[Cone Beam CT New tool in diagnostic imaging]. / Comment j'explore... Cone Beam CT Nouvel outil dans l'imagerie diagnostique.

The goal of this article is to show the advantages of the Cone Beam Computerized Tomography (CBCT) compared to classical Computerized Tomography (CT) and to describe several clinical applications of interest with this rather new technology. Invented practically for dentistry, in particular in implantology, the CBCT found major indications in paranasal sinus imaging, in maxillofacial and oral surgery, in periodontology, endodontics and orthodontics. CBCT is very useful to characterize various lesions of jaws with a reserve concerning the study of soft tissues (in that case, an MRI or CT with contrast injection should be preferred). Recently, CBCT is more and more used for temporal bone imaging and studies of small peripheral articulations.

Le but de cet article est de présenter les avantages de la tomographie computérisée à faisceau conique (CBCT) par rapport à la tomographie computérisée (CT) classique et de rapporter quelques applications cliniques. Inventé pratiquement pour les dentistes, en particulier pour l'implantologie, le CBCT a trouvé une indication incontournable dans l'imagerie des sinus, de la chirurgie maxillo-faciale et orale, en parodontologie, endodontie et orthodontie. Le CBCT s'est avéré utile également dans l'imagerie des lésions de différentes origines des mâchoires avec, toutefois, une réserve concernant le bilan d'atteinte des tissus mous (dans ce cas, une IRM - ou un CT avec injection de produit de contraste - serait préférable). Dernièrement, l'application du CBCT s'est élargie à l'imagerie du rocher et, même, des petites articulations des extrémités.

[Spiegelian hernia : a report of three cases]. / Le cas clinique La hernie de Spiegel : à propos de trois cas du mois.

Spiegelian hernia is a rare anterior abdominal wall hernia, described in 1764 by a Hungarian surgeon. It often remains undiagnosed because of its unusual location on the semilunar line, laterally to the rectus muscle. CT presentation is specific. Because of its high risk of strangulation, a surgical management should be proposed, even in case of fortuitous discovery. We present three cases of Spiegelian hernia, two fortuitously discovered and one detected on the occasion of a small bowel incarceration. We also evoke a similar case of eventration on the lunate line requesting the knowledge of the detailed surgical antecedents for diagnosis.

La hernie de Spiegel est une hernie rare de la paroi abdominale antérieure, décrite en 1764 par un chirurgien Hongrois. Elle est souvent non diagnostiquée en raison de sa localisation inhabituelle pour une hernie, sur la ligne semilunaire, latéralement par rapport au muscle grand droit. Sa présentation tomodensitométrique est spécifique. Au vu de son grand risque d'étranglement, une prise en charge chirurgicale doit être proposée, même en cas de découverte inopinée. Nous présentons trois cas de hernie de Spiegel, deux où la découverte a été fortuite et le troisième à l'occasion d'une occlusion par incarcération du grêle. Nous évoquons aussi un cas similaire d'éventration sur la ligne semi-lunaire dont le diagnostic requiert la connaissance des antécédents chirurgicaux précis.

[Impact of the mode of arrival in the emergency department for patients with a STEMI and the clinical outcomes in terms of ejection fraction and survival]. / Impact du mode d'arrivée aux urgences chez les patients avec un syndrome coronarien aigu avec elevation du segment ST (SCAST+) sur le devenir clinique en termes de FEVG et de survie.

Emergency Medical Services (EMSs) play a key role in the recognition and treatment of ST-segment elevation myocardial infarction (STEMI). This study evaluates patient outcome according to his mode of arrival in the care unit dealing with acute coronary syndromes. METHODS: Retrospective analysis of STEMI infarctions registered by the Belgian Interdisciplinary Working Group on Acute Cardiology (BIWAC) at Saint-Pierre University Hospital, Brussels (C.H.U. Saint-Pierre), between 01/01/2005 and 31/12/2006. Comparison of two groups according to their arrival in the care system: group 1: brought in following an emergency call by mobile medical team (SMUR) or normal ambulance ; group 2: arrived at the hospital by their own means and classic admission to Emergency Service. STUDIED PARAMETERS: descriptive patient characteristics, localisation of the infarction and survival to the end of hospitalization, to six months and to one year. RESULTS: Among 136 patients, 56.6 % arrived by EMS and 43.4 % by their own means. Patients who arrived by EMS were older (p = 0.008) and had a higher Killip score (p < 0.05). Pain-to-Angiography and Door-to-Angiography intervals were shorter in patients who arrived by EMS (222 vs 416 mins, p < 0.0001 and 62.6 vs 147 mins, p < 0.0001, respectively). There were no differences in the left ventricular ejection fraction (LVEF) and survival. However, for patients suffering an IVA attack, survival to six months and one year was better in the EMS group (88.9% vs 78.3%, p < 0.05 and 80.5 % vs 69.6 %, p = 0.05). In conclusion, dealing with STEMI infarctions is quicker by EMS admission. The infarctions admitted by this way are more serious. Wherever STEMI infarctions were localised, no improvement of LV function and survival was observed according to the mode of arrival, contrary to the subgroup with an IVA attack where survival is better at six months and one year by EMS admission.

Superior vena cava syndrome associated with Nocardia farcinica infection.

A case is described of severe Nocardia farcinica infection which mimicked a pulmonary neoplasm with pneumonia, superior vena cava syndrome, pericarditis, and hypertrophic osteoarthropathy. Treatment with trimethoprim-sulphamethoxazole and surgery resulted in complete recovery.

Adult onset Kawasaki disease diagnosed by the echocardiographic demonstration of coronary aneurysms.

A 17-year-old boy presented with fever, bilateral conjunctival infection, angina and extensive cervical adenopathy. Amoxycillin was started. Ten days later he was admitted to hospital because of persistent high fever, cervical adenopathy, erythema of the pharynx and tongue and lip fissuration. The most important interventions of his first hospitalization were endotracheal intubation because of increasing dyspnoea due to adult respiratory distress syndrome and haemodialysis for renal insufficiency. His admission to our hospital was marked by the echocardiographic discovery of giant coronary aneurysms in the first few centimeters of both right and left coronary arteries. Coronary angiography confirmed giant aneurysm formation of the right and left coronary arteries. Similarly, medium sized arteries (cerebral, hepatic, mesenteric, iliac) presented abnormalities and laboratory findings. This is the first description of adult-onset Kawasaki disease with giant coronary aneurysm formation and more generalized arterial involvement. The severity of the clinical symptoms and the severity of the coronary disease indicates that Kawasaki disease of the adult does not always have a benign course.

The sinus node and the autonomic nervous system in normals and in sick sinus patients.

To determine the evolution with age, of extrinsic and intrinsic sinus node electrophysiological parameters and to assess the role of each component of the autonomic nervous system relative to age in patients with and without sick sinus syndrome, electrophysiological studies of sinus node function were performed in 227 patients subdivided into four groups according to the results of their electrophysiological testings: group I included patients with normal extrinsic and intrinsic sinus node function, group II patients with exclusive extrinsic sinus dysfunction, group III patients with exclusive intrinsic sinus dysfunction and group IV patients with extrinsic and intrinsic sinus node dysfunction. The electrophysiological study was performed 4 times: at basal state, after sympathetic, autonomic and parasympathetic blockades. Whatever the sinus node function (normal or abnormal) the extrinsic sinus node electrophysiological variables did not correlate with age; inversely all the electrophysiological measurements of the intrinsic sinus node (normal or abnormal) lengthened progressively with age, suggesting an ageing phenomenon of the intrinsic sinus node throughout life. Moreover, the study of the percentage of chronotropy of the sinus node electrophysiological variables shows a predominance of vagal tone in young subjects, whereas sympathetic activity is most prominent in elderly patients with and without sick sinus syndrome. Besides, sympathetic activity increases and vagal tone decreases with increasing age in normals whereas the age-related modifications of each component of the autonomic nervous system in sick sinus patients vary according to the type of sinus node dysfunction. The sinus node (normal or pathological) represents an equilibrated system: the age-related modification of the autonomic nervous system counterbalances the senescence of the intrinsic sinus node in such a way that the basal electrophysiological characteristics remain stable throughout life.

[Treatment of arrhythmias in the elderly]. / Traitement des troubles du rytheme du sujet âgé.

The disorders of cardiac rhythm in the elderly are frequent and important since they are generally less tolerated than in young patients. Sinus bradycardia is one of the most common disorder of cardiac rhythm; symptomatic sinus bradycardia will be treated by pacemaker insertion in most cases. Atrial fibrillation is frequent in the elderly and often poorly tolerated; the aim of therapy is to restore sinus rhythm and prevent recurrences. In order to avoid strokes (emboli), old patients, with chronic atrial fibrillation should be submitted to low-level anticoagulation. Elderly patients may also suffer from supraventricular and ventricular premature beats which should be treated if they present some degree of malignancy.

The sinus node function: normal and pathological.

To determine the evolution with age, of extrinsic and intrinsic sinus node electrophysiological parameters and to assess the role of each component of the autonomic nervous system relative to age in patients with and without sick sinus syndrome, electrophysiological studies of sinus node function were performed in 223 patients subdivided into four groups according to the results of their electrophysiological testings: group I included patients with normal extrinsic and intrinsic sinus node function, group II patients with exclusive extrinsic sinus dysfunction, group III patients with exclusive intrinsic sinus dysfunction and group IV patients with extrinsic and intrinsic sinus node dysfunction. The electrophysiological study was performed twice: at basal state and after autonomic blockade. Whatever the sinus node function (normal or abnormal) the extrinsic sinus node electrophysiological variables did not correlate with age; inversely all the electrophysiological measurements of the intrinsic sinus node (normal or abnormal) lengthened progressively with age, suggesting an ageing phenomenon of the intrinsic sinus node throughout life. Moreover, the study of the percentage of chronotropy of the sinus node electrophysiological variables shows a predominance of vagal tone in young subjects, whereas sympathetic activity is most prominent in elderly patients with and without sick sinus syndrome. The sinus node (normal or pathological) represents an equilibrated system: the age-related modification of the autonomic nervous system counterbalances the senescence of the intrinsic sinus node in such a way that the basal electrophysiological characteristics remain stable throughout life.

[Percutaneous transluminal coronary angioplasty]. / L'angioplastie coronaire transluminale percutanée.

Since a decade, new treatments have been developed in the field of Cardiology as thrombolysis in acute myocardial infarction, use of angiotension converting enzyme inhibitors in cardiac insufficiency, heart transplantation... Percutaneous transluminal coronary angioplasty has been developed since 1977. The aim of this new technology is to treat myocardial ischemia and appears complementary to coronary artery bypass graft.

[Variability of the RR interval: a measure of systemic sympathetic activity]. / La variabilité de l'intervalle RR: une mesure de l'activité du système sympathique.

Beat-to-Beat variability may now be measured, from 24h ECG recordings (Holter monitoring), in the time domain (by statistical indexes) and in the frequency domain (spectral analysis). This variability gives essential informations about the interactions of different cardiovascular variables, and especially about the balance of the two components of the sympathetic nervous system. It is generally thought that a malfunction of the ortho/parasympathetic balance favours ventricular fibrillation. So the potential interest of this new technique as a predictor of sudden cardiac death seems enormous.

Electrophysiologic effects of intravenous xamoterol in patients with sinus node dysfunction.

The electrophysiologic effects of xamoterol were studied in ten patients with electrophysiologic evidence of sinus node dysfunction. A significant shortening of mean sinus cycle length, maximal corrected sinus-node recovery time, and the mean of the three longest corrected sinus-node recovery times was observed after intravenous administration of 0.1 mg/kg of xamoterol. The atrioventricular (AV) conduction time and the effective and functional refractory periods of the AV node were shortened as the effective refractory period of the atrium. These effects suggest that xamoterol could be tried safely for the treatment of patients with moderate symptoms due to sinus-node disease.

[Refractory arterial hypoxemia and interatrial right-left shunt in myocardial infarction of the right ventricle]. / Hypoxémie artérielle réfractaire et shunt interauriculaire droit-gauche au cours de l'infarctus myocardique du ventricule droit.

The authors report the case of a 63 year old woman who developed refractory arterial hypoxemia due to a right-to-left interatrial shunt through a patent foramen ovale during the acute phase of right ventricular infarction. The precarious haemodynamic condition of the patient contra-indicated surgical intervention and so the effects of the shunt were reduced by obstructing the atrial septal defect with the balloon of a Swan-Ganz catheter. The management of this type of shunt is discussed based on the degree of hypoxemia and the patient's haemodynamic status with reference to this particular case and a review of the literature.

[Short- and long-term prognosis of myocardial infarct. Contributions and limitations of the clinical aspects and non-invasive technics]. / Pronostic à court et à long terme de l'infarctus du myocarde. Apports et limitations de la clinique et des techniques non invasives.

Clinical variables and those obtained by non-invasive techniques were recorded in a series of 306 patients discharged from hospital after an acute myocardial infarction. We studied the prognostic value at 2 and 12 months of these variables (alive/dead). The results of simple clinical data were as discriminant as those from more elaborated techniques. When the prognostic value of the same data at 12 months was studied in those surviving for two months, most of the predictive variables lost their discriminant power. The study shows that the predictive value of many of the predischarge variables usually taken into account in the assessment of long term risk, does not extend beyond the first two months.

Limitations on the prognostic value of predischarge data after myocardial infarction.

Clinical variables and those obtained by non-invasive techniques were studied prospectively in a series of 306 patients discharged from hospital after an acute myocardial infarction. The predictive value of the data at two and 12 months was assessed by univariate and multivariate analyses. The best correlation was found for age, hypertension, bundle branch block, early and late heart failure, x ray cardiothoracic ratio, digoxin use, the number of metabolic equivalents reached during the stress test, echocardiographic wall motion score index, left ventricular end diastolic diameter, left ventricular ejection fraction, and the presence of an aneurysm. The prognostic value of the same data at 12 months was studied in those surviving for two months. There was a noticeable decline in the relative risk of all but two of the factors (number of metabolic equivalents, ventricular arrhythmias). All of the predictive variables except the x ray cardiothoracic ratio, number of metabolic equivalents, and the presence of an aneurysm lost their discriminant power. The explanation for this is the strength of statistical relations of these variables with the outcome at two months. They continued to influence the score at 12 months even when the entire patient series was considered. In conclusion, the study shows that the predictive value of most of the predischarge variables usually taken into account in the assessment of risk in patients one year after infarction does not extend beyond the first two months.

Variations of normal sinus node function in relation to age: role of autonomic influence.

An electrophysiological study of sinus node function, including measurements of resting heart rate, maximal corrected sinus node recovery time and sinoatrial conduction time, was performed in 30 patients, 12-79 years of age, without any clinical, electrocardiographic or electrophysiological evidence of sinus node disease. To analyse autonomic influences, variables were measured before and after sympathetic and parasympathetic blockade. No significant correlations were observed between age and electrophysiological measurements of sinus node function at the control study or after sympathetic blockade. In contrast, the electrophysiological parameters of intrinsic sinus node activity were correlated with age and showed a progressive lengthening of mean sinus cycle length, of maximal corrected sinus node recovery time and of sinoatrial conduction time. In addition, measurements after vagolysis suggest a progressive decrease of parasympathetic activity with increasing age. These data also indicate that the respective role of the two components of the autonomic nervous system vary with increasing age: parasympathetic activity predominates in younger subjects; sympathetic and parasympathetic tones are equilibrated in older subjects. The normal sinus node function represents an equilibrated system: in parallel with ageing of the intrinsic properties of the sinus node, parasympathetic activity decreases so that basal properties remain stable throughout life.

Reproducibility of electrophysiologic parameters of extrinsic sinus node function in patients with and without sick sinus syndrome.

In a group of 50 patients we investigated the daily reproducibility of the resting heart rate (RHR), the maximal corrected sinus node recovery time (CSNRTM), the pacing rate at which the CSNRTM occurred (OP), and the sinoatrial conduction time (SACT) during basal state. The study population was divided into two groups according to the presence or absence (as evidenced during the initial electrophysiologic study) of sinus node disease: group I included 35 patients with normal sinus node function, and group II included 15 patients with sick sinus syndrome. The electrophysiologic study was repeated approximately at the same hour and under similar conditions after an interval of at least two days (mean: 3.2 days for group I and 4.7 days for group II). The results showed good reproducibility with the exception of RHR in group I which slightly but significantly decreased in the second electrophysiologic study. The daily variations of the sinus node parameters appeared to be of similar levels in the two groups except for the CSNRTM; this parameter showed wide variations in single values in both groups, more marked in group II than in group I. Furthermore, if the CSNRTM and/or SACT were normal, it was likely that they would remain normal whatever the electrophysiologic status of the patient. Inversely, the change of status from abnormal to normal CSNRTM or SACT was not uncommon in patients with electrophysiologic signs of sinus node disease.

Predictors of early death after acute myocardial infarction: two months follow-up.

Clinical variables and the results of non-invasive tests (exercise test, echocardiogram, gated equilibrium radionuclide ventriculography and 24 h ECG) were recorded in a series of 202 patients who left the hospital alive after an acute myocardial infarction. The short term (two months) predictive value of all these data was prospectively assessed by uni- and multi-variate analysis. The best correlation with early death was observed with the variables related to the extent of infarction and left ventricular dysfunction, namely: early clinical signs of heart failure, high peak CK-MB level, complete bundle branch block, increased cardiothoracic ratio on chest X-Ray, number of Mets reached during the stress test, echocardiographic dyskinesia index, and decreased left ventricular ejection fraction as measured by radionuclide ventriculography. Using multi-variate stepwise discriminant analysis, the following independent prognostic factors appeared by order of entry: early clinical signs of heart failure, peak CK-MB level and cardiothoracic ratio on chest X-Ray. These results highlight the short-term predictive value of the data related to left ventricular dysfunction and especially of simple clinical data for patients surviving an acute myocardial infarction.

High-dose intravenous thrombolytic therapy in acute myocardial infarction: efficiency, tolerance, complications and influence on left ventricular performance.

Ten patients with acute myocardial infarction (AMI) underwent coronarographic studies before, immediately after and ten days after an intravenous infusion of 1 500 000 I.U. streptokinase (STK). Mean time between onset of symptoms to initiation of STK infusion was 03 hours 34 minutes. Occlusion of the infarct-related vessel was present in all of them and successful thrombolysis was obtained in 8 of the patients. Systemic fibrinolytic activity was present in 9 patients, one of whom required a transfusion of blood because of severe bleeding. At ventriculography, the global left ventricular ejection fraction and the regional ventricular ejection fraction, whatever the area involved, showed no significant improvement 10 days after the procedure. This suggests that high-dose intravenous STK in AMI, although causing an effective thrombolysis, does not seem to improve early myocardial function.