[Infectious hazards in military personnel in operations.]

Military personnel in operations have always paid a high toll to infections, particularly epidemics. Currently, 40 000 servicemen serve overseas in various missions and operations of various durations in various countries. Infectious hazards persist in spite of the implementation of preventive measures. They are primarily due to poor sanitation, promiscuous living conditions, and the operational situation : bacterial diarrhea, amoebiasis, viral hepatitis A and E are relatively frequent. Others are due to the tropical environment ; malaria remains a concern due to its chemoresistance ; bilharziosis can also cause small epidemics, cutaneous leishmaniasis is not rare in Guyana. Exceptional but serious infections are observed. Infectious hazards associated with warfare are reviewed : biological warfare, infections of wounded, burnt and irradiated soldiers.

[Relative frequency of malignant and benign tumors in Arlit, Niger. Analysis of data from anatomopathological examinations over a 15-year period]

The purpose of this study was to determine the frequency and distribution of cancer in the uranium-mining region of Arlit, Niger, based on extensive data from all the anatomopathological examinations performed at local hospitals over a 15-year period. The overall annual incidence, i.e., 26 per 100000, was similar to incidences reported elsewhere in Africa. The rate of examinations leading to diagnosis of malignancy decreased between 1991 and 1997 and, for unexplained reasons, varied from one practitioner to another. There was no evidence of a higher rate of any cancer that might result from possible exposure to radiation during mining operations. The distribution of cancer by organ was unremarkable, i.e., in order of frequency, womb and ovaries in women; skin and prostate in men; thyroid and lymphatic tissue in both genders.

[Use of spirulina supplement for nutritional management of HIV-infected patients: study in Bangui, Central African Republic]

Treatment of HIV-infected persons including nutritional management is a major concern in Africa and in particular in the Central African Republic (CAR). This six-month randomized prospective longitudinal study was carried out at the Friends of Africa Center that was a facility for comprehensive management of persons infected and affected by HIV in Banqui, CAR. The purpose of the study was to assess the impact of spirulina supplement on clinical and laboratory findings in HIV-infected patients who were not indications for ARV treatment. A total of 160 patients were randomly assigned to two groups. Patients in group 1 (n=79) received 10 grams of spirulina per day on a regular basis while patients in group 2 (n = 81) received a placebo. In addition patients in both groups received dietary products supplied by the World Food Program (WFP). Follow-up of the 160 patients at three and six months showed that 16 patients had been lost from follow-up and 16 had died, with no difference in distribution between the two groups. A significant improvement in the main follow-up criteria, i.e., weight, arm girth, number of infectious episodes, CD4 count, and protidemia, was observed in both groups. No difference was found between the two groups except with regard to protidemia and creatinemia that were higher in the group receiving spirulina supplement. From a clinical standpoint results were less clear-cut since the Karnofsky score was better in the group receiving spirulina than in the group receiving the placebo at 3 months but not at 6 months and fewer patients presented pneumonia at six months. Further study over a longer period will be needed to determine if spirulina is useful and to evaluate if higher doses can have beneficial nutritional and immunitary effects without adverse effects, in particular renal problems.

[Ventricular tachycardia revealed by a left ventricular non-compaction]

We report a case of a 55-year-old woman who has a non-compaction of the left ventricular myocardium diagnosed after a cardiac arrest due to a polymorphic ventricular tachycardia. The patient was implanted with a cardioverter-defibrillator. A review of literature of this recently described cardiopathy is done.

[Poor access to antiretroviral treatment in French-speaking Africa: situation in 2004]

A survey by questionnaire and interview was carried out with persons in charge of purchasing central structures and AIDS control programs in 18 French-speaking African countries between June and October 2004. Survey data showed that a total of 3300 patients received antiretroviral (ARV) treatment during the study period. This corresponds to a treatment rate of 0.1 to 9.6% of the number of patients requiring ARV treatment. All countries reported interruptions of the ARV supply for a variety of reasons. The main causes were budgetary issues and procedural complexity involving financial aid. The prices charged to the patients varied greatly in function of national policies. Cost price also varied in function of the negotiating leverage of the purchasing central. Improve general access to ARV treatment and reducing the number of supply shortages will require more training in management and distribution of medicines. It would also be useful to improve communications between the persons in charge of national purchasing structures.

[Assessment of compliance with ARV treatment in Africa]

This study was conducted in health facilities in the capitals of five sub-Saharan African countries (Cotonou, Benin; Bangui, Central African Republic; Libreville, Gabon; Yaoundé, Cameroon; and Casablanca, Morocco). The purpose was to investigate factors promoting and impeding compliance with antiretroviral therapy (ART) and cotrimoxazole (CTX) prophylaxis in adult patients. Patients were interviewed immediately after follow-up examination to identify the problems that they encountered and the solutions that they proposed to improve compliance. Compliance was assessed based on three measurement modalities, i.e. skipping medication during the four days prior to attendance, counting the number of remaining tablets, and attendance assiduity. Compliance scores varied according to measurement modality from 65% to 90%. All patients underlined the impact of treatment on their daily life and the difficulty of following the prescribed regimen properly. Impeding factors for compliance were treatment-related hunger, lack of information, out-of-pocket expenses (including laboratory tests, transportation, and loss of income), side effects, long waiting time at the treatment centers, and fear stigma and discrimination. Efforts to increase access to treatment can only be successful if accompanied by measures to promote compliance.

[Difficulties of the patients to undergo their ARV treatment at the Libreville outpatient health center, Gabon]

The therapeutic observance is a real issue of chronic diseases. This issue is twice as much important in the case of aids treatment by antiretrovirals as a good observance is essential to avoid emergence of resistances and to improve patients' health. A research was conducted in Libreville, the capital of Gabon, at the ambulatory treatment center of HIV patients. The interviews of one hundred patients of the center, under treatment for more than two months, concerned their problems related to specific drugs intake and have helped to point out some reasons of non observance. The first reason refers to side effects inducing many difficulties in regular drugs intakes, a complete information is requested by the patients. Another main reason of non observance or bad observance is linked to material and financial problems or to treatment's reduced accessibility The research points out the importance of supplementary treatment costs (transportation, sick leave, food). At last, major observations were made on schedule management, drugs intake management, needs for more information and help for prevention, everyday life and diet.

[Study conducted at the Yaoundé University Hospital on anti-retroviral treatment compliance (Cameroon)]

To build the knowledge base on anti-retroviral (ARV) treatment compliance in Africa, a study has been carried out at Yaoundé University Hospital. It documented and studied the follow up of 231 patients under tri-therapy at the time of the study (December 2003). Respecting the strict time schedules is a crucial issue, especially for taking the morning and evening doses of medication. This is true for all patients, regardless of their social or economic status. The majority of the patients request more thorough information about their treatment. Some patients face economic problems which are more often related to the indirect costs rather than to the cost of treatment. Finally, the difficulty in confronting the treatment's side effects or the galenic nature of ARV treatment itself is noted. Nevertheless, it seems that the patients could better manage these issues and deal with the ensuing challenges if better communication with more complete information was provided to them at the beginning of their treatment, accompanied by written fact sheets specific to each type of treatment.

[Use of antiretroviral drugs invoices for the follow-up of a treatment programme. Example in Abidjan, Côte d'Ivoire]

A retrospective analysis of the prescriptions of the ARV treatment programme in Abidjan, Côte-d'Ivoire enabled the authors to assess the collected anonymous information in order to evaluate the efficacy of the programme. This collection of information helps to supervise each center at a lower cost, to alert on some working problems and to follow the quality of the observance. This supervision is possible regardless of the health care places, it can be carried out systematically from the administrative or financial services. In this study this follow-up reveals some problems.

[Syphilis test proposed within the context of a programme to reduce mother/child HIV transmission: example of the Wassakara Health Care Center in Abidjan]

During the program MTCT+ set up in Abidjan by the national authorities with the assistance of the FSTI and FGSK, free screening and treatment of the syphilis infection were proposed to pregnant women. One test of agglutination on blades VDRL (Carbon Antigen Biotec the U.K.) and one TPHA test on plates for the positive VDRL (TPHA Nosticon Biomérieux F) were performed. Over the period from June 1999 to December 2001, 4 320 samples were taken. The laboratory observed 84 positive tests VDRL and 59 confirmed by TPHA, that is to say a syphilis seroprevalence (TPHA) of 1.4%. In addition 391 results were not available for various reasons (errors of numbering, haemolysed blood, absence of reagents, etc.) ie. 9.0%. Among the 59 positive women (TPHA), 30 came back for their result and 23 women were correctly treated (3 or 4 penicillin delay injections). In addition 7 partners received a complete treatment and 8 incomplete treatment. The cost of each detected and treated case rose approximately to 150 Euros, which is relatively low except in time/ staff and indirect costs for women. This study confirmed that all the activities of SMI must be integrated to have an efficient PTME programme. The biological assessment must be accessible as a whole, to minimize the additional costs and transportations. A training of all the personnel in 2002 helped to improve in an important way the results of the intervention in the center.

[A study on antiretroviral treatment compliance in Casablanca (Morocco)]

OBJECTIVE

Compliance in HIV infection treatment is a major stake to give worldwide access to antiretroviral (ARV) treatment and especially in Africa. In September 2003, we undertook a study on compliance among HIV positive patients under antiretroviral treatment. These patients were included in a therapeutic educational program in the infectious diseases department of the Casablanca University Hospital (Morocco). The main objective of the study was to assess obstacles to compliance and to find possible solutions.

DESIGN

A transversal investigation was made, based on questionnaires for patients under ARV treatment, chosen consecutively. The physician's and the educator's opinion on patient compliance was collected.

RESULTS

Patients were between 21 and 65 years of age. Ninety-two patients were questioned and 89 analyzed. Treatment duration lasted from 2 to 67 months. Compliance according to educators was good (>90%) for 78 patients. The main obstacles for a good compliance were difficulty to respect administration schedule and the long distance between home and hospital, or the presence of adverse effects and other diseases.

CONCLUSIONS

The role of the therapeutic educational program in improving compliance was largely highlighted.

[Prevention of recurrent amiodarone-induced hyperthyroidism by iodine-131]

Amioradone-induced hyperthyroidism is a common complication of amiodarone therapy. Although definitive interruption of amiodarone is recommended because of the risks of aggravation of the arrhythmias, some patients may require the reintroduction of amiodarone several months after normalisation of thyroid function. The authors undertook a retrospective study of the effects of preventive treatment of recurrences of amiodarone-induced hyperthyroidism with I131. The indication of amiodarone therapy was recurrent, symptomatic, paroxysmal atrial fibrillation in 13 cases and ventricular tachycardia in 5 cases (M = 14, average age 64 +/- 13 years). The underlying cardiac disease was dilated cardiomyopathy (N = 5), ischaemic heart disease (N = 3), hypertensive heart disease (N = 2), arrhythmogenic right ventricular dysplasia (N = 2) or valvular heart disease (N = 2). Two patients had idiopathic atrial fibrillation. An average dose of 576 +/- 184 MBq of I131 was administered 34 +/- 37 months after an episode of amiodarone-induced hyperthyroidism. Amiodarone was reintroduced in 16 of the 18 patients after a treatment-free period of 98 +/- 262 days. Transient post-radioiodine hyperthyroidism was observed in 3 cases (17%). Sixteen patients (89%) developed hypothyroidism requiring replacement therapy with L-thyroxine. There were no recurrences of amiodarone-induced hyperthyroidism. After 24 +/- 17 months follow-up, the arrhythmias were controlled in 13 of the 16 patients (81%) who underwent the whole treatment sequence. The authors conclude that preventive treatment with I131 is an effective alternative to prevent recurrence of amiodarone-induced hyperthyroidism in patients requiring reintroduction of amiodarone to control their arrhythmias.

[Healthcare: a growing role in international politics]

Since the end of the cold war the tone of international relations has clearly changed. Whereas relations were once defined strictly in terms of more or less armed confrontation, economic and social issues now play a growing role. Healthcare policies in Africa have long been influenced by the policies of countries sponsoring bilateral and even multilateral foreign aid programs. However the last ten years have witnessed an increasing interaction between international policy and healthcare policy. The two main reasons for this trend involve 1) access to drug treatment and the WTO and 2) the extension and impact of the AIDS epidemic. The problem of access to drug treatment for poor populations (fundamental right) has led to the emergence of an increasingly strong and effective civil society. Because of its social and economic effects as well as its geopolitical and security implications, AIDS has become a major factor in international relations. With regard to both these issues the place and role of the USA is demonstrative of the interaction between healthcare and international relations.

[Sero-epidemiological study of the hepatitis epidemic in Mitrovica in the aftermath of the war in Kosovo (1999)]

In July 1999, after the return of the Kosovar refugees to their country, an outbreak of acute hepatitis A (HAV) and E (HEV) occurred. Epidemic hepatitis and diarrhoea are closely monitored communicable diseases which had been singled out as priorities by the health authorities of the former Republic of Yougoslavia. Several field surveys were undertaken: description of reported cases, serological study of clinical patients, study of anti-HAV seroprevalence in a school and a case control study to assess risk factors. The analysis of the reports indicates an epidemic peak at the end of September, 2 or 3 weeks after the start of the new school year, with an increase of cases relative to the age of the children in school. In a serologic study of 104 samples, we found an anti-HAV IgM positivity in 88% of the cases. Children were more likely to be positive when compared to teenagers and adults; likewise, consumers of well-water as versus those drinking network water (p = 0.03). The study of seroprevalence showed that transmission had taken place within the school. The case control study, in spite of its imperfections, indicated that consumption of water melon, the only fruit cultivated locally, is a factor which facilitates the HAV transmission. Circulation of the hepatitis E virus was confirmed for 4 sick persons (including 2 co-infected HAV-HEV) and in 4 persons without clinical symptoms. These results show the permanent risk of faeco-oral infections in this area and the need to develop a relevant prevention policy.

[Ectopic atrial tachycardia complicating a congenital left atrial aneurysm: value of an electro-anatomical mapping system]

The authors report the case of a patient with a congenital left atrial aneurysm complicated by ectopic atrial tachycardia treated successfully by surgery. Transoesophageal echocardiography and magnetic resonance imaging provided accurate measurements of the aneurysm and its anatomical relationships. Three-dimensional electro-anatomical mapping with the CARTO, system (Biosense) confirmed the shape and dimensions of the aneurysm. The system showed the electrically mute zones and the ectopic focus situated just beyond the aneurysmal neck. Surgical ablation confirmed the morphological and functional data of the imaging techniques and the patient was definitely cured.

[Dissection of the aorta complicated by aorto-pulmonary fistula]

The authors report the case of chronic dissection of the aorta presenting with congestive cardiac failure. The diagnosis was made for the first time by transoesophageal echocardiography which showed both the dissection of the aorta and its fistulalisation into the pulmonary artery. Aortography confirmed the diagnosis. The patient underwent surgery which consisted of suture of the fistula and replacement of the ascending aorta with a prosthetic tube. The outcome was favourable after 8 months follow-up.

[Pharmaceutical development concerning diseases predominating in tropical regions: the concept of indigent drugs]

When the WHO certified the eradication of smallpox in 1981, there was a general impression that the fight against infectious diseases which began with Jenner and Pasteur was entering a phase of achievement: poliomyelitis, dracunculasis, leprosy, Chagas' disease and neonatal tetanus were also responding to eradication campaigns. However, in 1995, infectious diseases are still an important cause of mortality and morbidity and the rising incidence of emerging or re-emerging diseases remains a matter of great concern. Although this situation can be explained, at least partly, by the deterioration of health care systems and diverse socio-economic and ecological disorders, important changes occurring in the drug industry since 1980 have also played a role due to changes in pharmaco-epidemiology and new policies of drug development. Among the 1061 new drugs developed from 1975 to 1994, less than 2.7% concern tropical diseases. Since praziquantel, novel drugs have issued from veterinary medicine (ivermectin), military research (halofantrine, mefloquine) or fortuitous analysis of pharmacopoeia (artesunate). The cost of investments and the lack of market potential and market security in developing countries have dampened interest in developing drugs for tropical diseases. Observing the combined effect of deficient pharmaceutical development, drug wear due to chemoresistance (chloroquine, sulfadoxine-pyrimethamine, aminopenicillins), the cost barrier (second generation molecules) and the potential abandon of major drugs (eflornithine, melarsoprol) has led us to establish a classification of these "indigent" drugs (in opposition to "orphan" drugs) into five classes: true indigent drugs (eflornithine), indigent drugs by indication (pentamidine), indigent drugs by function (ceftriaxone), indigent drugs by formulation (melarsoprol) and indigent drugs by default (suramin). This analysis can serve as a basis for a search for solutions (regulatory, administrative and financial incentives) favoring a reactivation of drug development for diseases predominating in intertropical regions.

[Protective effect of clothing impregnated with permethrin against D. reticulatus and D. marginatus in an open biotope of central western France]

During the period of major tick activity, in April and May 1998, in the Saint-Maixent l'Ecole area of Poitou, a comparative study was carried out in order to evaluate the protective effect of garments impregnated with permethrin cis/trans 25/75. Three groups of soldiers made up respectively of 208, 218 and 427 men were involved for 2 or 3 days in this experiment. Respectively 107, 107 and 215 wore impregnated uniforms. Out of a total of 319 ticks, 3 were lxodes ricinus, 305 Dermacentor marginatus and 11 D. reticulatus. There was a significant difference in both the intensity (number of ticks per individual, P < 0.0001) and prevalence (number of individuals with ticks, P < 0.001) of ticks on individuals between impregnated and non impregnated uniforms. The repellent effect of permethrin on ticks was observed at the site of preferential tick attachment (normally the head of the host for these two species of Dermacentor in France) where the number of ticks was significantly lower in impregnated uniforms.

Meningeal leiomyoma in an adult with AIDS: CT and MRI with pathological correlation

We describe the imaging features of a meningeal leiomyoma with pathological correlation in an adult with AIDS. On CT the tumour showed a central low-attenuation area and an enhancing peripheral ring. It gave low signal on T1 weighting and on T2-weighted images a central high-signal area was surrounded by a markedly low-signal band, which showed contrast enhancement. As far as we know, this is the first report of this condition in the radiological literature.

[Competition for the promotion of essential generic drugs in Africa]

STATEMENT OF THE PROBLEM

in most sub-Saharan countries, an extensive economic crisis coupled with a low level of existing resources has put most pharmaceuticals beyond the reach of the general public. This situation was worsened by the devaluation of the Franc CFA in 1994. The supply of lowprice drugs and the improvement of rational drug use is now a priority. Unfortunately, essential generic drugs are little known and used in Africa.

OBJECTIVE

1. To improve the knowledge of and confidence in essential and generic drugs among providers, prescribers and consumers, through the participation of the general public in an incentive-based, creative competition; 2. To collect locally-adapted promotional material, to be used in the future promotion of essential and generic drugs in Africa. Design, setting and method: a competition was announced in June 1995, via various networks, in French-speaking Africa: the population was invited to create one or several items promoting essential generic drugs. These items included slogans, posters, songs and short plays. Over 550 entries were received before the deadline (15 October 1995), from 22 countries (mostly Sub-Saharan and French-speaking). The entries included 387 slogans, 94 posters, 22 plays, and various (photos, comic strips, songs, poems).

RESULTS

1. Greater awareness of essential generic drugs in Western Africa, through the publicity given to the competition; 2. Selection of a pool of approximately 200 promotional items, produced by the target populations, to be published in a catalog and distributed in African countries; 3. Insights into popular practices and representations of Western medications, and local re-interpretation of the concept.

CONCLUSION

this public competition was effective at achieving three important goals: 1. Dynamic promotion (the competition was the opportunity for school projects, radio talkshows, etc. on generic drugs); 2. Re appropriation of a policy, thanks to a participative approach; 3. Analysis of the population's general comprehension of pharmaceuticals, through analysis of competition entries.

Correlation of thoracic aortic atherosclerotic plaque detected by multiplane transesophageal echocardiography and cardiovascular risk factors

This study of 416 patients identified age, male gender, smoking, diabetes, hypertension, and hypercholesterolemia as independent predictors of thoracic aortic atherosclerotic plaque. Age, smoking, hypercholesterolemia, hypertension, and diabetes were predictors of the severity and extent of thoracic aortic atherosclerosis.

[Diagnostic value of echocardiography and thoracic spiral CT angiography in the diagnosis of acute pulmonary embolism]

The objective of this study was to define the limits of echocardiography and to evaluate thoracic spiral CT angiography (TSCTA) for the diagnosis of pulmonary embolism (PE). One hundred twelve consecutive patients, hospitalised for suspected PE, were included in this prospective study. All were investigated by pulmonary ventilation-perfusion scintigraphy (Sc) and 50 had a high probability of PE on this examination. Sc was normal in 22 patients. Forty patients were excluded because of an intermediate probability. In 50 patients with PE confirmed on Sc, transthoracic echocardiography (TTE) showed only indirect evidence of PE (intracavitary thrombus in 4% of cases). TSCTA demonstrated PE in 82% of cases and did not show any thrombus image when Sc was normal. Its negative predictive value was therefore 70% and its positive predictive value was 100%. Its sensitivity varied according to degree of perfusion defect (96% in the case of lobar lesion, 66% in the case of segmental lesion and 16% for a subsegmental lesion). Multidimensional transoesophageal echocardiography (TOE), performed in 37 of the 50 patients with PE, only revealed thrombi in the pulmonary tree in 3 patients (8%), all presenting severe PE. No thrombus was visualized on TOE in patients with non-serious PE. All thrombi observed on TOE were also demonstrated by TSCTA. In conclusion, TTE usually provides only indirect signs of PE. TOE has a poor diagnostic sensitivity for PE. TSCTA has a better sensitivity than TOE for the detection of thrombi in the pulmonary artery trunk and proximal centimetres of its two branches, but normal CT angiography cannot exclude a distal PE.

Comparative value of Doppler echocardiography and cardiac catheterization in the decision to operate on patients with aortic stenosis

With the use of Doppler echocardiography, severity of valvular stenosis, etiology and type of valve lesions, and left ventricular function can be assessed accurately in patients with aortic stenosis. The purpose of this study was to compare the value of noninvasive clinical and Doppler echocardiographic findings, with cardiac catheterization, in the management decision-making for patients with aortic stenosis. One hundred and seventy consecutive patients with aortic stenosis who underwent cardiac catheterization and Doppler echocardiography were prospectively studied. A decision to operate, not operate or remain uncertain was made independently by experienced cardiologists given clinical information in combination with either Doppler echocardiographic (group I) or cardiac catheterization (group II) data. The severity of aortic stenosis agreed between Doppler echocardiography and cardiac catheterization in 168 patients (98.8%), and disagreed in two patients. There was agreement on clinical decision to operate or not operate between Group I and Group II in 160 patients (94.1%) and a discrepant decision in only two patients (1.1%). In eight patients (4.7%) with poor echogenecity or with discordance between clinical and echocardiographic data, the decision made by group I remained uncertain. We conclude that in a large majority of patients with aortic stenosis, Doppler echocardiographic assessment provides the same management decision reached by cardiac catheterization findings.

[The drug trade between European countries and developing countries]

The quality of medicinal products marketed in developing countries has recently become the focus of lively debate and new interest. This report describes a survey conducted among officials from exporting and importing countries designed to evaluate the content and enforcement of current regulations. Resulting data indicated that, despite the high volume of trading in medicinal products between European and developing countries, regulations are poorly applied and many infractions occur. The most obvious abnormalities involve definition of market status. A list of banned is issued by the WHO but not by the European Economic Community. Regulations regarding generic products differ from one country to another and, since determination of the exact origin of a product may be difficult, compliance with good manufacturing practices is often unverifiable. A more cooperative attitude on the part of exporting countries and standardization of formalities on the part of importing countries will be necessary to stem the growing tendency to consider medicinal products as ordinary goods.

Single-lead VDD pacing: long-term experience with four different systems

BACKGROUND

Previous multicenter studies have shown that single-lead VDD pacing systems provide satisfactory atrial-triggered ventricular pacing at middle term for treatment of atrioventricular block without sinus dysfunction. However, we lack data on long-term results obtained with different VDD systems implanted in a large number of patients from a single center.

METHODS

One hundred fifty patients (76 +/- 11 years) with second- or third-degree atrioventricular block (n = 147) or symptomatic hypertrophic cardiomyopathy (n = 3) without sinus dysfunction were paced with four different VDD pacing systems able to sense the atrium and to pace the ventricle. Atrioventricular synchronization was assessed during follow-up by ECG and Holter monitoring.

RESULTS

Mean value of the atrial electrogram during implantation was 2.01 +/- 0.94 mV without any differences among the four systems. With a mean follow-up of 24 +/- 11 months, 95% of patients remain paced in VDD mode, whereas 5% have been reprogrammed in VVI or VVIR mode for permanent atrial fibrillation or loss of atrial sensing; 96% of patients with sinus atrium have atrioventricular synchronization >90% and 94% of patients have >95%, without significant difference between the four systems used.

CONCLUSIONS

These different single-lead VDD systems can provide satisfactory long-term atrioventricular synchronization; results are comparable to those obtained with conventional DDD pacing systems with two leads.

Paradoxical embolism following acute pulmonary embolism: diagnosis and outcome

We report on ten cases of paradoxical embolism that occurred following pulmonary embolism and emphasize the echocardiographic contribution. Two patients had a thrombus trapped in a foramen ovale. An embolectomy was performed on one of those patients and the outcome was post-operative death. The other patient died suddenly prior to planned surgery. The remaining eight had inter atrial communication or foramen ovale that were highly patent upon contrast echography. Two of them who presented cardiogenic shock died rapidly despite resuscitation measures. The remaining six patients were treated medically with anticoagulants and have experienced no recurrence of embolism after a mean follow up 34+/-31 months.

[Chronical of a declared meningococcal meningitis epidemic (Goma, Zaire, August 1994)]

The authors relate their experience controlling an epidemic of meningitis which broke out in the refugee camps of the Goma region, in northern Zaire, after the dramatic events which had happened in Rwanda in April and June 1994. Out of the 348 cases of purulent meningitis diagnosed by the Bioforce team, meningococcal etiology was confirmed 327 times. The isolated meningococci were all of the serogroup A, serotype A; 4; P 1,9. They were resistant to streptomycin and to sulphamides. The epidemic lasted one month, touched people of all ages and spread progressively to all the camps. The epidemic surveillance set up meant that vaccination was carried out very quickly and the epidemic brought rapidly under control, even if other factors did intervene. All those called upon to intervene in such a context should be made aware of the interest of the basic triad to fight these epidemics: rapid vaccination, treatment of cases with oily chloramphenicol and bio-epidemiological surveillance.

[Drug therapy of ventricular tachycardia]

Despite the introduction of new therapeutic techniques such as radiofrequency ablation and the implantable defibrillator, the classical opposition of monomorphic ventricular tachycardia in apparently normal hearts and that arising from documented cardiac disease remains useful. In the first case, treatment is only symptomatic whereas, in the second, lethal progression to sudden death must be prevented. Generally speaking, in chronic post-infarct situations, betablockers are underused although they have been shown beyond doubt to reduce cardiovascular mortality. This is probably explained by the fear of possible haemodynamic decompensation in patients who often have left ventricular dysfunction. Nevertheless, different randomised studies of the use of betablockers in cardiac failure have reported reduced mortality with no serious side effects. The use of beta-blockers is therefore advisable, and possible inpatients with or without sustained ventricular tachycardia and underlying cardiac disease. In cases at high risk of sudden death, amiodarone may be associated. Recent randomised studies (MADIT, AVID), comparing the use of implantable defibrillators with those of antiarrhythmic therapy, have shown better results with the implantable defibrillator. However, in these studies, only about 10% of patients received betablockers in the antiarrhythmic treatment groups. This factor has introduced some doubt as to the real benefit of implantable defibrillators. Therefore, a randomised study comparing the efficacy of betablockers with amiodarone against implantable defibrillators is desirable in order to determine the respective indications of each of these two therapeutic modalities.

Use of transesophageal echocardiography to predict significant coronary artery disease in aortic stenosis

STUDY OBJECTIVES

This study was conducted to examine if the use of multiplane transesophageal echocardiography (TEE) could predict the absence or the presence of significant coronary artery disease (CAD) in patients with aortic stenosis.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Clinical, angiographic features and TEE findings were prospectively analyzed in 132 consecutive patients with aortic stenosis.

MEASUREMENTS AND RESULTS

In 63 patients with significant CAD, 57 had thoracic aortic plaque on TEE studies. In contrast, aortic plaque existed in only 19 of the remaining 69 patients with normal or mildly abnormal coronary arteries. Therefore, the presence of aortic plaque on the TEE identified significant CAD with a sensitivity of 90.5%, a specificity of 72.5%, and with positive and negative predictive values of 75.0% and 89.3%, respectively. There was a significant relation between the severity of thoracic aortic atherosclerosis and the severity of CAD (p<0.0001). Multivariate logistic regression analysis revealed that aortic plaque, angina, and age were independent predictors of CAD. Aortic plaque was the most significant independent predictor.

CONCLUSION

This prospective study indicates that TEE examination of thoracic atherosclerotic plaque is a powerful predictor of absence of significant CAD in patients with aortic stenosis.

Fibrinogen is an independent marker for thoracic aortic atherosclerosis

The fibrinogen level is an independent risk factor for coronary events and stroke, but no detailed data are available concerning fibrinogen and atherosclerotic disease of the thoracic aorta. This prospective study using multiplane transesophageal echocardiography examined the relation between atherosclerotic thoracic aortic plaque and fibrinogen level. One-hundred forty-eight patients (65 +/- 11 years) with valvular heart disease underwent multiplane transesophageal echocardiography and coronary angiography. We measured plasma fibrinogen level for each patient and recorded the following cardiovascular risk factors: age, sex, systemic hypertension, history of smoking, hypercholesterolemia, diabetes mellitus, body mass index, and family history of coronary artery disease (CAD). Patients with thoracic aortic plaque had a higher level of plasma fibrinogen (p = 0.0001), were older (p = 0.0001), and had significantly more risk factors: history of smoking (p = 0.009), hypertension (p = 0.008), hypercholesterolemia (p = 0.0001), diabetes mellitus (p = 0.01), and family history of CAD (p = 0.003). Multivariate logistic regression analysis of fibrinogen level and risk factors revealed 4 independent predictors of thoracic aortic plaque: fibrinogen, age, hypercholesterolemia, and history of smoking. Fibrinogen was also an independent predictor of CAD. There was a relation between fibrinogen levels and the severity of aortic atherosclerosis (r = 0.46; p = 0.0001) and the severity of CAD (r = 0.30; p = 0.0001). This prospective study indicates that fibrinogen is an independent marker for thoracic aortic plaque related to the severity of thoracic aortic atherosclerosis and confirms that fibrinogen constitutes an independent marker for CAD related to the severity of angiographically evaluated coronary atherosclerosis.

[Transesophageal echocardiography before electric cardioversion for supraventricular arrhythmia]

OBJECTIVES

The aim of this prospective study was to assess the risks of electrical shock cardio-version in the treatment of supraventricular rhythm disorders when administered under effective-dose but short duration anticoagulation in patients with no intracavitary thrombus detectable by transesophageal echocardiography.

PATIENTS AND METHODS

One hundred nineteen patients, mean age 66 years, with permanent arrhythmia due to atrial fibrillation (n = 102), atrial flutter (n = 16) or atrial tachycardia (n = 1) and taking no long-term anticoagulant therapy were treated by electrical shock cardioversion. The patients were given heparin at an effective dose 72 hours prior to cardioversion. A transthoracic and a transesophageal echocardiography were performed less than 24 hours prior to cardioversion.

RESULTS

Twenty-one thrombi were evidenced in 16 patients (14.6%) including 18 in the left auricle, 1 in the left atrium and 2 in the right atrium. A spontaneous contrast was visualized in 38 patients (32%). Cardioversion was performed in 103 patients without thrombus and later in 9 of the 16 patients with thrombus after absorption under anticoagulant therapy as evidenced on the control transesophageal echocardiography. A sinus rhythm was obtained in 82% of the cases. All patients were given anti-vitamin K anticoagulants for one month. There were no clinical manifestation of ischemic vascular events during cardioversion nor during the one-month follow-up.

CONCLUSION

Early use of electrical shock cardioversion in patients with supraventricular rhythm disorders can be proposed without long-term anticoagulation therapy if the absence of thrombi is demonstrated by transesophageal echocardiography and short-term heparin is given followed by oral anticoagulants for at least 4 weeks. A large-scale randomized prospective study comparing the conventional strategy with the protocol used in this study would be required to definitively validate this approach and determine its possible advantages.

Multiplane transoesophageal echocardiographic detection of thoracic aortic plaque is a marker for coronary artery disease in women

OBJECTIVE

This study was conducted to examine if the multiplane transoesophageal echocardiographic detection of atherosclerotic plaque in the thoracic aorta could predict the absence or the presence and the severity of significant coronary artery disease in women. Its association with coronary disease is attractive and may have great influence on foregoing routine preoperative cardiac catheterization in patients with valvular heart disease but no data are available in women.

METHODS

Clinical and angiographic features and transoesophageal echocardiographic findings were prospectively analysed in 111 women.

RESULTS

In 24 women with significant coronary disease, 20 had thoracic aortic plaque on transoesophageal echocardiographic studies. In contrast, aortic plaque existed in only 12 of the remaining 87 women with normal or mildly abnormal coronary arteries. Therefore, the presence of aortic plaque had a sensitivity of 83%, a specificity of 86%, a positive and negative predictive values of 62% and 95%, respectively for the detection of significant coronary disease. There was a significant relation between the severity and the extent of atherosclerotic lesions and the angiographic coronary score (P<0.0001). Multivariate logistic regression analysis revealed that aortic plaque was the most significant independent marker of coronary disease (odds ratio=27.9; 95% confidence interval=5.5-131.6; P<0.0001).

CONCLUSIONS

This prospective study indicates that multiplane transoesophageal echocardiographic examination of thoracic atherosclerotic plaque is a marker for coronary disease in women and especially a powerful predictor of absence of significant coronary artery disease. Transoesophageal echocardiographic aortic examination might be used with risk factors and angina symptoms to discuss the need for preoperative coronary angiography in women with valvular heart disease.

Multiplane transoesophageal echocardiographic absence of thoracic aortic plaque is a powerful predictor for absence of significant coronary artery disease in valvular patients, even in the elderly. A large prospective study

AIMS

This study was conducted to examine whether detection of atherosclerotic aortic plaque by multiplane transoesophageal echocardiography could predict the absence or presence of significant coronary artery disease in young and elderly valvular patients.

METHODS AND RESULTS

Clinical and angiographic features and transoesophageal echocardiography findings were prospectively analysed in 278 consecutive valvular patients. In 93 patients with significant coronary artery disease, 85 had thoracic aortic plaque on transoesophageal echocardiography studies. In contrast, aortic plaque existed in only 33 of the remaining 185 patients with normal or mildly abnormal coronary arteries. Therefore, the presence of aortic plaque on transoesophageal echocardiography studies had a sensitivity of 91%, a specificity of 82%, and positive and negative predictive values of 72% and 95%, respectively, for significant coronary artery disease. In the 109 patients aged > or = 70 years, these sensitivity, specificity, and positive and negative predictive values were 96%, 78%, 79%, and 96%, respectively. The above high negative predictive value was the major finding of this study and indicated that the absence of thoracic plaque is a strong predictor for absence of significant coronary artery disease. There was a significant relationship between the degree of aortic intimal changes and the severity of coronary artery disease (P < 0.0001). Multivariate logistic regression analysis revealed that aortic plaque, angina, hypercholesterolaemia and age were significant predictors of coronary artery disease: aortic plaque was the most significant independent predictor, even in patients > or = to 70 years.

CONCLUSION

This large prospective study indicates that examination of thoracic atherosclerotic plaque, by multiplane transoesophageal echocardiography, is a marker for coronary artery disease, and is a particularly powerful predictor for absence of significant coronary artery disease in valvular patients, even in the elderly.

Familial incidence of late ventricular potentials and electrocardiographic abnormalities in arrhythmogenic right ventricular dysplasia

Familial forms of arrhythmogenic right ventricular dysplasia (ARVD) have been described. Signal-averaged electrocardiograms (SAECGs) and standard electrocardiograms have been used to detect ARVD. The purpose of this prospective study, for a given family member, was to evaluate the risk of having ARVD or only belonging to an affected family. To address these issues, we assessed the incidence of late ventricular potentials and electrocardiographic (ECG) abnormalities in the families of our patients with ARVD. SAECGs and electrocardiograms were recorded in 101 eligible family members and compared with those recorded in ARVD patients with sustained ventricular tachycardia (13 patients in 12 families), and in 37 control subjects with a normal electrocardiogram. The incidence of late ventricular potentials was significantly higher in family members than in control subjects (16% vs 3%, p <0.05). The incidence of ECG abnormalities was 34% in family members. When the incidence of late ventricular potentials and/or ECG abnormalities were added up, results were 38% abnormal findings in family members. Late ventricular potentials and/or ECG abnormalities were found in members of all 7 families; these abnormalities were initially thought to be sporadic forms, and thereafter were classified as familial forms. Thus, SAECGs and standard ECG recordings in ARVD family members showed 38% abnormal findings, and that all cases of ARVD could be classified as familial forms. The incidence of familial forms of ARVD was greater than was previously believed, which is highly suggestive of a genetic transmission of the disease in our geographic area.

[Can Doppler echocardiography help to avoid cardiac catheterization in the surgical decision-making in isolated left heart valve diseases?]

The aim of this study was to assess the value of non-invasive investigation based on clinical evaluation and Doppler echography in deciding the operative indications of patients with isolated left heart valvular lesions compared. Three hundred and thirty five patients were included in a prospective study: 78 had MR, 57 had AR, 150 had AS and 50 had MS. All underwent clinical. Doppler echography and catheter studies. The therapeutic decision was taken blind by two groups of 2 cardiologists. Group I took its decision based on clinical findings and results of Doppler echography whilst Group II took its decision on the clinical and catheter data. For each patient, one of the following three choices was proposed: 1) medical treatment: 2) surgery or valvuloplasty with balloon catheter; 3) request for further information. In addition, in group I, the need for coronary angiography was left to the appreciation of two cardiologists. The quantification of the valvular disease was concordant for groups I and II in 93, 97, 98.5 and 100% for MR, AR, AS and MS respectively. These percentages were respectively 97, 95, 92 and 100% for assessment of left ventricular function. The theoretical management decision was concordant between the two groups for 97% of MR, 94.7% of AR, 95.3% of AS and 94% of MS. Complementary information requiring invasive studies was required by group I in 3.9% of cases. A discordant opinion was obtained in 0.6% of cases (2 cases of AS). Coronary angiography was requested by the cardiologists of Group I in 34% of patients, identifying all patients who underwent coronary bypass surgery. These results show that cardiac catheterisation is no longer an essential diagnostic procedure for discussing the indications of valvular surgery in the majority of patients with isolated left heart lesions.

[Benign gingival granular cell tumor in the newborn: congenital epulis]

Gingival granular cell tumor, or congenital epulis, was first described by Neumman in 1871 and subsequently 201 cases have been published in 173 patients. It is an uncommon benign tumor that is present like a pedunculated, smooth surfaced, isolated lesion on the alveolar mucosa of the maxillar of the newborn child. Its firm consistency and variable size can occasionally cause problems in the child's breathing or feeding. This tumor is easily diagnosed clinically and, although spontaneous regression of the tumor mass has occasionally been reported, the current treatment is surgical removal. Two new cases of congenital epulis are reported and a literature review is included.

Dual chamber pacing with a single lead system: initial clinical results

A new mode of biphasic pacing was used in 26 patients to assess the feasibility of atrial pacing by means of the floating atrial ring electrodes of a single lead VDD permanent pacing system. During implantation, atrial pacing was possible in 25 patients with a 1-ms total pulse duration, a mean atrial threshold of 1.70 +/- 0.60 V (range, 0.6-3.0), and a mean diaphragmatic threshold of 6.7 +/- 2.5 V (range, 2.5-10.0). At 3 months, the atrial threshold had increased beyond 4.8 V in three patients. In the 22 other patients, the mean atrial threshold was 2.2 +/- 0.5 V (range, 1.50-3.50) in the supine position and 2.5 +/- 0.8 V (range, 1.5-4.8) in the sitting position. Stable atrial capture without diaphragmatic stimulation was achieved in 76% of patients.