Hôpital Saint-Philibert

AimsThere is still conflicting evidence if women with persistent atrial fibrillation (AF) profit from a pulmonary vein isolation (PVI) plus strategy. We evaluated the efficacy of a spatio-temporal dispersion-targeted ablation strategy in women from the TAILORED-AF trial.Methods and resultsIn TAILORED-AF, 370 patients were randomised to either a personalised, artificial intelligence (AI)-guided tailored ablation or to PVI-only. AF substrate mapping data and 12-month ablation outcomes were compared between women and men. Overall, 21% patients were female (70.4 ± 6.9 vs. 64.5 ± 8.5 years for men, P < 0.001). While spatio-temporal dispersion extent was similar between groups, left atrial low-voltage surface area (<0.2 mV) was significantly larger in women (P < 0.01). In women, the single-procedure freedom from AF (76% vs. 50%, log-rank P < 0.001) and any atrial arrhythmia (56% vs. 38%, log-rank P < 0.05) were significantly superior to PVI alone with a tailored procedure. In the PVI-only group, the single-procedure freedom from AF (50% vs. 70%, log-rank P < 0.001) and any atrial arrhythmia (38% vs. 61%, log-rank P < 0.001) were significantly lower in women. After a tailored ablation, no significant differences were observed between women and men regarding freedom from AF (76% vs. 91%, log-rank P = 0.07) or any atrial arrhythmia (56% vs. 62%, log-rank P = 0.69) free survival.ConclusionCompared to men, PVI-only in women with persistent AF leads to a significantly lower freedom from atrial arrhythmia. A personalised spatio-temporal dispersion-targeted ablation strategy led to a higher rate of freedom from any atrial arrhythmia than standard PVI after a single procedure in women and comparable outcomes between women and men.Registration identificationclinicaltrials.gov NCT04702451

This article explores the fundamental importance of clinical observation in psychiatry by assessing a case report drafted by Gaëtan Gatian de Clérambault (1872–1934) in 1901, during his internship at the Sainte-Anne Asylum (Paris, France). The detailed observation of patient M.’s complex clinical picture illustrates the method based on questioning and observation developed by de Clérambault under the influence of his mentors [notably Valentin Magnan (1835–1916)]. This approach was characterized by meticulous attention to the details of the patient's behaviour and discourse and had a profound influence on the French school of psychiatry–particularly through its impact on Jacques Lacan (1901–1981). This article highlights the importance of clinical observation in psychiatry training and emphasizes the need to learn how to “look” before making a diagnosis. It argues that an approach based on close observation and apprenticeship is essential for maintaining the richness and depth of psychiatric practice, faced with the current trend towards the rapid categorization of mental disorders. The article closes by emphasizing the importance of preserving this legacy in contemporary psychiatric training and practice. Cet article explore l’importance fondamentale de l’observation clinique en psychiatrie à travers l’étude d’un cas clinique rédigé par Gaëtan Gatian de Clérambault (1872–1934) lors de son internat à l’Asile Sainte-Anne en 1901. L’observation détaillée de Mme M., une patiente présentant un tableau clinique complexe, illustre la méthode d’interrogatoire et d’observation développée par Clérambault sous l’influence de ses maîtres, notamment Valentin Magnan (1835–1916). Cette approche, caractérisée par une attention minutieuse aux détails comportementaux et discursifs du patient, a profondément influencé l’École française de psychiatrie, notamment à travers son impact sur Jacques Lacan (1901–1981). L’article souligne l’importance de cette méthode dans la formation des psychiatres, mettant en avant la nécessité d’apprendre à « regarder » avant de diagnostiquer. Il argue que cette approche, basée sur l’observation fine et le compagnonnage, est essentielle pour maintenir la richesse et la profondeur de la pratique psychiatrique face aux tendances actuelles de catégorisation rapide des troubles mentaux. L’article conclut sur l’importance de préserver cet héritage dans la formation et la pratique psychiatrique contemporaine.

The objective was to identify factors determining acute arthritis resolution and safety with colchicine and prednisone in acute calcium pyrophosphate (CPP) crystal arthritis. We conducted a post hoc analysis of the COLCHICORT trial, which compared colchicine and prednisone for the treatment of acute CPP crystal arthritis, using a composite outcome of secondary endpoints of the primary analysis. Factors associated with the sustained arthritis resolution with prednisone or colchicine treatment on day three, and the occurrence of gastrointestinal adverse events (AEs) with colchicine, were examined. Two different machine-learning approaches were used to identify independent factors associated with the efficacy outcome: multiple logistic regressions and a decision tree were used. In total, 43 of 89 (48.3%) of participants were considered definite responders. In univariable analysis, definitive responders were more often hospitalized for stroke (9 of 43; P = 0.04), had an age ≥80 years old (39 of 43; P = 0.045), and were dyslipidemic (25 of 43; P = 0.03), whereas poor responders were more commonly hospitalized to manage the acute arthritis episode (22 of 43; P < 0.001) In multiple logistic regression, acute arthritis of the wrists (odds ratio [OR] 4.06, 95% confidence interval [CI] 1.21-15.50.85) were associated with arthritis resolution on day three, whereas randomization in the colchicine arm (OR 0.31, 95% CI 0.11-0.83) and diuretic use (OR 0.23, 95% CI 0.097-0.95) were associated with a poor treatment response. Hospital admission for acute arthritis, C-reactive protein levels, and estimated glomerular filtration rate were decision tree nodes selected as crucial for predicting definitive flare resolution. Three candidate variables were identified in the multiple logistic regression model explaining the occurrence of gastrointestinal AEs with colchicine: male sex (OR 0.33, 95% CI 0.07-1.29) and diabetes (OR 0.24, 95% CI 0.030-1.24) seemed protective, whereas statin use (OR 3.54, 95% CI 0.83-18.82) seemed associated with their occurrence. This study identified factors associated with the definitive response to colchicine and prednisone treatment in acute CPP crystal arthritis. Colchicine was associated with poorer efficacy and was impacted by a dual effect on its safety and efficacy by medications and associated conditions.

Stomal hyperflow, a frequent complication of ileostomy, is associated with high morbidity and mortality, particularly when linked to intestinal failure. This situation, especially when conventional treatments fail, often results in a poor prognosis for the patient.In this case report, we present the history of a patient suffering from stomal hyperflow with intestinal failure, in the context of short small bowel syndrome following multifocal venous mesenteric ischaemia. In a critical condition at the time of admission to our hospital, he was able to benefit from The Insides® System, a chyme reinstillation device, with the aim of improving his general condition and ultimately enabling surgical restoration of digestive continuity.This system led to clinical and biological improvement, allowing surgery to restore continuity. However, certain difficulties related to the use of the device were also encountered during management.

BackgroundMost data on atrial fibrillation (AF) ablation using the first available pentaspline pulsed field ablation (PFA) catheter (Farapulse, Boston Scientific Inc) come from retrospective center-level registries collected in highly experienced centers.ObjectiveThis study aimed to provide exhaustive and prospective patient-level data on this new ablation modality.MethodsFRANCE-PFA is a nationwide registry (NCT06497933) that included all patients undergoing a first AF ablation using the pentaspline PFA catheter since the introduction of this technology in France. All French centers using this technology participated. Procedural data were prospectively collected at a patient level.ResultsThis registry included 5223 patients from 33 centers between March 2021 and February 2024 (mean age 65 ± 11 years, 55.4% paroxysmal AF). The procedure duration was 54 ± 23 minutes. Acute pulmonary vein isolation was achieved in 5211 patients (99.8%). The total number of PFA applications was 50 ± 22 with >70 applications in 746 patients (14.3%). Pulmonary vein isolation only was performed in 64.7% of patients (82.7% of paroxysmal AF, 44.5% of persistent AF, and 26.6% of long-standing persistent AF). The most common location for additional PFA lesion sets was the left atrium posterior wall in 1335 patients (25.6%), left atrium roof in 999 patients (19.1%), and mitral isthmus in 514 patients (9.8%). Major complications occurred in 50 patients (0.96%), with no esophageal complication or symptomatic phrenic nerve palsy reported in past hospital discharge.ConclusionIn this prospective and nationwide registry, AF ablation using the pentaspline PFA catheter seemed to be safe and acutely efficient, despite considerable heterogeneity in the number of patients treated at each center.Trial RegistrationNCT06497933.