Gout: radiographic findings mimicking infection.

OBJECTIVE: To describe radiographic features of gout that may mimic infection. DESIGN AND PATIENTS: We report five patients with acute bacterial gout who presented with clinical as well as radiological findings mimicking acute bacterial septic arthritis or osteomyelitis. Three patients had delay in the appropriate treatment with the final diagnosis being established after needle aspiration and identification of urate crystals under polarized light microscopy. Two patients underwent digit amputation for not responding to antibiotic treatment and had histological findings confirming the diagnosis of gout. CONCLUSION: It is important for the radiologist to be aware of the radiological manifestations of acute gout that can resemble infection in order to avoid inappropriate diagnosis and delay in adequate treatment. The definitive diagnosis should rely on needle aspiration and a specific search for urate crystals.

[Prognosis and risk evaluation of postoperative coronary patients (PERISCOP). Methodology and study population characteristics]. / Pronostic et évaluation du risque chez le coronarien opéré (PERISCOP). Méthodologie et caractéristiques de la population incluse.

The aim of the PERISCOP study was to evaluate the predictive value of cardiological investigations performed after recent coronary bypass surgery with regards to cardiac event and mortality at one year. The treatment of lipid abnormalities was also analysed. This first article describes the methodology and patient characteristics at inclusion. This prospective national multicenter trial included 2065 patients (86% men) with an average age of 63.1 +/- 9.9 years. The number of diseased vessels was 2.6 +/- 0.6. Preoperative left ventricular function was normal (ejection fraction 60 +/- 13%). Revascularisation was complete in 73% of cases (22% of arterial grafts). The cardiological investigations were performed at Day 20 +/- 10 after surgery. The duration of exercise on stress testing was 429 +/- 170 seconds. It was positive or doubtful in 9% of cases. Ventricular arrhythmias were observed in 6.5% of cases. The blood pressure response was abnormal in 6% of cases. Holter monitoring showed a median number of ventricular extrasystoles over 24 hours of 44. Three per cent of patients had one episode of ventricular tachycardia and 7% had ischaemic episodes. The echocardiographic index of segmental contractility was on average 1.75 (ejection fraction: 52.6%). The lipid analysis performed at one month, under lipid therapy in 34% of cases, showed a total cholesterol level at 1.91 +/- 0.10 g/l, an LDL-cholesterol of 1.27 +/- 0.08 g/l. The therapeutic target (LDL-cholesterol < 1 g/l) was attained in 46% of cases with treatment and in 18% of cases without treatment.

[Apparently idiopathic chronic pericardial effusion. Long-term outcome in 71 cases]. / Epanchements péricardiques chroniques d'apparence idiopathique. Evolution à long terme de 71 cas.

Seventy one cases of apparently idiopathic chronic pericardial effusion were systematicaly followed up. There were 3 inclusion criteria: patients had to be symptomatic with radiological cardiomegaly without tamponade or an acute onset; the effusion had to be stable for more than 3 months despite medical therapy at the time of surgery; the parietal pericardium removed at surgery had to be of normal histopathological appearances. Cases with a discernable classical cause of pericardial effusion were excluded: previous mediastinal radiotherapy, connective tissue diseases, malignancies, chronic infection or a recent episode of acute pericarditis. There were 9 deaths during the first five postoperative years, one of which was related to the pericardial disease and surgery. By definition, no cause was found but in one third of cases a relationship between the pericarditis and other disease processes was possible. The management of these large pericardial effusions resistant to treatment without any apparent underlying pathology and in which echocardiography only shows a large effusion should be surgical with drainage of the pericardial cavity, allowing exclusion of aetiologies which are non-identifiable by other methods, with a negligeable operative risk even in elderly patients and good long-term clinical results. This recommendation is based on systematic follow-up of over 5 years in 57 of our 71 cases; after drainage, only one of the nine deaths observed was related to the pericardial disease itself and 59, subjects (83%) had no further symptomatic pericardial disease.

Risk and results of bypass grafting using bilateral internal mammary and right gastroepiploic arteries.

From January 1990 to June 1994, 240 patients (mean age, 60 +/- 10 years) underwent myocardial revascularization with the exclusive use of in situ bilateral internal mammary and right gastroepiploic arteries. Left ventricular function was normal in 34% of patients, moderately impaired in 58.5%, and severely impaired in 7.5%. The mean number of distal anastomoses was 3.5 +/- 0.7 and the rate of complete myocardial revascularization was 80%. Early mortality was 0.4%, and complications occurred in 20 patients: myocardial infarction, 1.6%; intraaortic balloon pump, 0.8%; reoperation for bleeding, 0.8%; and mediastinitis, 0.4%. Early (15th postoperative day) angiographic control of grafts was performed in 51 patients; the rate of functional and patent anastomoses was 100% for internal mammary arteries and 96% for gastroepiploic arteries. Early functional results (3 +/- 1 postoperative months) were studied in 141 patients during exercise test with medical treatment: 99% were symptom-free and 14% had ischemic modification of electrocardiograms. A 2-year postoperative functional assessment without medical treatment was performed during exercise test in 66 patients: 98% were symptom-free and 26% had ischemic modification of electrocardiograms; during the same procedure, thallium myocardial scintigraphy was obtained in 50 patients and 18 patients had moderate ischemic defect on exercise. Ischemic modifications of electrocardiograms and defects seen on thallium scintigraphy were correlated significantly with incomplete revascularization (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Technical aspects and late functional results of gastroepiploic bypass grafting (400 cases).

From January 1990 to February 1994, 400 patients (mean age 59 +/- 9 years) underwent myocardial revascularization using the right gastroepiploic artery (GEA) to bypass the right coronary artery trunk or branches. They represented 40% of all patients undergoing isolated coronary surgery during the same period, from 19% in 1990 to 54% in 1994. Left ventricular function was normal in 32% of patients, moderately impaired in 62% and severely impaired in 6%. The GEA was used alone in six patients, associated with one internal mammary artery (IMA) in 111 patients (two arterial grafts, 2.2 +/- 0.4 anastomoses) and with both IMAs in 283 patients (three arterial grafts, 3.4 +/- 0.6 anastomoses); no vein graft was used. The rate of complete myocardial revascularization was 79%. Early mortality was 1.7% and influenced by left ventricular ejection fraction (P < 0.05). Complications occurred in 37 patients: myocardial infarction 4%, intra-aortic balloon pump 0.5%, reoperation for bleeding 0.5%, mediastinitis 0.25%. Early (15th postoperative day) angiographic control of the GEA graft was performed in 104 patients operated from January 1990 to December 1991 and the patency rate was 92%; anomalies of GEA were three occlusions, five stenoses, three competitive flow, no string or slender sign. Early functional results (3 +/- 1 months postoperatively) were studied in 192 patients during exercise test with medical treatment: 99% were symptom-free and 14% had electrocardiographic (ECG) ischemic modification significantly correlated with incomplete revascularization (P < 0.01). The 2- and 4-year actuarial survival rate was 96.7 +/- 1.9%. The rate of late cardiac events was 2% patient/year; Angioplasty for GEA graft failure was required in four patients. A 2-year postoperative functional assessment without medical treatment was performed during exercise test in 66 patients who had received three arterial grafts: 98% were symptom-free and 26% had ECG ischemic modification significantly correlated with incomplete revascularization (P < 0.01); during the same procedure, thallium myocardial scintigraphy was obtained in 50 patients: 18 patients (36%) had asymptomatic ischemic defects on exercise significantly correlated with incomplete revascularization and ECG ischemic changes (P < 0.01). However, posterior thallium defects demonstrated limited GEA flow at the maximum level of exercise in at least 8% of patients. Myocardial revascularization using the GEA can be achieved with minimal operative risk and offers satisfactory functional results and midterm survival rate.

Late hemodynamic results after cardiomyoplasty in congestive heart failure.

Between November 1989 and September 1990, a cardiomyoplasty procedure was performed in 12 male patients with a mean age of 59 years. All patients were in New York Heart Association class III. Reinforcement cardiomyoplasty was isolated in 4 patients and associated with a cardiac procedure in 8. There were no perioperative deaths. Failure of cardiomyoplasty occurred in 5 patients because of recurrence of disabling congestive heart failure: 3 patients died late, and 2 had heart transplantation. The actuarial survival rate was 83% at 1 year and 73% at 2 years. Hemodynamic studies were done preoperatively in all patients, at 6 months postoperatively in 11 patients, at 1 year in 8, and at 2 years in 7. At the 2-year follow-up, 6 of the 7 survivors who did not have transplantation were functionally improved with reduced medical treatment. The following indices improved significantly at the 2-year evaluation compared with baseline: exercise capacity (63 +/- 13 W versus 83 +/- 17 W); left ventricular (LV) end-diastolic pressure (20 +/- 7 mm Hg versus 11 +/- 5 mm Hg); and angiographic LV ejection fraction (0.25 +/- 0.09 versus 0.40 +/- 0.15). Pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac index remained unchanged. Four patients underwent beat-to-beat analysis of LV function at 2 years; during skeletal muscle stimulation, stroke volume increased by 7% to 35% and LV end-systolic pressure, by 5% to 9%. In the 5 patients with failed cardiomyoplasty, mean pulmonary artery pressure and LV end-diastolic volume were higher preoperatively than in the 7 survivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiomyoplasty does not preclude heart transplantation.

Stimulated skeletal muscle grafts have been proposed to improve left ventricle function in patients with severe myocardial failure. In 1 particular case reported here, however, the postoperative functional improvement was only transient and disabling heart failure recurred after 9 months in spite of a vigorous latissimus muscle contraction. Heart transplantation was proposed to this patient and performed successfully. Technically, the key to heart removal depends on the retrograde dissection of the ventricular cavities, starting from the right atrioventricular groove. The intraoperative observations confirmed the viability of the latissimus dorsi muscle, inefficient on a highly dilated cardiomyopathy. Histopathological examination of the latissimus dorsi muscles showed that the transformation process of the stimulated muscle was good. Thus, severe cardiac dilatation seems to be one of the limitations of cardiomyoplasty. Cardiomyoplasty, when it fails, does not preclude heart transplantation. The histochemical studies confirm the electrophysiologic principle of cardiomyoplasty in humans.

Latissimus dorsi cardiomyoplasty in severe congestive heart failure: the Lyon experience.

Eleven male patients, New York Heart Association (NYHA) Class III, have undergone cardiomyoplasty (Chachques and Carpentier technique). There were no deaths. Two patients suffered from low cardiac output, one patient suffered a massive aortic bifurcation embolism, and one patient had a Legionella pneumonia. All patients recovered well. The follow-up was 6.9 +/- 2.3 months. One patient had a Cardiomyostimulator Pulse Train Generator failure and had it replaced. The first seven patients were evaluated 6 months after surgery. They all improved (Class II) except for one, who was transplanted. The maximal level of exercise was improved (92 +/- 18 W vs 60 +/- 24 W), as was the heart rate-systolic blood pressure product (30,262 +/- 3,119 vs 19,908 +/- 4,190), mainly due to an increase in systolic blood pressure (200.0 +/- 25.5 vs 141.5 +/- 20.3 mmHg). Echographic parameters, maximal oxygen consumption, left ventricular ejection fraction (LVEF), cardiac index, oxygen arteriovenous difference, and cardiac filling pressures did not change. The left ventricular (LV) angiography always showed good contraction of the latissimus dorsi. A problem needing investigation is the principle of cardiomyoplasty (CMP) itself, as the muscle acts more as a lift than as pincers. Our patients, and patients from other series, improved functionally, and they exercised more. Improvement in survival can be studied only by a randomized clinical trial.

[Radiation-induced pericarditis. Long-term outcome. 45 cases with thoracotomy and biopsy]. / Péricardites radiques. Evolution à long terme. 45 cas avec thoracotomie et biopsie.

Between 1970 and 1989, 45 cases of pericarditis consecutive to thoracic irradiation for cancer were studied to determine their long-term outcome and the course of their pericardial lesions. All patients were symptomatic and required surgery on account of cardiac dysfunction or, more rarely, for diagnostic purposes, i.e. to distinguish between pure autonomous pericardial complications and recurrent mediastinal neoplasias, the latter being excluded from the study. All patients were explored by thoracotomy which permitted histopathological examination of the pericardium and the pericardial fluid, at the same time as therapeutic surgery (pericardial decortication for constriction in 22 cases, creation of pleuro-pericardial windows to ensure drainage of major effusions in 23 cases). The outcome was often poor owing to associated post-radiotherapy myocardial and pulmonary lesions: there were 20 deaths, 5 of which were directly due to the neoplasia and 13 to the radiotherapeutic complications; 5 patients remained with impaired cardiorespiratory function.

[Value of the positive exercise test without angina (after myocardial infarct)]. / Valeur de l'épreuve d'effort positive sans angor (après infarctus du myocarde).

In order to determine the value of a positive exercise test (ET) (i.e. ischaemic ST depression) without chest pain observed after a myocardial infarction (MI), 102 ET's were reviewed. ET was performed without anti-ischaemic drugs. The mean time-lag between MI and ET was 51 +/- 55 months. The MI was inferior in 26 cases, inferior and/or posterior in 74 cases and of undetermined location in 2 cases. Thirty patients had both ST depression and chest pain (group 1); 35 had electrocardiographic signs of ischaemia without pain (group 2), and 37 had neither chest pain nor signs of ischaemia (group 3). Age, sex ratio, site of infarction and time-lag between MI and ET were similar in all three groups. The post-ET follow-up period was 33 +/- 18 months (range: 6 to 66 months); 2 patients in group 3 were lost sight of. There was no significant difference between groups 1 and 2 as regards total duration of ET, workload attained, heart rate, systolic arterial pressure, pressure-rate product and amplitude of ST depression at maximum exercise level. Group 3 differed from the other 2 groups in workload attained (p less than 0.05) and in pressure-rate product (p less than 0.05 vs group 1, p less than 0.01 vs group 2). There was no significant difference between groups 1 and 2 as regards post-ET events (recurrent angina, reinfarction, coronary bypass, transluminal angioplasty).(ABSTRACT TRUNCATED AT 250 WORDS)

[Methods of evaluating myocardial revascularization surgery]. / Méthodes d'évaluation de la chirurgie de revascularisation myocardique.

The quality of revascularization is evaluated by measurements of blood flow and various imaging methods. The quality of the anastomosis and the graft flow are evaluated per-operatively by ultrasounds and by measurements of intramyocardial pH. After surgery, Doppler velocimetry and radioisotope scanning assess the basal coronary flow and the coronary reserve. Graft patency can be studied by noninvasive methods (Doppler and kinetic CT with contrast injection), but conventional or digital angiography is irreplaceable for visualization. Residual myocardial ischaemia and left ventricular function are evaluated by the usual methods. Angina is not sensitive enough to serve as an indicator of residual or recurrent myocardial ischaemia. ECG at rest detects most peri-operative infarctions; Holter recordings may reveal a silent myocardial ischaemia; exercise stress ECG evaluates (albeit with insufficient sensitivity) post-bypass changes in myocardial ischaemia. Myocardial scintigraphy with thallium-201 is more sensitive, and it locates low perfusion areas. Cardiac wall kinetics and left ventricular function at rest and during exercise are studied by echocardiography and contrast or isotopic ventriculography, pending advances in nuclear magnetic resonance imaging. Surgical results have never been compared with other methods of direct myocardial revascularization, but only with medical treatments. Outstanding among the controlled studies carried out are a European study (E.C.S.S.) and two North American studies (V.A.S. and C.A.S.S.); they have shown what can be expected from coronary bypass, globally and in some subgroups of patients.

Non-neoplastic stenoses of the rectum.

Rectal stenoses, often accompanied by a simple, non-specific symptomatology, have multiple and varied causes. The clinical picture is far from specific and can go from absolute latency to the full picture of a distinct colic occlusion. The clinical examination mainly relies on the data from the proctologic examination and, in particular, the rectal touch that enables detection of the lesion. This proctologic examination is completed with a uro-genital clinical check-up. The complementary endoscopic, X-ray and biological examinations are dominated by rectoscopy, barium enema and, if necessary, scanner, ultrasonography and anatomopathology. The etiological forms comprise stenoses by extrinsic compression; inflammatory or non-inflammatory pseudo-tumoral stenoses; inflammatory cryptogenetic (RCH, Crohn) or specific (infectious, parasitic and venereal) stenoses; ischaemic stenoses; traumatic stenoses by internal or external traumatism and medical iatrogenic, post-physiotherapeutic or post-surgical stenoses. The therapeutic problems depend on the type, age and size of the evolution as well as the cause (etiology) of the lesions. Depending on the case, we have to "make do with it", circumvent the problem, force or remove the obstacle.

[Prognostic value of the exercise test performed less than 40 days after the first infarction]. / Valeur pronostique de l'épreuve d'effort réalisée moins de 40 jours après primo-infarctus.

Stress testing was performed in 159 men (mean age 49.83 years) between the 10th and 40th day after primary myocardial infarction. The average work achieved was 79 watts with a heart rate of 121/min, systolic blood pressure of 169 mmHg, and a double product of 20 544. The result was negative in 53 p. 100 of cases, and positive in 47 p. 100: the positive response was ischaemic in 23 p. 100 and non ischaemic in 24 p. 100 of cases. In the 2 years which followed, post-infarction angina was observed in 44 p. 100 of cases (14 p. 100 unstable angina), recurrent infarction in 7 p. 100 and death in 4 p. 100; coronary angiography was performed in 19 p. 100 of cases and coronary bypass surgery in 6 p. 100; 53 p. 100 of patients remained asymptomatic. The difference in predictive value between negative stress testing for an asymptomatic outcome and a positive ischaemic test for post-infarction angina and bypass surgery was important (p less than 0.001). The correlation was not as significant for death and recurrent infarction. The non-ischaemic positive result was of less value. There was no relationship to age but the prediction was more accurate in postero-inferior (p less than 0.001) than anterior infarction (p less than 0.05). The timing of the test affected the performance and patient comfort but had less influence on the results. Nevertheless, the predictive values were less good at 2 weeks than later on and significantly improved when testing was performed between the 10th and 11th week. However, early stress testing was valuable for identifying high risk subgroups.

[Correlations between coronary and ventricular angiography and the exercise test after myocardial infarction]. / Corrélations entre coronaro-ventriculographie et épreuve d'effort après infarctus du myocarde.

The aim of this study to assess the predictive value of exercise stress testing (ET) compared with coronary angiography-left ventriculography (CLV) in 102 patients undergoing physical rehabilitation (PH) after myocardial infarction (MI). The ET was optimised in its performance by the PH and in its interpretation by the selection of the parameters according to the site of MI. In anterior MI, angina (30%) and ischemic ST depression outside the acute period (35%) had little predictive value of multivessel disease which was demonstrated in 40% of cases; on the other hand, ST elevation in the same area as MI (65%) had an 88% predictive value for severe LV impairment which was found in 66% of cases. In inferior MI, ischemic ST depression (75%) more than angina (27%) was of greater predictive value (82%) for multivessel disease which was demonstrated in 59% of cases. The sensitivity was 97% and the specificity 64%; the LAD artery was diseased in 48% of cases. LV function was preserved in 63% of cases, but ET was not useful in the prediction of this parameter. In all cases of MI, the absence of ST changes predicted single vessel disease in 94%; ventricular arrhythmias (5%) stopped the patients reaching a discriminative exercise level but indicated poor LV function. The extreme values of heart rate and double product improved the correlations between ET and CLV. Therefore, ET may provide some of the information of CLV before the usual evolutive criteria and may help avoid this investigation in patients with favourable results, especially with inferior infarction. Although it has no absolute value, systematic ET is justified after MI as it enables the most severe cases to be distinguished from the most benign.

[The limits of the medical treatment of angina pectoris]. / Les limites du traitement médical de l'angine de poitrine.

The limitations of medical treatment in angina pectoris depend on its efficacity and indications. 1. Efficacity of medical treatment.--Anti-anginal drugs are able to relieve anginal pain in at least 3/4 of cases. However, the ability of medical measures (diet, exercise, stopping smoking, hypolipidemic drugs, antihypertensive drugs, anticoagulants, platelet anti-aggregants, antiarrhythmics, inotropic agents, vasodilators and diuretics) to prevent coronary atherosclerosis delay its progression and prevent its complications--so increasing the life expectancy of coronary patients--remains very uncertain. 2. Frontiers and judications of medical treatment.--Coronary patients with few or no symptoms appear to be best suited for long-term anti-anginal treatment with long acting nitrate derivatives and/or betablockers. The ability of the latter group to increase the life expectancy of all coronary patients remains to be shown. The limits of the indications of medical treatment are more difficult to define either by purely subjective criteria (incapacitating angina after trials of anti-anginal drugs at adapted doses) or by "objective" criteria (ergometry, coronary angiography).