[Swallowing magnets: a dangerous game. A case report]

Complications related to the ingestion of magnetic foreign bodies by children represents an affirmed health hazard in the United States. In France, an alert has been announced. We report the 1st case in France. Our aim is to alert pediatricians and emergency physicians and to draw attention to the particularities of this type of foreign body. Responsible for complications is the ingestion of at least 2 magnets, or 1 magnet and a metallic foreign body, with a time interval between ingestions. In these cases, it is strongly recommended to extract the foreign bodies with endoscopy if they have not yet passed the pylorus. For those further advanced in the intestinal tract, continuous observation is warranted and surgical extraction is indicated on apparition of 1st clinical symptoms.

[Organization of patient management in level II centers in the Paris area: a prospective survey]

Perinatal asphyxia is a common emergency for both obstetricians and pediatricians. A prospective study was conducted in 14 maternity hospitals (type II centres) in the Paris suburbs in order to assess pediatric activity and neonatal morbidity associated with supposed perinatal asphyxia in term newborns. Pediatricians were called in at birth very frequently: 1/20 deliveries. Intubation and/or resuscitation procedures were needed in 20% of cases and 20% of infants were referred to a neonatal unit for birth asphyxia or associated pathology. Moderate encephalopathy was observed in 1.5% of all term newborns who needed medical intervention for supposed birth asphyxia.

Titanium-Thiolate-Aluminum-Carbide Complexes by Multiple C-H Bond Activation

All three C-H bonds of a methyl group are activated in the reaction of [Cp(iPr(3)PN)Ti(SR)(2)] with AlMe(3) [Eq. (1)]. The Ti-Al-carbide clusters formed contain a severely distorted tetrahedral carbide carbon atom with a relatively short bond to Ti, which is attributed to a relative increase in the Lewis acidity of the Ti center as a result of the interaction of the S and N donors with Al.

Cognitive processing of drawing abilities

This critical review examines constructional apraxia from a cognitive neuropsychological perspective. To our knowledge, van Sommers (1989) is the only researcher to present a global cognitive model of drawing abilities. He organizes it into two hierarchical systems: Marr's model of visual perception and a graphic production system. The latter comprises four hierarchically organized components: depiction decisions, production strategy, contingent planning, and articulatory and economic constraints. Van Sommers' model will be discussed in light of other models and on the basis of empirical neuropsychological studies (Farah, 1984; Kosslyn & Koenig, 1992; Roncato, Sartori, Masterson, & Rumiati, 1987; van Sommers, 1989). We find that: (1) the Kosslyn and Koenig visual perception model describes more accurately the perceptual components underlying copying than the visual perception system of van Sommers' drawing model, (2) Van Sommers' arguments in favor of a depiction processing as opposed to visual imagery are not convincing, (3) Van Sommers' assumption that a production strategy is a component is unclear, and (4) articulatory and economic constraints are not cognitive components, but constraints imposed during action programming. This literature review leads to a discussion of future research topics and the specificity of constructional apraxia.

[Extra-coronary atherosclerosis in documented coronary patients]

The prevalence and severity of extracoronary atherosclerosis in 728 patients (572 men and 156 women; average age 59 years) referred for coronary angiography and who had a history of coronary disease for at least 2 years, were assessed by ultrasonography. This population was divided into 3 groups: Group I, 115 patients without lesions at coronary angiography: Group II, 76 patients with mild coronary stenosis ang Group III, 537 patients with at least one severe coronary artery stenosis, a group which included 294 cases of single vessel disease. The authors observed a strong correlation between the presence, severity and diffusion of the coronary artery disease and ultra sonographic signs of peripheral arterial disease: the frequency increased regularly from 45% in Group I to 88% in patients with triple vessel disease in Group III. About two thirds of patients in Group III had carotid or lower limb atherosclerosis and half of them had atherosclerosis or aneurysm of the abdominal aorta. Severe peripheral lesions were not common but all the aortic aneurysms were observed in Group III. Similarly, simultaneous disease in all three peripheral arterial territories ranged from 12% in Group I to 51% in Group III. The risk of finding peripheral arterial disease was increased in patients with coronary artery disease compared with normal subjects. For each peripheral localisation, the risk was two-fold in cases of mild coronary disease and three or four-fold in patients with triple vessel disease in whom the risk of finding at least one severe peripheral lesion was multiplied by ten. The authors conclude that the prevalence and severity of ultrasonographic peripheral atherosclerosis in documented coronary patients was closely related to the presence, severity and diffusion of the coronary lesions.

[Coronary angiography by left radial approach. A bi-center prospective pilot study]

The aim of this study was to assess prospectively the feasibility, safety and quality of coronary angiography performed by a left radial arterial approach. The investigation was performed under local anesthesia with a Lidocaine gel using Judkins 5f catheter. A bolus of heparin was injected intravenously at the start of the procedure (no heparin in phase 0.2 to 3.000 IU during phase 1 and 5.000 IU in phase 2). Between March 1994 and January 1996, after exclusion of 108 patients (15.1%) mainly because of an abnormal Allen test, coronary angiography was carried out in 540 patients aged 58.4 +/- 11.7 years, 85% of whom were men. The failure rate was 8%. The quality of opacification of the left coronary artery (scale 1 to 3) was 2.91 +/- 0.27 and of the right coronary artery was 2.96 +/- 0.18. There were no complications during the procedure. Analysis of the learning curve showed a failure rate decreasing to less than 5% after 60 procedures/operator. In the last 100 procedures, the failure rate fell to 3%, the canulation time was 2.2 +/- 2.5 min, the duration of fluoroscopy was 6.5 +/- 3.9 min and the duration of the procedure was 17.5 +/- 4.7 min (14.7 +/- 3.8 min, p < 0.01, by the femoral approach). Clinical and Doppler ultrasonographic follow-up revealed one in-hospital complication (a spontaneously regressive compressive haematoma). No clinical complications were observed at 3 months. Doppler ultrasonography showed the radial artery occlusion rate to be 71% in phase 0.32% in phase 1 and 3.2% in phase 2 (p < 0.0001). These results show that the left radial arterial approach for coronary angiography is safe and effective but requires a period of training. A 5.000 IU dose of heparin limits the risk of radial artery occlusion to 3%. The absence of complications in this large series which included the training period and the patient comfort suggest that this technique may be an excellent alternative to the femoral approach and especially the brachial approach when the Allen test is normal.

Rotational atherectomy with adjunctive balloon angioplasty versus conventional percutaneous transluminal coronary angioplasty in type B2 lesions: results of a randomized study

A randomized pilot study was performed comparing conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA] group) and rotational atherectomy (RA) with a medium size burr (50% to 70% burr/artery ratio) with systematic adjunctive balloon angioplasty (RA group) in type B2 stenosis. A total of 64 patients were included. Primary success was 93.7% in the RA group and 87.5% in the PTCA group (p = NS). Technical failure with no complication occurred once in each group. Acute complications occurred in three patients in the PTCA group and in one in the RA group. Angiographic restenosis rates were similar (RA group: 39%, PTCA group: 42%, p = NS) with a follow-up rate of 93%. In type B2 lesions, when compared with conventional angioplasty, RA with systematic balloon angioplasty does not seem to increase procedural success, and the restenosis rate remains comparable. However, these results must be confirmed in a larger series of patients.

Stent implantation in acute myocardial infarction

Among 138 patients treated with coronary angioplasty during acute myocardial infarction (AMI), 35 (25%) had stent implantation. Mean age was 56 years and 83% were men. Mean onset of chest pain was 6.0 +/- 5.3 hours, and previous thrombolytic therapy was given to 10 patients (29%). Infarct location was anterior in 19 (54%), inferior in 14 (40%), and lateral in 2 patients (6%). Thrombolysis in Myocardial Infarction trial flows 0,1, and 2 were seen in 24 (69%), 6 (17%), and 5 patients (14%), respectively. The culprit vessel was the left anterior descending artery in 18 (51%), right coronary artery in 14 (40%), left circumflex in 2 (6%), and left main coronary artery in 1 patient (3%). Mean vessel diameter was 3.3 +/- 0.3 mm. Indications were: primary in 5 (14%), suboptimal result in 8 (23%), nonocclusive dissection in 14 (40%), and occlusive dissection in 8 patients (23%). Angiographic thrombus after initial angioplasty was present in 12 patients (34%). A total of 46 stents were implanted; mean balloon diameter and pressure were 3.4 +/- 0.4 mm and 15.5 +/- 2.2 atm, respectively. Residual diameter stenosis was 4 +/- 7%. There were 2 deaths; sudden 1, and after elective coronary artery bypass grafting in the other; 2 patients (6%) had groin hematomas. Mean hospitalization was 9.9 +/- 5.0 days. Repeat angiography revealed no stent occlusion. With initial intravenous heparin for 3 to 7 days, all patients received aspirin and ticlopidine for 1 month. Thus, AMI is not a contraindication for stent implantation. The benefits of stenting are a high success rte, low residual diameter stenosis, and low incidence of in-hospital recurrent ischemia. Reduction in restenosis rate in this setting is likely but remains to be determined.

[Detection of asymptomatic abdominal aorta in coronary disease patients having undergone coronarography]

Detection of asymptomatic abdominal aortic aneurysm (AAAA) was studied in 780 patients whose coronary disease had been evolving for less than 2 years, who had undergone coronagraphy within the framework of the French ALAC Survey (Autres Localisations de l'Athérosclérose chez le Coronarien--other locations of atherosclerosis in coronary disease) and had an interpretable abdominal aortic echography. Clinical and echographic research detected 19 AAAA cases in 15 men and 4 women aged 53 to 77 years having at coronagraphy at least one stenosis > or = 70% on one of the 3 coronary trunks or > or = 50% on the commun trunk. Among the 577 coronary disease patients with at least one significant stenosis, the prevalence of AAAA was 3.3%. Seventeen aneurysms were missed at abdominal palpation. A subgroup of 458 patients aged 50 to 79 years had significant coronary stenosis without history of aortic surgery. There was no significant difference between the 19 AAAA cases and the 439 cases of coronary disease without aortic aneurysm, as regards risk factors, especially age, high blood pressure and tobacco consumption. On the other hand, the 19 AAAA cases had more diffused and more severe atherosclerotic lesions in the lower limbs and carotid arteries. Abdominal echography is essential for the detection of AAAA in patients with coronary disease.

[Severe cardiomyopathy revealing amylopectinosis. Two cases in adolescents from the same family]

Type IV glycogen storage disease, also termed Andersen's disease or amylopectinosis, is a rare autosomic recessive hereditary disease usually caused by a deficit in glycogen branching enzyme. We report our observation of two siblings with type IV glycogen storage disease who had normal branching enzyme activity. The initial symptom was severe heart failure. A 14-year-old boy, born to consanguinous parents, was seen for severe global heart failure. Growth retardation had been diagnosed since the age of 6 and abnormal fatigability since the age of 12. Muscle and endomyocardium biopsies revealed abnormal glycogen storage with normal branching enzyme activity. The patient's condition improved after symptomatic treatment, but death occurred due to infectious complications after orthoptic heart transplantation. One year later, the proband's 12-year-old sister, with an uneventful personal medical history, was hospitalized for severe left ventricular failure. Muscle and liver biopsies demonstrated the same anomalies, again without branching enzyme deficiency in the liver. Heart failure was controlled with symptomatic care and the patient's current condition remains satisfactory. This observation demonstrates the clinical expression of familial type IV glycogen storage disease in patients with normal branching enzyme activity. Age at onset is quite variable, reported from 5 to 70 years, as is the clinical course before diagnosis.

[Coronary embolism revealing mitral valve stenosis]

We report a case of myocardial infarction with normal coronary arteriography in a 39-year-old woman presenting with tight mitral stenosis complicated by atrial extrasystoles and spontaneous atrial contrast at echocardiography. The diagnosis of coronary embolism was most probable. Coronary embolism is a rare disease, usually due to a blood clot or, less frequently, to a vegetation of endocarditis starting in a heart valve. The left network is usually involved, with typical myocardial necrosis. Coronary arteriography is sufficient to make the diagnosis. Preventive treatment is essential.

[Arrhythmia and syndrome of obstructive sleep apnea in adults]

Many nocturnal cardiac arrhythmias and conduction defects have been reported in the adult sleep apnoea syndrome. The most original is the great variability of the heart rate which is cyclical and related to the apnoeic episodes, and easily differentiated from simple respiratory sinus arrhythmia. It is characterised by an initial bradycardia followed by rebound tachycardia. The bradycardia is vagally dependent (inhibited by atropine) probably secondary to carotid chemoreceptor stimulation by the hypoxaemia. The tachycardia is mainly attributed to the cessation of vagal hypertonicity although catecholamine stimulation has been suggested. The origin of these changes is purely functional, regressing with treatment of apnoea (waking, tracheotomy), the maintenance of arterial oxygen concentrations with oxygen therapy and parasympathetic blockade (atropine). The intensity of the phenomenon is related to the degree of arterial desaturation, which is itself related to basal arterial saturation (SaO2) and the duration of the apnoeas. Prolonged systole due to paroxysmal sino-atrial or atrioventricular block may be observed at night in these patients. The influence of vagal overactivity is confirmed (suppression of vagotomy) with no organic pathology (diurnal absence, tracheotomy, normal electrophysiological testing) in favour of a relationship with apnoea. Though less common than conduction abnormalities, atrial arrhythmias (extrasystoles, flutter, fibrillation) are also possible complications of sleep apnoea. The absence of an organic substrate is indicated by their regression post-tracheotomy and the efficacy of atropine (again in favour of a vagally-induced mechanism). Finally, nocturnal ventricular hyper-excitabilty is sometimes observed, the probable mechanism being the association of severe hypoxaemias (SaO2 < 60%) and the increased sympathetic tone at the end of the apnoea.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography

BACKGROUND AND PURPOSE

An association between atrial septal aneurysm and embolic events has been suggested. Atrial septal aneurysm has been shown to be associated with patent foramen ovale and, in some reports, with mitral valve prolapse. These two latter cardiac disorders have been identified as potential risk factors for ischemic stroke. The aim of this prospective study was to assess the role of atrial septal aneurysm as an independent risk factor for stroke, especially for cryptogenic stroke.

METHODS

We studied the prevalence of atrial septal aneurysm, patent foramen ovale, and mitral valve prolapse in 100 consecutive patients < 55 years of age with ischemic stroke who underwent extensive etiological investigations. We compared these results with those in a control group of 50 consecutive patients. The diagnosis of atrial septal aneurysm and patent foramen ovale relied on transesophageal echocardiography with a contrast study and that of mitral valve prolapse, on two-dimensional transthoracic echocardiography.

RESULTS

Stepwise logistic regression analysis showed that atrial septal aneurysm (odds ratio, 4.3; 95% confidence interval, 1.3 to 14.6; P = .01) and patent foramen ovale (odds ratio, 3.9; 95% confidence interval, 1.5 to 10; P = .003) but not mitral valve prolapse were significantly associated with the diagnosis of cryptogenic stroke. The stroke odds of a patient with both atrial septal aneurysm and patent foramen ovale were 33.3 times (95% confidence interval, 4.1 to 270) the stroke odds of a patient with neither of these cardiac disorders. For a patient with atrial septal aneurysm of > 10-mm excursion, the stroke odds were approximately 8 times the stroke odds of a patient with atrial septal aneurysm of < 10 mm.

CONCLUSIONS

This study shows that atrial septal aneurysm and patent foramen ovale are both significantly associated with cryptogenic stroke and that their association has a marked synergistic effect. Atrial septal aneurysms of > 10-mm excursion are associated with a higher risk of stroke.

[Cardiac involvement in certain muscular diseases. Apropos of 216 cases]

Myopathy may be associated with very variable cardiac involvement, the expression of which is related to the type of neuromuscular disease and also to the individual. This retrospective study, performed between 1986 and 1991, was undertaken to determine the prevalence of cardiac involvement in myopathy. A total of 216 subjects with an average age of 34 years were reviewed by clinical examination, ECG, echocardiography and Holter ECG monitoring. Some patients also underwent complementary radionuclide (scintigraphy, angiography) and electrophysiological investigations. The results confirmed cardiac disease in over a half of patients. Although 3/4 of the patients were asymptomatic from the cardiac point of view at the time of evaluation, the severity of certain lesions led to a number of specific therapeutic interventions. This suggests that simple, non-invasive cardiac diagnostic procedures should be undertaken systematically in the early stages of myopathic disease.

[Left pulmonary artery originating from the ascending aorta in tetralogy of Fallot. Therapeutic strategy]

The authors report the rare case of a 12 year old child with an anomalous origin of the left pulmonary artery from the ascending aorta associated with Tetralogy of Fallot. This complex congenital malformation was treated surgically by a Deleval anastanosis between the right subclavian and right pulmonary arteries. The result was good with a 9 year follow-up, the patient having only Grade II effort duspnoea and cyanosis. The authors discuss the advantages and drawbacks of the different possible surgical approaches to this problem in the light of the outcome of this case and a review of the literature.

[Primary leiomyosarcoma of the pulmonary artery. Apropos of a case. Review of the literature]

A 59-year-old woman hospitalised because of dyspnea and a heart murmur in a context of pyrexia was found to have evidence of obstruction of the pulmonary arterial system, clearly defined by ultrasonography, catheterisation and angiography and Imatron scan. The particular feature of this fifth reported case of pulmonary artery leiomyosarcoma is its documentation by transesophageal ultrasonography and tumor biopsy during catheterisation. Surgery with partial excision of the tumor was followed by survival for 6 months, bearing in mind the absence of chemo- or radiosensitivity of this type of tumor. Cases from the literature are reviewed.

[Isolated atrial fibrillation. The risk of embolism and its prevention]

Whether or not atrial fibrillation is alone, if not idiopathic, is difficult to determine. The risk of embolization in lone atrial fibrillation is distinctly higher in healthy subjects over 60 years of age when the left atrium is dilated. In chronic atrial fibrillation this risk is higher than in paroxysmal fibrillation, especially within the year following the onset of the arrhythmia. In most patients anticoagulant therapy is effective in the primary or secondary prevention of embolic accidents. In subjects older than 75 aspirin given in daily doses of 325 mg seems to give similar results. The risk of antithrombosis therapy must not be underevaluated. The alternative is to maintain or restore the sinus rhythm, even at an advanced age, if the arrhythmia is recent and the left atrium is moderately dilated.