Status report on standard-setting work in the area of environmental radioactivity measurement.

Environmental assessment studies are regularly commissioned to study the impact of radioactive substances on the environment and the public, in response to concern about the presence of such substances. The credibility of such studies relies on the quality and reliability of radionuclide analysis as well as the sample representativity of the radiological situation. The recent expansion from national stakeholders to those involving other states requires that activity measured in effluents or environmental samples in a country are reliable and reproducible so as to be accepted by all states potentially concerned by regional contamination. The standard-setting approach, based on consensus, seemed to lend itself to a settlement of technical aspects of potential dispute. This document describes standardization organizations, French and international, the standards published, as well as standardization work under way on the measurement of radionuclides found in environmental matrices.

Plasma and erythrocyte manganese concentrations. Influence of age and acute myocardial infarction.

This study was carried out to assess manganese (Mn) status after an acute episode of myocardial infarction. Plasma and erythrocyte Mn concentrations were measured from admission to hospital to day 15 postadmission in 21 patients suffering from acute myocardial infarction and in three control groups. The determination of Mn in these biological fluids was performed by electrothermal atomic absorption spectrometry. Plasma Mn was higher (p < 0.01) and erythrocyte Mn was similar in the acute myocardial infarction group compared to healthy age-matched control group. Plasma and erythrocyte Mn remained unchanged during the 2 wk after acute myocardial infarction and were not correlated to enzyme activities. A decrease of erythrocyte Mn with age, expressed in nmol/L, was noted (p < 0.02). These results suggest that plasma and erythrocyte Mn do not provide an indication of myocardial damage. Nonetheless, Mn status in elderly merits further attention.

Longitudinal changes in serum zinc concentration and distribution after acute myocardial infarction.

The authors studied the changes in serum zinc concentration and distribution during the 15 days following acute myocardial infarction in 21 patients. The method is based on ultrafiltration and electrothermal atomic absorption spectrometry. It is rapid and needs only 2.5 ml of serum. Serum and erythrocyte copper and zinc, serum zinc-binding ligands and serum enzyme activities were also determined. Serum zinc (P < 0.00001) and exchangeable zinc (mainly albumin-bound zinc, P = 0.01) declined within the first 3 days and then returned gradually to reference ranges. Exchangeable zinc was correlated with transthyretin (P = 0.00001) and total serum zinc (P < 0.00001). Exchangeable zinc accounted for virtually all of the differences in total serum zinc concentration after myocardial infarction. This result could be related to an increase of zinc uptake by tissues. Therefore, studies are needed to evaluate whether zinc supplementation in the early stages of acute myocardial infarction might improve prognosis.

[Influence of the sclerosing of esophageal varices on portal pressure and azygos venous blood flow]. / Influence de la sclérose des varices oesophagiennes sur la pression portale et le débit veineux azygos.

Endoscopic sclerotherapy is widely employed for esophageal variceal hemorrhage. However it has side effects and can aggravate portal hypertension by suppression of portosystemic shunt. The purpose of the present investigation was to study the effect of variceal thrombosis on hepatic venous pressure gradient and azygos blood flow. Eight alcoholic cirrhotic patients with a first variceal hemorrhage were included. According to Child Pugh's classification, 4 patients were group A, 2 group B and 2 group C. At each session 40 to 60 ml of 1 p. 100 polidocanol were injected into the varices. A hemodynamic study was performed in each patient before and about one week after variceal obliteration (mean 3.3 procedures). Mean value of hepatic venous pressure gradient was 16.6 +/- 5.5 mm Hg and 17.0 +/- 3.8, respectively, before sclerotherapy and after eradication of varices; azygos blood flow 663 +/- 506 ml/mn before and 682 +/- 522 after; cardiac, output was 6.5 +/- 0.7 ml/min before and 6.5 +/- 0.8 after. None of these differences were significant. These results suggest that endoscopic sclerotherapy using polidocanol does not change hepatic venous pressure gradient and azygos blood flow, and does not lower blood flow through the gastroesophageal collaterals draining into the azygos vein. This is consistent with the hypothesis that thrombosis remains localized.

[Value of magnetic resonance imaging in a lipoma of the left ventricle]. / Intérêt de l'imagerie par résonance magnétique au cours d'un lipome du ventricule gauche.

A patient with benign left ventricular lipoma was explored pre- and post-operatively with echocardiography, computerized tomography (CT) and magnetic resonance imaging (MRI). With MRI spin-echo sequences the lipoma emitted a bright signal similar to that of normal fatty tissue on the two echoes of the sequence (28 ms and 65 ms). MRI was not better than CT to demonstrate that the tumour was a lipoma, but it proved to be the best technique to obtain information on tumoral spread to the myocardium and pericardium, and it showed the intracavitary extension without the need for contrast medium injection. After surgery, MRI displayed the remains of a septal lipomatous lesion. This case underlines the usefulness of MRI for the evaluation of cardiac tumours, and particularly lipomas.

[Magnetic resonance imaging in dissection of the aorta]. / Imagerie par résonance magnétique au cours des dissections de l'aorte.

In order to evaluate the usefulness of this new exploratory method in dissection of the aorta, 13 patients (10 men and 3 women, mean age 58 +/- 14 years) were examined by means of an 0.5 Tesla Magniscan 5000 nuclear magnetic resonance machine. Fifteen examinations were performed: 5 in patients with actual aortic dissection (type A 4 including one acute, type B1), 5 in patients previously operated upon for type A dissection and 5 for suspected acute aortic dissection unconfirmed by other examinations. Magnetic resonance imaging (MRI), synchronized with electrocardiography, was carried out using spin-echo techniques with 1 to 3 echoes and multiple contiguous sections along several planes. In the 5 patients with actual dissection the 2 channels separating the membrane could be demonstrated, thus providing a firm diagnosis (MRI proved superior to angiography in 2/5 patients). All 5 patients could be classified as either type A or type B. Extension to the cervical vessels was observed in 3 cases and the portal of entry was seen in one case, but the origin of the coronary arteries was never visualized. In the 5 patients previously operated upon MRI provided detailed analysis of the prosthesis of the supra-coronary ascending aorta implanted in all cases, of the aorta proximal and distal to that segment and of the periaortic mediastinum. By studying the signal from the false channel distal to the prosthesis information was obtained as to the presence in it (2 patients) or absence of circulating blood.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cost/efficacy ratio in the diagnosis of coronary disease. Bayes' analysis by computer: respective role of the exercise test, isotopic methods and coronarography]. / Rapport efficacité/coût du diagnostic de la maladie coronarienne. Analyse bayesienne sur ordinateur: place respective de l'épreuve d'effort, des méthodes isotopiques et de la coronarographie.

UNLABELLED: Between January 1983 and May 1984, 104 patients with no known cardiac pathology were referred by their cardiologist for diagnosis of chest pain. They all underwent coronary angiography which was used as the reference investigation and the following sequential Bayes' analysis was performed. The percentage probability of coronary artery disease was estimated from clinical date (age, sex, characteristics of the chest pain subdivided into 3 groups); an exercise ECG was performed in all cases (classified as positive, negative or non diagnostic); if the probability of coronary artery disease was greater than 95% (or less than 5%) after exercise stress testing the patients was diagnosed as having (or not having) coronary artery disease. If the probability was between 6 and 94% the patient underwent Thallium myocardial scintigraphy (Thallium dipyridamole; analysis on a colour television screen); the coronary risk probability before Thallium was that calculated after exercise stress testing. If after myocardial scintigraphy the coronary risk remained between 6 and 94%, an exercise angioscintigraphy was performed and interpreted in the same way. The clinical and complementary date was analysed on a mini-computer, the values of the sensitivity and specificity of the tests used for the calculation of the probability of coronary artery disease were those previously published by our group. RESULTS: 31/88 (35%) of patients were classified in the 5% risk groups after exercise stress testing (24 coronary artery disease; 7 normals: no errors of classification). Fifty six out of the 88 patients (65%) were classified in the 5% risk group after myocardial scintigraphy (42 patients with coronary artery disease with 41 abnormal coronary angiographies and 14 normal patients, all of whom had normal coronary angiographies; this represents a 1.8% divergence of classification compared with coronary angiography). Angioscintigraphy only classified 3 of the remaining patients, one wrongly, and did not seem to be useful diagnostically as a third-line investigation after Thallium scintigraphy or as a second-line investigation instead of Thallium scintigraphy. This strategy is less costly than carrying out coronary angiography systematically in these patients: if diagnostic coronary angiography is performed alone in patients with a risk of 6 to 94% the cost is 4 800 FF vs 10 400 FF per patient; if coronary angiography is performed in all patients in whom coronary artery disease is possible or certain (all patients with a risk of over 5%), the cost is 8 400 FF vs 10 400 FF per patient, a saving of 20%.(ABSTRACT TRUNCATED AT 400 WORDS)

[Prospective study of the value of echocardiography and myocardial scintigraphy with Tc 99m pyrophosphate during the acute stage of right ventricular infarction]. / Etude prospective de l'intérêt de l'échocardiographie et de la scintigraphie myocardique au 99m Tc pyrophosphate au stade aigu de l'infarctus du ventricule droit.

The aim of this study was to compare the clinical values of 99mTc pyrophosphate scintigraphy and M mode and 2D echography in the diagnosis of right ventricular infarction and in the predicting of some of its complications. Fifty-two patients were prospectively studied by echocardiography and scintigraphy at the acute stage of inferior wall infarction. Scintigraphy was performed in the antero-posterior and 45 degrees left anterior oblique incidences during the first 3 days of infarction. Right ventricular infarction was diagnosed if the right ventricular fixation was separated from the left ventricle by fixation at the base of the septum. Echocardiography was performed at an early stage by the usual 3 incidence. Dilatation of the right ventricle on the parasternal and submitral incidences; abnormal right ventricular contraction was searched for in all the incidences. The following results were obtained: scintigraphy showed a localised fixation allowing a topographic study in 40/52 patients (77%); satisfactory echocardiographic studies were obtained in 46/52 patients (88.5%). Signs of right ventricular infarction: scintigraphy showed signs of necrosis of the right ventricle in 12/40 patients (30%) who had a localised fixation; echocardiography showed dilatation (greater than 25 mm) of the superior part of the right ventricle with a right/left ventricle ratio greater than 0.5 in 16/46 patients (37%) with interpretable studies and obvious abnormalities of right ventricular wall motion in 7 patients (15.2%), less obvious in 10 other patients (22%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Topographic diagnosis of true posterior infarction. Comparison of the vectorcardiogram and myocardial scintigraphy]. / Diagnostic topographique de l'infarctus postérieur vrai. Comparaison du vectocardiogramme et des scintigraphies myocardiques.

The aims of this comparative study by vectorcardiography and myocardial scintigraphy in the topographical analysis of primary inferior and/or posterior wall infarction, were: to obtain data confirming the value of identifying true posterior wall infarction; to confirm the diagnostic value of vectorcardiography in this condition. The patients in this retrospective study were admitted to hospital for primary inferior and/or posterior wall infarction and underwent vectorcardiography and myocardial scintigraphy either with Thallium 201 (137 patients) or 99m Technetium (88 patients) in the acute phase. The scintigraphies of all patients included showed hypofixation compatible with inferior and/or posterior infarction as this was used as the topographical reference. The results of vectorcardiography and myocardial scintigraphy were concordant in 164 of the 225 patients (72.8%), 18 with true posterior infarction [%), 110 with inferior wall infarction (48.8%) and 36 with postero-inferior wall infarction (16%). The results were discordant in 61 patients (27.1%); infarcts of the inferior or posterior walls according to one technique, were observed on the posterior or inferior walls with the other. The majority of these cases had postero-inferior wall changes on vectorcardiography and inferior wall infarction alone on scintigraphy (35 patients: 15.5%). The specificity of the vectorcardiographic signs of true posterior wall infarction remained satisfactory.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of cardiac failure with refractory edema using extracorporeal ultrafiltration]. / Traitement des insuffisances cardiaques avec oedèmes réfractaires par ultrafiltration extracorporelle.

Thirteen patients with chronic congestive cardiac failure and refractory oedema were treated by haemodialysis. All patients had severe cardiac failure (Class IV NYHA) due to primary myocardial disease (5 cases), ischaemic heart disease (4 cases) or valvular heart disease (4 cases). Haemodialysis was performed via a Shaldon Y-shaped catheter in the internal jugular vein, with input and output through the same catheter using an alternating clamp. Filtration was carried out through a highly permeable membrane by a simple hydrostatic pressure gradient without a dialysis bath. The sessions were monitored haemodynamically by measuring the pulmonary artery pressures. The mean weight loss was 4.9 +/- 0.4 kg obtained after 3 three hour dialysis sessions with 24 hour intervals between each session (mean filtration flow = 12 ml/min). Hypotension was observed in one patient with low initial pulmonary artery pressures; two patients with severe valvular stenosis (1 mitral stenosis; 1 aortic stenosis) failed to lose weight. In the 10 remaining cases, there was a clearcut symptomatic improvement (5 patients Class III; 5 patients Class II NYHA) with total regression of oedema. There was a significant fall in pulmonary artery (mean PAP 40.5 +/- 6.5 mmHg to 34.6 +/- 6.5 mmHg; p less than 0.001) and pulmonary capillary pressure (27.6 +/- 6.9 mmHg to 22.5 +/- 5.8 mmHg; p less than 0.05) in these 10 cases. Cardiac output did not change significantly (cardiac index 2.2 +/- 0.5 l/m2/min compared to 2.3 +/- 0.4 l/m2/min after dialysis).(ABSTRACT TRUNCATED AT 250 WORDS)

[Bilateral coronaro-pulmonary fistula. Apropos of a new case with review of the literature]. / Fistule coronaro-pulmonaire bilatérale. A propos d'un nouveau cas avec revue de la littérature.

Two coronary pulmonary fistulae were demonstrated between the right coronary and left anterior descending arteries and the main pulmonary artery at coronary angiography, in a 66 year old woman with a continuous murmur in the third left intercostal space. This double malformation, though uncommon is not rare (18 previously published cases). It is usually diagnosed late (17 to 76 years) and the presentation is limited in half the cases to a localised continuous murmur, the localisation of which may simulate a patent ductus arteriosus. The hypothesis of a supernumerary coronary artery arising from the main pulmonary artery is suggested by the constancy of the anatomical characteristics of the reported cases. Eight patients presented typical attacks of angina which were due to severe coronary atherosclerosis, affecting two or three main vessels except in one case. Therefore, it is unlikely that these fistulae cause coronary insufficiency by a coronary steal syndrome. However, this mechanism may aggravate symptoms in patients with coronary artery disease and necessitate surgical cure of the fistulae at the same time as coronary bypass surgery. On the other hand, surgery does not seem to be indicated in asymptomatic patients.

[Role of left ventricle angioscintigraphy during exercise in the diagnosis of coronary disease. Comparison of static and dynamic exercise]. / Place de l'angio-scintigraphie cavitaire gauche à l'effort dans le diagnostic de la maladie coronarienne. Comparaison de l'effort statique et de l'effort dynamique.

The aim of this study was to compare the diagnostic value of exercise stress testing, Thallium 201 myocardial scintigraphy or after administration of dipyridamole and left ventricular angioscintigraphy performed either during a static (handgrip) or dynamic exercise (bicycle ergometry) for the positive diagnosis of stenosing coronary artery disease. The exercise angioscintigraphy was performed at equilibrium with 99m Tc red blood cell labelling. The global ejection fraction and that of seven radial segments of the left ventricle were measured, the data being recorded within a period of 2 minutes. The handgrip consisted in compressing a dynamometric ball at 1/3 maximal force for 3 minutes, with both hands; the ergometric exercise was increased by 30 Watt 2 minute increments until a positive ECG or 85% of the theoretical maximal heart rate for age was obtained. Normal subjects (n = 29) increased their global (+ 8%) and regional ejection fractions in each of the seven segments (p less than 0.05) during ergometric exercise: there was no significant change of global (-3% NS) or segmental ejection fractions during the handgrip exercise. In the coronary group (at least one greater than 70% stenosis) (n = 61) the fall in global ejection fraction was the same (-14%) with both forms of exercise; a similar fall in the segmental ejection fraction in the territory distal to the stenosis was observed with the handgrip (-22%) and bicycle ergometry (-28% NS). Dynamic exercise testing seemed superior to handgrip exercise. Therefore, the finding of an abnormal global ejection fraction on exercise (i.e. either a global ejection fraction less than the lower limit of normal on exercise, or lower than the global ejection fraction at rest), or of an abnormal regional ejection fraction (i.e. either a regional ejection fraction less than the lower limit of normal over at least 3 segments, or a regional ejection fraction on exercise lower than the regional ejection fraction at rest over at least 3 segments) detected coronary artery disease with a sensitivity of 94% and a specificity of 72%. Dynamic exercise angiography seemed to be more sensitive than maximal ECG stress testing (94% compared to 64%) more rapidly positive (p less than 0.05), as sensitive (94% compared to 83% NS) than Thallium myocardial scintigraphy, but less specific (72% compared to 90%, p less than 0.05), and as unspecific as ECG stress testing.(ABSTRACT TRUNCATED AT 400 WORDS)

[Aortic and tricuspid valve involvement caused by myxoid degeneration associated with a severe mitral prolapse. Apropos of 2 patients undergoing a double valve replacement]. / Atteintes valvulaires aortique et tricuspidienne par dégénérescence myxoïde associées au prolapsus mitral grave. A propos de 2 patients ayant bénéficié d'un double remplacement valvulaire.

Idiopathic mitral valve prolapse due to severe myxoid degeneration may be associated with aortic and/or tricuspid valve disease of the same aetiology. These localisations, which usually give rise few symptoms, can be detected by echocardiography. Sometimes, however, they may give rise to serious valvular regurgitation requiring surgical correction at each diseased valve. The authors report two cases of "floppy" mitral valve prolapse, the first requiring mitral and tricuspid, and the second, mitral and aortic, valve replacement. These cases underline the value of especially by echocardiography, in view of their serious complications.