[Use of the CAGE questionnaire for detecting alcohol use disorders in the emergency room]. / Emprego do questionário CAGE para detecção de transtornos de uso de álcool em pronto-socorro.

BACKGROUND: Alcoholism is seldom detected among emergency room outpatients, which is attributed to the non-adoption of diagnostic routines, to the difficulty of doing a special anamnesis for diagnosing alcoholism, and to the lack of sensitivity and specificity of the laboratory tests. This study has the purpose to determine whether the CAGE assay (composed by 4 questions of easy memorization) is able to supply this difficulty in detecting alcoholism. MATERIAL AND METHODS: We did a transversal study with consecutive sampling among outpatients of the Internal Medicine Department at Cajuru University Hospital emergency room. They were submitted to a standardized interview constituted by the CAGE and the CIDI assays (Composite International Diagnostic Interview, "demographics" and "disorders resulting from the use of alcohol" sections). From the sample obtained (n=374), we correlated the prevalence of alcoholism according to both questionnaires, considering the CIDI (DSM-IV criteria) to be the gold standard. RESULTS: The prevalence of alcohol dependence according to the DSM-IV criteria was 15.77%. We verified that the CAGE has 84.74% of sensitivity and 73.33% of specificity, with a cut point of 2 positive responses. CONCLUSIONS: We concluded that the CAGE is an instrument of easy application and good sensitivity and specificity when used at the emergency room, being able to supply the difficulties of alcoholism detection. We suggest that the CAGE be adapted as a routine at emergency rooms, increasing the alcoholism detection rate.

Emprego do questionário CAGE para detecçäo de transtornos de uso de álcool em pronto-socorro / Use of the CAGE questionnaire for detecting alcohol use disorders at the emergency room

OBJETIVO: Determinar se o questionário CAGE (composto por quatro perguntas de fácil memorizaçäo) é capaz de suprir a dificuldade de detecçäo do alcoolismo. MATERIAL E METODO: Realizamos um estudo transversal com amostragem consecutiva em pacientes da Clínica Médica do pronto-socorro do Hospital Universitário Cajuru, os quais foram submetidos a uma entrevista padronizada constituída pelo questionário CAGE e pelo CIDI (Composite International Diagnostic Interview, seções "demografia" e "desordens resultantes do uso de ßlcool"). Da amostra obtida (n=374), correlacionamos a prevalência de alcoolismo segundo ambos os questionários, considerando o CIDI (critérios do DSM-IV) como sendo o padräo-ouro. RESULTADOS: A prevalência de dependência de álcool segundo os critérios do DSM-IV foi de 15,77 por cento. Nós verificamos que o CAGE possui sensibilidade igual a 84,74 por cento e especificidade igual a 73,33 por cento para um ponto de corte igual a duas respostas afirmativas. Conclusöes: Concluímos que o questionário CAGE é um instrumento de fácil aplicaçäo e boa sensibilidade e especificidade quando usado no ambiente de pronto-socorro, podendo suprir as dificuldades de detecçäo do alcoolismo. Sugerimos que o questionário CAGE seja adotado como rotina no pronto-socorro, permitindo que o Ýndice de detecçäo de alcoolismo aumente

Detection of atrial septal defect with left-to-right shunt by inferior vena cava contrast echocardiography.

Contrast echocardiography was used before cardiac catheterisation in 37 patients with atrial septal defect and a left-to-right shunt and in 18 patients with a raised right atrial and ventricular pressure to assess the contrast echo effect in the inferior vena cava. Using two dimensional contrast apical echocardiography we found a negative contrast echo effect within the right atrium in many but not all patients with atrial defect. Contrast echoes entering the inferior vena cava during presystole or early to mid-diastole were detected in patients with heart disease causing raised right atrial and ventricular pressures and also in all patients with atrial septal defect. No contrast echo effect in the inferior vena cava was detected in 10 normal subjects. The sensitivity of this contrast pattern in the inferior vena cava in diagnosing atrial septal defect was 100%. When other conditions causing raised right atrial pressure were excluded, the specificity and predictive accuracy were 100% for both. The presystolic contrast echo effect in the inferior vena cava, semiquantitatively graded, correlated with the size of the shunt determined by oximetry. In 20 patients re-examined after the surgical correction of the atrial septal defect, no presystolic contrast echo effect was detected in the inferior vena cava. Contrast echocardiography of the inferior vena cava is a valuable and reliable method for diagnosing atrial septal defect with left-to-right shunt.

Reliability of subcostal TD echocardiography to detect atrial septal defect.

Echocardiography was used in 40 patients with atrial septal defect (ASD), diagnosed by cardiac catheterization. A dilated right ventricle and abnormal interventricular septal motion were observed at M-mode echocardiography in patients with large L-R shunt. The two-dimensional apical four chamber view was reliable to detect the ostium primum type but not the secundum type of ASD. Moreover the presence of false positives reduced the specificity and predictivity of this approach. The two-dimensional subcostal view provided a direct visualization of the interatrial communication (sensitivity, specificity and predictivity = 100%) and whether the defect was in the uppermost, lowermost or midportion of the septum. Subcostal two-dimensional echocardiography is considered valuable and reliable technique to detect atrial septal defect and the type of the defect itself.

Contrast echocardiographic features of pulmonary hypertension and regurgitation.

Linear contrast echo configuration on the pulmonary valve M-mode echogram was assessed in 28 patients with pulmonary hypertension, in 10 with pulmonary regurgitation, and in 10 normal subjects. Contrast echo parallel lines filling the total systolic phase of the pulmonary valve were recorded in normal subjects. Contrast echo lines stopping in early systole around the pulmonary valve mid-systolic notch were seen in all the patients with pulmonary hypertension in relation to changes with the pulmonary flow. Contrast echo lines reversing the early diastole and crossing the pulmonary valve echogram during diastole were detected in all the patients with pulmonary regurgitation, consistent with the reversed flow across the valve. The use of contrast echocardiography to diagnose both pulmonary hypertension and regurgitation may provide further useful information, particularly when the orientation and time of appearance of the contrast echo lines are related to the systolic and/or diastolic phases of the pulmonary valve M-mode echogram.

Subxiphoid echocardiographic assessment of left ventricular wall in old myocardial infarction.

We studied by cineangiography and standard and subxiphoid echocardiography the left ventricular wall motion in 50 patients with old myocardial infarction and 10 normal subjects. Coronary artery angiography showed a good correlation with the electrocardiographic site of infarction and with the asynergic areas detected by cineventriculographic examination and bidimensional echocardiography. From the correlation of data related to the asynergic areas detected by angiographic and echocardiographic methods it was possible to establish that subxiphoid approach allows to visualize the posterior-lateral wall whereas the parasternal approach the posterior-inferior wall of the left ventricle. Two-dimensional echocardiography from the subxiphoid approach resulted to be a useful and reliable technique for detecting the apical asynergies. The left ventricular wall motion parameters detected by M-mode echocardiography showed significant modifications in all the groups either in the comparison SUBX versus ST or in that with the control group. The subxiphoid approach either M-mode or bidimensional was, therefore, useful in the evaluation of the asynergic areas of the left ventricular lateral wall. The association of SUBX with ST provides further information on the left ventricular wall motion and then, since different areas are visualized with the two techniques, on the extent of myocardial damage.

Contrast echocardiography of the inferior vena cava.

M-mode and two-dimensional subcostal contrast echocardiography were used in 67 patients and 10 normal subjects to evaluate the contrast echo effect on the inferior vena cava echogram in relation to the cardiac cycle and respiratory events. No contrast echoes were recorded in the inferior vena cava in normals during normal breathing. Contrast echoes were recorded entering the inferior vena cava in systole in 20 patients with tricuspid regurgitation and in pre-systole in patients with atrial septal defect and left-to-right shunt and in some of the patients with elevated right atrial and ventricular end-diastolic pressure. Forced inspiration increased the contrast echo effect and determined the penetration of microbubbles into the inferior vena cava. This latter feature occurred in all the patients and only in 1 normal subject. The entry of the contrast echoes into the inferior vena cava was attributed to the high right atrial ventricular end-diastolic pressure and to the reversed flow, from the right ventricle to the right atrium and inferior vena cava in tricuspid regurgitation and from the left atrium to the inferior vena cava in atrial septal defect. The contrast echocardiographic diagnosis of tricuspid regurgitation appeared to be most reliable. New encouraging results were obtained by this technique in diagnosing atrial septal defect and left-to-right shunt. The first appearance of the contrast, the time of appearance in relation to the cardiac cycle and the direction of the to and fro motion of contrast echoes were the most important factors considered for a correct diagnosis.

[Observations on the sequence of endocardial activation in the left ventricle of the normal subject]. / Osservazioni sulla sequenza d'attivazione endocardica nel ventricolo sinistro del soggetto normale.

To obtain information on normal left ventricular activation, endocardial recordings with an electrode catheter were made a seven left ventricular sites in ten patients undergoing diagnostic heart catheterization. All the patients had: 1) sinus rhythm; 2) normal duration and shape of the QRS complex of left chest leads; 3) normal left ventriculography, i.e. normal volume and contractility of the left ventricle. The earliest left ventricular endocardial activation was recorded at septal and/or posterior level, i.e. at the septum (6 to 16 msec, average 9.7 msec, after the onset of intracardiac QRS complex) in seven patients; at the posterior wall (0 to 4 msec, average 2.6 msec, after the onset of intracardiac QRS complex) in three patients (in one of these, the earliest activation occurred at the posterior wall and apex simulaneously). If the earliest activation occurred at the left interventricular septum, the next excited point was found on the posterior wall or at the apex, and vice versa. The latest part to be activated was on the lateral free wall in seven patients; on the posterior wall in two patients; at the apex in the last one.

[Swallowing-induced supraventricular tachycardias in an asymptomatic young man (author's transl)]. / Tachicardie sopraventricolari da deglutizione in un giovane asintomatico.

Three patterns of swallowing-induced supraventricular tachycardia in an asymptomatic young man are described. The patient had no esophageal disease. The electrophysiologic mechanism of arrhythmias remains speculative. Vagal stimulation produced by swallowing appears to cause tachcardias because atropine (1,5 mg iv) prevents their occurrrence.

[The Italian experience in permanent pacing. A casuistry for more of 10 years: a policentric study (author's transl)]. / L'esperienza italiana con l'elettrostimolazione permanente a lungo termine. Casistica in trattamento da oltre 10 anni: studio policentrico.

According to a recent national survey, 387 patients were treated by permanent pacing in 10 Italian centers, between 1961 and 1966. Of these patients 205 have died; 131 (77 males and 54 females) are still alive and no informations could be obtained for the remaining 51 (13%). The overall survival of patients treated during this period of time is therefore not less than 34% which is comparable to that of general population of the same age group. The 131 patients still alive have totaled 1,486 years of pacing and have used up to 784 pacers. Comparing the incidence of the most common causes for replacement during the periods 1961-66 and 1973-77, electrode failures dropped from 21 to 0.9%; circuitry malfunctions occurred in 10.5 and 7.8%; battery depletion rose from 36.8 to 69% of the cases. According to their clinical conditions, the 131 patients on long-term follow-up can be grouped as follows: 62% are in class 1 or 2 of NYHA; 26.7% are in class 3, and 3.8% in class 4. Moreover, 53.4% of patients are living an active life, having some sort of occupation and 29% are holding a driving license.

[Electrophysiological evaluation of ventricular tachycardia by right and left ventricle endocardial mapping (author's transl)]. / Rilievi elettrofisiologici nelle tachicardie ventricolari con il mappaggio endoventricolare destro e sinistro.

Eight patients with ventricular tachycardia (VT) have been studied by unipolar recordings of 7 endocardial points of the left ventricle (LV) and 6 endocardial points of the right ventricle (RV) in order to record if possible: 1) where the VT arose; 2) a continuous electrical activity during the sistodiastolic phase of the intracardiac ECG [late potentials (LP)], suggesting the reciprocating mechanism of VT. All the patients underwent cardiac catheterization with left and/or right ventriculography. A coronary arteriography was performed in four cases. Four patients had no evidence of heart disease; one patient had aortic stenosis; one patient had two vessels coronary disease and extensive ipo-akinesis of the LV; two patients had dyskinetic areas of the RV. In all the cases it was possible to identify where the VT arose by means of recordings during spontaneous VT episodes (the sites of origin of the VTs were stated in the points where the intracardiac QRS began with an intrinsic deflection), or by means of asyncronous ventricular stimulation (the sites of origin of the VTs were stated in the points where the ventricular stimulation reproduced a surface ECG similar to the one recorded during spontaneous VT). The fact that the site of origin of the VT is never in the same point of the earliest endocardial activation during sinus rhythm and the fact that this site is located in a zone with rich terminations of the conduction system, suggest the reciprocating VT may develop in a circuit, with both conduction and myocardial tissue.

[The endocardial ventricular activation map in a case of intermittent BBS in phase III (author's transl)]. / Mappa dell'attivazione ventricolare endocardica in un caso di blocco di branca sinistra (BBS) intermittente (BBS in fase 3).

To obtain information on endocardial activation-sequence, unipolar recordings at seven left ventricular and six right ventricular points were performed in a 37-year-old man suffering from cardiomyopathy and tachycardia-dependent left bundle branch block (LBBB). Results were as follows: 1) the recovery time was longer in anterior than in posterior portion of left bundle branch fibers; 2) an high posterior left ventricular point was directly activated via posterior left bundle branch fibers; 3) the directly activated left ventricular zone was too small and relatively too late excited in respect of the right interventricular septum, from which the stimulus reached the left septum, to mask the LBBB electrocardiographic pattern; 4) in the presence of tachycardia-dependent LBBB the duration of left ventricular endocardial activation was about twice (62 msec) that found in the absence of tachycardia-dependent LBBB (28 msec).