%, 95% CIu2003=u2003−0.8–31.6%, Pu2003=u20030.063). Finally, patients carrying at least one copy of allele 2 were found to produce slightly more TNF‐α at the colonic level. The −308 TNF gene polymorphism may have a slight influence on the behaviour of CD. The carriage of allele 2 may favour steroid‐dependent disease and to a lesser extent fistulizing and colonic disease, possibly secondary to a more intense TNF‐α‐driven inflammatory reaction at the mucosal level.

A frozen heart

An 81-year-old woman was found unconscious on a walking path. The patient had severe hypothermia (central body temperature: 30°C). She was known to be insulin-dependent diabetic for many years and recently developed signs of dementia. Biological …

Diagnostic accuracy of computed tomography coronary angiography in routine practice.

Objectives — The recent newer advances in computed tomography have dramatically changed our approach to imaging cardiac disease. This study sought to compare the diagnostic value of 16-multi-detector spiral computed tomography (MSCT) for detecting coronary artery stenosis. Methods — A total of 88 consecutive patients (52 men, mean age 68 ± 8 years) with atypical chest pain, stable angina or suspicion of ischaemia at stress test were studied by MSCT and invasive coronary angiography (ICA).The MSCT images and multiplanar reconstructions were analysed regarding the presence of > 50% coronary artery lesion. Results — All 88 scans obtained at a mean heart rate of 68 ± 8 beats/min were interpretable. Sixteen coronary segments were evaluated in each patient. Of the 1320 segments examined, 148 (11%) showed poor image quality.A total of 150 significant lesions were detected using ICA, and 80 of 150 (53%) were detected by MSCT. Sensitivity, specificity, positive and negative predictive values were as follows: 53%, 97%, 68%, and 94%. Fifty-four patients had > 50% coronary stenosis.The diagnosis was confirmed by MSCT in 42 patients and correctly ruled out in 30. By patient-based analysis, positive and negative predictive values were 91% and 71%. Conclusion — Although its specificity is high, the sensitivity of 16-slice MSCT for detecting > 50% coronary stenosis in non-selected patients submitted to ICA is rather low suggesting that for daily practice the diagnostic value of this technique should be improved.

Aortic Stenosis Grading and Outcome: New Categories, New Therapeutic Challenges

T he current understanding of severe aortic stenosis (AS) has changed considerably. Transthoracic echocardiography is the cornerstone noninvasive technique to assess severity. Evaluation of AS severity should integrate the transvalvular flow, in the form of stroke volume index (SVi), to mean pressure gradient (MPG) and aortic valve area (AVA) measurement (1–3). As underpinned by Bavishi et al. (4), the SVi has become a barometer in the interpretation of the relationship between MPG and AVA (5,6). Only a modest decrease of flow may, in fact, lead to an important reduction in MPG (square function of flow) and to misinterpretation of AS severity, which may potentially lead to inappropriate delay of aortic valve replacement (AVR) in symptomatic patients. SVi is an estimate of left ventricular (LV) pump function and is influenced by the LV contractility and geometry, and the global afterload (valvular þ arterial). It suffers from imprecise means of estimation because the Doppler method through which it is assessed may be prone to measurement errors (underestimation of LV outflow tract diameter, misplacement of pulsed-wave Doppler sample in the outflow tract, underestimation of MPG by misalignment with flow direction or very eccentric jets) (7). Despite these limitations, SVi still proved to be an independent predictor of mortality in patients with severe AS (AVA <1.0 cm) and preserved left ventricular ejection fraction (LVEF >50%) (8). In these patients, 4 flow-gradient patterns have been described: normal flow/low gradient (NF/LG, i.e., SVi

Non-invasive imaging of a giant right coronary artery due to a coronary fistula

35 ml/m and MPG <40 mm Hg), normal flow/high gradient

A moving heart

Coronary artery fistula is a relatively rare finding in patients undergoing diagnostic cardiac catheterization. Incidence, angiographic characteristics and natural history of coronary fistulas of this type have not been well defined in the literature. We report a case of a 54-year-old man in whom such abnormalities have been diagnosed with invasive and non-invasive coronary imaging and review the epidemiology, treatment and prognosis of coronary fistulas.

La tomodensitométrie cardiaque dans la mise au point préopératoire d’une anomalie congénitale d’une artère coronaire

A 44-year-old man presented for evaluation of position-dependent chest pain. He had no previous medical history. The physical examination only revealed a lateral displacement of the cardiac apical impulse into the left axilla.nnECG showed incomplete right bundle branch block and extreme QRS axis deviation. Echocardiography required unusual echocardiographic …

L'image du mois. Les valvules cardiaques en tomodensitometrie multidetecteur et echo 3D.

We report the case of a 81-year-old man presenting with stable exercise angina pectoris. The stress test is positive and the coronaro-angiographic evaluation demonstrates a coronary fistula between the left anterior descending (LAD) artery and the pulmonary artery trunk. The mid LAD presents a significant lesion after the origin of the fistula. A cardiac computed tomography is used before surgical treatment. Coronary artery fistulas are unusual congenital or acquired coronary artery abnormalities in which blood is shunt into a cardiac chamber, great vessel or other structure. Low-pressure structure is the most common site of drainage of the coronary fistula. The clinical presentation of coronary fistulas is mainly dependent on the severity of the left-to-right shunt. Various cardiac imaging modalities are used for diagnosis and anatomical exploration before surgical or percutaneous intervention if the closure of the fistula is indicated.