Images in gerontology: a case report.

Left ventricular aneurysm can complicate acute myocardial infarction. Clinical and electrocardiogram features are not specific. We describe a case with asymptomatic left ventricular aneurysm diagnosed by computerized-tomography angiography.

[Study of methicillin-resistant Staphylococcus aureus colonization among intermediate-care facility patients]. / Etude de la colonisation par Staphylococcus aureus résistant à la méticilline dans des services de soins de suite.

PURPOSE: Prevalence of methicillin-resistant Staphylococcus aureus is high in the Poitiers teaching hospital, particularly in the intermediate care facilities. We performed a survey of methicillin-resistant Staphylococcus aureus colonization in the intermediate care facilities and 265 patients were included. METHODS: Nasal, cutaneous and wound swab cultures were done at the time of admission and at the time of the patients' departure. A decolonization procedure of methicillin-resistant Staphylococcus aureus carriers was performed using nasal application of fusidic acid and different soaps for the skin. At entry, 17.7% of patients were methicillin-resistant Staphylococcus aureus carriers (of at least one location). At departure, 30.4% were methicillin-resistant Staphylococcus aureus carriers. Among methicillin-resistant Staphylococcus aureus non-carriers at entry, 24.3% became methicillin-resistant Staphylococcus aureus carriers. RESULTS: The principal risk factor of carriage was the initial presence of a wound (RR = 3.6). The incidence rate of methicillin-resistant Staphylococcus aureus infection among the 265 patients included was 3%. CONCLUSION: The systematic screening of patients at the time of admission is expensive and isolation technically hard to manage in the intermediate care facilities. The risk factor we found in this study allow us to propose a 'light' screening limited to patients with wounds.

An epidemic of respiratory syncytial virus in elderly people: clinical and serological findings.

In 1984-1985, an outbreak of respiratory syncytial virus (RSV) infection occurred in two geriatric wards. Among 68 patients (mean age +/- SD = 82.5 +/- 12.5 with respiratory signs, 52 had signs caused by RSV infection. Among all patients, the clinical and serological attack rates were 61.2% and 75.0%, respectively. The most frequent clinical presentation was intensive coughing (96.1%) and fever (96.1%) associated with expectorate (63.5%). The duration of the respiratory symptoms was 5 to 7 days. The disease gradually resolved, although in eight (15.4%) patients complications occurred. For periods of up to 1 year after infection, 172 sera were obtained and tested by complement fixation test (CFT), fluorescent assays for titrating specific IgG, IgA, and IgM, and Western blotting. Specific IgM appeared in six (11.5%) of the infected patients and peaked 2 to 6 months after infection, and there was no significant correlation with severity of clinical symptoms. However, higher peak G and A antibody responses were observed in persons with rales (CFT: P = 0.008; IgG: P = 0.042; IgA: P = 0.020), cough (IgG: P = 0.034), sputum (IgG: P = 0.030), dyspnea (CFT: P = 0.024), conjunctivitis (CFT: P = 0.025), and bronchitis (CFT: P = 0.018). The temporal patterns of IgA and CFT results were found to be similar, whereas IgG peaked later, i.e., between 2 and 6 months. The patients with the most severe symptoms had the highest antibody titers obtained by conventional tests and by Western blots. Thus, RSV can be an epidemic pathogen among elderly persons, although this illness is usually mild.

[Development at 5 years of chronic branchial blocks in 164 patients fitted with pacemakers without documented spontaneous atrioventricular block. Study of predictive criteria]. / Evolution à 5 ans des blocs de branches chroniques chez 164 patients appareillés par stimulateur sans bloc auriculo-ventriculaire spontané documenté. Etude des critères prédictifs.

When no complete atrioventricular block (CAVB), paroxysmal and spontaneous, is recorded, implanting a pacemaker in patients with chronic bundle branch block (CBB) has an arbitrary aspect which must be reduced as much as possible. In order to determine more precisely the criteria predicting an evolution towards CAVB, we studied the electrocardiographic changes observed in 164 patients with various types of CBB. 110 patients had a right bundle branch block which was isolated (RBB) in 16 cases, associated with a left anterior hemiblock (RBB + LAH) in 74 cases and associated with a left posterior hemiblock (RBB + LPH) in 20 cases; 54 patients had a left bundle branch block with a normal axis in 26 cases (LBB - NA) and with a strongly left axis in 28 cases (LBB - LA). All patients had been fitted with a pacemaker. Patients were followed up for a mean period of 5 years (59.1 +/- 25.3 months), the minimum being 2 years. 49.4 p. 100 of them had experienced one ore serveral syncopes. The basal HV interval, studied in 90.2 p. 100 of the patients, was 60 ms or more in 64.9 p. 100 of those who were explored. An ajmaline test, performed in 60 of the 85 patients whose basal HV was less than 70 ms, demonstrated at least a 100 ms or more prolongation of HV in 41 cases (68.3 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of ventricular and sequential cardiac stimulation on carotid output]. / Effet de la stimulation cardiaque ventriculaire et séquentielle sur le débit carotidien.

12 patients (10 men and 2 women), of 59 +/- 10.5 years of age, including 4 with a patent cardiomyopathy and 7 with a cardiothoracic index higher than 0.52, presenting a permanent and complete atrio-ventricular block and fitted with a two-chambers cardiac stimulator, underwent a carotid output study by Doppler-sonography. The objective of this study was to determine the factors which could influence the carotid output: synchronous atrial systole, frequency of the electro-stimulated rhythm, atrio-ventricular delay in sequential mode, cardiomyopathy, increase of the cardiothoracic index, age and body area. It appears that the carotid output, for an identical stimulation frequency, is significantly higher in sequential mode than in one-chamber ventricular electrostimulation (p less than 0.05 at 70 c/min, p less than 0.01 at 80 c/min and p less than 0.001 at 90 c/min) and this is even more marked in case of cardiomyopathy (p less than 0.01 versus p less than 0.05). On the contrary, an elevated cardiothoracic index does not alter the nature of the results. An accelerated electrostimulated rhythm discloses an increase of the carotid output (p = 0.01) up to a threshold frequency of 70 c/min in the entire population and of 60 c/min in case of cardiomyopathy. Beyond that, the carotid output decreases. Sequential stimulation does not prevent this decrease from 80 c/min (p = 0.001). The carotid output is significantly lower (p less than 0.01) with an atrio-ventricular delay of 115 ms than with a delay of 165 ms. The carotid output decreases in direct ratio to age (p = 0.01) but the gradient of the regression axis is lower in sequential mode.(ABSTRACT TRUNCATED AT 250 WORDS)

[Atypical echocardiographic aspects of cardiac amylosis]. / Aspects échographiques atypiques de l'amylose cardiaque.

Echographic abnormalities of cardiac amylosis are now well known and quite useful to the diagnosis. Forms that are morphologically atypical are rare. From three observations (2 hypertrophic, asymmetrical and obstructive forms, and 1 hypertrophic and dilated form) and a review from the literature, we study the nosological, diagnostic and therapeutic problems presented by these atypical echographic of cardiac amylosis.

[Ultrasonic detection of arteriosclerosis of the main arterial trunks in the coronary patient]. / Athérosclérose des gros troncs artériels chez le coronarien, dépistage ultrasonore.

Ultrasonic investigations of the peripheral vessels (continuous Doppler with spectral analysis, echotomography) were performed to evaluate atherosclerosis of the main arteries (abdominal aorta, cervical arteries, lower limb arteries) in 50 coronary patients and 40 control subjects. In the main, our results support those of previously published series (epidemiological and autopsy studies): Atherosclerosis of the main arterial vessels is significantly more common (p less than 0.01) in coronary patients than in control subjects: carotid lesions: 70% (including 10% with severe stenosis) compared to 32% (no severe stenosis); aortic lesions: 50% (including 20% with severe stenosis) compared to 17.5% (7.5% severe stenosis); lower limb arteries: 58% (including 16% severe stenosis) compared to 12.5% (no severe stenosis). The difference of incidences of associations of atherosclerosed vessels between the two groups was significant (p less than 0.01): no peripheral vascular disease was detected in 57.5% of controls compared to only 12% of coronary patients; more than one territory diseased in 15% of controls compared to 58% of coronary patients. The severity of these lesions correlated with the presence of the three major cardiovascular risk factors which were studied (hypertension, smoking, hypercholesterolaemia) and was significantly higher (p less than 0.01) in coronary patients (38% had more than one major risk factor and only 10% had none) than in controls (47% had no risk factors and 6% had more than one). In addition, the preferential sites of atherosclerosis were also confirmed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Myocardial infarction with normal coronary vessels in young subjects. Apropos of 2 cases with an interval of 2 months in 2 brothers aged 32 and 34]. / L'infarctus du myocarde à coronaires normales chez le sujet jeune. A propos de 2 cas à 2 mois d'intervalle chez 2 frères de 32 et 34 ans.

The authors report 2 cases of myocardial infarction with normal coronary arteries occurring at an interval of 2 months in 2 brothers aged 32 and 34. Following an episode of angina, the younger brother, a sportsman, but a smoker, developed an antero-septal infarct at rest, which was complicated by complete persistent right bundle branch block. Ventriculography and coronary angiography were normal. Induced spasm tests were not performed. The elder brother presented an infero-apico-lateral infarct on effort, without any prodromal syndrome, which was complicated by apical akinesia. Ventriculography revealed mitral prolapse. Coronary angiography was normal and the methylergometrine test was negative. In relation to this example of familial infarction with normal coronary vessels, the authors review the features of this type of infarction reported in the literature which predominantly occurs in young people. They discuss the principal points of interest, including the incidence, the criteria of definition based on the coronary angiography, the elements of the prognosis, the pathophysiological mechanisms and the possibility of a genetic predisposition.

[Cardiac insufficiency in infectious endocarditis]. / L'insuffisance cardiaque dans l'endocardite infectieuse.

The aim of this study of 101 cases of infective endocarditis was to determine the factors predisposing to cardiac failure, the prognostic factors of this complication and the therapeutic implications. A significant (p less than 0.05) Chi square test was the statistical reference. Fifty-two per cent of patients developed cardiac failure which was biventricular in 48 p. 100 of cases and the presenting symptom in 64 p. 100. The mean age of the patients with cardiac failure was 56.6 years with a clear male predominance. In 48 p. 100 of cases, cardiac failure complicated a pre-existing cardiac lesion which was usually acquired (84 p. 100). The commonest condition was valvular insufficiency of the aortic and mitral valves (70 p. 100 of cases with cardiac failure). Severe cardiac failure was observed more frequently and earlier in aortic than in mitral regurgitation. The commonest infecting organism was the streptococcus (53 p. 100 of cases with cardiac failure) and the most frequent presumed portal of entry was dental (25 p. 100). Arrhythmias were observed in 51 p. 100 of patients in cardiac failure, the commonest being atrial fibrillation (34 p. 100) complicating mitral valve disease in 56 p. 100 of cases; 17 p. 100 of arrhythmias were ventricular. Conduction defects were observed in 26 p. 100 of cases with cardiac failure, 55 p. 100 of which had aortic valve disease. Valvular vegetations were demonstrated by echocardiography in 43 p. 100 of cases with cardiac failure. Valve replacement had to be performed for resistant cardiac failure in 13 p. 100 of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Current aspects of infectious endocarditis. Review of 101 cases]. / Aspects actuels des endocardites infectieuses. Revue de 101 observations.

One hundred and one cases of infectious endocarditis were reviewed, from 1966 to 1982. The mean age of the patients was 56.3 +/- 15 years. There was a marked predominance of men (70.2 p. 100); the commonest portal of entry was dental (45.9 p. 100); the number of iatrogenic portals of entry and cases of endocarditis on prosthetic valves has been increasing in recent years. Blood cultures were positive in 83 p. 100 of cases; the commonest responsible organism was the non-D streptococcus (31 p. 100 of cases) followed by the D streptococcus (18.8 p. 100), the staphylococcus aureus (17.8 p. 100), and the staphylococcus epidermidis (2.9 p. 100). Gram-negative bacilli were isolated in 9.9 p. 100 of cases. Rare and slow growing organisms have been isolated since 1977. Echocardiography was then introduced and helped the diagnostic in 70 p. 100 of cases. Circulating immune complexes were measured in 25 patients and were found to be raised in 14 cases (56 p. 100). The commonest complication was cardiac failure (43 p. 100) which led to valve replacement in the acute phase in 14 p. 100 of cases. The occurrence of cardiac arrhythmias was a poor prognostic factor. The other complications were neurological (15 p. 100), renal (10 p. 100), embolic (19 p. 100), and pulmonary (9 p. 100). The mortality rate in the acute phase was 30 p. 100 and the probability of a five year survival was 54 p. 100.

[Cardiac complications of infectious endocarditis]. / Les complications cardiaques des endocardites infectieuses.

Factors predisposing to cardiac complications and influencing hospital survival, were analysed in a retrospective study of 101 cases of infective endocarditis. Heart failure occurred in 52 p. 100 of our patients. A significantly greater incidence of heart failure was observed in endocarditis with no preexisting heart disease (p less than 0.01), aortic and mitral valve involvement (p less than 0.01), staphylococcus aureus infections (p less than 0.05), arrhythmias (p less than 0.001), and conduction disturbances (p less than 0.01). Significantly more patients with congestive cardiac failure died in hospital (51 p. 100) than those without congestive cardiac failure (17 p. 100) (p less than 0.001). Severe heart failure before treatment (p less than 0.05), streptococcus D endocarditis (p = 0.05), supraventricular arrhythmias (p less than 0.05), and intracardiac conduction disturbances (p less than 0.05), significantly increased the hospital mortality in patients with congestive heart failure. Electrocardiographic findings revealed arrhythmias in 34 p. 100 of cases, more commonly with mitral valve involvement (71 p. 100) and 52 p. 100 died in hospital. The development of intracardiac conduction disturbance during the course of 18 cases of endocarditis (aortic valve in 11 cases) was associated with a hospital mortality rate of 60 p. 100. The incidence of pericarditis and pulmonary embolism was 4 and 7 p. 100 respectively, and all patients died in hospital. Acute inferior myocardial infarction compatible with coronary embolism was suspected in one patient. Early cardiac valve replacement improved the hospital survival in patients with cardiac complications of infective endocarditis.

[Infectious endocarditis in the elderly]. / L'endocardite infectieuse chez les sujets âgés.

Thirty three cases of infectious endocarditis in patients over 65 years of age (mean age: 72,5 years) observed between 1966 and 1982, were analysed; there were 22 male and 11 female patients, a male predominance of 67%. The data was compared with 68 cases of patients aged less than 65 years of age (mean age: 48,4 years; 49 male and 19 female patients, a male predominance of 72%) treated during the same period. In the patients over 65 years old, compared to those under the age of 65, we observed that: the previous condition of the cardiac valves was more commonly unknown (39% compared to 21%), rheumatic valvular disease was rare (12% of cases), the diagnosis was not delayed, the reason for hospital admission was usually a complication (30% compared to 7%), the two cardinal signs (pyrexia and a cardiac murmur) were always present, as in the younger age group, the urinary tract was the only commoner site of primary infection, the blood cultures were as frequently positive in both groups (79% compared to 85%), in cases with negative blood cultures, antibiotics had not always been given beforehand, but this was commoner than in the younger age group, the causal organisms and usual biological changes were unremarkable, echocardiography, often more difficult because of the high incidence of valvular thickening, remained a valuable tool for diagnosis and management, cardiac failure was more common (55% compared to 37%) as were neurological complications (24% compared to 10%) and renal failure, mortality was greater (39% compared to 25%) and higher in both groups in patients with aortic valve disease and infection with staph-aureus.

Rheumatological manifestations of infective endocarditis.

A retrospective study showed musculoskeletal manifestations in 32 of 108 patients treated for infective endocarditis in several departments at the Poitiers CHU. Such manifestations included articular pain or aseptic arthritis, typically involving the major joints, as well as vertebral osteomyelitis, low back pain (inflammatory or non-inflammatory), and myalgia. Patients showing such signs were generally younger than those without musculoskeletal involvement, diagnosis was made later, and prognosis was worse; streptococcus D was more often involved, and microscopic haematuria was more common. With the exception of vertebral osteomyelitis, the pathogenesis was not clear.

[Thrombopenia induced by heparin]. / Les thrombopénies induites par l'héparine.

The authors report three cases of heparin-induced thrombocytopenia. Two cases were associated with deep venous thrombosis and pulmonary embolism and the other case was associated with arterial embolism. The clinical course was serious, with one death and one amputation of a limb. The thrombocytopenia developed suddenly, 10 to 15 days after the start of treatment; the platelet count was always below 100 000/mm3. The platelet aggregation test is an important diagnostic element, together with the rapid return to normal of the platelet count once the heparin is stopped. An anti-platelet antibody was detected in two patients, suggesting an immuno-allergic mechanism for this new complication of heparin treatment. The treatment consist of immediately stopping the heparin and replacing it with an anti-vitamin K drug or low-molecular weight heparin. The platelet count should be monitored systematically in all patients receiving heparin treatment for more than 8 days.

[Determination of the optimal dose of captopril in the treatment of severe cardiac failure by hourly hemodynamic monitoring]. / Recherche de la posologie optimale de captopril dans le traitement de l'insuffisance cardiaque sévère par la surveillance hémodynamique horaire.

The optimal dose of Captopril was evaluated by hourly haemodynamic monitoring in 10 patients with chronic congestive cardiac failure (Stage IV of the NYHA Classification) after administration of 25 mg, 50 mg, and 100 mg of Captopril. A similar improvement was observed in all the parameters considered with all three dosages. At its peak effect (90 minutes) 25 mg of Captopril caused a fall in pulmonary capillary, and mean pulmonary artery pressures, and a fall in systemic resistance of 40%, 20% and 30% respectively; with 50 mg of Captopril, the effect was a fall of 36%, 24% and 35% respectively. The cardiac index rose by 17% with 25 mg of Captopril, 28% with 50 mg and 12% with 100 mg of Captopril. Although the fall in pulmonary capillary pressure remained significant up to the 6th hour, the improvement in cardiac index was not significant after the 3rd hour. After 8 days' treatment, plasma renin activity increased from 7.01 +/- 4.68 to 23.6 +/- 18.3 ng/ml/hour (p less than 0.02) and serum aldosterone fell from 1.175 +/- 386 p. moles/l to 497 +/- 277 p. moles/l (p less than 0.001). There was no correlation between basal plasma renin activity and pre- or post-therapeutic systemic resistances. The clinical and haemodynamic improvement was sustained after 2 months' treatment in 5 of these patients without side effects. Increasing the dosage of Captopril does not reinforce or prolong its action; moderate doses (25 mg) are as effective as high doses (100 mg). Captopril, which acts by inhibiting the renin- angiotensin-aldosterone system is the current treatment of choice in severe refractory cardiac failure.

[Treatment of atrial fibrillation with fenoxedil hydrochloride. Apropos of 112 cases]. / Traitement de la fibrillation auriculaire par le chlorhydrate de fénoxédil. A propos de 112 observations.

One hundred and twelve patients with atrial fibrillation of different causes were treated with fenoxedil chlorhydrate. Sinus rhythm was restored in 81 cases (72.3 p. 100). The best results were obtained in the following conditions: hypertensive heart disease (77.6 p. 100), ischemic heart disease (75 p. 100), idiopathic atrial fibrillation (76.4 p. 100), senile lone fibrillation (78.2 p. 100). The results were average in valvular heart disease (57.1 p. 100) and in hyperthyroidism (40%). Age did not appear to be a deciding factor, the overall results being comparable in patients under 70 years of age (70.8 p. 100) and over 70 years of age (73.4 p. 100). Although recent atrial fibrillation was reduced more easily (83.3 p. 100), the results were satisfactory in chronic arrhythmias (over 3 years) (77.7 p. 100). The success rate was 76.3 p. 100 when the cardiothoracic index was over 0.60, and 66.6 p. 100 when less than 0.60. The antiarrhythmic effect of fenoxedil chlorhydrate is related to its electrophysiological properties as it depresses sinus node activity and atrioventricular conduction. No arrhythmic or conduction complications were observed during a short period (maximum 5 days) of close monitoring. However, lengthening of the QT and PR intervals was a common phenomenon. The advantages of fenoxedil chlorhydrate over electrical cardioversion (atraumatic, possibility of associating digitalis) and the results obtained whilst respecting the prescribing advice, justify its adoption as a method of converting atrial fibrillation.

[Right atrial myxoma - about a case revealed by a pseudopericarditic symptomatology (author's transl)]. / Les myxomes de l'oreillette droite. A propos d'une observation révélée par une symptomatologie pseudo-péricardique.

The authors relate a case of right atrial myxoma, developing as an inflamatory pericarditis. They insist on the misleading aspect of these tumors, on the delay usually occuring before the diagnosis can be reached and on the notable contribution of echocardiography which should be considered as the main investigation in future and should doubtless be sufficient for the cardiac surgeon, while permitting to avoid furthermore invasive investigations (catheterization and angiography).

[Electrophysiological study of a Portuguese case of amyloidosis with conduction disorders]. / Etude électrophysiologique d'un cas d'amyloïdose portugaise avec troubles de la conduction.

Cardiac involvement in the course of familial Portuguese amyloidosis, as apart from the other primary amyloidosis, is characterised by the early and wide-spread intracardiac conduction disorders, and the contrasting late presentation of the clinical signs. A case is presented of Portuguese amyloidosis which was typical from the viewpoint of the neurological disorders, the familial characteristics, and the positive biopsy; the main conduction defects found in primitive amyloidoses are also recalled. The patient described had for many years suffered from first degree heart block, and then presented with lipid changes with syncopal attacks which led to electrophysiological investigation of the conduction defect, no similar example of which has been found in the literature. The severity and widespread nature of the disorders which were found, together with the localisation of a sub-His block led us to implant the pacemaker. We have only found two other patients who had implants for disorders of conduction secondary to cardiac amyloidosis. Emphasis has been laid on the importance of this investigation which, when it leads to the positioning of a pacemaker, should avoid the onset of syncopal attacks and sudden death which together constitute one of the primary causes of mortality in primary amyloidosis. The length of follow-up in our case has been 14 months (April 1977).