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We presented a case of a 73-year-old woman presenting to the emergency department with a spinal cord compression secondary to a T2 mass lesion and needing emergency surgery. The lesion was consistent with a papillary thyroid carcinoma. The patient had a previous history of thyroidectomy in a setting of a multinodular goiter 6 years before. A rereading of the previous anatomopathological thyroid tissue confirmed the presence of a papillary thyroid carcinoma that was initially misdiagnosed.Nous présentons le cas clinique d’une femme âgée de 73 ans se présentant au service des Urgences avec une compression de la moelle épinière secondaire à une lésion de masse au niveau de la vertèbre T2 et nécessitant une intervention chirurgicale d’urgence. La lésion est compatible avec un carcinome papillaire de la thyroïde. La patiente avait bénéficié d’une thyroïdectomie dans un contexte de goitre multinodulaire 6 ans auparavant. Une relecture de la pièce anatomopathologique confirme la présence d’un carcinome papillaire de la thyroïde non diagnostiqué au départ.

Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.

Resume Il a ete evoque, et mis en evidence, dans des travaux avant tout epidemiologiques, un lien entre carence en vitamine B12 (cobalamine) et prise de metformine au long cours. Ce lien semble se faire par le biais d’un syndrome de maldigestion des cobalamines alimentaires. Cet article developpe les acquisitions recentes, utiles au praticien, concernant ce syndrome. Il s’agit d’une entite nouvellement decrite, qui occupe actuellement la premiere place parmi les etiologies des carences en cobalamine.

The objective of the GER-e-TEC project is to provide recorded personalized medical monitoring of residents in nursing homes using an intelligent telemedicine platform. It will assist healthcare staff by automatically processing the information from sensors and questionnaires to provide early detection and escalate alerts to enable health professionals, operating in retirement homes, to optimize patient care.

Telemedicine is now in vogue, allowing thanks to the computer and communication tools to be deployed in the field of health, such as Dermatology, areas in which it has shown interest. As the population is aging, Geriatrics is more and more concerned by this innovative practice and nursing homes are more and more concerned. We take a look at telemedicine projects in France deployed in the field of dermatology in the elderly.

Depuis les etudes princeps de phase III de non-inf eriorite comparant les anticoagulants oraux directs (AOD) a la warfarine, de nombreuses etudes ont essaye de repondre a la question de l’efficacite et de la securite d’utilisation des AOD chez les patients âges. Ces etudes sont des etudes de sous-groupes complementaires issues des etudes princeps ou des etudes de pharmacovigilance en postmarketing utilisant des donnees medicoeconomiques a grande echelle. De nombreux biais, par definition, peuvent entrainer une distorsion des resultats dans de telles etudes, rendant leur interpretation prudente. Aucun essai randomise controle n’a a ce jour compare les AOD a la warfarine chez des patients de 80 ans ou plus et a fortiori chez des sujets âges fragiles. En pratique, chez le patient âge fragile, il n’y a pas de consensus quant au choix des anticoagulants a prescrire en cas de fibrillation atriale (FA) et de la maladie thromboembolique veineuse (MTEV). Quant au choix de l’AOD a privilegier chez le sujet âge, faute d’etudes de comparaison directe disponibles a ce jour, il apparait difficile de se prononcer. Toutefois, les donnees disponibles, tant sur le plan pharmacologique que celles issues des etudes complementaires, semblent montrer que le dabigatran offre un profil benefice/risque moins favorable que les autres AOD. Neanmoins, les resultats prometteurs de l’idarucizumab, antidote du dabigatran, pourraient contribuer a ameliorer ce rapport a l’avenir.

Dans la population generale, les nouveaux anticoagulantsoraux directs (NACO ou AOD) sont des traitements prometteurs. Ils ont en effet un profil pharmacocinetique predictible,une action immediate, une fenetre therapeutique large, ne necessitent pas de surveillance biologique, ont peu d’interactions medicamenteuses, pas d’interaction alimentaireet des dosages fixes. Leur efficacite et tolerance ont ete documentees par plusieurs etudes de grande envergurerepondant aux criteres de la medecine factuelle. Chez les sujets âges, les donnees sont plus parcellaires, encore limitees, bien que les donnees issues des analyses en sousgroupesdes grands essais soutiennent l’interet de ces molecules.Dans la vraie vie, les donnees semblent rassurantes comme le montre notre experience a propos de 417 patients,d’âge moyen 71,4, avec un indice de Charlson moyen de 5,1,polymediques, prenant des anticoagulants au long cours,dont 52 des NACO. Il nous semble donc y avoir incontestablementune place pour la prescription de NACO chez la personne âgee. Celle-ci doit etre raisonnee (benefice/risque) et tenir compte du contexte et des comorbidites (prescription « sur mesure ») pour ne pas galvauder les NACO.

Resume Les carences en vitamine B9 et/ou en vitamine B12 sont frequentes chez les sujets âges. Leurs causes respectives sont differentes, denutrition principalement pour la vitamine B9 et malabsorption essentiellement pour la vitamine B12. La carence de l’une ou l’autre de ces deux vitamines peut etre a l’origine d’une hyperhomocysteinemie qui est un facteur de risque cardiovasculaire independant. De nombreuses etudes ont evalue l’association entre carence en vitamine B9 et/ou vitamine B12 (ainsi que la presence d’une hyperhomocysteinemie) et le risque de troubles cognitifs. Les methodologies utilisees demeurent tres divergentes, comme les resultats rapportes. Certaines etudes longitudinales ont observe des associations entre des apports alimentaires faibles en vitamines B9 et B12 ou des taux plasmatiques bas en vitamines B9 et B12 et une augmentation des troubles cognitifs incidents, notamment des demences incidentes. Les etudes d’intervention, en revanche, rapportent des donnees contradictoires. A ce jour, il n’est pas possible d’affirmer, au vu des resultats des essais randomises, que la supplementation en vitamines du groupe B apporte des effets favorables sur la cognition.

Although vitamin B12 (cobalamin) was isolated almost 60 years ago, its metabolism remains incompletely defined. Cobalamin metabolism is complex and requires many processes and steps, any one of which, if not present, may lead to cobalamin deficiency. Studies of the cobalamin metabolism showed that many causes of vitamin B12 deficiency have been uncovered to date, including mutations in genes encoding important proteins of the cobalamin metabolic pathway. However, in practice, pernicious anemia (Addison's disease) and food-cobalamin malabsorption are the leading causes of subtle or documented vitamin B12 deficiency in adults. The latter has led to the development of new routes of cobalamin therapy.

It could be shown using the in vitro cell culture aging model, that elastase-type endopeptidase activity is progressively upregulated with successive passages (in vitro aging). Similar results were obtained previously by determining elastase-type activity as a function of age in aorta extracts (human) and skin extracts (mouse). Among the possible mechanisms involved we tested the role of advanced glycation endproducts (AGEs) on this process. AGE-production was shown to increase with age, exemplified by the exponential age-dependent crosslinking of collagen, demonstrated by Fritz Verzár, already in 1963. Several AGEs significantly upregulated elastase-type activity when added to the culture medium of fibroblasts. This effect appears to be mediated by some AGE-receptors as shown previously, and could be inhibited by a 5 kDa rhamnose-rich oligosaccharide (RROP-3) as well as by a fucose-rich oligosaccharide (FROP-3). When present in the culture media, RROP-3 and FROP-3 efficiently inhibited the passage-dependent upregulation of elastase-type activity expressed by human skin fibroblasts. The use of specific inhibitors and zymography suggested that matrix metalloproteinases (MMP)-9 activation and expression are mainly involved. A detailed discussion is proposed for the interpretation of age-dependent modifications of tissues as vascular wall and skin in the light of these and related experiments, highlighting the role of several specific receptors in the mediation of the observed reactions.

Resume La fievre mediterraneenne familiale (FMF) est une maladie genetique, a transmission autosomique recessive, affectant surtout les populations du pourtour mediterraneen. La symptomatologie principale consiste en des fievres recurrentes, associees a des douleurs abdominales, articulaires et thoraciques. A partir d’un cas clinique, nous presentons les principales atteintes thoraciques de la FMF, qui comportent des douleurs pleurales, des epanchements pleuraux et de l’amylose pulmonaire. Nous discutons egalement le lien eventuel associant mesotheliome et FMF. Le principal traitement de la FMF est la colchicine.

The study of the age and passage dependent modifications of collagen biosynthesis requires a simple, rapid and reproducible procedure adaptable to serial cell cultures. To make such a method comparable to other methods of collagen determination, we calibrated a colorimetric procedure both by hydroxyproline (HYP) determinations and in terms of collagen concentration. For collagen types I and IV, widely different slopes were obtained with the colorimetric procedure. To further refine the procedure, we tempted to completely inhibit collagen synthesis by beta-aminopropionitrile (beta APN) added to cultures in order to obtain a negative control. Using the 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl 2H-tetrazolium bromide (MTT-test), it could be shown that relatively high concentrations of beta APN are tolerated by the cells. It appeared, however, that even the highest concentration of beta APN (1mM) still tolerated by the fibroblasts did not completely inhibit collagen synthesis. At low concentrations, beta APN even stimulated cell-proliferation. The colorimetric procedure calibrated in terms of collagen type I concentration, was therefore retained for the serial determination of collagen synthesis and accumulation. We shall here describe the methodological details of its validation as well as its application for the pharmacological study of the effect of aging on collagen biosynthesis. Among the factors involved, the accumulation of advanced glycation end-products (AGEs) might well play an important role. Several of such AGE-products showed a significant inhibition of collagen deposition. On the contrary, retinol, ascorbic acid as well as the rhamnose-rich oligo- and polysaccharides (RROPs) did produce a significant upregulation collagen deposition. Polysaccharide preparations, rich in rhamnose and fucose (the EROB-mixture) could protect against the AGEs-induced inhibition of collagen accumulation.

Monitoring patients with heart failure by telemedicine systems is a potential means susceptible to optimize the management of these patients and avoid life-threatening emergencies. In this context, we experimented in internal medicine unit an e-platform E-care dedicated to automated, intelligent detection of situations at risk of heart failure.The E-care platform based on medical sensors (blood pressure, heart rate, O2, weight), communicating (Bluetooth), to go up, in real time, to an intelligent physiological information and an analysis of the ontology medical, leading ultimately to the generation of alerts. After a development phase (proof of concept), the E-care platform has been deployed and tested by health professionals and patients in an internal medicine unit with 20 beds, opened on emergencies to the Strasbourg University Hospitals.One hundred and eighty patients were included and 1500 measurements were obtained. The patient profile included in this experiment was an elderly patient, with comorbidity in 90% of cases, with a loss of autonomy in 25%. Health professionals were using E-care platform every day to their great satisfaction. This experiment made it possible to validate the technology choices, to consolidate the system, and to test the robustness of the platform E-care. The collection continuously allowed us to have the critical number of patients for more detailed analysis of the relevance of alerts related to heart impairment. A preliminary analysis showed the relevance of the generated alerts.Preliminary results following the deployment of E-care platform in hospitals appear to show the relevance of technological choices, tools and solutions developed and adopted. This telemedicine system allows automatic, non-intrusive, generate alerts related to the detection of situations at risk for heart failure. Ultimately, E-care was capable of preventing hospitalization. A home deployment is currently underway.

The antithyroid agents (carbimazole, methimazole, thiamazole, propylthiouracil and benzylthiouracile) are the drug class that is associated with a high risk of agranulocytosis. Acute and profound (0.5×10(9)/L) isolated neutropenia occurring in a subject treated with antithyroid agents should be considered as a drug-induced agranulocytosis, until proven otherwise. The clinical spectrum ranges from discovery of acute severe but asymptomatic neutropenia, to isolated fever, localized infections (especially ear, nose and throat, or pulmonary) or septicemia. With an optimal management (discontinuation of antithyroid agents, antibiotics in the presence of fever or a documented infection, or use of hematopoietic growth factor) the current mortality is close to 2%.

Rhamnose-rich oligo- and polysaccharides (RROPs) were tested for their potential pharmacological properties using human skin fibroblasts in serial cultures. The substances tested were shown to stimulate cell proliferation, decrease elastase-type activity, stimulate collagen biosynthesis, and protect hyaluronan against free radical mediated degradation. These reactions appear to be triggered by the mediation of a specific α-L-rhamnose recognizing lectin-site acting as a receptor, transmitting signals to the cell-interior. The rapid increase of intracellular free calcium after addition of RROP-1 and preliminary data using micro arrays appear also to confirm this contention.