Hypertension pulmonaire associée aux maladies du coeur gauche: quelle définition et quelle prise en charge en 2013 [Pulmonary hypertension in left heart disease: how to define it and how to manage it in 2013?].

Pulmonary hypertension is a frequent complication of left heart disease arising from a wide range of cardiac disorders and is associated with poor prognosis. Its pathophysiology is complex with both passive mechanisms of elevated filling pressures in left cavities and occasionally reactive mechanisms of arterial vasoconstriction and remodelling to interplay. This stage, called <out-of-proportions> pulmonary hypertension, further worsens the heart failure patients' prognosis but is still a matter of debate concerning the criteria to apply for its diagnosis and concerning the best way to manage it. This article gives an overview of the importance and pathophysiology of pulmonary hypertension associated with left heart disease, and discusses the challenges associated with its diagnosis and treatment.

How family caregivers' medical and moral assumptions influence decision making for patients in the vegetative state: a qualitative interview study.

Background Decisions on limiting life-sustaining treatment for patients in the vegetative state (VS) are emotionally and morally challenging. In Germany, doctors have to discuss, together with the legal surrogate (often a family member), whether the proposed treatment is in accordance with the patient's will. However, it is unknown whether family members of the patient in the VS actually base their decisions on the patient's wishes. Objective To examine the role of advance directives, orally expressed wishes, or the presumed will of patients in a VS for family caregivers' decisions on life-sustaining treatment. Methods and sample A qualitative interview study with 14 next of kin of patients in a VS in a long-term care setting was conducted; 13 participants were the patient's legal surrogates. Interviews were analysed according to qualitative content analysis. Results The majority of family caregivers said that they were aware of aforementioned wishes of the patient that could be applied to the VS condition, but did not base their decisions primarily on these wishes. They gave three reasons for this: (a) the expectation of clinical improvement, (b) the caregivers' definition of life-sustaining treatments and (c) the moral obligation not to harm the patient. If the patient's wishes were not known or not revealed, the caregivers interpreted a will to live into the patient's survival and non-verbal behaviour. Conclusions Whether or not prior treatment wishes of patients in a VS are respected depends on their applicability, and also on the medical assumptions and moral attitudes of the surrogates. We recommend repeated communication, support for the caregivers and advance care planning.

How to set up and apply reference levels in fluoroscopy at a national level.

A nationwide survey was launched to investigate the use of fluoroscopy and establish national reference levels (RL) for dose-intensive procedures. The 2-year investigation covered five radiology and nine cardiology departments in public hospitals and private clinics, and focused on 12 examination types: 6 diagnostic and 6 interventional. A total of 1,000 examinations was registered. Information including the fluoroscopy time (T), the number of frames (N) and the dose-area product (DAP) was provided. The data set was used to establish the distributions of T, N and the DAP and the associated RL values. The examinations were pooled to improve the statistics. A wide variation in dose and image quality in fixed geometry was observed. As an example, the skin dose rate for abdominal examinations varied in the range of 10 to 45 mGy/min for comparable image quality. A wide variability was found for several types of examinations, mainly complex ones. DAP RLs of 210, 125, 80, 240, 440 and 110 Gy cm2 were established for lower limb and iliac angiography, cerebral angiography, coronary angiography, biliary drainage and stenting, cerebral embolization and PTCA, respectively. The RL values established are compared to the data published in the literature.

Cancers du sein : comment associer l'hormonothérapie et la radiothérapie en situation adjuvante [How to combine hormonotherapy and radiation treatment in adjuvant breast cancer?]

Combined radiation and hormone therapies have become common clinical practice in recent years for locally-advanced prostate cancers. The use of such concomitant therapy in the treatment of breast disease has been infrequently reported in the literature, but seems justified given the common hormonal dependence of breast cancer and the potential synergistic effect of these two treatment modalities. As adjuvant therapy, two strategies are used in daily clinical practice: upfront aromatase inhibitors or sequentially after a variable delay of tamoxifen. These molecules may, thus, interact with radiotherapy. Retrospectives studies recently published did not show any differences in terms of locoregional recurrences between concurrent or sequential radiohormonotherapy. Lung and skin fibroses due to concurrent treatment are still under debate. Nevertheless, late side effects appeared to be increased by such a treatment, particularly in hypersensitive patients identified at risk by the lymphocyte predictive test. Concurrent radiohormonotherapy should, thus, be delivered cautiously at least for these patients. This article details the potent advantages and risks of concurrent use of adjuvant hormonotherapy and radiotherapy in localized breast cancers.

Target organ damage: how to detect it and how to treat it?

The early detection of cardiac organ damage in clinical practice is primordial for cardiovascular risk profiling of patients with hypertension. In this respect the determination of microalbuminuria is very appealing because it increasingly appears to be the most cost-effective means to identify cardiovascular and renal complications. Considering the treatment of patients with target organ damage, blockers of the renin-angiotensin system have a key position as they are very effective in regressing left ventricular hypertrophy, lowering urinary albumin excretion and delaying the progression of nephropathy. In high-risk patients with atherosclerosis, the use of a blocker of the renin-angiotensin system is also appealing, and it appears increasingly judicious to combine such a blocker with a calcium antagonist whenever required to control blood pressure.

Formation continue: comment concilier devoir et besoins [Continuing education: how to reconcile needs and wants]

La formation continue fait à l'évidence partie intégrante de la vie du médecin, elle est non seulement un devoir éthique envers les patients mais également l'expression du besoin de se maintenir «à la page» dans sa pratique quotidienne, conséquence des progrès rapides en médecine, particulièrement en oncologie médicale. Elle peut être également source de plaisir quand il s'agit d'accroître ses connaissances. Ses règles minimales ont été définies depuis plusieurs années par la FMH qui délègue aux sociétés de disciplines son application pratique. En 2008, une révision nécessaire pour différentes raisons a facilité le calcul des crédits. Même si le total des heures de formation est resté le même (50 crédits), il a été partagé par deux : 25 pour la formation spécifique et 25 qui peuvent être acquis dans une autre discipline (révision de mars 2009 du Règlement pour la formation continue, art. 5a). Cette révision n'a pas réjoui toutes les sociétés de spécialistes qui gardent la faculté de revoir à la hausse le minimum jugé nécessaire à leur discipline. La quantité des offres de formation continue pour les médecins pose le problème d'être proprement pléthorique (congrès nationaux et internationaux, e-learning, symposiums locaux, etc.), il n'en va pas de même de leur qualité. Dans le domaine de l'oncologie médicale, les offres sont abondantes dans un contexte de marketing évident : les maisons pharmaceutiques parrainent des réunions avec un orateur mercenaire, prestigieux si possible, invité à vanter un produit spécifique dans un cycle de présentations en différents lieux de Romandie (avec à chaque fois, la possibilité d'inscrire des crédits à l'actif des participants)... Elles soutiennent également, par leur logistique, de miniconférences organisées par les différentes institutions locales et auxquelles les médecins ne participent que de façon sporadique vu leur intérêt souvent très secondaire - il n'est pas rare que l'auditoire médical se résume à cinq ou dix participants. Au final, ces offres dispersées et de qualité discutable monopolisent les ressources qui se raréfient rapidement dans le contexte économique actuel et qui doivent impérativement être utilisées de manière plus judicieuse, notamment en évitant les manifestations répétitives. Devant toutes ces offres, il est souvent difficile pour la société de discipline de séparer le bon grain de l'ivraie et en conséquence d'attribuer de manière objective les crédits de formation. Partant de ce constat, un petit groupe romand de médecins oncologues praticiens installés et des centres universitaires ont réfléchi à l'idée de regrouper au sein d'une seule structure romande l'organisation d'une formation continue qui réponde à la fois aux besoins et à l'exigence de qualité. Ses tâches sont multiples : mettre sur pied annuellement plusieurs demi-journées de formation, préaviser avec un comité scientifique de la qualité de la formation continue distillée sur son territoire de compétence (sans empiéter sur les prérogatives de la commission pour la formation postgraduée de la Société suisse d'oncologie médicale - SSOM) en rapprochant les centres universitaires, les hôpitaux cantonaux et régionaux, et les praticiens. Ainsi est née l'association FoROMe (Formation romande en oncologie médicale). Sa légitimité a été établie par la SSOM et par le Comité pour la formation postgraduée et continue (nouvellement SIWF) de la FMH. Elle est maintenant en mesure de mettre en application les tâches pour lesquelles elle a été constituée. Il est évident que cela n'ira pas sans résistance et que certains diront qu'ils ne voient pas la nécessité d'une structure supplémentaire, que les sociétés de disciplines font très bien leur travail, qu'il s'agit encore là d'une atteinte à la liberté. Cependant les nécessités économiques vont tôt ou tard venir au secours de la logique pour confirmer les changements que cette démarche a permis d'anticiper. A l'avenir, il s'agira d'assurer le bien-fondé de cette initiative et de rester vigilant au bon fonctionnement de cette structure à la satisfaction de nos membres.

Intoxications alcooliques massives aux urgences: combien, qui, quoi et comment [Massive alcoholic poisoning in the emergency department: how many, who, what and how?].

Alcohol abuse causes numerous medical and social problems. In spite of the decrease of the global consumption of alcohol per capita in Switzerland during the last years, the cases of massive alcoholic poisoning seem increasing in emergency departments. Very few data is available at the moment on this phenomenon. The present article focuses on this problem within the framework of the emergency department of the CHUV. It aims at bringing to light on the sociodemographic and medical characteristics, as well as on the characteristics of the stay of these patients who are admitted with such a problem, to have a global vision of this phenomenon.

Cancers du sein : comment associer l'hormonothérapie et la radiothérapie en situation adjuvante ? [How to combine hormonotherapy and radiation treatment in adjuvant breast cancer ?]

L'hormonoradiothérapie concomitante est utilisée depuis plusieurs années en pratique clinique quotidienne dans les cancers localement évolués de la prostate. Le transfert de ce concept en pathologie mammaire a été très peu rapporté dans la littérature, mais semble pourtant licite devant l'hormonodépendance fréquente des cancers du sein et la synergie potentielle de ces deux armes thérapeutiques. En situation adjuvante, deux stratégies sont actuellement utilisées : la prescription d'un inhibiteur de l'aromatase d'emblée ou après un délai plus ou moins long de tamoxifène. En pratique, ces molécules peuvent donc interagir avec la radiothérapie adjuvante. Les études rétrospectives récemment publiées n'ont pas mis en évidence de différence significative sur l'incidence des évènements, notamment locorégionaux, de l'association concomitante ou séquentielle du tamoxifène à la radiothérapie. La toxicité de l'association reste discutable en termes de fibroses sous-cutanée et pulmonaire. Il semble que le tamoxifène aggraverait les séquelles postradiques uniquement chez les patientes prédisposées à souffrir d'effets tardifs de la radiothérapie et identifiées par un test prédictif biologique. La prudence reste donc encore de mise du moins pour ces patientes. Cet article détaille les avantages et les risques de l'utilisation concomitante de la radiothérapie et de l'hormonothérapie adjuvantes des cancers localisés du sein. Combined radiation and hormone therapies have become common clinical practice in recent years for locally-advanced prostate cancers. The use of such concomitant therapy in the treatment of breast disease has been infrequently reported in the literature, but seems justified given the common hormonal dependence of breast cancer and the potential synergistic effect of these two treatment modalities. As adjuvant therapy, two strategies are used in daily clinical practice: upfront aromatase inhibitors or sequentially after a variable delay of tamoxifen. These molecules may, thus, interact with radiotherapy. Retrospectives studies recently published did not show any differences in terms of locoregional recurrences between concurrent or sequential radiohormonotherapy. Lung and skin fibroses due to concurrent treatment are still under debate. Nevertheless, late side effects appeared to be increased by such a treatment, particularly in hypersensitive patients identified at risk by the lymphocyte predictive test. Concurrent radiohormonotherapy should, thus, be delivered cautiously at least for these patients. This article details the potent advantages and risks of concurrent use of adjuvant hormonotherapy and radiotherapy in localized breast cancers.

How demography, life history, and kinship shape the evolution of genomic imprinting.

How phenomena like helping, dispersal, or the sex ratio evolve depends critically on demographic and life-history factors. One phenotype that is of particular interest to biologists is genomic imprinting, which results in parent-of-origin-specific gene expression and thus deviates from the predictions of Mendel's rules. The most prominent explanation for the evolution of genomic imprinting, the kinship theory, originally specified that multiple paternity can cause the evolution of imprinting when offspring affect maternal resource provisioning. Most models of the kinship theory do not detail how population subdivision, demography, and life history affect the evolution of imprinting. In this work, we embed the classic kinship theory within an island model of population structure and allow for diverse demographic and life-history features to affect the direction of selection on imprinting. We find that population structure does not change how multiple paternity affects the evolution of imprinting under the classic kinship theory. However, if the degree of multiple paternity is not too large, we find that sex-specific migration and survival and generation overlap are the primary factors determining which allele is silenced. This indicates that imprinting can evolve purely as a result of sex-related asymmetries in the demographic structure or life history of a species.