Annales De Medecine Interne[JOURNAL]
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200 papers
[Interactions between benzodiazepines and opioids].
Megarbane B, Gueye P, Baud F
Ann Med Interne (Paris) · 2003 Nov · PMID 14760228
Benzodiazepines and opiates or opioids are used concomitantly in various circumstances, for example in anesthesiology, for the management of acute or chronic pain and for substitution therapy in heroin addiction. There a...
Benzodiazepines and opiates or opioids are used concomitantly in various circumstances, for example in anesthesiology, for the management of acute or chronic pain and for substitution therapy in heroin addiction. There are numerous interactions between these two families of substances. The objective of this review is to present the interactions identified in clinical and experimental studies reported in the literature dealing with their effects on pain, anxiety, sedation and respiration. The exact mechanism of benzodiazepine and opioid interactions remains to be established. It may depend on pharmacokinetic or pharmacodynamic mechanisms. Certain arguments would support the pharmacodynamic hypothesis: the co-location of GABA and opiate receptors in the central nervous system, the existence of possible cross-reactivity and common pathways of intracellular transduction. The deleterious interaction of benzodiazepines and opioids on respiration may take place at the level of the central command of ventilation or may be related to additive actions on the different neuromuscular components of the respiration. A better understanding of the exact mechanisms implicated in these interactions would increase the safety of prescription of these drugs.
[Misuse of tianeptine: five cases of abuse].
Leterme L, Singlan YS, Auclair V … +2 more , Le Boisselier R, Frimas V
Ann Med Interne (Paris) · 2003 Nov · PMID 14760227
Five cases of excessive consumption of tianeptine suggest possible drug-abuse of this substance. This side effect is unknown in animals and humans. According to DSM IV, CIM 10 criteria and the French public health code,...
Five cases of excessive consumption of tianeptine suggest possible drug-abuse of this substance. This side effect is unknown in animals and humans. According to DSM IV, CIM 10 criteria and the French public health code, these five patients had pathological profiles of psychoactive drug abusers. Tianeptine dosage was always used higher than recommended and the drug was taken in association with other psychotropes. Withdrawal was difficult and induced anxiety and other disorders which led to relapse in most of the patients.
[Doping: health risks and relation to addictive behaviors].
Siri F, Roques BP
Ann Med Interne (Paris) · 2003 Nov · PMID 14760226
UNLABELLED: The paper presents the health hazards of the major doping substances and raises some questions about the relationship between doping and addictive behavior. AIMS: Current definitions of doping and addictive b...
UNLABELLED: The paper presents the health hazards of the major doping substances and raises some questions about the relationship between doping and addictive behavior. AIMS: Current definitions of doping and addictive behavior are examined. The paper's goal is: 1- to assess the risks of neurotoxicity and overall toxicity of doping substances: stimulants, narcotics (seldom used as doping substances), and hormones, and assess their addictive potential; 2- to present available data on drug-dependent patients with a record of early prolonged and intensive physical activity or athletic practice. RESULTS AND DISCUSSION: Some doping substances present high risks for health at large doses, but usually low addictive potential and neurotoxicity. Dependency on doping substances and drift towards dependency to addictive drugs, if any, are therefore determined by genetic and environmental factors. A significant susceptibility to drug dependence has been observed in some cases of very intensive and competitive practice. Over-representation of intensive and competitive athletic antecedents among some drug-dependent patients could be accounted for in either of two ways. On the first account, the causal factor is a sensation-seeking character trait, with a likely genetic component, which predisposes the individual to the use of drugs or doping substances, as the opportunities arise. On the second account, the sudden interruption of intensive practice, and of the associated organic stress and hypersensitization of the hedonic pathway, creates a weaning syndrome and leads to the search for relief through drugs. Further exploration of this hypothesis is called for.
[Development of diagnosis criteria for physical activity abuse and dependence: a qualitative study].
Mangon E, Simon S, Franques-Rénéric P … +1 more , Auriacombe M
Ann Med Interne (Paris) · 2003 Nov · PMID 14760225
AIM: The purpose of this work was to search for criteria of physical activity abuse and dependence, patterned after abuse and dependence criteria for psychoactive substances described in DSM IV and CIM10, and to determin...
AIM: The purpose of this work was to search for criteria of physical activity abuse and dependence, patterned after abuse and dependence criteria for psychoactive substances described in DSM IV and CIM10, and to determine whether these criteria could be found in individuals practising sports. This preliminary work was designed as the first step in the search for a possible physical activity dependence syndrome. METHODS: Operational criteria for physical activity abuse and dependence were defined by using the DSM IV and CIM 10 criteria for psychoactive substances abuse and dependence as a pattern. We searched for these criteria among a group of 8 persons (4 men and 4 women, aged 17-25 years) who practised 7 different sports. The subjects participated in a qualitative interview during which the defined criteria were not mentioned directly. The script of the interview was analyzed with a pre-established grid in order to search for the operational diagnostic criteria. RESULTS: All of the defined operational criteria except two concerning physical activity abuse were identified in the interview scripts. All of the participants fulfilled at least one of the defined criteria. The importance of physical activity dependence criteria spontaneously mentioned by the participants was notable; abuse criteria were found less often. DISCUSSION: Based on the findings of this qualitative study, the development of diagnostic criteria for physical activity abuse or dependence patterned after psychoactive abuse and dependence criteria appears to be a realistic possibility. The operational criteria we defined were found in all of the participants in this study, irrespective of the sports they practised. Although a large number of dependence criteria were found for each participant, this study was not designed to determine the number of participants for whom the diagnosis of physical activity dependence could be retained. This would require search for notions such as duration of the manifestations, changing functional behavior, or clinically significant suffering in order to identify the pathological nature of the behavior. Other studies are now needed to determine whether individual subjects who present a sufficient number of criteria simultaneously can be identified as presenting physical activity abuse or dependence.
[French nationwide survey of abstinence-oriented treatments in opiate-addicted patients. Results at 12 months].
Vignau J, Boissonnas A, Tignol J … +2 more , Millot Y, Mucchielli A
Ann Med Interne (Paris) · 2003 Nov · PMID 14760224
UNLABELLED: Over the last few years, general practitioners and pharmacists in France have become more directly involved in the treatment of opiate-addicted patients with the rapid development of office-based buprenorphin...
UNLABELLED: Over the last few years, general practitioners and pharmacists in France have become more directly involved in the treatment of opiate-addicted patients with the rapid development of office-based buprenorphine and methadone maintenance programs. At the same time, demand for abstinence-oriented interventions outside established maintenance programs continues to be addressed to the primary care system. METHOD: Our prospective and multicentric survey was conducted to monitor the follow-up of such abstinence-oriented interventions during a 12 months period, by means of questionnaires investigating the psychosocial, medical and addictive status of the patients recruited. RESULTS: One hundred and sixty five general practitioners have accepted to participate in the survey. Initially, they recruited 414 patients (51% terminating a buprenorphine maintenance treatment, 5% a methadone treatment and 36% withdrawing from heroin). Naltrexone chlorhydrate was prescribed for 50% early after entry in the survey. During the 12-month follow-up period: four data collections were proposed at 1, 3, 6, and 12 months. In all, data were collected for 158 patients. No data could be collected for 63 patients who were excluded from follow-up analysis. Out of the 351 patients who attended at least one follow-up visit, 137 (one third) moved to an opiate agonist maintenance program. When naltrexone was prescribed, total duration of treatment averaged 4785 days with no significant difference in terms of heroin relapse and attendance to follow-up visits. Between the first and the last data collection, out of the 113 HCV-positive patients, 13 received/started an anti-viral treatment. No significant difference was noted according to indicators of social outcome. CONCLUSION: Our survey shows that office-base abstinence-oriented interventions in opiate-addicted patients can produce a moderate benefit. Research concerning alternative formulations for opiate antagonists (e.g., long-acting naltrexone) could be helpfully in developing new options for treatment.
[Sports practices and violent behaviors in 14-16 year-olds: analysis based on the ESPAD 99 survey data].
Choquet M, Arvers P
Ann Med Interne (Paris) · 2003 Nov · PMID 14760223
To date, there has been little research into the relationship between violent behavior and the practice of sport in young adolescents (both girls and boys) in the general population. Indeed, sport is often recommended as...
To date, there has been little research into the relationship between violent behavior and the practice of sport in young adolescents (both girls and boys) in the general population. Indeed, sport is often recommended as a means of prevention and an alternative to violence in adolescence. For this reason, we studied this issue in a representative sample of 14-16 year-olds (ESPAD 99). Among this sample, boys practised some form of extra-curricular sport more than girls (75% vs. 57%), this practice being more intensive (13% boys vs. 4% girls practising sport more than 8 hours per week outside of school) and more "competitive" (14% vs. 4% taking part in national and/or international events). Boys also exhibited more violent behavior than girls, including stealing (mean 0.91 for boys vs. 0.49 in girls), fighting (mean 1.71 in boys vs. 0.49 in girls) or serious offences (mean 0.66 in boys vs. 0.34 in girls). Taking part in competitions was found to be highly associated with violent behavior. In particular, competition at a national or international level was associated (in decreasing order of significance) with fighting (OR=2.35), serious offences (OR=1.78) and stealing (OR=1.58), after adjustment for age, gender, father's educational level and type of school attended. The practical implications of this study are that it is important to moderate one's judgment about the positive effects of sport in reducing youth violence, to be attentive to violent acts perpetrated in stadiums and to better analyze the eventual beneficial effects of sports clubs.
[Effect of maintenance treatments on social life. A study with general practitioners].
Bilal S, Menares J, De La Selle P … +2 more , Toufik A, Perdrieux Y
Ann Med Interne (Paris) · 2003 Nov · PMID 14760222
The objective of this retrospective study was to describe drug maintenance treatments (DMT) in ambulatory care, and to evaluate their impact on social life. A convenience sample of 665 patients on DMT was recruited by 94...
The objective of this retrospective study was to describe drug maintenance treatments (DMT) in ambulatory care, and to evaluate their impact on social life. A convenience sample of 665 patients on DMT was recruited by 94 general practitioners in three geographic areas (Ile-de-France, Alsace, Aquitaine), and interviewed face to face by independent staff with a standardized questionnaire on three periods (one month before DMT, 6 months after beginning of DMT and 1 month before inclusion within the survey). Among the 665 patients, 76% were on buprenorphine, 20% on methadone, and 4% on morphine sulfate. Consumption of heroin and other psychoactive drugs was lower 6 months after DMT initiation. Patients were more likely to have relationships with people who did not have any problem with alcohol and drugs after DMT initiation than before treatment. They were also more likely to spend their free time alone after having begun DMT than before. All markers of social vulnerability evaluated through standardized questionnaires (employment, housing, social insurance, days of in-patient treatment related to drug consumption and number of condemnations) were improved after a six-month period with DMT. This research contributes to demonstrating the positive impact of DMT both on drug consumption and social life. Health professionals should include social support in their clinical practice.
[Stumbling blocks of sports].
Lowenstein W
Ann Med Interne (Paris) · 2003 Nov · PMID 14760221
Abstract loading — click title to view on PubMed.
Extra-anatomic bypass shunting in aorto-iliac occlusive disease. Clinical results and risk factors in a Belgian population.
Tueche SG
Ann Med Interne (Paris) · 2003 Nov · PMID 14732842
We present a retrospective study of 38 patients undergoing axillofemoral bypass shunting (AXF, n=42, including 29 axillobifemoral (AXBF) and 9 axillo-unifemoral (AXUF)) from 1988 to 1998, for aorto-iliac occlusive diseas...
We present a retrospective study of 38 patients undergoing axillofemoral bypass shunting (AXF, n=42, including 29 axillobifemoral (AXBF) and 9 axillo-unifemoral (AXUF)) from 1988 to 1998, for aorto-iliac occlusive disease (AOD). Six were excluded from the study as they did not meet entry criteria; the remaining 32 patients were retained. All patients had histories of failed medical treatment. Indications for grafting were limb salvage (n=19), pain at rest (n=10), and high grade claudication (n=9). There were 28 males. Mean age was 73 years (range: 56-86). Preoperative assessment, risk factors and early outcome were considered. Knitted Dacron and Gore-Tex prostheses were used. Indications for AXF was poor general status, locally hostile or septic abdomen. All the patients were symptom-free early after surgery, with disappearance of pain at rest, improvement in trophic necrotic, and gangrenous lesions of the limbs, and better independence in walking ability. One patient died during the first 30 days (3% operative mortality). Most deaths occurred within 6 months due to causes unrelated to surgery, mainly in patients with comorbid conditions. AXF bypass is an acceptable procedure for high risk AOD patients or when conventional anatomic in situ repair is contraindicated.
[Antisynthetase syndrome. Three cases and a review of the literature].
Imbert-Masseau A, Hamidou M, Agard C … +5 more , Halloun A, Delangle MH, Audrain M, Grolleau JY, Mussini JM
Ann Med Interne (Paris) · 2003 Nov · PMID 14732841
Antisynthetase syndrome belongs to the idiopathic myositis group which includes pulmonary interstitial disease, arthritis, Raynaud's phenomenon, and mechanic's hands , associated with the anti-Jo1 antibody. We report thr...
Antisynthetase syndrome belongs to the idiopathic myositis group which includes pulmonary interstitial disease, arthritis, Raynaud's phenomenon, and mechanic's hands , associated with the anti-Jo1 antibody. We report three cases of antisynthetase syndrome, and review the clinical characteristics, and prognosis factors dominated by interstitial pneumonia.
Neurological manifestations of polyarteritis nodosa associated with the antiphospholipid syndrome.
Valeyrie L, Bachot N, Roujeau JC … +3 more , Authier J, Gherardi R, Hosseini H
Ann Med Interne (Paris) · 2003 Nov · PMID 14732840
The association between antiphospholipid syndrome (APS) and vasculitis is rare and continues to evoke great interest. We report a case with neurological manifestations of polyarteritis nodosa (PAN) and concurrent APS. El...
The association between antiphospholipid syndrome (APS) and vasculitis is rare and continues to evoke great interest. We report a case with neurological manifestations of polyarteritis nodosa (PAN) and concurrent APS. Electromyography and neuromuscular biopsy of the limb showed an axonal polyneuropathy following obliteration and necrosis of medium sized arteries, initially suggesting PAN. This vasculitis was confirmed on visceral selective arteriography, with the presence of numerous aneurysms. Cerebral MRI revealed multiple cortical and subcortical signals in the fronto-parietal areas, corresponding to ischemic microvascular lesions of APS. This association was confirmed by the presence IgG anticardiolipid, the past medical history of skin necrotic lesions and central retinal obliteration. Pulse intravenous cyclophosphamide, oral prednisolone and curative anticoagulation led to stabilization for 8 months.
[Subacute motor neuropathy induced by T3 hyperthyroidism].
Caparros-Lefebvre D, Benabdallah S, Bertagna X … +1 more , Ekindi N
Ann Med Interne (Paris) · 2003 Nov · PMID 14732839
Subacute motor neuropathy involving bulbar nerves is an unusual complication of hyperthyroidism. Clinical and neurophysiologic follow-up of such patients has been rarely reported. We describe a 41-year-old Colombian pati...
Subacute motor neuropathy involving bulbar nerves is an unusual complication of hyperthyroidism. Clinical and neurophysiologic follow-up of such patients has been rarely reported. We describe a 41-year-old Colombian patient who developed respiratory failure associated with motor neuropathy and severe weight loss. The major clinical features included diffuse amyotrophy, bilateral facial paresis, and fasciculations, suggesting motor neuropathy. Electromyography confirmed the presence of axonal neuropathy, with predominant motor involvement. Goiter with hypervascularization was noticed, associated with pure T3 hyperthyroidism (T3l=26 pg/ml; N<3.8). The patient was given carbimazole which induced a severe skin vasculitis 10 days later. Carbimazole was stopped and replaced by propylthiouracile, which also induced vasculitis with secondary cardiac failure. Total thyroidectomy was then performed. General status improved rapidly as well as motor deficit, amyotrophy and pyramidal syndrome. Electromyographic abnormalities improved significantly within 3 months. This observation demonstrates that hyperthyroidism can produce motor axonal neuropathy, curable with radical surgery.
[Cluster headache].
Ducros A, Bousser MG
Ann Med Interne (Paris) · 2003 Nov · PMID 14732838
Cluster headache is characterized by recurrent unilateral attacks of headache of great intensity and brief duration (15-180 minutes), accompanied by local signs and symptoms of autonomic dysfunction including conjunctiva...
Cluster headache is characterized by recurrent unilateral attacks of headache of great intensity and brief duration (15-180 minutes), accompanied by local signs and symptoms of autonomic dysfunction including conjunctival injection, lacrimation, nasal congestion, rhinnorrhea, forehead and facial sweating, miosis, ptosis or eyelid edema. Attacks occur in so-called cluster periods lasting for weeks or months. About 10% of patients have chronic symptoms with no period of remission. There are only two abortive treatments with proven efficacy: subcutaneous sumatriptan and nasal oxygen inhalation. Prophylactic treatment is often needed to reduce the daily frequency of attacks: verapamil in episodic cluster headache and lithium in chronic cluster headache.
[Abdominal and digestive manifestations in systemic vasculitides].
Pagnoux C, Mahr A, Guillevin L
Ann Med Interne (Paris) · 2003 Nov · PMID 14732837
Digestive involvement is frequent during the course of systemic small and medium-sized vessel vasculitides. Clinical manifestations range from rapidly regressive abdominal pain to surgical manifestations associated with...
Digestive involvement is frequent during the course of systemic small and medium-sized vessel vasculitides. Clinical manifestations range from rapidly regressive abdominal pain to surgical manifestations associated with poor prognosis. These are usually associated with extra-abdominal signs, reflecting vasculitis activity. Isolated gastrointestinal involvement is observed in only 16% of these patients. The main clinical manifestations are common to all vasculitides (ischemia, bowel infarction and perforations, gastrointestinal hemorrhage due to mucosal ulcerations or aneurysmal ruptures), but some are more specific to one type (granulomatous ileo-colitis during Wegener's granulomatosis, eosinophilic colitis during Churg-Strauss syndrome). Gastrointestinal arteriography can be helpful for diagnosis, but has no prognostic value, likewise for the presence of ANCA. As there are no identified factors predictive of a surgical abdomen, therapy must be adapted individually, using steroids and immunosuppressive agents, generally cyclophosphamide. Prompt surgical and medical care of these seriously ill patients has lowered mortality from nearly 100% twenty years ago to approximately 23 to 56% currently.
[EGF receptors in urological cancer. Molecular basis and therapeutic involvements].
Paule B, Brion N
Ann Med Interne (Paris) · 2003 Nov · PMID 14732836
Many epithelial cancers have been found to overexpress the receptor to epidermal growth factor (EGFR) including head and neck, breast, colon, lung, prostate, kidney, ovary, brain, pancreas and bladder cancer. Because of...
Many epithelial cancers have been found to overexpress the receptor to epidermal growth factor (EGFR) including head and neck, breast, colon, lung, prostate, kidney, ovary, brain, pancreas and bladder cancer. Because of the association of EGFR overexpression with overall poor prognosis in patients with cancer, a number of strategies to block or downregulate EGFR have been developed to inhibit tumor proliferation and improve clinical outcome. These include monoclonal antibodies directed against the EGFR such as IMC-C225 which specifically targets EGFR and ZD 1839 (Iressa) capable of inhibiting EGFR tyrosine-kinase in vitro. This report will focus on antibodies that target EGFR in renal cell carcinoma, prostate cancer and bladder cancer.
[Opinion of general and specialized physicians toward euthanasia. Results from the French survey on attitudes and practices against palliative care, 2002].
Ben Diane MK, Peretti-Watel P, Lapiana JM … +5 more , Favre R, Galinier A, Pegliasco H, Obadia Y, Comité de Pilotage Soins Palliatifs PACA
Ann Med Interne (Paris) · 2003 Nov · PMID 14732835
OBJECTIVES: To evaluate opinion of physicians about the legalization of euthanasia according to their professional characteristics, their attitudes toward morphine, their attitudes toward communication with end-of-life p...
OBJECTIVES: To evaluate opinion of physicians about the legalization of euthanasia according to their professional characteristics, their attitudes toward morphine, their attitudes toward communication with end-of-life patients, and their perception of specific types of terminal care. METHOD: Univariate and multivariate analyses were carried out from data collected among 1.000 general practitioners, oncologists, neurologists and HIV specialists (French cross-sectional survey on palliative care, 2002). RESULTS: 42.5% of physicians agreed with the statement that euthanasia should be legalized as it is already the case in the Netherlands. Inadequate prescription of morphine and calling terminal sedation as active euthanasia were associated with a favorable opinion toward legalization of euthanasia. CONCLUSION: Specific training on pain management and terminal sedation would help physicians to have a better view of the problem of euthanasia.
[Hairy-cell leukemia: 30 cases and a review of the literature].
Malfuson JV, Gisserot O, Cremades S … +6 more , Doghmi K, Fagot T, Souleau B, de Revel T, de Jaureguiberry JP, Nedellec G
Ann Med Interne (Paris) · 2003 Nov · PMID 14732834
From 1978 to 2002, 30 patients presenting hairy-cell leukemia were seen in two different hospitals. We reviewed clinical, biological and therapeutic data. At diagnosis, the median age was 67.8 years; 47% were clinically...
From 1978 to 2002, 30 patients presenting hairy-cell leukemia were seen in two different hospitals. We reviewed clinical, biological and therapeutic data. At diagnosis, the median age was 67.8 years; 47% were clinically asymptomatic, 12 patients had anaemia, 15 thrombocytopenia (platelets<100,000/mm3). A treatment was required for 29 patients. At the end of the study, 27 patients are alive and none died because of the disease. This study confirms the good prognosis of hairy-cell leukemia, especially since the advent of new therapeutics such as purine analogs. Based on the results in this series, we examined the different aspects of the disease referring to diagnosis, treatment and prognosis.
[Lemierre syndrome: unusual, but still possible].
Monge M, Aubry P, Dayen C … +4 more , Ben Taarit I, Ducroix JP, Strunski V, Jounieaux V
Ann Med Interne (Paris) · 2003 Sep · PMID 14593318
Lemierre syndrome is a rare disease, which was life-threatening before the antibiotics era. We report here two cases with favorable outcome. Clinical features are stereotypic: tonsillis, cervical pain revealing deep vein...
Lemierre syndrome is a rare disease, which was life-threatening before the antibiotics era. We report here two cases with favorable outcome. Clinical features are stereotypic: tonsillis, cervical pain revealing deep vein thrombosis, and pulmonary septic metastasis. The most frequent causal germ on blood cultures is Fusobacterium necrophorum but other anaerobial bacteries can be found. Cervical Doppler-ultrasonography, and thoracic tomodensitometry are useful. Medical treatment is antibiotic therapy and anticoagulation.
[Management of the emphysematous pyelonephritis].
Paparel P, Cognet F, Cercueil JP … +2 more , Krause D, Michel F
Ann Med Interne (Paris) · 2003 Sep · PMID 14593317
We report two cases of emphysematous pyelonephritis in diabetic patients. The first suffered from emphysematous pyelonephritis and emergency nephrectomy was performed. The second patient suffered from emphysematous pyeli...
We report two cases of emphysematous pyelonephritis in diabetic patients. The first suffered from emphysematous pyelonephritis and emergency nephrectomy was performed. The second patient suffered from emphysematous pyelitis and was successfully treated by nephrostomy. We present a comprehensive review of the literature on emphysematous pyelonephritis and discuss the indications and the results of treatments of this rare and severe infection.
Renal manifestations of tuberous sclerosis complex.
Fatihi el M, Khanfri N, Niang A … +6 more , Ghafel C, Hachim K, Zahiri K, Benghanem MG, Ramdani B, Zaid D
Ann Med Interne (Paris) · 2003 Sep · PMID 14593316
Tuberous sclerosis complex (TSC) is an autosomal-dominant neurocutaneous disorder involving the skin, brain, kidney, heart and other organs. Renal manifestations are mainly angiomyolipomas, renal cysts and cancer. We rep...
Tuberous sclerosis complex (TSC) is an autosomal-dominant neurocutaneous disorder involving the skin, brain, kidney, heart and other organs. Renal manifestations are mainly angiomyolipomas, renal cysts and cancer. We report three female patients, mean aged of 31 years (range: 22-37), with a family history of TSC in one case. Cutaneous and nervous symptoms were found in all patients. Clinical complaints were mainly abdominal pain (3 cases), hematuria (2 cases), right flank palpable mass (1 case). Angiomyolipomas (AML) were diagnosed by ultrasonography in all patients, associated to renal cysts in one case. A patient underwent total right nephrectomy without any event during the follow-up. In a second patient, a selective arterial embolization of AML was indicated. Total left nephrectomy was performed due to the persistence of hematuria and the increased flank mass. Pathological examination of the kidney revealed a clear cell carcinoma. The third patient with small AML, associated with renal cysts, required careful monitoring. Renal manifestations in TSC are frequent and serious, they are the second leading cause of death after nervous lesions. Clinical and morphological aspects are variable and different therapeutic indications must be discussed.
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