[Hospital production cost of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression]. / Coût de production hospitalier de la stimulation magnétique transcrânienne répétée (rTMS) dans le traitement de la dépression.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is an effective and well-tolerated treatment in resistant depression with mild to moderate intensity. This indication has not yet been approved in France. The cost and medico-economic value of rTMS in psychiatry remains unknown. The aim of this preliminary study was to assess rTMS cost production analysis as an in-hospital treatment for depression. METHODS: The methodology, derived from analytical accounts, was validated by a multidisciplinary task force (clinicians, public health doctors, pharmacists, administrative officials and health economist). It was pragmatic, based on official and institutional documentary sources and from field practice. It included equipment, staff, and structure costs, to get an estimate as close to reality as possible. First, we estimated the production cost of rTMS session, based on our annual activity. We then estimated the cost of a cure, which includes 15 sessions. A sensitivity analysis was also performed. RESULTS: The hospital production cost of a cure for treating depression was estimated at € 1932.94 (€ 503.55 for equipment, € 1082.75 for the staff, and € 346.65 for structural expenses). CONCLUSION: This cost-estimate has resulted from an innovative, pragmatic, and cooperative approach. It is slightly higher but more comprehensive than the costs estimated by the few international studies. However, it is limited due to structure-specific problems and activity. This work could be repeated in other circumstances in order to obtain a more general estimate, potentially helpful for determining an official price for the French health care system. Moreover, budgetary constraints and public health choices should be taken into consideration.

[Aortic insufficiency in certain so-called systemic diseases]. / Insuffisance aortique au cours de certaines maladies dites systémiques.

The authors present a retrospective study of all the patient followed up for systemic disease in the rheumatology Department of Bichat hospital between 1975 and 1984 in whom aortic regurgitation developed. Only rare or previously undescribed associations were retained: two MacDuffie syndromes, one adult form of Still's disease, one Takayashu's disease, one association of rheumatoid arthritis and Takayashu's disease, one rheumatoid arthritis, one Cogan's syndrome and two cases of disseminated lupus erythematosis. The authors use these cases and a review of the literature to discuss the possible physiopathological mechanisms of the aortic regurgitation. This study confirms the value of regular clinical cardiovascular examination with echocardiography in cases with progressive symptoms. The evolution of the vascular disease seems to be more or less parallel to that of the systemic disease and in a significant number of cases it becomes sufficiently severe to become the main clinical problem. In our series, there was one sudden death, one death due to cardiogenic pulmonary oedema and three patients required aortic valve replacement.

[Right intraventricular tumors. Apropos of a case]. / Tumeurs intraventriculaires droites. A propos d'une observation.

The authors report a case of right ventricular tumour in a 16 year old girl who presented with dyspnoea on effort, chest pain on exertion and loss of consciousness. The diagnosis was made on the basis of abnormal right intraventricular echoes on two dimensional echocardiography and was confirmed by angiography. The patient was operated with success. Histology revealed a mesenchymoma, a benign tumour, but whose infiltrating nature calls for a reserved prognosis. The echocardiogram can be used for regular post-operative surveillance. The young patient is well after 18 months' follow-up.

[Aorto-septal angulation: a new cause of disorder in left ventricular ejection? (a 2-dimensional echocardiographic study apropos of 66 cases)]. / La désaxation aorto-septale: une nouvelle cause de gêne à l'éjection ventriculaire gauche? (étude échocardiographique bidimensionnelle à propos de 66 cas).

Aorto-septal angulation is defined as an acute angled connection between the anterior aortic wall and the interventricular septum. It is quite a common 2D-echo finding. Does it correspond to a simple anatomical curiosity or is it associated with certain well defined diseases? Could it be a cause of obstruction to left ventricular ejection? To try to answer these questions, 66 consecutive cases of aorto-septal angulation were analysed; the echocardiographic and clinical data were correlated. The dynamic features of angulation were studied during the cardiac cycle and the investigations were completed by a phonomecanogramme with pharmacodynamic stress tests. All patients had cardiovascular pathology: aorto-septal angulation was not observed in normal subjects. The dynamic 2D-echo study distinguished two types of angulation with respect to the cardiac cycle: predominantly diastolic angulation tending to correct itself in systole (16 patients: Group CI); the majority of these patients had severe compensated aortic regurgitation; fixed angulation with no significant change between diastole and systole (50 patients: Group C2). This group consisted of patients with ventricular deformation due to coronary artery disease and patients with hypertension associated in some cases with other pathologies. Phonomecanography with pharmacodynamic stress testing in Group C2 revealed the possibility of dynamic obstruction to left ventricular ejection (6 cases) and the apparition of an ejectional systolic murmur (2 cases). Aorto-septal angulation seems to be closely related to hypertension (57% of patients) irrespective of age. Therefore, it should not be classified exclusively as a change observed in the "aging heart" but it may be the direct consequence of an adaptation to systolic strain of the left ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical study of the action of dobutamine in acute cardiac insufficiency]. / Etude clinique de l'action de la dobutamine dans l'insuffisance cardiaque aiguë.

78 patients were treated with dobutamine for a severe episode of heart failure at a mean dose of 9.51 micrograms . kg-1 . min-1 for an average of 5 days. 59 of these patients had ischaemic heart disease, including 34 with recent infarcts. The monitoring of treatment was essentially clinical, consisting of repeated measurement of the heart rate, the systolic and diastolic blood pressure and the diuresis. A haemodynamic survey was performed in only 25 cases. 48 patients were improved. 24 of these patients had no clinical or radiological signs of heart failure at the end of the treatment. Dobutamine significantly increases the blood pressure (97.7 +/- 24.9 to 105.8 +/- 21 mm Hg), the diuresis and the cardiac index (2.02 +/- 0.51 to 2.52 +/- 0.54 l . min-1 . m-2) and it significantly decreases the mean capillary pressure (25.36 +/- 6.20 to 21.03 +/- 6.94 mm Hg). The tolerance was very satisfactory, particularly in terms of the heart rate, ventricular excitability and the progression of the coronary disease. This clinical study confirms the value of dobutamine in the treatment of severe heart failure, either alone or in combination with vasodilators. The authors do not believe tha haemodynamic monitoring is essential at the doses used, which means that dobutamine could be used more widely in these indications.

[Visualization by bidimensional echocardiography of the trunk of the left coronary artery. Affirmation of its integrity before coronary angiography]. / Visualisation par échocardiographie bidimensionnelle du tronc de la coronaire gauche. Affirmation de son intégrité avant coronarographie.

The aim of this study was to visualise and analyse the status of the main left coronary artery by 2D echocardiography before coronary angiography. Fifty two patients were studied. The recordings were performed from the left parasternal position on video cassettes and played back frame by frame for each patient, to analyse the left main coronary artery and its bifurcation. The patients had known stenosis of this vessel; there were echocardiographic abnormalities in all 10 cases; the stenosis was visualised directly in 5 patients and the vessel was considered to be abnormal in the other 5 patients. Forty two patients underwent 2D echo before coronary angiography. The echo of the left main coronary artery was considered to be abnormal in 8 patients: these results were compared with those of coronary angiography. In 33 cases there were no echocardiographic abnormalities and there were no angiographic lesions. The false positive results were due to the inability to record the bifurcation (proximal stenosis of the LAD interpreted as stenosis of the left main coronary) or to the direction of the left main coronary which is curved and thus cannot be analysed in the plane of the transducer. False negative results corresponded to slight stenosis (less than 50 p. 100). The bifurcation can be visualised in 60 p. 100 of patients with normal left main coronary arteries. It is only in these cases that the absence of significant lesions can be confirmed before coronary angiography.

[Treatment with intracoronary streptokinase in the acute phase of myocardial infarct. Preliminary results apropos of 20 cases]. / Traitement par streptokinase intra-coronarienne à la phase aiguë de l'infarctus du myocarde. Résultats préliminaires à propos de 20 cas.

Twenty patients with primary myocardial infarction (mean age 55 years +/- 6) were treated with intracoronary streptokinase in the acute phase. The mean interval between the onset of chest pain and treatment was 4 hours 30 minutes (extremes, 30 minutes and 6 hours). The total quantity of streptokinase required to obtain coronary revascularisation varied from patient to patient and with the technique used, but it was less than 350,000 units in all cases. The immediate results were favourable in 80 p. 100 of cases with respect to the coronary obstruction, in 50 p. 100 of cases with respect to relief of pain and in 35 p. 100 of cases with respect to ST elevation. It is not possible to confirm the efficacy of this therapy in left ventricular function from the results of this preliminary study. The authors observed, however, that the best results as assessed by 2D echocardiography, left ventricular angiography, and Thallium 201 myocardial scintigraphy were obtained in patients treated early (before the 3rd hour). They emphasise the need to check the level of antistreptokinase antibodies before starting treatment to assess the optimal total dosage for each individual patient, in order to obtain a local effect without disturbing the overall coagulation mechanism.

[Cardiac toxicity of ajmaline. Comparison of acute voluntary poisoning with complications of the ajmaline test]. / Toxicité cardiaque de l'ajmaline. Comparaison des intoxications aiguës volontaires et des accidents du test à l'ajmaline.

A comparative and retrospective study of 59 cases of acute voluntary self-poisoning observed at the Toxicology Department of Fernand Widal Hospital, and 15 cases of complications of the Ajmaline test observed in the Cardiology Department of Bichat Hospital showed a similarity in the cardiac effects of high dosage regardless of the mode of administration of the antiarrhythmic. Acute suicidal poisoning in adults or accidental poisoning in children caused toxic effects at doses over more than Ig: they are characterised by their sudden onset after a latent period of 1 to 2 hours and their short duration (no effects after the 12th hour). The ECG changes included:--First degree atrioventricular block (15 p. 100).--Intraventricular conduction defects were observed in almost all cases. They were proportional to the dose taken and were of prognostic interes (no cardiac arrests when the QRS remained less then 0,2 sec).--ST-T wave changes were observed in all patients. They lasted longer and were of no prognostic importance.--Extrasystoles and ventricular tachycardia are nearly always associated with poor hemodynamic tolerance (70 p. 100 of cardiac arrests, compared to only 16 p. 100 in this absence). This intoxication is serious with a mortality of 24 p. 100 of the reported cases and of 9 p. 100 of cases admitted to an Intensive Care Unit.--The complications of the Ajmaline test were similar, the time of apparition being a few minutes instead of a few hours. There were no deaths or serious hemodynamic complications in this series. This is without doubt related to the observation of the contraindications and the fractional administration of the Ajmaline. We conclude that oral Ajmaline, though well tolerated at therapeutic does may cause severe toxic overdose effects. Although its use remains justified in the treatment of arrhythmias, it should not be used for the symptomatic treatment of palpitations and neurovegetative imbalance.

[Intracoronary thrombolytic treatment in the acute phase of myocardial infarction (author's transl)]. / Traitement thrombolytique par voie coronarienne directe à la phase aiguë de l'infarctus du myocarde.

Thrombolysis by intracoronary injection of streptokinase was attempted in 18 patients with recent myocardial infarction. Streptokinase was administered by continuous i.v. infusion or by repeated injections to a maximal total dose of 250 000 units. Complete recanalization was obtained in 13 out of 16 patients with total occlusion of one vessel confirmed by angiography of the coronary arteries. Pain was relieved in 12 of these 13 patients and there was immediate and significant reduction of the lesion current in 9. The treatment was well tolerated. Arrhythmias in an usually minor form (ventricular ectopy) may occur during thrombolysis. No haemorrhage has been reported. There is no systemic fibrolysis in most cases.

[Predictive value of the ajmaline test for the diagnosis of distal paroxysmal atrioventricular block (author's transl)]. / Valeur prédictive du test à l'ajmaline dans le diagnostic des blocs auriculo-ventriculaires paroxystiques distaux.

An ajmaline test was conducted in 120 patients with a history of disorders of consciousness : Adams-Stokes syndrome (n = 49), loss of consciousness (n = 42), or lipothymia (n = 29). Four types of response were observed after ajmaline : VH less than 80 ms (n = 63); VH between 80 and 100 ms (n = 19); VH greater than 100 ms (n = 17); distal block (n = 21). One hundred and fifteen of these patients were followed-up for from three to six years (mean 56 months). Pacemakers had been fitted in 46 of them. Atrioventricular block was eventually detected in 37 patients but was excluded in the other 78 cases, either because the syncope attacks did not recur or because another cause was demonstrated. The predictive value of the ajmaline test was confirmed by the subsequent course of the disorders. Based on only clinical findings, diagnosis was confirmed in 42 p. cent, excluded in 12 p. cent, and impossible to define in 46 p.cent of cases. After the ajmaline test, diagnosis was confirmed in 79 p.cent, excluded in 6 p.cent, and impossible to define in 15 p.cent. The risk of atrioventricular block can be evaluated as 1-6 p.cent when the increase in VH is less than 80 ms, 35.3 p.cent when the increase is between 80 and 100 ms, 62.5 p.cent when it is greater than 100 ms, and 100 p.cent when there is a distal block. The indications for fitting a pacemaker depend upon the results of this test. If contra-indications are respected (recent history of an infarct, cardiac failure, marked enlargement of the heart), complications are rare, being observed in less than 3 p.cent of cases.