MODUL cohort 2: an adaptable, randomized, signal-seeking trial of fluoropyrimidine plus bevacizumab with or without atezolizumab maintenance therapy for BRAFwt metastatic colorectal cancer

Background

MODUL is an adaptable, signal-seeking trial designed to test novel agents in predefined patient subgroups in first-line metastatic colorectal cancer (mCRC).

Patients and methods

Patients with measurable, unresectable, previously untreated mCRC received induction with ≤8 cycles of FOLFOX + bevacizumab followed by randomization to maintenance treatment comprising control [fluoropyrimidine (FP)/bevacizumab: 5-fluorouracil 1600-2400 mg/m² 46-h intravenous (i.v.) infusion day 1 q2 weeks plus leucovorin 400 mg/m² 2-h infusion i.v. day 1 q2 weeks or capecitabine 1000 mg/m² b.i.d. orally days 1-14 every 21 days; bevacizumab 5 mg/kg 15-30-min i.v. infusion q2 weeks] or experimental treatment in one of four biomarker-driven cohorts. In patients with BRAF wild-type (BRAF^wt) tumors (cohort 2), experimental treatment was FP/bevacizumab + atezolizumab (800 mg 60-min i.v. infusion q2 weeks). Primary efficacy endpoint was progression-free survival (PFS; intent-to-treat population). Enrollment is complete; efficacy and safety findings from cohort 2 are presented.

Results

Four hundred and forty-five patients with BRAF^wt mCRC were randomized (2 : 1) to maintenance in cohort 2. At a median follow-up of 10.5 months, PFS outcome hypothesis was not met [hazard ratio (HR) 0.92; 95% confidence interval (CI) 0.72-1.17; P = 0.48]; overall survival (OS) was immature. At a median follow-up of 20.3 months (2-year survival follow-up), PFS benefit was also not met (HR 0.95; 95% CI 0.77-1.18; P = 0.666); OS HR with nearly two-thirds of patients with events was 0.83 (95% CI 0.65-1.05; P = 0.117). No new safety signals were identified. The most common grade ≥3 treatment-emergent adverse events (TEAEs) for experimental versus control arms were hypertension (6.1% versus 4.2%), diarrhea (3.1% versus 2.1%), and palmar-plantar erythrodysesthesia syndrome (1.0% versus 2.5%). Four patients experienced TEAEs with fatal outcome, two were study treatment-related: hepatic failure (experimental arm) and large intestine perforation (control arm; bevacizumab-related).

Conclusions

Adding atezolizumab to FP/bevacizumab as first-line maintenance treatment after FOLFOX + bevacizumab induction for BRAF^wt mCRC did not improve efficacy outcomes.

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MODUL is an adaptable, signal-seeking trial of novel combinations in predefined subgroups of patients with mCRC.

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In cohort 2 (BRAF^wt mCRC), adding atezolizumab to FP/bevacizumab (bev) first-line maintenance therapy did not improve PFS or OS versus FP/bev.

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ORR and DCR were numerically but not statistically significantly higher with atezolizumab + FP/bev versus FP/bev.

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The safety profile of atezolizumab + FP/bev was consistent with previous findings with no new safety signals identified.

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Findings from MODUL cohort 2 indicate that immunotherapy has limited efficacy in patients with microsatellite stable mCRC.

Environmental Effects of Temperature and Water Potential on Mycelial Growth of Neocosmospora solani and Fusarium spp. Causing Dry Root Rot of Citrus

This study aimed at evaluating the effect of environmental factors temperature and water potential (Ψw) on the growth of Neocosmospora (Fusarium) solani and three Fusarium species (F. oxysporum, F. equiseti and F. brachygibbosum) associated with citrus dry root rot and to determine the optimum and marginal rate for their growth. The effects of incubation temperature (5-40 °C), water potentials (Ψw) (- 15.54; - 0.67 MPa) (0.89-0.995 a_w) and their interaction (5-30 °C) was evaluated on the in vitro radial growth rates of Fusarium spp. and on their lag phase. Secondary models were used to model the combined effect of these factors on radial growth rate. The results underlined a highly significant effects (P < 0.001) of Ψw and temperature and their interactions on radial growth rates and lag phases (λ). The Four studied species were shown tolerant to a temperature of 35 °C with an optimum mycelial growth at 30 for N. solani and F. oxysporum and at 25 °C for F. equiseti and F. brachygibbosum. However, no growth was observed at both temperatures 5 and 40 °C and at Ψw of - 9.68 MPa (0.93 a_w). The optimum water potential for growth was ≥- 2.69 MPA (>0.98 a_w). The results from the polynomial model and response surface showing good agreement between observed and predicted values. The external validation on citrus fruit indicated slight differences between predicted and observed values of radial growth. The results of this study will be beneficial for understanding the ecological knowledge of these species and thereby limited preventively their occurrence.

The typical RB76 recombination breakpoint of the invasive recombinant tomato yellow leaf curl virus of Morocco can be generated experimentally but is not positively selected in tomato

TYLCV-IS76 is an unusual recombinant between the highly recombinogenic tomato yellow leaf curl virus (TYLCV) and tomato yellow leaf curl Sardinia virus (TYLCSV), two Mediterranean begomoviruses (Geminiviridae). In contrast with the previously reported TYLCV/TYLCSV recombinants, it has a TYLCSV derived fragment of only 76 nucleotides, and has replaced its parental viruses in natural conditions (Morocco, Souss region). The viral population shift coincided with the deployment of the popular Ty-1 resistant tomato cultivars, and according to experimental studies, has been driven by a strong positive selection in such resistant plants. However, although Ty-1 cultivars were extensively used in Mediterranean countries, TYLCV-IS76 was not reported outside Morocco. This, in combination with its unusual recombination pattern suggests that it was generated through a rare and possibly multistep process. The potential generation of a recombination breakpoint (RB) at locus 76 (RB76) was investigated over time in 10 Ty-1 resistant and 10 nearly isogenic susceptible tomato plants co-inoculated with TYLCV and TYLCSV clones. RB76 could not be detected in the recombinant progeny using the standard PCR/sequencing approach that was previously designed to monitor the emergence of TYLCV-IS76 in Morocco. Using a more sensitive PCR test, RB76 was detected in one resistant and five susceptible plants. The results are consistent with a very low intra-plant frequency of RB76 bearing recombinants throughout the test and support the hypothesis of a rare emergence of TYLCV-IS76. More generally, RBs were more scattered in resistant than in susceptible plants and an unusual RB at position 141 (RB141) was positively selected in the resistant cultivar; interestingly, RB141 bearing recombinants were detected in resistant tomato plants from the field. Scenarios of TYLCV-IS76 pre-emergence are proposed.

Abstract P6-08-05: Protein tyrosine kinase activity and miRNA expression profiling reveals differences according to progesterone-receptor-status in HER-2 negative breast cancer

Background: Kinases are considered as promising source of biomarkers for diagnostic, prognostic and therapeutic purposes in cancer patients. We assessed tyrosine kinase activity in 39 primary breast cancer samples that were all hormone receptor positive (ER+ and/or PR+) with differential HER-2 status, using microarray technology. Methods: Pamchip® peptide microarrays were used to measure the activity of protein tyrosine kinases in 32 breast cancer samples. The breast cancer cell lines MCF-7, BT474 and ZR75-1, was studied for kinase activity, both untreated and treated with estradiol. Results: Results showed differences in phosphorylation amongst breast cancer samples. A total of 37 peptide kinases were highly phosphorylated in a group of breast cancer samples representing 33 protein tyrosine kinases involved in cancer pathways and immunological responses. In vitro studies with breast cancer cell lines exhibited the same phosphorylation profiles, but increased phosphorylation was only observed in one cell line, ZR75-1. Eliminating HER-2 positive samples, we obtained differences in phosphorylation profiles based on PR-status only. Samples lacking PR-expression exhibited higher kinase activity of downstream kinases compared to PR-positive samples. Similar results were obtained with miRNA expression profiles of 31 breast cancer samples. Five miRNAs were identified to be significantly differentially expressed (p &lt; 0.05) between PR-negative and PR-positive samples. This effect was even stronger when eliminating HER-2 positive samples, with 13 miRNAs exhibiting significant differential expression based on PR-status. Conclusion: Although our data are based on a small dataset, the lack of PR expression seems to have a profound effect on tyrosine kinase activity and miRNA expression in HER-2 negative breast cancers without any effect on gene expression. This indicates that regulatory and functional molecules might exhibit phenotypical features of cancer that cannot be explained by gene expression alone.

Citation Format: Tahiri A, Satheesh SV, de Wijn R, Lders T, Aure MR, Quigley DA, Bukholm IR, Hurtado A, Kristensen VN, Geisler J. Protein tyrosine kinase activity and miRNA expression profiling reveals differences according to progesterone-receptor-status in HER-2 negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-08-05.

[Pulmonary arterial hypertension and porto-caval fistula in a 17 year old patient]

The authors report the case of a 17 year old patient with severe pulmonary arterial hypertension accompanied with a congenital porto-caval shunt. This patient had been admitted with dyspnoea on exertion with signs of pulmonary arterial hypertension on clinical examination. Echocardiography revealed a systolic pulmonary arterial pressure of 80 mmHg with no left heart anomaly or intracardiac shunt. Pulmonary investigations, as well as immunology, clotting, liver function and retroviral serology were all negative. A routine abdominal ultrasound showed a 10 mm proximal porto-caval fistula with no sign of portal hypertension. This case shows that anomalies of the portal system can cause pulmonary arterial hypertension even in the absence of any symptoms suggestive of hepatic disorder.

[Cardiac hydatid cysts: report of 10 cases]

Authors report 10 observations of cardiac hydatid cyst collected to cardiovascular unit of Ibn Rochd hospital in Casablanca during last 7 years. Clinical investigation included in all cases chest X ray, ECG and ultrasonography (US). A computed tomography (CT) scan was performed in 6 cases, magnetic resonance imaging in four cases, transoesophageal US in two cases. Examination for other hydatic sites was realized in all cases, and brain CT was performed in 5 cases. The hydatid cyst was variably localized in the left ventricle in 6 cases, the pericardium in 4 cases, the interventricular septum in 2 cases, the right auricle in 2 cases and multiple locations in one case. The existence of other cardiac hydatid sites was found in 7 cases. Seven patients have been operated (2 cases to closed heart). Outcome was favorable in 6 cases with a mean of three years survey. Two patients died and 2 others have been lost of view. The diagnosis of the cardiac hydatid cyst has benefits from the combination USCT scan that allowed a precise topographical inventory, reducing the need for MRI to the complicated cases and to the rare cases of inconclusive results by US-CT scan.

[False aneurysm complicating ligation of patent ductus arteriosus operated on successfully]

Postoperative aneurysm of ductus arteriosus is a rare complication but may be lethal without treatment. It is less frequent than spontaneous aneurysm of ductus arteriosus. We report the case of 5 years-old girl who underwent a ligation of patent ductus arteriosus complicated, 6 months later, with a false aneurysm of ductus arteriosus and endocarditis of the ductus and the aortic valve. The diagnosis of the aneurysm was suspected on the anteroposterior chest X-ray which showed a left superior mediastinal opacity and confirmed by echocardiography. Through bilateral thoracotomy, an anevrismorraphy and aortic repair was carried out without problem. The postoperative course was unremarkable.

[Cardiovascular abnormalities of the antiphospholipid antibody syndrome]

The antiphospholipid antibody syndrome (APS) may present with serious cardiovascular complications which should be recognised by the cardiologist. The authors report a series of 6 cases of APS diagnosed after thrombotic events and the finding of antiphospholipid antibodies. The APS was primary in 5 cases and associated with tuberculous lymphadenitis in 1 case. There was cardiac involvement in 5 patients with pericardial effusion in 3 cases, complicated by tamponade as the presenting sign of primary APS in the other 2, valvular disease in one case (moderate mitral stenosis with aortic valve disease) and pulmonary embolism in one case. Five patients developed recurrent deep vein thrombosis of the legs. One patient had a transient ischaemic cerebral attack.

[Hypertrophic cardiomyopathy disclosing Friedreich's disease. Report of a case]

The authors report the case of a 21 year old woman admitted to hospital for congestive cardiac failure due to concentric hypertrophic cardiomyopathy. Echocardiography showed severe systolo-diastolic left ventricular dysfunction without obstruction to ejection. Neurological examination showed a stato-kinetic cerebellar syndrome, a posterior radiculo-cordonal syndrome and a dysmorphic syndrome which characterise Friedreich's disease. In the light of this case and a review of the literature, the authors underline the rarity of cardiomyopathy in Friedreich's disease, its particular presentation and its poor prognostic significance in this disease.

[Hypocalcemic dilated cardiomyopathy: rare cause of heart failure]

Hypocalcemic dilated cardiomyopathy is a rare cause of heart failure in adults. We report a case in a 19-year-old woman who developed congestive heart failure induced by severe chronic hypocalcemia disclosing primary hypoparathyroidism. Complete regression of the clinical signs was achieved with vitamin-calcium treatment, but left ventricular systolic dysfunction persisted eight months after treatment.

[Malignant non-Hodgkin's lymphoma presenting with cardiac tamponade]

Malignant non-Hodgkin's lymphoma rarely involves the heart. However, all cardiac structures may be invaded, although the myocardium and pericardium are affected more often than the valvular structures. Diagnosis is important because treatment must be adapted. The cardiac signs are usually non-specific and lymphomas presenting in this way have only occasionally been reported. The authors report two cases in which malignant non-Hodgkin's lymphoma presented with cardiac tamponade.

[Aneurysm of the posterior sinus of Valsalva ruptured into right atrium]

Sinus of Valsalva aneurysm is rare malformation, which takes origin from one of the three aortic sinuses. Diagnosis of this abnormality is usually made when rupture has occurred. Our observation underlines the severity of the posterior sinus of Valsalva aneurysm ruptured into right atrium, and emphasizes the utility of transthoracic and transoesophageal echocardiography for diagnosis.

[Obstructive left triatrial heart in the adult. Echocardiographic appearances]

The authors report the case of a 23-year old man who presented with signs of pulmonary hypertension due to an obstructive left triatrial heart in adulthood. Transthoracic and transoesophageal echocardiography showed a partially calcified intra-left atrial membrane perforated in its centre. Doppler analysis of flow through the membrane showed continuous systolo-diastolic flow at high velocity indicating haemodynamic obstruction. The systolic pulmonary artery pressure was estimated at 80 mmHg. The patient was treated by surgical excision of the intra-left atrial membrane.

Electroporation-mediated delivery of 3'-protected phosphodiester oligodeoxynucleotides to the skin

The feasibility of topical delivery in the skin of 3' end modified phosphodiester oligonucleotides using electroporation was investigated. Experiments were performed in vitro, using hairless rat skin. Five pulses of (200 V, 450 ms) were applied. The 3' end modifications of the 15 mer oligonucleotide were: (1) 3'-aminohexyl, (2) biotin, with a triethyleneglycol arm, (3) methylphosphonate links between nucleotides 13, 14 and 15, and (4) 2-O-methyl nucleotides at 13, 14 and 15 positions. All the modifications were efficient to protect the oligonucleotides against degradation in the skin. Electroporation increased the topical delivery of the 3' end-modified phosphodiesters by two orders of magnitude compared to passive diffusion, without significant differences between the derivatives. Oligonucleotide concentrations in the range of 1 microm could be achieved in the viable skin. The delivery of a phosphorothioate congener was lower than phosphodiester delivery due to the interaction of phosphorothioate with the stratum corneum. Consequently, 3' end-protected phosphodiesters could be an interesting alternative to phosphorothioate oligonucleotides for topical treatment of cutaneous diseases.

[Malignant mediastinal schwannoma in Recklinghausen's disease presenting as cardiac tamponade. Report of two cases]

The authors report two cases of Recklinghausen's disease admitted for cardiac tamponade. Two-dimensional echocardiography showed a pericardial tumour in addition to a compressive pericardial effusion. After pericardial drainage, the outcome was rapidly fatal. Histological examination confirmed the diagnosis of a malignant intrapericardial schwannoma. A review of the literature revealed the scarcity of mediastinal malignant schwannoma. Associated with Von Reckinghausen's disease in 2 to 13% of cases, the prognosis is poor. The presentation of malignant mediastinal schwannoma with cardiac tamponade remains very rare.

[Horton's disease presenting as a myocardial infarction]

The authors report the case of a 60-year-old man admitted for uncomplicated acute myocardial infarction. The history of persistent fronto-occipital headaches and palpation of bilateral tortuous temporal arteries with a decreased pulse suggested the diagnosis of temporal arteritis, particularly in the presence of marked laboratory signs of inflammation and the coronary angiograph findings. The diagnosis was confirmed by temporal artery biopsy. Treatment consisted of corticosteroid therapy, with a satisfactory outcome at three months. The diagnosis of temporal arteritis should be systematically suggested in patients over the age of 50 years, presenting with a marked inflammatory syndrome and recent-onset arterial disease. Similarly, any form of arterial disease occurring during treated temporal arteritis should initially be considered to be a secondary site of the arteritis, requiring intensification of corticosteroid therapy.

Pericardial tamponade as the first manifestation of dermatopolymyositis

Pericardial involvement in polymyositis and dermatomyositis (PM/DM) is rare, usually asymptomatic and exceptionally part of the initial presentation. We describe a 37-year-old patient hospitalized for overt acute pericarditis, revealing dermatomyositis, which to our knowledge has not been previously reported. Pericardial puncture relieved the patient. The pericardial fluid was citrine yellow, exsudative, and mainly contained lymphocytes. Search for LE cells and anti-DNA antibodies was negative, whereas the antinuclear antibodies and the rheumatoid factor were present in the pericardial fluid. A biopsy of the pericardium showed a non-specific chronic inflammatory state and the search for an etiology was negative. There was no sign of tuberculosis, systemic lupus, nor neoplasia. Moreover bacteriological cultures and HIV serology were negative. After pericardiostomy associated with corticosteroid therapy at the dose of 1 mg/kg/day, outcome was good with a resolution of the pericarditis confirmed at one-year follow-up. Since pericardial tamponade, even though rare, may be fatal in a patient with dermatomyositis, we emphasize that a two dimensional echocardiographic study should be performed in all patient presenting with dermatopolymyositis.

[Approach of Moroccan cardiologists to arterial hypertension]

The authors conducted a survey among 300 cardiologists in order to evaluate their knowledge of HT. Most of the 200 cardiologists answering the survey considered that systolic HT was defined by a systolic blood pressure greater than 160 mmHg (75%). Only 14 cardiologists (7%), defined systolic HT as a blood pressure greater than 140 mmHg. 121 cardiologists (60.5%) defined diastolic HT as a pressure greater than 95 mmHg. 2/3 of cardiologists were not familiar with the conclusions of the JNCV for the detection, evaluation and treatment of HT. All cardiologists agreed that treatment of HT should start with single-agent therapy. In the case of insufficient control, 11% doubled the dose, 5% changed the drug in the same class, 53% changed therapeutic category and 30% prescribed two-agent therapy. Once BP was stabilized, one half of cardiologists reviewed their patients once every 3 months, and 22.5% reviewed their patients once every six months. These results demonstrate that cardiologists do not correctly follow the rules of management of HT recently defined by the various working parties. The authors propose a number of points to remedy some of the deficiencies revealed by this survey.

[Variations of blood pressure during the month of Ramadan]

The goal of this work is to study the consequences of the last on variations of the blood pressure (BP) in the course of 24 hours. From 1994 to 1997 we have selected 99 hypertensive patients and studied their BP profile. This study included 72 women and 27 men. Their age varies from 22 to 72 years (average 56.7 +/- 9 years). All these patients has an ambulatory blood pressure measurement (ABPM) before the fast and during Ramadan. Before Ramadan the period of the sleep goes from 10 pm +/- 1 h to 8 am +/- 1 h. During the month of Ramadan, the sleep lasts from 0 h +/- 1 to 9 am +/- 1 h. [table: see text] No statistically significant difference is noted between these 2 periods neither for the systolic BP (SBP) nor for the diastolic BP (DBP), for the BP of 24 hours, and the diurnal and nocturnal periods. We have then the compared the hourly average on 24 hours of the 99 patients. We observed that during the month of Ramadan the peak of the awakening is delayed by 2 hours and the nocturnal through is delayed by 1 hour. After this study, which is the first one to deal with variations of blood pressure during the fast of Ramadan we can confirm that in patients with essential hypertension without complications, the fast is well supported. The variations of BP are minimal and are related to the variations of the sleep, activity and eating pattern.

[Hypertension and Takayasu disease. Report of 8 cases]

In this paper, the authors report 8 cases of Takayasu disease presenting in the form of hypertension, observed in the Cardiology of Ibn Rochd University Hospital in Casablanca between 1983 and 1995. The majority of cases presented with renovascular HT, secondary to unilateral or bilateral renal artery stenosis. More rarely, the patients presented proximal hypertension secondary to coarctation of the aorta. Medical treatment was prescribed all 8 cases, associated with surgery in 8 cases.

[Cardiac tamponade and transient ischemia revealing a syndrome of primary antiphospholipid antibodies]

The authors report a case of echocardiographically confirmed cardiac tamponade, which required emergency pericardial aspiration, and a transient ischaemic attack revealing an underlying primary antiphospholipid antibody syndrome in a 29-year-old patient. The test for antiphospholipid antibodies was positive on 2 occasions (IgG > 91.41 micrograms/l). The diagnosis of systemic lupus erythematosus was eliminated. A favourable course was observed after 3 months of corticosteroids and platelet antiaggregants. Any case of cardiac tamponade or transient ischaemic attack with an unexplained aetiology in a young patient must suggest the diagnosis of antiphospholipid antibody syndrome.

[Blood pressure determination and medical competence]

Hypertension diagnosis depends closely to the blood pressure measurement. The aim of this work is to show whether blood pressure measurement should be done by a beginner or a competent doctor. The blood pressure of 180 patients, (150 females, 30 males) was taken by two physicians. The patients' average age was 51 +/- 11. One of the two physicians was a cardiologist who took all the patients blood pressure. Others where six doctors in training, that is sixth' year students at the faculty of medicine. They took part in this study for a week. The procedure was that the cardiologist and one of the training doctors took the patient's blood pressure at the same time after 15 min rest. We have calculated the average systolic blood pressure and diastolic blood pressure of 720 measures. Then the difference between the cardiologist's measures and those of all the training doctors. After that we have analysed the difference between the average of 120 measures taken by one of the training doctors and the corresponding measurement of the specialist. We have then compared the difference of the 20 measures of every day taken by the training doctor and the ones taken by the specialist. The difference wasn't statistically significant either for the systolic blood pressure or the diastolic blood pressurement. We have studied the evolution of the average of the 20 measurements of every day during the whole week. So, we have noticed that the difference lowers from the first days to the sixth. In the end, we were interested in the last figure of each measurement of blood pressure. The training doctor often gave measurements up to 0 or 5 whereas the specialist gave precise measurements. We have concluded from this work that if experience is needed, the physician has to know the principals and the tricks of blood pressurement. Moreover, the blood pressure variations by "white coat" effect can't be explained by measurements techniques. This effect can be considered as psychic, interactions between doctors and patients.

[Deep venous thromboses and occult cancers]

The association between venous thrombosis and cancer has been known for a long time. Thrombophlebitis often occurs during the course of a known cancer, but sometimes constitutes the presenting sign. Based on a series of 10 cases of deep venous thrombosis (DVT) revealing an underlying cancer, the authors analyse the various aspects of this association and the elements which help to guide the diagnosis towards a cancer. A simple assessment comprising clinical examination, full blood count and differential white cell count, erythrocyte sedimentation rate, protein electrophoresis, chest x-ray and abdomino-pelvic ultrasonography was performed on admission in 75 cases of presumably idiopathic DVT and revealed a cancer in 10 cases: 6 women and 4 men with a mean age of 53 years. Cancers were located in the urogenital tract in 5 cases, in the bronchi in 2 cases, in the stomach in one case, and there was one case of acute myeloblastic leukaemia (AML) and another case of liposarcoma of the left iliac fossa. The histological type most frequently encountered was adenocarcinoma in 6 cases. In 9 out of 10 cases, the cancer was discovered at the stage of metastases. However, a localized cancer was detected in one case, in which surgical treatment allowed cure of the patient. Comparison of the various characteristics of DVT between the group of DVT revealing a cancer and the group of DVT which remained idiopathic did not reveal any statistically significant difference. A simple, inexpensive assessment looking for a cancer must be systematically performed in all cases of idiopathic DVT in patients between the ages of 50 and 85 years. Other more elaborate examinations may be requested on the basis of the results of the preliminary assessment.

[Bacterial endocarditis in Morocco]

This retrospective study was based on 157 cases of infectious endocarditis observed in the Cardiology department of Ibn Rochd Hospital in Casablanca between January 1983 and December 1994. The mean age of the patients was 27.5 years (11 to 65 years) with a male predominance (62.8%). Infectious endocarditis was secondary to rheumatic valvular heart disease in 63.% of patients and was primary in 29.9% of cases. Mitral or mitro-aortic valve involvement was clearly predominant. A portal of entry of the infection was identified in 63% of patients. It was dental in 64% of cases. Blood cultures were positive in 42% of cases with a predominance of unclassifiable Streptococci (37.8%) and coagulase-negative Staphylococci (25.7% of cases). Echocardiography was very useful, particularly in the presence of negative blood cultures. It demonstrated specific lesions of infectious endocarditis in 73.2% of cases and revealed very large, mobile vegetations in every case complicated by systemic embolism. The clinical course was complicated by heart failure (47.8%), renal failure (14.6%) or neurological lesions (11.5%). The global mortality was 28.7%, related to refractory heart failure in most cases.

[Cardiac manifestations of diffuse systemic scleroderma. Apropos of 4 cases]

Based on a series of four cases and a review of the literature, the authors describe the lesions of the various cardiac tissues in the course of systemic scleroderma. Pericardial involvement presents in the form of either acute pericarditis or chronic pericarditis. Pericardial tamponade is exceptional. Sclerodermal cardiomyopathy is frequent and serious and can be responsible for heart failure. Arrhythmias are frequent and may be either ventricular or supraventricular. Involvement of the conduction tissue often requires implantation of a pacemaker. Endocardial and valvular involvement is very rare. Lastly, coronary involvement appears to be fairly rare and responsible for vasospastic episodes in the coronary artery territory.

[Cardiac tamponade disclosing neoplasm: apropos of 23 cases]

The authors report a series of cardio-pericardial metastases presenting acutely with tamponade. There were 14 men and 9 women with an average age of 39 years. The primary tumour was mainly bronchial in the men (5 cases: 20.8%) and breast (3 cases: 16.6%) or uterine (4 cases: 16.6%) in the women. The other malignancies were blood dyscrasias (5 NHL and 1 MHL) one pericardial mesothelioma, one Schwannoma, one Ewing's sarcoma and one carcinoma of the larynx. The primary tumour was not found in one case. Echocardiography showed a large, circumferential pericardial effusion in all cases and compressing the right heart chambers (RA and/or RV) in half the cases. Rounded echogenic masses implanted on the pericardial membranes (2 cases) or images of false membranes (10 cases) were also demonstrated. The clinical emergency led to pericardiocentesis with surgical drainage in 5 cases. A pleuro-pericardial window was fashioned in 4 cases. The effusion was important in all cases and bloody in 75% of cases. Cytology of the pericardial liquid was positive for malignant cells in 1 out of 2 cases. The diagnosis was made after death in 3 cases. The other biopsies, bronchial, lymph node, pleural and bone marrow also provided valuable diagnostic information. Undifferentiated carcinoma was found in 75% of bronchial carcinomas. In all three breast tumours, the histology showed moderately well differentiated adenocarcinoma. The authors underline the paucity of therapeutic measures: at this stage, pericardiocentesis is almost the only procedure apart from the cases of haemopathy. Some authors have suggested radiotherapy of the precordial region and others, intrapericardial chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Meadows syndrome: puerperal cardiomyopathy]

This retrospective study concerns six cases of gravido-puerperal cardiomyopathy. These six cases account for 18% of all cases of non-obstructive cardiomyopathy (NOCM) affecting women in general and 67% of NOCM in women of childbearing age. Mean age was 28.5 with a range of 18 to 39. Reported risk factors include poor socio-economic conditions, multiparity, twin pregnancies and anemia. The clinical picture is that of cardiac failure, most often congestive (83.3%), with a systolic murmur of functional mitral incompetence (50%) and atypical chest pain (50%). The ECG is invariably abnormal, without specific signs. The high incidence of repolarisation disturbances is a fairly special feature. Echocardiography is the technique of choice, enabling detection, diagnosis and study of ventricular function, which is an important factor in prognostic evaluation. Medical treatment is based upon a combination of rest, salt-free diet, diuretics, digitalis and vasodilators. The etiology remains unknown and the prognosis is severe despite cases of complete recovery.

[Aortic coarctation and pregnancy. Apropos of 3 cases followed-up during a period of 10 years]

Classically, coarctation of the aorta is poorly tolerated during pregnancy or at least is associated with a risk of rupture of the aorta, rupture of a cerebral aneurysm or, more rarely, cardiac failure or bacterial infection. The authors turned their attention to this association of coarctation of the aorta and pregnancy in the light of 3 cases of pregnancy brought to term in the Department of Cardiology of the Ibn Rochd Teaching Hospital Group, Casablanca, Morocco. During a 10 year period, 20 patients were hospitalised in the department with coarctation of the aorta. There were 10 women, 3 of them pregnant. The mean age of these women was 26, with a range of 24 to 30. All patients had a normal pregnancy, delivery and post-partum, with neither cardiovascular, renal nor cerebral complications. There were no maternal deaths, ruptures of the aorta, cerebrovascular accidents, bacterial infections nor myocardial failure. All the pregnancies were brought to term. One patient was delivered vaginally with the use of forceps after full dilatation facilitating expulsion. One cesarean section with extraction of a live infant was induced at 38 weeks. One patient was lost to follow-up at 7 months and was seen again only after delivery at home, i.e. without supervision but equally without complications. The 3 newborn infants had an Apgar of 10/10 and a birth weight of 3.2-3.5 kilos. There were no spontaneous abortions and no premature deliveries.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiovascular manifestations of hereditary dysplasias of connective tissue]

The purpose of this study was to demonstrate the special features of cardiovascular effects in connective tissue disorders through a group of fifteen cases observed over a period of ten years. The group consisted of eleven cases of Marfan syndrome (or Marfan-like syndrome), two cases of pseudoxanthoma elasticum and two cases of Ehlers-Danlos disease. The cardiovascular lesions were as follows: 1) dissection of the ascending aorta which was confirmed and had been treated surgically in 2 cases; 2) aneurysmal dilatation of the ascending aorta in 5 cases; 3) moderate mitral valve prolapse, which was isolated in 2 other cases; 4) distention of the mitral valve in 2 cases; 5) mitral valve prolapse combined with tricuspid valve prolapse in 1 case; the mitral incompetence was severe and made it necessary to carry out mitral valve replacement; 6) moderate aortic valve prolapse combined with tricuspid prolapse in a case of type-I Ehlers-Danlos disease; 7) Fallot's tetralogy combined with Marfan's syndrome and treated surgically in one case; 8) severe hypertension with abnormalities of the iliac and renal arteries in one case of elastic pseudoxanthoma elasticum. In three cases complications occurred leading to death, extension of the dissection of the abdominal aorta and global recalcitrant heart failure respectively. The outcome in the other 12 cases, with a mean follow-up time of 3 and one half years (range: 3 years to 7 years) was not marked by complications.