[Diagnosis of invasive pulmonary aspergillosis: value of bronchoalveolar lavage galactomannan for immunocompromised patients]. / Diagnostic de l'aspergillose bronchopulmonaire invasive: valeur du dosage du galactomannane dans le lavage bronchoalvéolaire de patients immunodéprimés.

Invasive pulmonary aspergillosis (IPA) is an emerging disease associated with high mortality. The diagnosis is difficult, based on a combination of elements that are clinical, radiological and biological. For early detection of cases of IPA, during 25 months, we have systematically carried out on the LBA (N=355) of immunocompromised patients (N=313) a determination of Aspergillus galactomannan (GM) by ELISA (PlateliaAspergillus, BioRad). We observed 14 cases of probable API. The sensitivity of GM compared to direct examination (DE) and culture is, respectively, 64% versus 29% and 57%. The determination of GM is definitely more sensitive than the ED. Excellent specificity (98%) allows its implementation as a screening test in patients at risk.

[How can the cost of screening for toxoplasmosis during pregnancy be reduced?]. / Comment réduire le coût du dépistage de la toxoplasmose chez la femme enceinte?

BACKGROUND: A program of systematic serology screening for toxoplasmosis during pregnancy has been running in France since 1978. The program involves monthly follow-ups for all non-immune pregnant women. Due to the steady decline in the seroprevalence of toxoplasmosis, the cost of the program is steadily increasing. Current screening is based on the detection of IgG and IgM isotypes. The aim of this work was to estimate the benefit of replacing combined dosage of two isotypes, by an alternative strategy that detects total anti-Toxoplasma immunoglobulins. METHODS: The rate of decreasing seroprevalence and the increasing burden on serological examinations was measured in a study population of pregnant women who were checked for toxoplasmosis by the parasitology laboratory of the Cochin Hospital, Paris. The increase in screening costs was estimated for the all-pregnant women and the expected benefits stemming from simply measuring total anti-Toxoplasma immunoglobulins compared to the double IgG-IgM assay were estimated. RESULTS: Between 1987 and 2008, the seroprevalence of toxoplasmosis measured at the Cochin hospital dropped from 70.8% to 48.6% with a 1.77% annual rate of decline. This downward trend is similar to that observed by the national perinatal surveys performed in 1995 and in 2003. As the number of non-immune women to follow-up each month is constantly increasing, the proportion of negative tests issued reached 87.6% in 2008. Extrapolating these results to the whole of France, we estimated that the number of required screening tests perform was increasing by 93,000 units per year with an additional associated cost of one million euros. Various alternative scenarios of antibody detection are proposed that could save between 40.2% and 48.4% of current screening costs. CONCLUSION: Replacement of combined dosage of IgG and IgM isotypes by determination of just total Ig would significantly reduce costs of toxoplasmosis screening for pregnant women, without effecting either the general strategy, or proven efficiency of the national program.

Clinical and ultrasound results after aortic valve replacement: intermediate-term follow-up with the St. Jude Medical prosthesis.

Mortality, morbidity, quality of life, and left ventricular (LV) function were evaluated in 49 patients after aortic valve replacement with the St. Jude prosthesis. Total follow-up was 2577 patient-months; survivors were followed-up for 4 to 7 years by clinical examination and echocardiography. The actuarial survival rate at 6 years was 79.6%, and there were no valve-related deaths. The linearized rates for thromboembolism and hemorrhage were 0.93% and 3.26% per patient-year, respectively. In 34% of the survivors the quality of life was poor. In the first three postoperative months, patients with aortic stenosis (n = 12) had a significant decrease in the muscle cross-sectional area (p less than 0.01) and patients with aortic regurgitation (n = 11) had decreases in both LV end-diastolic diameter (p less than 0.05) and cross-sectional area (p less than 0.001). All of these results were maintained at 5 years without modification of LV systolic function. Despite the good overall results, six patients deteriorated and had major LV dilatation. Multivariate logistic regression analysis identified two independent preoperative variables associated with a poor outcome defined as death of LV dysfunction (p less than 0.05): age and end-diastolic diameter. Thus meticulous follow-up showed a high incidence of hemorrhage and a poor quality of life in many of the survivors. It was concluded that in high-risk patients (age and end-diastolic diameter) surgery should probably be considered earlier.

[Doppler ultrasound evaluation of aortic insufficiency using half-pressure time. Absence of arterial rigidity influence]. / Evaluation doppler de l'insuffisance aortique par le temps de demi-pression. Absence d'influence de la rigidité artérielle.

In 20 patients with pure aortic regurgitation we studied the relationship between the severity of regurgitation, as assessed haemodynamically by the percentage of leakage (%L), and the half-pressure (T 1/2 P) and half-velocity (T 1/2 V) times, as obtained from doppler aortic blood velocity curves, taking into account the rigidity of the systemic vascular circuit characterized by the pressure wave propagation velocity (PWPV). The systemic arterial circuit was supple in 14 patients (PWPV less than 7.5 m/sec) and rigid in 6 patients (PWPV greater than 7.5 m/sec). The regression slopes between %L and T 1/2 P and between %L and T 1/2 V were calculated with their confidence limits in the 14 patients with supple arteries. The 6 patients with rigid arteries fitted into this nomogram, thus demonstrating that systemic arterial rigidity makes no difference in the relationship between %L and doppler indices. The half-velocity and half-pressure times measured by doppler ultrasound were acquired from a velocity signal directly determined by the aortic regurgitation, without any detectable effect of vascular circuit rigidity. Being equivalent by nature to the signal decrease time constant, they are independent of the absolute protodiastolic value of diastolic pressure gradient or blood flow velocity. For this reason these two doppler parameters are reliable to evaluate the severity of aortic regurgitation.

[Echographic evaluation of the severity of aortic stenosis in cases with associated mitral stenosis]. / Appréciation échographique de la sévérité du rétrécissement aortique en cas de sténose mitrale associée.

The echocardiographic findings of six patients with pure mitral stenosis associated with pure aortic stenosis were compared with the findings from a series of ten cases of pure aortic stenosis without mitral disease. Each patient also underwent haemodynamic studies in order to quantitate the severity of the stenoses. The aortic stenosis was of the same degree of severity in both series (0.71 +/- 0.24 cm2 and 0.73 +/- 0.16 cm2). The systolic separation of the aortic valve was greater than 1 cm in 4 of the 6 cases on echocardiography, corresponding to a false negative of tight aortic stenosis. This appearance corresponded to a doming of the aortic valve on 2D echocardiography. The wall thickness was significantly less in the AS + MS series than in pure SA series (1.13 +/- 0.13 cm compared with 1.52 +/- 0.21 cm; p less than 0.01). The wall was found to be thicker, the tighter the MS. Overall, the diagnostic criteria of the severity of AS on echocardiography (restricted opening of the valve and the severity of ventricular wall hypertrophy) were absent in the association of AS + MS. The absence of myocardial hypertrophy can not be fully explained. It could be related to a decreased filling on the left ventricle and therefore a smaller systolic ejection volume because of the mitral obstruction.

[Differential diagnosis between constrictive pericarditis and cardiac amyloidosis by computerized M-mode echocardiography]. / Diagnostic différentiel entre péricardite constrictive et amylose cardiaque par échocardiographie TM digitalisée.

A diastole is a non specific haemodynamic syndrome which may result from constrictive pericarditis or from a restrictive cardiomyopathy. The aim of this study was to differentiate these two types of condition by analysis of computerised M mode recordings of the left ventricle. Three groups of patients were studied: 5 cases of confirmed cardiac amyloidosis (Am); 5 cases of constrictive pericarditis confirmed surgically (CP) and 10 normal subjects (NL). The study was based on analysis of parameters of ventricular filling and of diastolic thinning of the LV free wall. A significant difference was observed between AM and CP but not between PC and NL. Amyloidosis was characterised by a reduction in the maximum velocity of endocavitary diameter lengthening (AM 0,84 +/- 0,56 cir/sec; PC 3,95 +/- 0,77, p less than 0,01), prolongation of the rapid filling phase (AM 0,42 +/- 0,17 sec; PC 0,16 +/- 0,06 sec, p less than 0,02) and a decrease in maximum velocity of free wall thinning (AM 0,45 +/- 0,23 th/syst/sec; PC 4,79 +/- 2,1, p less than 0,01). The diastolic thickness of the free wall was greater in the amyloidosis group (AM 1,73 +/- 0,61 cm; PC 1,05 +/- 0,21, p less than 0,05) and correlated with the reduction of maximum velocity of free wall thinning. Parameters of global diastolic filling did not distinguish the two conditions. The M mode recordings were therefore digitalised to provide graphs of chamber filling and wall thinning and their derivatives.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral systolic anterior motion and left ventricular function in obstructive cardiomyopathy]. / Avancée mitrale systolique et fonction ventriculaire gauche dans la myocardiopathie obstructive.

The term hypertrophic cardiomyopathy with obstruction encompasses a wide range of clinico-pathological conditions. The mildest forms have localised septal hypertrophy and obstruction only during pharmacodynamic stimulation. The more severe forms have major wall hypertrophy and are obstructive under basal conditions. Mitral systolic anterior motion (SAM) recorded at echocardiography is generally attributed to obstruction. However, the construction of this image by subvalvular structures and the relationship between the obstruction and anatomical deformation led us to study left ventricular haemodynamics with respect to the presence or absence of SAM under basal conditions. Thirty one cases of hypertrophic obstructive cardiomyopathy were divided into 2 groups: -- Group 1 without basal SAM (11 cases); -- Group 2 with SAM under basal conditions (20 cases). Under basal conditions there was no significant difference in LVEDP or ventricular volume between the two groups. An intraventricular pressure gradient was commoner in Group 2 (65% compared to 27%) as was mitral incompetence (53% compared to 27% in the 30 patients undergoing selective left ventriculography). Left ventriculography in the right anterior oblique plane distinguished two types of LV deformation: systolic biloculation of the chamber and systolic apical obliteration. The second form was mainly observed in Group 2. The effect of isoproterenol on LVEDP was studied in 9 cases in Group 1 and 13 cases in Group 2: LVEDP decreased from 14 +/- 6 mmHg to 8 +/- 6 mmHg in Group 1, and increased from 14.5 +/- 6 to 23.5 +/- 6.5 mmHg in Group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Calculation of the peak systolic wall stress at the equator of the left ventricle by coupled M mode echo and pressure recordings]. / Calcul du pic de contrainte systolique à l'équateur du ventricule gauche par le couplage écho TM/pression.

The peak systolic wall stress at the equator of the left ventricle (sigma max) is the maximum load that the myocardial fibres bear during contraction. It is an index of the adaptation of the left ventricle to cardiac disease, and, when elevated, it indicates cardiac decompensation. sigma max was calculated by coupled M mode echo-LV pressure recordings in 51 cases: 11 patients without LV disease, 14 patients with aortic stenosis (AS), 14 patients with aortic incompetence (AI), 7 patients with severe mitral incompetence (MI) and 5 patients with cardiomyopathy with dilatation (CMP). sigma max was calculated from Mirsky's formula, the length of the long axis being deduced from the short axis and the diastolic:systolic ratio of these two axes from ventriculography. The normal value of sigma max by this method is 220 dynes 10(3)/cm2 +/- 30 with an upper limit of normal of 280 dynes 10(3)/cm2. sigma max was normal in patients with AS and AI, and increased in the cases of MI and CMP, in positive correlation with LV volume (r = 0,47) and the shape of the LV (long:short axis ratio). No correlations were found between sigma max and maximum LV pressure. The relatively low values of sigma max compared to the results obtained from coupled echo-angio recordings are partly due to the thick walled LV model and, to a large extent, to the lower values of short axis when measured by echo compared to angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis and evaluation of isthmic coarctations of the aorta by bidimensional echocardiography]. / Diagnostic et bilan des coarctations isthmiques de l'aorte par échocardiographie bidimensionnelle.

Two cases of thoracic aortic coarctation seen on the suprasternal incidence of bidimensional echocardiography are reported. In one case, the observed echocardiographic image is an obstruction of the vascular lumen. In the other there is only reduction of the vascular calibre. In both cases, a complete examination of the aortic arch and its major branches, substrictural aortic region, and cardiac valves was obtained. The echographic results were concordant with those of the angiography, except for an underestimation of the severity of the thoracic stenosis in the second case, with the echography. An echographic post-operative control in the first case showed normalization of the vascular calibre in the isthmus region. Echocardiography allows visualization of thoracic aortic coarctations and examination of associated vascular and cardiac lesions. However, problems remain in the quantification of stenosis, which are inherent to the technique.

[Echocardiographic study of the effects of a nitroglycerin microcapsule preparation (author's transl)]. / Etude échocardiographique des effets d'une trinitrine microencapsulée.

An echocardiographic study performed on 15 patients after administration of sublingual nitroglycerin showed a significant decrease in internal diameters of the left ventricle, associated with a moderate fall in blood pressure. A significant, but smaller decrease in diameters was also found 3 to 4 hours after oral administration of a nitroglycerin microcapsule preparation. The parameters measuring cardiac performance and the quality of myocardial contraction remained unchanged. The decrease in left ventricle internal diameters may be attributed to a reduction in pre-load and intraparietal ventricular tension. In addition, these results obtained by a non-invasive technique have confirmed the prolonged activity of nitroglycerin microcapsule preparations, previously demonstrated by hemodynamic and pharmacological experiments.

[Echocardiographic diagnosis of obstructive myocardiopathies: study of the systolic anterior motion of the mitral valve and septal hypertrophy as compared with the hemodynamic and mechanographic findings. Evolution under medical treatment]. / Diagnostic échocardiographique des myocardopathies obstructives: étude de l'avancée mitrale systolique et de l'hypertrophie septale par comparaison avec les données hémodynamiques et mécanographiques. Evolution sous traitement médical.

Characteristic echocardiographic features of hypertrophic obstructive cardiomyopathy were recorded in 24 patients, all of whom had asymmetric septal hypertrophy and systolic anterior motion of the mitral valve (SAM) at rest or after pharmacodynamic stimulation. The relationship between outflow tract obstruction and SAM was assessed by comparison with data obtained at cardiac catheterisation and external mechanography: SAM seems to be a non-specific phenomenon and may be recorded in cases of hypertrophic cardiomyopathy without obstruction during pharmacodynamic stimulation. In forms with obstruction, SAM and the severity of obstruction increase with the degree of spetal hypertrophy. The increased contractility of the left ventricular posterior wall appears to be an important factor in the mechanism of SAM which can be prevented by betablockade in moderate or labile forms. When SAM is permanent, whatever the gradient recorded, it is a sign of anatomical deformation of the left ventricle and may be an additional indication for cardiac surgery.