[HOW TO EXPLORE BIPOLARITY IN CHILD PSYCHIATRY: A DIMENSIONAL SEMIOLOGY]. / COMMENT J'EXPLORE... la bipolarité en pédopsychiatrie une sémiologie dimensionnelle.

Despite its high frequency, bipolarity in childhood is little understood and is often diagnosed only after several years of development, and this during a time when the child's psychosocial future is at stake. A proper diagnosis requires recognition of accurate clinical signs. It is therefore essential to furnish clinicians with precise semiological markers. This paper presents a dimensional semiology for use in anamnesis and in clinical observation of the child. These clinical signs enable the identification of a bipolar manic temperament in the child and/or the identification of various different forms of childhood bipolar and depressive disorder. The relevant differential diagnoses and comorbidities are also presented.

[Dual chamber rate responsive pacing and chronotropic insufficiency. Comparison of double and respiratory sensors]. / Stimulation double chambre à fréquence asservie et incompétence chronotrope. Comparaison d'un capteur d'activité, de ventilation et d'un double capteur.

Late responsive DDD pacemakers are the most technically advanced devices presently available. These pacemakers are particularly useful in patients with chronotropic insufficiency when the sinus node is incapable of accelerating during exercise. The latest pacemakers have two sensors to reproduce optimal physiological sinus acceleration. The aim of this study was to analyse the performances of a new rate responsive pacemaker with a double activity and respiratory sensor, the interaction of which is automatically controlled by a sophisticated algorithm, in 12 patients (8 men and 4 women) with a mean age of 75 +/- 7 years. Analysis was based on the performance of the sensors used singly or in association: during three exercise stress tests with measurement of the VO2 max; during everyday activities using the data archived by the pacemaker and the answers to a simplified questionnaire on quality of life. The results showed that during exercise stress testing with measurement of VO2 max, the best performances were obtained with the double sensor or the respiratory sensor compared with the activity sensor alone, suggesting that these two sensors are more effective in intense exercise. This tendency was also observed in the analysis of the memory bank of the pacemaker which showed that the total duration of the faster heart rates was greater with the two sensors. On the other hand, the quality of life was not significantly different, whichever sensor was studied. Longer scale trials are necessary to appreciate the real value of these new double sensor pacing devices and to identify the best indications for their usage.

[Enoximone: hemodynamic effect in patients with cardiac insufficiency]. / Enoximone: effet hémodynamique chez l'insuffisant cardiaque.

Enoximone, a phosphodiesterase inhibitor, is a positive inotropic agent with direct vasodilator properties. Its acute effects after I.V. administration and the possibility of oral relay were studied in 14 patients (13 men and 1 woman), 40 to 78 years of age (mean 61 years) with Stage IV cardiac failure (NYHA Classification). Eleven patients had dilated cardiomyopathy, 2 had ischemic heart disease and 1 a dilated hypertrophic cardiomyopathy. The haemodynamic inclusion criteria were: cardiac index less than or equal to 2.2 l/mn/m2 and pulmonary capillary pressure greater than or equal to 18 mmHg. Patients with cardiogenic shock and severe renal or hepatic failure were excluded. The drug was administered as a bolus of 1 mg/kg followed by a continuous infusion of 5 to 15 g/kg/mn (average 8.9 +/- 2.6 for 7 to 72 hours; average 27 +/- 16 hours). Haemodynamic effects of I.V. administration: no change in heart rate, slight lowering of blood pressure, very significant reduction in right atrial and pulmonary capillary pressures, of pulmonary artery pressures, of arteriolo-capillary and systemic resistances and marked increase in cardiac output. General tolerance was excellent with no clinical secondary effects and no signs of hepatic, renal or haematological (platelets) toxicity. Cardiac tolerance was also excellent, no aggravation of preexisting arrhythmias. There was no immediate mortality. Oral relay was undertaken in 14 patients with a daily dose of 300 mg in 12 cases, 400 mg in 1 case and 500 mg in 1 case. Six patients underwent control haemodynamic evaluation on the 8th day: there were no signs of the haemodynamic improvement obtained by I.V. administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary liposarcoma of the heart.

We report the eleventh illustrated case of primary liposarcoma of the heart in a 28-year-old man. The tumor arose from the mitral valve and the left ventricle and was revealed by a solitary brain metastasis 1 year before. The primary tumor and the metastasis were surgically removed. The cardiac and brain neoplasms were myxoid liposarcoma, as confirmed by histochemical, immunohistochemical, and ultrastructural studies. Although review of the literature points out the poor survival of patients with malignant liposarcoma of the heart, no recurrence or metastasis was observed after a 6-month follow-up.

[Long-term prognosis of spastic angina with normal or irregular coronary arteries. Apropos of 48 cases]. / Pronostic à long terme de l'angor spastique à coronaires normales ou irrégulières. A propos de 48 cas.

Forty-eight consecutive patients (37 men, 11 women, mean age 49 +/- 8 years) were followed up regularly for a mean period of 7 years. All presented with spontaneous angina, documented coronary spasm and no stenosis greater than 50 p. 100 at coronary arteriography. The first attack of pain had taken place 3 days to 9 years previously; exertion angina was also present in 47 p. 100 of the cases and severe arrhythmia in 17 p. 100. Treatment was based on calcium antagonists in doses and combinations that varied with the course of the disease. The follow-up period lasted from 16 to 122 months (mean 85 +/- 24 months). 3 patients are now known to be alive but were lost sight of after 12 to 21 months. Major cardiac complications were 1 death (2 p. 100) and 3 cases of myocardial infarction (6.6 p. 100). None of the patients died suddenly. 70 p. 100 of the remaining 41 patients became asymptomatic; angina persisted in 15 p. 100 and 14 p. 100 had episodes of severe angina but with remissions of at least one year. No predictive factor of functional deterioration or major cardiac complications could be elicited. The long-term prognosis of vasospastic angina in patients with little or no coronary stenosis is favourable, but there is a very small risk of myocardial infarction or death.

Long-term prognosis of medically treated patients with vasospastic angina and no fixed significant coronary atherosclerosis.

The clinical course of 48 consecutive patients with vasospastic angina and minor coronary atherosclerosis (no stenoses greater than 50%) was analyzed during an average follow-up period of 47 months. The study group consisted of 37 men and 11 women. Patients were treated with usual doses of calcium antagonists. One patient died (2%) and three had myocardial infarctions (6%). Seventy-one percent were asymptomatic or had infrequent angina; 13% had recurrences but had periods of remission lasting at least 10 months. Only 16% had persistent angina. None of the clinical or angiographic findings at the time of diagnosis were predictive of myocardial infarction or death, and they could not separate angina-free patients from those with recurrences. Thus, vasospastic angina without fixed coronary narrowing has a good prognosis despite the possibility of recurrences. However, there is a slight risk of myocardial infarction and death. This fact should be considered if there are plans to discontinue treatment.

[Permeability of venous aortocoronary bypasses one year after their implantation]. / Perméabilité des pontages veineux aorto-coronaires un an après leur implantation.

For a short-term evaluation of the patency of aortocoronary bypass vein grafts, 54 consecutive patients who underwent this operation alone were examined, irrespective of their functional state, 12.4 +/- 2.1 months after surgery. Examinations included coronary arteriography, selective opacification of the graft and ventriculography. The patients were 47 men and 7 women who had coronary arteriography for stable angina pectoris (22.4%) or a recent episode of unstable angina (59.3%) or a recent myocardial infarction (18.5%). Coronary arteriography showed one-vessel (5.5%), two-vessel (27.8%) or three-vessel (42.6) disease or stenosis of the main left coronary artery (24.1%). The mean number of distal anastomoses in multiple-vessel patients was 2.6. Peri-operative mortality was 1.04%, and the proportion of peri-operative electrocardiographic signs of necrosis was 11%. At the time of control examination, 82% of the patients had few or no symptoms, and 88% were improved by at least one functional class. 79% (97/123) of distal venous anastomoses were patent. All anastomoses were patent in 59% (22/54) and all were occluded in 7% (4/54) of the patients. Localized stenosis of the graft was found in 11% and diffuse stenosis in 4% of the cases. The patency of vein grafts was higher when the distal bed was of normal size than when it was small or poorly visualized at the initial angiography (85% vs 62%, p less than 0.01), or when the diameter of the artery bypassed was greater than 1.3 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of risk factors in vasospastic angina without significant fixed coronary narrowing to significant fixed coronary narrowing and no vasospastic angina.

To determine the importance of usual risk factors of coronary artery disease (CAD) in patients with coronary artery spasm, 40 patients with vasospastic angina (VA), normal or nearly normal coronary arteries and without previous myocardial infarction were compared with 2 control groups of 40 patients each, matched for age and sex: 1 group with CAD and 1 without heart disease. Ninety percent of patients with VA were cigarette smokers and 70% were heavy smokers (more than 20 cigarettes daily), compared with 53% and 33% in patients with CAD (p less than 0.001) and 30% and 15% in those without heart disease (p less than 0.001). Except for cigarette smoking, the risk factor profile of patients with VA appeared more like the profile of patients without heart disease than that of patients with CAD. The results suggest that cigarette smoking may play a role in CAD independent of atherosclerosis and possibly favoring coronary artery spasm.

Improved exercise tolerance after propranolol, diltiazem or nifedipine in angina pectoris: comparison at 1, 3 and 8 hours and correlation with plasma drug concentration.

Exercise tolerance 1, 3 and 8 hours after 80 mg of propranolol, 120 mg of diltiazem and 20 mg of nifedipine, and after 20 minutes of 0.6 mg of sublingual nitroglycerin were compared with placebo in 15 men who had chronic stable angina pectoris. Three hours after drug ingestion, the exercise time was prolonged by 72 +/- 26, 162 +/- 27 and 161 +/- 30 seconds (p less than 0.05) for propranolol, diltiazem and nifedipine, respectively, and by 123 +/- 35 seconds (p less than 0.001) 20 minutes after sublingual nitroglycerin compared with placebo. The onset of ST-segment depression greater than or equal to 0.1 mV was delayed by 120 +/- 34, 203 +/- 29 and 189 +/- 35 seconds (p less than 0.05) and by 79 +/- 23 seconds (p less than 0.05), respectively. After propranolol, the peak rate-pressure product decreased compared with placebo (15.1 +/- 1.1 U [10(-3)] vs 20.0 +/- 1.5 U, p less than 0.01). In contrast, the peak rate-pressure product was greater after diltiazem and nifedipine than after placebo (22.2 +/- 1.3 U [p less than 0.05] and 23.8 +/- 1.4 U [p less than 0.01]). The maximal increase in exercise tolerance was most marked for each drug at 3 hours, but was also significant at 1 hour for nifedipine and at 8 hours for diltiazem. At 3 hours, an increase in exercise time of more than 2 minutes was observed in 4 of 6 patients who had plasma propranolol concentrations greater than 40 ng/ml, 8 of 9 who had a plasma diltiazem concentration greater than 150 ng/ml, and in 7 of 7 who had a plasma nifedipine concentration greater than 90 ng/ml.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary spasm and thrombosis associated with myocardial infarction in a patient with nearly normal coronary arteries.

A 37-year-old man presented with an evolving inferior myocardial infarction. Coronary angiography performed within 3 hours after the onset of the pain showed spasm of the right coronary artery and the presence of intracoronary thrombi. After resolution of spasm and the disappearance of thrombi, angiography revealed nearly normal coronary arteries. An ergonovine test was positive when the patient was not taking medication and became negative when he was taking diltiazem. The course was uncomplicated, and after 9 months the patient is free of angina.

Comparative diagnostic performance of the Telemed computer ECG program.

One thousand consecutive ECG's from an ambulatory population of patients with suspected or proven cardiac disease were evaluated using two versions of the Telemed computerized ECG system. Only minor differences were found between the two programs. In version 6 vs. version 5, 87% vs. 90% of 287 normal ECG's were correctly classified and 93% vs. 96% of abnormal ECG's were correctly classified; the percent of acceptable diagnostic agreement was 86.2% and 87.4% respectively (NS). The sensitivity for arrhythmia detection, transmural inferior infarction and ST-T wave abnormalities was slightly greater in version 6. The increased sensitivity was not accompanied by decreased specificity. The sensitivity for left ventricular hypertrophy decreased from 95.2% to 91.4% in version 6 with a slight increase in specificity (95.2% to 97.0%). In conclusion, criteria changes in the most recent version of the Telemed program have not resulted in a major change in diagnostic performance. Arrhythmia detection is slightly but not significantly improved.

Beneficial effect of intravenous diltiazem in the acute management of paroxysmal supraventricular tachyarrhythmias.

We tested the effectiveness and safety of i.v. diltiazem in the management of paroxysmal supraventricular tachyarrhythmias in 39 patients, 21 with organic heart disease and seven in heart failure. Fifteen patients presented with supraventricular tachycardia, 12 with atrial fibrillation and 12 with atrial flutter. End points were conversion to sinus rhythm or slowing of the ventricular rate to 100 beats/min or less. Diltiazem was given as an i.v. bolus of either 150 or 300 micrograms/kg over 2 minutes. A second injection was administered to patients who received the lower dose and failed to reach either end point within 30 minutes. The overall success rate was 82% (32 of 39 patients). Time to end point was 5 minutes or less in 20 patients. Conversion to sinus rhythm occurred in 13 of 15 patients (87%) with supraventricular tachycardia and in two of 12 patients with atrial fibrillation. Treatment side effects included a slow ventricular rate in one patient who had a sick sinus syndrome and hypotension in two patients that rapidly responded to fluid administration. We conclude that i.v. diltiazem is effective and well tolerated and advocate its use in the management of paroxysmal supraventricular tachyarrhythmias.

Percutaneous transluminal coronary angioplasty in patients with variant angina.

Among the first 83 patients treated with percutaneous transluminal coronary angioplasty (PTCA) at our institution, typical variant angina was recognized beforehand in five cases and was discovered within 4 months of PTCA in six others. All patients had a 65-95% proximal left anterior descending coronary artery stenosis and only one had a coronary lesion greater than 50% in other coronary arteries. Before PTCA, all patients were premedicated with calcium-antagonist drugs. Thirteen of 15 PTCAs, including three of four repeat PTCAs, were technically successful. However, variant angina recurred after successful PTCA in three of the five patients in whom it was documented beforehand and in an additional two of two patients with variant angina before a successful repeat PTCA. Overall, among the nine patients with variant angina after successful PTCA, five had restenosis at the site of PTCA and two others developed severe lesions adjacent to the site of PTCA within 4 months of the procedure. The three patients without restenosis have been treated with calcium-antagonist drugs from soon after PTCA and have remained angina-free. These results suggest that PTCA is technically feasible in patients with variant angina who have organic lesions, but symptoms due to coronary spasm usually persist or recur, often with restenosis.

Diagnostic accuracy of exercise ECG lead systems in clinical subsets of women.

The diagnostic accuracy of 14-lead exercise electrocardiography was evaluated in 112 women who had no history of myocardial infarction and underwent coronary angiography. The sensitivity of ST-segment displacement of 0.1 mV or more in any of 14 ECG leads was 0.79 for coronary artery stenosis of at least 70%; the specificity was 0.66. Results were similar using bipolar ECG leads CC5 and CM5 or 11 standard ECG leads. The ST-segment shifts that occurred only during exercise were associated with a 77% false-positive rate (10 of 13). Downsloping ST-segment depression did not provide more diagnostic information than horizontal ST-segment depression in the three clinical subsets of women. In women with typical angina pectoris, ST-segment depression of at least 0.15 mV for 0.08 second after the J point or a final treadmill time less than 360 seconds was predictive of proximal left or multivessel coronary artery disease. In the women with probable angina or nonspecific chest pain, this finding was not of diagnostic value. ST-segment elevation of 0.1 mV or more in leads V1-2 or a VL predicted proximal stenosis of at lest 80% in the left anterior descending coronary artery in all six women with typical angina pectoris. Maximal exercise testing in women with typical angina provides important diagnostic information when 11 standard ECG leads are recorded. In women with probable angina or nonspecific chest pain, diagnostic exercise testing is less useful and bipolar leads CC5 and CM5 are sufficient for most clinical purposes.

Exercise testing in patients with variant angina: results, correlation with clinical and angiographic features and prognostic significance.

Eighty-two patients with variant angina underwent a treadmill exercise test using 14 ECG leads, and 67 also underwent exercise thallium-201 scans. The test induced ST elevation in 25 patients (30%), ST depression in 21 (26%) and no ST-segment abnormality in 36 (44%). ST elevation during exercise occurred in the same ECG leads as during spontaneous attacks at rest, and was always associated with a large perfusion defect on the exercise thallium scan. In contrast, exercise-induced ST depression often did not occur in the leads that exhibited ST elevation during episodes at rest. The ST-segment response to exercise did not accurately predict coronary anatomy: Coronary stenoses greater than or equal to 70% were present in 14 of 25 patients (56%) with ST elevation, in 13 of 21 (62%) with ST depression and in 14 of 36 (39%) with no ST-segment abnormality (NS). However, the degree of disease activity did correlate with the result of the exercise test: ST elevation occurred during exercise in 11 of 14 patients who had an average of more than two spontaneous attacks per day, in 12 of 24 who had between two attacks per day and two per week, and in only two of 31 who had fewer than two attacks per week (p less than 0.005). St elevation during exercise was reproducible in five of five patients retested during an active phase of their disease, but not in three of three patients who had been angina-free for at least 1 month before the repeat test. Twelve patients wih exercise-induced ST elevation were retested during treatment with calcium antagonist drugs; in 10 of 12, ST elevation did not occur with the second test. During a mean follow-up of 20.3 +/- 14.5 months, death or myocardial infarction occurred in three of the 25 patients with ST elevation during exercise, none of 21 with ST depression and two of 36 with no ST abnormality. We conclude that in variant angina patients, the results of an exercise test correlate well with the degree of disease activity but not with coronary anatomy, and do not define a high-risk subgroup.

[Value of the automated analysis of the electrocardiogram by the Telemed program (V version)]. / Valeur de la lecture automatisée de l'électrocardiogramme par le programme Télémed (version V).

A series of 1000 12 lead ECGs recorded in 1000 consecutive ambulatory patients were analysed by the Telemed (V Version) programme and its interpretation and the precision of the French translation were compared with the interpretation of two physicians using standard criteria. The computer identified 90% of the 285 ECGs coded as "normal" by the physicians, 69% of the 57 ECGs coded as "borderline" and 96% of the 658 ECGs coded as "abnormal". The computer interpretation was correct in 74% of cases and acceptable in 87,4% of cases. The computer classified 80% of the 240 arrhythmias correctly. Atrial fibrillation was detected in 91% of cases, and ventricular and supraventricular extrasystoles in 88% of cases. The recognition of other arrhythmias was not as good but the small number of cases did not allow statistical evaluation. The 148 cases of axis deviation and 98% of ventricular conduction defects were identified. The programme detected 84% of transmural infarcts, the sensitivity being greater for anterior or lateral than inferior infarctions. The majority of undiagnosed infarcts were "possibles" according to the criteria of the Minnesota Code. Of 536 ECGs with ST-T segment abnormalities, 81% were classified correctly; ST depression of less than 0.5 mm comprised the majority of false negatives. The sensitivity of the programme to left ventricular hypertrophy was excellent (95%) with a specificity of only 92,5% as the programme uses the Romhilt-Estes criteria which are more liberal than those of the Minnesota Code. The comparison of the sensitivity and specificity for the commonest ECG changes showed excellent all round diagnostic performance of the Telemed programme. In conclusion, despite the large number of abnormal ECGs, the level of computer-physician concordance was high. The French translation of the V Version of the Telemed programme is therefore suitable for clinical use Nevertheless, the computer interpretation should still be checked by a physician.