[Bilateral periostitis and arthritis: about a case of hypertrophic osteoarthropathy]. / Périostite bilatérale et polyarthrite : à propos d'un cas d'ostéoarthropathie hypertrophique pneumique.

We report the case of a 67-year-old female patient presenting swelling of the hands and feet and pain in both legs. Clinical examination and bone scintigraphy identify the triad "digital clubbing - arthritis - bilateral periostitis of the long bones", leading to a diagnosis of hypertrophic osteoarthropathy, a syndrome usually associated with pulmonary neoplasia. The thoracic CT-scan, followed by a biopsy, effectively diagnosed a right upper lobe adenocarcinoma. Surgical treatment of the neoplasia allowed the resolution of the clinical complaints and the pathological scintigraphic findings.

Nous rapportons le cas d'une patiente de 67 ans présentant des gonflements des mains et des pieds ainsi que des douleurs des deux jambes. L'examen clinique et la scintigraphie osseuse identifient la triade «hippocratisme digital - arthrites - périostite bilatérale des os longs¼, permettant de poser un diagnostic d'ostéoarthropathie hypertrophique, un syndrome habituellement associé à une néoplasie pulmonaire. Le scanner thoracique, suivi d'une biopsie, ont en effet diagnostiqué un adénocarcinome localisé au niveau du lobe supérieur droit. La prise en charge chirurgicale de la néoplasie a permis la résolution des plaintes cliniques et de l'aspect scintigraphique pathologique.

Dispersion of ventricular repolarisation: a marker of ventricular arrhythmias in patients with previous myocardial infarction.

OBJECTIVE: To examine whether, in coronary patients after myocardial infarction, the dispersion of ventricular repolarisation measured through QT and JT intervals from a surface electrocardiogram could allow separation of those with ventricular tachyarrhythmias (VT) complicating their myocardial infarct from those without. DESIGN: A retrospective comparative study. SETTING: University hospital. PATIENTS: 39 patients with myocardial infarction complicated by VT, 300 patients after myocardial infarction without arrhythmic events, and 1000 normal subjects. The myocardial infarction groups were divided into anterior, inferior, and mixed locations. INTERVENTIONS: A computer algorithm examined an averaged cycle from a 10 second record of 15 simultaneous leads (12 lead ECG + Frank XYZ leads). After interactive editing, four intervals were computed: QTapex, JTapex, QTend, and JTend. For each interval, the dispersion was defined as the difference between the maximum and minimum values across the 15 leads. RESULTS: The mean values of all four dispersion indices were higher in patients with myocardial infarction than in normal subjects (p < 0.01). In the infarct groups, patients with VT had significantly greater mean and centile dispersion values than those without VT. For instance, the 97.5th centile value of QTend was 65 ms in normal individuals, 90 ms in infarct patients without arrhythmia, and 128 ms in those with VT; 70% of the infarct patients who developed serious ventricular arrhythmias had values exceeding the 97.5th centile of the normal group, while only 18% of the infarct patients without arrhythmia had dispersion values above this normal upper limit. Among the infarct patients, nearly half of those (18 of 39) with tachyarrhythmias had dispersion values that exceeded the 97.5th centile of those without arrhythmia. CONCLUSIONS: Dispersion of ventricular repolarisation may be a good non-invasive tool for discriminating coronary patients susceptible to VT from those who are at low risk.

Methodology of ECG interpretation in the Louvain program.

The Louvain program performs the analysis and interpretation of the vectorcardiogram (VCG) to increase the clinical utility of ECG analysis. Among its original features, there are (1) a high-resolution vector-loop display for visual analysis, (2) quantitative analysis of the spatial VCG using age-sex stratified limits, (3) separate software for adult and pediatric series and (4) complementary deterministic and statistical methods of diagnostic classification. Using objective, ECG-independent evidence as a reference standard, the Louvain program has shown satisfactory levels of diagnostic accuracy in most basic categories. However, its usefulness is especially marked in "borderline" or "complex" situations, where the 12-lead ECG cannot provide a clear answer. It corresponds to the concept of "computer-assisted ECG interpretation" as opposed to "computer ECG analysis".

Implementation of the Louvain program for exercise ECG analysis on a microprocessor system.

Several years ago we developed a computer system for the processing of exercise ECGs: the Louvain program for exercise ECG analysis which runs on a minicomputer "Modcomp Classic" and processes XYZ data remotely collected on digital cartridge at the exercise room. This off-line batch procedure is time consuming for the technician (reading of cartridge), but theoretically could be fast. Our experience shows that the results of the exercise test are provided to the referring physician from one day to one week after the procedure because of delays at different levels. The implementation of the programs in a stand-alone unit can produce the results one minute after the end of the test. This solution obviously is more satisfactory for routine clinical testing.

The normal pediatric Frank orthogonal electrocardiogram: variations according to age and sex.

Quantitative computerized analysis of QRS and ST-T parameters of the Frank orthogonal electrocardiogram and vectorcardiogram was undertaken in a large series of 1317 normal infants, children and adolescents stratified according to age and sex. This study confirms the influence of these two constitutional variables, age and sex, over the normal VCG in the whole time span between birth and late adolescence. As children mature, the mid-portion of the spatial QRS loop shifts leftward and posteriorly with relatively little change in the initial and terminal vectors. The spatial T loop shifts anteriorly but at a different rate in males and in females. Unidirectional changes in many amplitude parameters are observed until age 19 in males whereas in females these changes stop earlier or even show a reverse trend around puberty, leading to more important differences between adolescent males and females. Sex-related differences are the most marked for parameters representing the repolarization process. Infants under six months of age form a distinct group with larger dispersions and more disparate variations in the values of vectorcardiographic parameters than in older children. In the newborn period larger sample size might be necessary in order to reduce the normal ranges of vectorcardiographic parameters.

The normal pediatric Frank orthogonal electrocardiogram: influence of weight, height and chest circumference.

The influence of body weight, height and chest circumference on the pediatric Frank vectorcardiogram (VCG) was investigated in a population of 1317 normal infants, children and adolescents. Simple linear regression analysis showed that 94, 96 and 57 VCG variables were significantly correlated with weight, height and chest circumference, respectively. These numbers were reduced to 10, 18 and 6 VCG variables after a stepwise multiple correlation analysis. The relationship between the VCG and the somatic variables was also studied in ten different age/sex subgroups. Simple regression analysis showed a residual significant correlation between the VCG and all three somatic variables in each group. The multiple correlation analysis allowed us to define a minimum set of VCG variables, from one to six, which could explain all the variation produced by the somatic variables. The coefficient of multiple correlation between VCG and weight was the highest in babies 0 to 6 months old (R = 0.73). For height, the strongest correlation was found in females two to five years old (R = 0.76). In subjects older than two years of age, the correlation between chest circumference and VCG (R = 0.30 to 0.69) was weaker than between VCG and pediatric VCG after stratification for age and sex, especially in the youngest groups.

Dispersion of ventricular repolarization in dilated cardiomyopathy.

OBJECTIVE: Increased dispersion of ventricular repolarization has been shown to be a marker for increased risk of ventricular tachyarrhythmias in various cardiac disorders. The present study is aimed at comparing the values of four dispersion indices in four clinical groups: normal subjects (n = 23), patients with intraventricular conduction defects (QRS > 0.12 s) without underlying cardiac disease (n = 30), patients with dilated cardiomyopathy (n = 36), and patients with both dilated cardiomyopathy and ventricular conduction defects (n = 18). METHODS: On an averaged cycle from a 10 s record of 15 simultaneous leads (12-lead ECG and XYZ leads), and after interactive editing, four intervals were computed: JTapex, JTend, QTapex and QTend. For each interval, the dispersion is defined as the difference between the maximal and minimal values across the 15 leads. RESULTS: The mean values of all four dispersion indices were significantly smaller in the normal group than in the three other groups (P < 0.001). Among patients with dilated cardiomyopathy, those with intraventricular conduction defects had significantly higher dispersion values than those without, even disregarding the QRS duration (P < 0.01). Thus, patients with both dilated cardiomyopathy and ventricular conduction defects have larger dispersion values than patients with ventricular conduction defects alone (P < 0.01) and than those with dilated cardiomyopathy without intraventricular conduction defects. CONCLUSION: Dispersion of ventricular repolarization is increased in patients with dilated cardiomyopathy, especially in those with ventricular conduction defects, suggesting that they are at higher risk of arrhythmic events.

Dispersion of ventricular repolarization in hypertrophic cardiomyopathy.

On an averaged QRS-T cycle from a 15-lead record (12-lead electrocardiogram + XYZ leads) and through interactive editing, four electrocardiographic indices of the dispersion of ventricular repolarization (DVR) are automatically computed and represent the maximal interlead difference of QT and JTend and QT and JTapex. The values of these indices were then examined in three clinical groups matched for age and sex: normal subjects (control), patients with left ventricular hypertrophy (LVH group), and patients with hypertrophic cardiomyopathy (HCM group) without ventricular arrhythmias and without interacting drugs. The mean values of all four DVR indices were significantly increased in the HCM group compared with the control group and the LVH group of another origin (ie, for the QTe dispersion index, the mean values and the 97.5th percentiles were, respectively, 65 +/- 18 ms and 97 ms in the HCM group, 41 +/- 25 ms and 79 ms in the LVH group, and 31 +/- 15 ms and 58 ms in the control group). The maximal QT interval was also significantly longer in the HCM group (464 +/- 30 ms) than in the LVH group (436 +/- 32 ms) and the control group (428 +/- 25 ms).

Computer-assisted study of ECG indices of the dispersion of ventricular repolarization.

A new computer-assisted method for the quantitative assessment of the dispersion of ventricular repolarization (DVR) has been developed. Through interactive editing of an averaged QRS-T cycle from a 15-lead electrocardiographic (ECG) record (12-lead ECG + XYZ leads), five ECG indices of DVR are automatically computed: they represent the maximal interlead difference of QT and the intervals from the J point to the T wave end, from the J point to the T wave apex, and from the T wave apex to the T wave end. The standard limits of these indices were then established in six clinical groups, including normal subjects and patients with left ventricular hypertrophy, with myocardial infarction, and with intraventricular conduction defect, all subjects being without ventricular arrhythmias and without interacting drugs. The mean values and percentile ranges of all DVR indices were lower in the normal group than in all pathologic groups. The 97.5th percentiles of the QT end dispersion and the JT end dispersion were, respectively, 65 and 76 ms in normal subjects, 84 and 86 ms in patients with inferior MI; 89 and 100 ms in those with anterior MI; 90 and 98 ms in those with left ventricular hypertrophy; and 94 and 99 ms in those with intraventricular conduction defects. This suggests that increased DVR is associated with the varieties of heart disease represented in this study, even in the absence of ventricular arrhythmias, and also that individual measurements of DVR used as predictors of future arrhythmic events should be referred to the standard range of their own clinical group.

Computer interpretation of pediatric orthogonal electrocardiograms: statistical and deterministic classification methods.

Statistical multivariate and conventional deterministic methods of computerized interpretation of the electrocardiogram (ECG) were compared in the analysis of 1711 pediatric orthogonal ECGs validated by nonelectrocardiographic criteria on the basis of clinical and anatomic diagnoses. Among 642 children catheterized for the evaluation of congenital heart disease, there were 140 patients with left ventricular hypertrophy, 299 with right ventricular hypertrophy, and 203 with biventricular hypertrophy. A group of 1069 obviously healthy school children was studied as a control. The overall accuracy of multigroup ECG diagnosis was 85% and 79% for the statistical and deterministic methods, respectively. The diagnostic performances of both methods expressed in terms of sensitivity and predictive value were the highest for normal children and those with right ventricular hypertrophy and lowest for children with biventricular hypertrophy. The statistical method was more sensitive in the diagnosis of left ventricular hypertrophy (74% vs 64%), right ventricular hypertrophy (86% vs 83%), and biventricular hypertrophy (62% vs 50%). Mutual agreement for a correct diagnosis by the two methods was 83% for normal children and 82% for those with right ventricular hypertrophy but only 61% for children with left ventricular hypertrophy and 39% for those with biventricular hypertrophy. In conclusion, better classification results are obtained with statistical multivariate techniques as compared with conventional deterministic analysis, but both methods of ECG interpretation are complementary and their combination in the same electrocardiographic computer program can improve diagnostic accuracy.