Association of malignant insulinoma and type 2 diabetes mellitus: a case report.

We report a case of recurrent hypoglycemia due to malignant insulinoma in a type 2 diabetic patient correctly controlled for years with the same doses of oral antidiabetic agents. A 79-year-old woman was admitted for recurrent severe hypoglycemia. She had a history of type 2 diabetes since 2000. HbA1c was 7.8% when she reported mild hypoglycemia and 5.8% when recurrent hypoglycemia appeared despite progressive diminution of glicazide. Severe hypoglycemia continued despite interrupting diabetes medications. At admission, results showed inappropriately elevated insulin, C-peptide and proinsulin levels despite significant hypoglycemia. CT scan showed "cystic" nodes in the pancreas and in the liver. Liver biopsy found a well-differentiated neuroendocrine carcinoma with positive staining for chromogranin A and negative staining for insulin. Hypoglycemia improved with diazoxide, lanreotide and dextrose infusion. Liver chemoembolization was planned. Severe edema, dyspnea, hyponatremia, and hypo-osmolarity occurred. The patient's clinical status deteriorated rapidly with severe cardiac, renal and hepatic failure. She died in a few days. Association of diabetes mellitus and insulinoma is extremely rare. Malignant insulinoma survival is less than two years, shorter when hepatic localizations are present at diagnosis. Association of diabetes with insulinoma delays the diagnosis, but does not alter prognosis or favor carcinoma frequency. Lanreotide was inefficient in our patient despite good responses described in the literature. Heart, respiratory and renal failures have been described with diazoxide independently of the doses; this may in part explain the rapid death. Insulinoma should be considered as a cause of unusual and recurrent hypoglycemia in a diabetic patient especially if it persists after interrupting antidiabetic agents.

[Hypertrophic obstructive cardiomyopathy in elderly patients. Retrospective study of 23 cases]. / Myocardiopathie hypertrophique et obstructive chez le sujet âgé. Etude rétrospective de 23 observations.

This retrospective study was based on data obtained from 23 patients over 65 years old (72 +/- 1.04 years) with hypertrophic obstructive cardiomyopathy followed up for 3 years (37.2 +/- 5.4 months) in whom the diagnosis was established essentially on phonomechanographic and echocardiographic criteria under basal conditions or during pharmacodynamic stress testing when the initial examination was inconclusive. Under these conditions, diagnostic catheterisation was only required in 9 cases. The incidence of this disease seems to be substantially underestimated in this age group; clinical symptoms and ECG or chest X-ray changes are often attributed to other pathologies if these patients are not thoroughly investigated. In our experience, patients over 65 years represent 20 per cent of the total population of hypertrophic obstructive cardiomyopathy admitted to our Department during the 6 years' study period. Accurate diagnosis is important because of the therapeutic implications; digitalis and vasodilator therapy especially with nitrate derivatives are poorly tolerated by these patients. Betablockers and verapamil seem to be beneficial, judged on the decrease in the number of symptomatic patients when given these drugs. Only one of the 3 deaths observed in the 20 patients followed-up was attributed to cardiac causes, which seems to confirm the lower mortality rate in older patients with this condition.

[Obstructive myocardiopathy in the elderly. A retrospective study of 18 cases]. / Myocardiopathie obstructive chez le sujet âgé. Etude rétrospective de 18 observations.

From a retrospective study of 18 cases of obstructive cardiomyopathy in elderly people collected over a 5-year period, it appears that the incidence of the disease is probably underestimated. It seems to vary in severity, but only one-third of the patients present suggestive clinical symptoms associated with an obvious obstructive syndrome. The best diagnostic method is phonomechanography, which is easy to perform, systematically completed by a pharmaco-dynamic test. Hyperkinesia and disorders of cardiac compliance add useful specific data to the clinical picture. Echocardiography provides information on cardiac anatomy and on the obstructive mechanism. Left ventricular function tests are of particular interest in these old-age patients with cardiopathy. In our opinion, the two non-invasive methods are sufficient for a firm diagnosis, even when some criteria, notably ultrasonic, are lacking. Once the condition is diagnosed, the patient should be put on beta-blockers or calcium inhibitors, such as verapamil, which constitute an effective treatment.

[Left intraventricular thrombosis. From diagnosis to treatment]. / Thrombose intraventriculaire gauche. Du diagnostic au traitement.

Left ventricular thrombi are the source of much concern in numerous conditions affecting the ventricles. Refinement in echocardiographic and isotopic techniques is enabling earlier diagnosis and a more rational approach to therapy. These thrombi occur very frequently, and are most often asymptomatic (more than 2 to 3 times out of 4), and their natural course is not well known. Recent studies have dealt with acute ischemic cardiopathies, but these should not obscure the fact that thrombi occur with similar frequency in chronic conditions, in particular, hypokinetic cardiomyopathies. Three recent cases emphasize this, demonstrate the frequency of these thrombi, and help illustrate available diagnostic methods and a practical approach to this condition. These recent developments only confirm the importance of effective anticoagulation in all patients at risk and the necessity of optimal treatment with inotropic agents which do not suppress thrombus formation, but appear to prevent their complications.

[Emboligenic abscess of the aortic ring disclosing gonococcal endocarditis. Value of echocardiography]. / Abcès emboligène de l'anneau aortique révélateur d'une endocardite à gonocoques. Intérêt de l'échocardiographie.

Echocardiography has become a valuable diagnostic modality in bacterial endocarditis and of even more importance in following the subsequent course of the infection while on medical therapy. It can play an extremely important role in certain clinical circumstances, even before blood culture results are available or hemodynamic or auscultatory abnormalities appear. Nevertheless, in spite of this usefulness, the limitations of echocardiography should be recognized. The examination lacks absolute specificity and sensitivity which could result in inaccurate or delayed information in diagnosing a lesion or in recognizing local or regional complications. These advantages and limitations are well illustrated in an unusual case due to Neisseria gonorrhoeae, a causative agent whose incidence may increase over the years to come.

Mechanocardiography in evaluation of left ventricular function. Relevance of combined study of apex cardiogram and systolic time intervals in diagnosis of cardiomyopathies.

The study of left ventricular performance by means of systolic time intervals, especially represented by the PEP/LVET ratio and indices drawn from the first derivative of the apex cardiogram, makes possible a good approach to the functional anomalies of patients suffering from hypokinetic cardiomyopathies or hyperkinetic conditions of obstructive or unobstructive hypertrophic cardiomyopathies and of patients with hyperthyroid conditions. In hypokinetic states, the sensitivity and the specificity of the PEP/LVET ratio proved to be good, as was the case for indices taken from the first derivative of the apex cardiogram. However, the sensitivity and the specificity of the cardiogram were much better in the detection and evaluation of hyperkinetic conditions, hypertrophic cardiopathies or hyperthyroiditis. By providing the elements required for analysis of isometric contraction through indices drawn from the first derivative of the apex cardiogram and from the ejection phase, through the PEP/LVET ratio, and by adding exploitation of the diastolic phase, in particular through the A/H ratio exploring diastolic compliance, mechanocardiograms allow an all-round, quasi-physiopathological approach to disorders of left ventricular function during cardiomyopathies.

[Phonomechanographic evaluation of left ventricular function in hyperthyroid states]. / Evaluation phonomécanographique de la fonction ventriculaire gauche dans les états hyperthyroïdiens.

Hyperthyroidism is associated with a hyperkinetic syndrome, the mechanisms of which are not fully understood but which include an increase in heart rate, a reduction in systemic arterial resistance and a debatable increase in myocardial contractility. The limitations of radioimmunological assay of the hormonal mediators underline the diagnostic value of an atraumatic method of quantifying left ventricular systolic function. In view of the variable sensitivity of phonomechanographic and echocardiographic indices with respect to changes in heart rate, pre- and after load, we studied apex cardiographic indices during the phase of isovolumetric contraction. Fifty-eight patients with hyperthyroidism but without patent cardiovascular disease were divided into two subgroups: Grave's disease: 38 cases, and toxic adenoma: 22 cases. The results of the measurements of systolic time intervals and the calculation of "indices of contractility" obtained from the apex cardiogram and its first derivative, were compared with those of 36 young, normal subjects. The results show that: the pre-ejection period of the study population was much shorter than normal (65,7 ms +/- 2,5 vs 84,6 ms +/- 3,4; p less than 0,001); this was clearly related to the chronotropic factor (p less than 0,05). The pre-ejection/ejection period ratio did not differentiate hyperthyroid from normal subjects (0,265 vs 0,283, p greater than 0,20), except in Graves' disease (0,249, p less than 0,02). On the other hand, measurements made from the apex cardiogram showed significant differences in both types of hyperthyroidism. (Formula: see text). In conclusion, phonomechanography may be used to quantify the increase in left ventricular function in hyperthyroidism.(ABSTRACT TRUNCATED AT 250 WORDS)

[Semi-automatic acquisition and processing of mechanocardiograms]. / Acquisition et traitement semi-automatique des mécanocardiogrammes.

Like echocardiography and radio-isotope techniques, mechanocardiography has a special place in the evaluation of left ventricular function in heart disease. This recognized technique can be easily performed by clinicians or pharmacologists or in aerospace medicine. A programme has been developed from micro-processor material (HP 9845 S - SP 9835 - HP 6940 B multi-programmer) already in use in the department. After sampling at 700 Hz and quantification, this programme can reproduce a complete mechanocardiographic tracing consisting of ECG, phonocardiogram, carotidogram and apexogram . The first derivative of the apex cardiogram is calculated numerically and visualized. The characteristic events of the systolic phase of the apex cardiogram are then checked manually or semi-automatically by the operator. After confirmation, the calculations are performed and are edited with the tracings. This system eliminates the need for a recorder, as the tracings can be stored on cassette or diskette and recalled later for statistical analysis. These programmes make the interpretation of the mechanocardiographic tracings considerably simpler and faster.

[Evaluation of left ventricular function and regional kinetics following myocardial infarction. Comparative study of angiocardiography, echography and radionuclide angiography]. / Evaluation de la fonction ventriculaire gauche et de la cinétique segmentaire dans les suites de l'infarctus du myocarde. Etude comparative entre les données de l'angiocardiographie, de l'échographie et de la scintigraphie cavitaire à l'équilibre.

Left ventricular function and regional wall motion were studied three weeks after a myocardial infarction in 25 patients who had undergone L.V. monoplane cineangiography. The patients were studied by echocardiography (TM and 2D) and radionuclide angiography. Evaluation of global ejection fraction provides evidence of a close correlation between left ventricular angiography and radionuclide examination (r= 0.79). Measurement of ejection fraction by echocardiography (TM) remains clearly correlated with the same evaluation by angiography (r = 0.68). The correlations are markedly increased in the patients without significant wall motion defects (r = 0.87 for radionuclide angiography and r = 0.82 for echographic measurement). Sensitivity in the detection of L.V. aneurysms is excellent with our method of radionuclide examination (12/13) and can be compared with angiography (12/13). Two-dimensional echocardiography performed on a routine basis is less sensitive than radionuclide angiography in this diagnosis (4/13).

[Phonomechanography: a premature requiem]. / Phonomécanographie: un requiem prématuré.

The value of phonomechanographic recordings has been contested in recent years. This seems to be the result of the upsurge in other non-invasive methods of investigating cardiac diseases and left ventricular function such as those based on ultrasound, pulsed Doppler or radioisotopes. Far from opposing these techniques, phonocardiography has benefited from their comparison and association which have validated the systolic time and amplitude indices previously used empirically. This validation justifies maintaining and developing phonomechanographic recordings. Whilst recognising their limits, five of their main advantages are emphasised. As a true extension of our senses and complementary to the human ear phonomechanography is, foremost, the continuation of clinical examination and an unique and ideal instrument for teaching cardiac auscultation. By confirming and explaining the nature of an auscultatory abnormality, recording the morphology and timing of the arterial and venous pulses and of the apex beat, phonomechanography participates in the positive and etiological diagnosis of various conditions and even provides a semiquantitative assessment in some diseases. Left ventricular function may be assessed by measuring the systolic time intervals and by quantifying the systolic apical impulse. This appreciation based on the period of isovolumic contraction is complementary to echocardiographic assessments of LV function which are calculated during the ejection period. Only by combining the various non-invasive methods can the weakness and practical limitations of each particular method be avoided. Finally, as the reliability of systolic time and amplitude indices have been validated, the relative ease of their determination and their economic advantages must be emphasised.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bacterial endocarditis and mitral valve prolapse]. / Endocardite bactérienne et prolapsus valvulaire mitral.

The suspected diagnosis of bacterial endocarditis is based on a presumption. Over the last few years, ultrasound, which can identify valvular lesions and their repercussions, has established itself as a supplementary diagnostic tool in the early stages of this disease. The existence of false negatives should not be underestimated, but one must also be aware of the possibility of false positives. These false positives are mostly due to mitral valve prolapse. An unusual cas serves as an illustration of the potential diagnostic difficulties of this association and confirms the value of the ultrasound examination, provided it is performed under optimal conditions and repeatedly. However, the abnormalities of ventricular kinetics in the course of mitral valve prolapse limit the evaluation of the haemodynamic repercussions of the regurgitation. The authors stress the supplementary contribution of phonomechanographic examinations. In this particular case, they gave an idea of the severity of the mitral leak and of its recent onset and they strongly suggested the integrity of left ventricular function and the presence of major valvular dysplasia.

[Valvular or muscular cause of heart sounds?]. / Origine valvulaire ou musculaire des bruits du coeur?

During the last twenty years, the genesis of the high frequency heart sounds could be outlined in the opposition between "valvular" and "muscular" theories challengers. The latter argued with haemodynamic results and the former with echographic results. The improving investigation methods permitted recently the understanding of valvular closure and authorize conciliation. A valvulo-muscular theory is suggested on the basis of non invasive methods: sound and external pulses recordings, and echography.

[Cardiac sarcoidosis. Mechanisms of valvular dysfunctions]. / Sarcoïdose cardiaque. Mécanismes des dysfonctions valvulaires.

The sudden onset of massive tricuspid insufficiency in a patient with ocular and pulmonary sarcoïdosis diagnosed fifteen years earlier exemplifies the possible occurrence of sarcoid heart disease, an entity often misdiagnosed or overlooked. After excluding pericardial effusion and rhythm disturbances we point out the specific characteristics of endomyocardial involvement and discuss the mechanisms of valvular dysfunction. In this particular localization, the possibly deleterious effect of steroid therapy is mentioned.

[Calcifications of the mitral annulus mimicking rheumatic mitral valve disease. A case]. / Calcifications de l'anneau mitral simulant une maladie mitrale rhumatismale. Une observation.

Long neglected, the significance of mitral annulus calcification had now been re-evaluated with the help of echocardiography. An unusual case with clinical symptoms mimicking rheumatic mitral valve disease has enabled the authors to discuss the acoustic manifestations of this entity, its evolutive potential and its causative factors. It is concluded that mitral annulus calcification should no longer be considered as a benign feature of the ageing heart.