Publications

Objective: Coronavirus disease 19 is a well-established cause of rare arterial thrombosis. Nevertheless, the exact mechanism of arterial thrombosis remains to be elucidated. We herein report the case of a large floating thrombus of the aortic arch, its surgical management and histological analysis. Case: A 65-year-old patient presented to the emergency department with a suspected stroke. He was non-smoker, but presented cardiovascular risk factors, namely hypertension, type 2 diabetes and hyperlipidaemia. A computed tomography of the aorta revealed a large floating thrombus of the aortic arch, at the base of the brachiocephalic trunk, suspected to be the etiology of stroke. Therapeutic anticoagulation was immediately started. The decision was made to perform an open aortic replacement surgery because of the symptomatic thromboembolic event with recent cerebral infarction and the potential harmfulness of the thrombus due to its size. A mobile thrombus was observed at the base of the brachiocephalic trunk by echocardiography. It was attached to a small area of the upper aortic wall and had an irregular surface. Histology revealed a platelet-rich thrombus lying on an aortic atherosclerotic plaque without pronounced inflammation. No plaque ulceration was present but endothelial cell desquamation was observed consistent with plaque erosion. Conclusion: In our case, there was a thrombus lying on an atherosclerotic plaque with intact thick fibrous cap, but associated with a plaque erosion mechanism. The thrombus formation appeared more likely to relate to a very localized endothelial injury.

Background: Idarucizumab has been included in guidelines for the management of bleeding or surgical procedure in dabigatran-treated patients without need for biological monitoring. The aim of the study was to assess the prognostic value of dabigatran plasma level before reversal to test the hemostatic efficacy of idarucizumab. The secondary objectives were (i) to analyze plasma dabigatran level according to the risk of rebound and (ii) to evaluate the incidence of post-reversal non-favorable clinical outcomes (including thromboembolism, bleeding, antithrombotic, and death) and antithrombotic resumption. Methods and Results: This was an observational multicentric cohort study, which included all French patients who required idarucizumab for dabigatran reversal. Between May 2016 and April 2019, 87 patients from 21 French centers were enrolled. Patients received idarucizumab for overt bleeding ( n = 61), urgent procedures ( n = 24), or overdose without bleeding ( n = 2). Among patients with major bleeding ( n = 57), treatment with idarucizumab was considered effective in 44 (77.2%) of them. Patients who did not achieve effective hemostasis after reversal had a significantly higher mean level of plasma dabigatran at baseline (524.5 ± 386 vs. 252.8 ng/mL ± 235, p = 0.033). Furthermore, patients who did not achieve effective hemostasis after reversal had less favorable outcomes during follow-up (46.2 vs. 81.8%, p = 0.027). ROC curve identified a cutoff of 264 ng/mL for dabigatran level at admission to be predictive of ineffective hemostasis. No plasma dabigatran rebound was observed after reversal in patients with dabigatran plasma level < 264 ng/mL at baseline. Conclusion: This retrospective study shows that dabigatran level before reversal could predict hemostatic effectiveness and dabigatran plasma rebound after idarucizumab injection.

The assessment of von Willebrand factor (VWF) multimer distribution, particularly following the implantation of circulatory support devices, is a crucial parameter in hemostasis. Our study aimed to evaluate the semi-automated quantification of VWF multimers using the Sebia Hydrasys analyzer. Our analysis focused on quantifying high molecular weight, intermediate weight, and low molecular weight VWF multimers. Electrophoretic migration was performed using the Hydrasys 2 scan, and interpretation was carried out using densitometric analysis with the Phoresis software. The Hydrasys scan 2 successfully separated all the expected VWF multimer profiles based on the type of von Willebrand disease. The analysis revealed that in patients with circulatory support devices, elevated levels of plasma VWF rendered multimer migration unanalyzable using the methodology recommended by the manufacturer. Therefore, adjustment to a 100 % VWF antigenic level improved gel precision. We also suggest using as a standardized control the Cryocheck™ plasma, and have established reference values. Overall, this semi-automated, standardized, and optimized VWF multimer analysis system allows for an effective assessment of the VWF multimeric profile.

Our findings support an activation loop in the skin in CLL associated with endothelial alteration and immune infiltration of cytotoxic and type I IFN-polarized cells leading to clinical manifestations.

La creation de ce groupe thematique Miramion au sein de l'Espace ethique AP-HP1 en octobre 1997, et sa constitution par Dominique Davous et le Docteur Elie Haddad relevent d'une demarche singuliere et authentique : l'histoire d'une jeune fille de 14 ans hospitalisee pour une leucemie dans un service parisien de tout premier plan, six mois de traitement, une decision de greffer, pas de donneur familial, l'existence d'un donneur de fichier, la greffe, au lendemain de la greffe, une faute dans l'execution d'une prescription medicale annulant tous les espoirs de guerison, la mort le 18 mai 1994, les liens forts entre une famille et une equipe soignante [1]. L'originalite de ce groupe et le caractere novateur de sa demarche sont de reunir des soignants et des parents pour parler, chacun de sa position, a partir d'experiences vecues et de reflexions menees a propos des maladies graves en pediatrie. Un premier groupe (constitue de 15 personnes) a travaille et presente ses travaux lors d'une journee Miramion le 17 mars 1999 dont est issu un court article dans une lettre de l'Espace ethique [2]. Une deuxieme equipe, composee de sept membres de la premiere equipe et de quatre nouveaux membres, presente ici l'etat de la reflexion du groupe sur : L'annonce du diagnostic en pediatrie. Le groupe a travaille de facon reguliere (toutes les six a huit semaines environ) entre septembre 1999 et juin 2001. Il a privilegie l'oralite et l'echange dans le groupe. Deux precisions complementaires cadrent la reflexion du groupe. Tout d'abord, la situation decrite dans l'article est celle de l'annonce a l'hopital, en cas de maladie grave, hors urgence. Ensuite, comme dans le groupe precedent, la majorite des participants, soignants et parents ont une experience en hemato-oncologie. Il existe, a notre connaissance, peu de publications sur l'annonce du diagnostic en pediatrie et peu, voire pas, de publications communes parents-soignants. Nous abordons dans un premier temps le cadre de l'annonce, c'est-a-dire une analyse de ce moment particulier dans la maladie d'un enfant, en essayant de pointer a partir de nos experiences les questions qu'il est important de se poser au moment ou devrait se mettre en place l'alliance therapeutique entre l'enfant, ses parents et l'equipe soignante. Dans un deuxieme temps, nous exposons quelques pistes de reflexion sur les enjeux psychologiques autour de l'annonce du diagnostic, et les questionnements ethiques et philosophiques sur la pratique soignante et sur la position centrale de l'enfant malade. Certaines questions semblent evidentes, mais comme beaucoup d'evidences, elles se font, souvent, trop facilement oublier...