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The percutaneous aortic valve replacement (TAVI) is the most recent and promising procedure in the area of interventional cardiology with a rapidly growing number of interventions worldwide. The transfemoral approach being less invasive, it has become the predominant access for the device delivery. The prevention of vascular complications by an optimal risk stratification using appropriate imaging techniques (vascular CT scan and angiography), optimised techniques for femoral puncture (active control of the arterial punction, crossover...) and skilled teams for peripheral angioplasty and percutaneous arterial closure devices (Prostar) has become mandatory given the fragile target population for TAVI. Vascular complications remain indeed one of the most frequent complication although the trend toward reduced sheeths size led to significant reduction This is mandatory regarding the needed size of the vascular arterial access - itself with constant improvement by minimising the initial 24 French with mandatory real chirurgical closure to the actual 18-19 French and soon 16 French. The improvement of the implanted devices is due to the recent evidence of the promising future of this technique and the important technological effort realised by the industry not only on the implanted aortic prosthesis but also on their delivering catheters.

The objective of the study was to determine the concordance of emergency physicians' and cardiologists' interpretations of emergency department (ED) electrocardiograms (ECG), to evaluate the impact of ECG misinterpretation on patient management, and to determine error rates as a function of the level of physician training and the specific ECG diagnoses. ECG interpretations were registered prospectively using a programmed-response data sheet. A second blinded interpretation by a staff cardiologist was assumed to be correct. Only ECG discrepancies with potential or probable clinical importance were considered as errors. The ED management of patients with ECG misinterpretations was reviewed by the investigators. The study was performed at an urban university hospital using 300 consecutive ED ECGs. The analysis found 154 errors of interpretation of which nine had probable clinical significance, and 56 had indeterminant significance. The concordance was weak at 0.69 (Kappa = 0.32, weighted Kappa = 0.30) with a significant discordance (McNemar Chi 2:P < 0.05). Error rates did not differ significantly between the diverse categories of physicians. In two cases, interpretation errors impacted patient management decisions but not patient outcomes. The most frequent errors involved repolarization abnormalities, ventricular hypertrophy and hemi-blocks. While discordance was significant, errors in ECG interpretation rarely impacted patient management. Prospective evaluation of ECG interpretation may be a useful means of gauging physician skills. It can also serve to focus educational activities on problem areas in electrocardiography.

The impact of accidental injury on childhood morbidity and mortality in Africa is underestimated. The frequency and severity of accidents is high. This retrospective study includes 381 children (3% of admission) between the ages of 0 and 15 years hospitalized for accidental injury at the Principal Hospital in Dakar, Senegal, between January 1, 1997 and December 31, 2000. The annual incidence of childhood injury doubled over the 4-year study period. Mean age was 48 months and the M/F sex ratio was 1.7. The causes were trauma (n = 184) due to domestic accidents (n = 109 including 91 falls) or road accidents (n = 75), poisoning (n = 129 including 38 caustic soda burns), foreign body aspiration or ingestion (n = 30), burns (n = 18), and miscellaneous accidents (n = 20). Most fatalities (9%) were due to road accidents and falls. Rapid uncontrolled urbanization and problems of displaced rural populations in adapting to city living may account for the high frequency of falls from high buildings and road accidents. As in industrialized countries road accidents, though not the most frequent, are the most lethal. Lack of emergency services accounts for severity. Vigorous information campaigns and prevention action will be needed to lower the high morbidity and mortality of childhood injury in developing countries.

Childhood cancer has often been considered as a problem mainly affecting industrialized countries. In reality more than half of cases occur in developing countries where management and diagnosis are major issues. This retrospective study includes 130 children (0.3% of admissions) between the ages of 0 and 15 years hospitalized for malignant disease at the Principal Hospital in Dakar, Senegal between January 1, 1990 and December 31, 2000. Mean age was 97 months and M/F sex ratio was 1.2. Mean delay for admission was 3 months. The five most frequent cancers, accounting for 75% of cases, were leukemia (n = 28), lymphoma (n = 21), nephroblastoma (n = 21), retinoblastoma (n = 16) and osteochondrosarcoma (n = 10). Treatment was completed in 18% of cases. Half of patient were lost from follow-up. The cure rate was 10% overall and 50% for patients receiving complete treatment. The highest cure rate was achieved for nephroblastoma, i.e., 58% of cases treated. Management of childhood cancer in Africa is confronted with numerous problems, namely, paucity of specialized staff, absence of expert centers, shortage of anticancer drugs, lack of financial resources, and delay in treatment. These factors associated with frequent malnutrition and recurrent infectious diseases, greatly lower cure rates in comparison with industrialized countries.

We studied thrombocytopenia during acute Plasmodium falciparum malaria in 64 traveller children from Paris (France), 85 children from Dakar (Senegal) with an intermittent exposure (69 with severe attack or cerebral malaria), and 81 children from Libreville (Gabon) with a perennial exposure (43 with severe attack or cerebral malaria). Initial thrombocytopenia was present in 43-58% of children with P falciparum malaria but was not more frequent in severe outcome or cerebral malaria. Low parasitaemia may lead to the misdiagnosis of malaria and delayed treatment when there is associated thrombocytopenia

The relevance of WHO criteria for severe and complicated malaria has been debated for a while, especially as regards children. Recent data led WHO experts to modify the definition of severe malaria. The objective of this study was to evaluate retrospectively the significance of the new definition on severity, lethality and intensive care distribution in children admitted with falciparum malaria (in 1997-99) to Hopital Principal de Dakar, Senegal. We used the paediatric risk of mortality score (PRISM) to compare the 2 definitions, WHO 2000 and WHO 1990. Finally, we evaluated the impact of the new definition in terms of major therapeutic interventions (MTIs): mechanical ventilation, haemodynamic support, transfusion, haemodialysis, and the use of sedatives. Among 311 patients, the frequencies of severe malaria cases and case-fatality rates thereof were 52% (n = 161) and 17% (n = 28) respectively using the 1990 WHO criteria, and 75% (n = 233) and 12% (n = 28) using the 2000 WHO criteria. Mean PRISM score among severe cases decreased with the new definition (6.5 versus 8.6). Both definitions predicted neurological sequelae and deaths with 100% sensitivity. One or more MTIs were required in severe malaria cases in 86% (n = 139) under the 1990 criteria and 73% (n = 170) under the 2000 criteria. In this area of low and seasonal transmission, the 2000 WHO definition of severe malaria proved broader and less specific, but was easier to apply and retained the high sensitivity of the earlier definition in identifying life-threatening infections.

The authors report a new case of isolated spontaneous nephrocutaneous fistula revealed by a persisting draining sinus in the left groin. Their present causative factors are identified. The computed tomography and magnetic resonance imaging actually may resolve the diagnostic dilemma and are helpful in the surgical treatment.

Percutaneous transluminal coronary angioplasty (PTCA) is an alternative to fibrinolysis in the treatment of acute myocardial infarction (AMI). However, after balloon PTCA, the rate of early re-occlusion, of re-infarctus and of restenosis remains high. Stent implantation with antiplatelet drug regimen (aspirin, ticlid) limits these risks. Abciximab (new GPIIb/IIIa receptors inhibitor) reduces PTCA complications rate in the acute coronary syndromes. Intravenous administration of abciximab can restore a normal flow in the infarcted related coronary artery (IRA) after few minutes. A monocentric, non randomized, prospective pilot study was iniated to assess the feasibility of pre-hospital treatment with abciximab in preparation to primary PTCA stenting in AMI (primary endpoint) and to appreciate potential benefits in initial IRA patency as well as prevention of PTCA thrombotic complications (secondary endpoint). Between April 1997 and January 1998, 38 AMI were treated with abciximab in pre-hospital phase (group A). Mobil Intensive Care Unit (MICU) team implemented the treatment and guaranteed immediate transport to the cathlab (abciximab bolus-coronary angiography time = 37 +/- 17 min). Immediate results were compared to those of 198 paired patients who were treated for AMI during the same period (Group T). Initial IRA flow TIMI grade 3 was significantly higher in group A, 24%, than in group T, 9% (p0.017). The rates of per-procedural complications (no flow, distal embolism), of local complications, of transfusions were not significantly different. During 1 month follow-up, there was no significant difference between group A and group T concerning death, re-MI, stent thrombosis and new revascularization. To conclude, the pre-hospital treatment with abciximab in AMI is feasible by MICU medical team without any delay of the cathlab admission. It is associated with no increased hemorrhagic complications rate. The abciximab pre-hospital treatment improves the initial IRA patency. These encouraging preliminary results expect to be confirmed by larger, multicentric, randomized and prospective studies.

Congenital syphilis is responsible for a variety of clinical symptoms, from subclinical attacks to septicemic forms that may be fatal. The most frequently encountered forms typically involve low birth weight, heptosplenomegaly and jaundice. Premature birth, anemia, cutaneous lesions, coryza, anasarca and pseudoparalysis may also occur. Neonatal X rays generally show characteristic but nonspecific osteochondrocyte lesions and periosteous dystrophy. A clinical form partly associated with growing tissues may be detected late. Diagnosis of fetal syphilis depends on the detection by immunofluorescence of specific IgM immunoglobulins in the newborn. Parenteral antibiotic treatment with 100,000 IU penicillin/kg.day for 15 days is given to newborns with symptoms. The classification and treatment of asymptomatic forms is unclear. A single injection of benzathine-penicillin is a good compromise between simple surveillance and admission to hospital for 10 days of intravenous treatment. In any case, serological surveillance is required to check that IgM disappears from the blood or that the titer of IgG decreases. Reinfection is always possible, even in a newborn treated correctly. In developing countries, pediatricians must be aware of the various clinical forms of congenital syphilis. In addition, national programs to combat sexually transmitted diseases should be supported and developed by international aid agencies. In economically advanced countries, attention is currently focused on the restricted nature of medical treatment. Improvements in the management of congenital syphilis depend above all on dealing with the social and cultural problems of populations affected by syphilis.

The object of this study was to assess the value of CK in the evaluation of left ventricular wall motion. Fifteen coronary patients aged 56 +/- 12 years were included: 8 patients were examined after acute myocardial infarction and 7 after unstable angina with a history of myocardial information. The left ventricle was divided into 7 segments after a modified Heger model, excluding the basal septal and basal lateral segments not seen on angiography. The left ventricular wall motion was assessed in two-dimensional echocardiography (2DE) and colour kinesis (CK) by two observers and compared with the results of left ventriculography, considered the reference method. Over all the 105 segments studied (7 segments for each of the 15 patients), CK was significantly better than 2DE (80% of segments correctly evaluated by CK vs 68% by 2DE, p0.05). Colour kinesis significantly improved the study of all segments except the interventricular septum (67% vs 60%, p = NS). The inter-observer variability in 2DE and CK evaluated over 135 segments (9 per patient) by the kappa was improved by colour kinesis (0.57 in 2DE, 0.7 in CK). The authors conclude that CK enables evaluation of left ventricular wall motion with greater precision and less inter-observer variability.

The authors report the case of a 34 year old woman, admitted to hospital because of myocardial infarction two months after delivery of her fifth child. The infarction was caused by spontaneous dissection of the left main coronary and left anterior descending arteries. Twenty-three months later, the patient was well with medical therapy. This case is an example of spontaneous post-partum coronary dissection which is the commonest cause of infarction occurring in that period. The physiopathology of this complication is not fully understood. The prognosis is poor, lethal in two thirds of cases. However, it must be emphasised that coronary dissection may regress spontaneously. Patients were previously referred systematically for surgery, but now it is usually reserved for cases with persistent myocardial ischaemia despite medical therapy. Angioplasty may be preferred despite the risks and may be successful in some cases.

The authors report the case of a 31 year old woman at 30 weeks' gestation who developed a non-Q wave postero-lateral myocardial infarction during treatment with salbutamol. There were no complications and delivery took place at term normally. Coronary angiography was performed 3 months post-partum and was normal: the Methergin test was negative. Myocardial ischaemia occurring during treatment with a beta-2 mimetic in pregnancy is rare and hardly ever progresses to myocardial infarction. The usual mechanism of ischaemia is an imbalance of myocardial oxygen demand and supply. Myocardial oxygen consumption is naturally increased during pregnancy and excess intracellular calcium secondary to the beta-1 stimulation occurring with the use of beta-2 mimetic drugs further aggravates matters. This hypothesis raises the question of the value of calcium inhibitors in these forms of myocardial ischaemia.

One case of repeated incisional hernia is reported. This hernia was initially repaired but repeated infection occurred. This hernia was then successfully treated with a fasciocutaneous tensor fasciae latae island flap. The patient was reexamined two years after surgery and presented a functional abdominal wall. Other different reconstructive possibilities of regional myocutaneous flaps are described.

BETTER THAN ANGIOPLASTY: Prolonging inflation with a perfusion balloon decreases the risk of acute coronary occlusion after angioplasty. The longer the artery remains patent, the greater the chances of 0% residual stenosis. This is what the sent allows. Stent act on both mechanisms of stenosis: elastic recoil and fibrous remodeling of the arterial plaque. TARGETTED ACTION: Stents improve angioplasty prevention of acute stenosis. They have a real action on preventing degeneration of the saphenous graft and lead to a significant reduction in the rate of restenosis of the dilated site. There are however two specific complications: subacute occlusion and greater incidence of vascular events. Stents are particularly indicated for the treatment of restenosis and chronic occlusions. TWO IMPROVEMENTS: Risks related to the implantation of a foreign body in the vascular system have been reduced with the use of ticlopidine and high-pressure stent implantation. POSITIVE RESULTS: Stents have produced better angiographic results. They limit restenosis and the number of revascularizations required in treated patients. Several questions concerning indications remain open.

GENERAL CHARACTERISTICS: Several criteria are used for coronary stent design: biocompatibility, i.e. the capacity to resist thrombotic events and corrosion, flexibility, radial force sufficient to resist elastic recoil, percentage of the lesion covered, radio-opacity, minimal shortening at opening, absence of effect on collateral branches, possibility to use small calibre probe guides, and cost. TWO CATEGORIES: Both tubular stents (self-expanding stents and balloon stents) and filamentary stents (made of stainless steel or tantalum) are used, THE IDEAL STENT: There is no one ideal stent. Choice is dictated by the characteristics of the lesion and by the status of the artery to treat.

RATIONALE FOR ANTITHROMBOSIS THERAPY: Introducing a foreign body into the coronaries raises the risk of thrombosis in the acute phase and for the 4 following weeks. The objective of antithrombotic therapy is to inhibit platelet adhesion and aggregation or to induce hypocoagulability. AT IMPLANTATION: High-dose heparin is given in a bolus following pretreatment with aspirin. ASPIRIN-TICLOPIDINE COMBINATION: The risk of subacute thrombosis is low, about 1%, and the rate of vascular complications is minimal. Treatment is simple and compatible with short hospitalization.

Right ventricular involvement during inferior wall myocardial infarction does not seem to alter long-term clinical prognosis but its specific outcome has not been clearly studied. We have previously demonstrated that pulmonary regurgitant (PR) flow tracings doppler analysis allows the accurate diagnosis of RV involvement, especially when the pressure half-time of PR wasor = 150 ms and the ratio of the minimal velocity to the maximal velocity wasor = 0.5. We studied 40 patients with acute inferior wall myocardial infarction and with PR flow. Doppler echocardiography was obtained during the first day, before discharge (early control) and between 12 and 24 months follow-up (late control). Among 22 patients with RV involvement defined with PR-derived doppler parameters (RVIPR). 8 had right ventricular enlargement and/or wall motion abnormalities, observed in 6 cases at early control and in 4 at late control. Doppler analysis showed remnant RVIPR parameters in 9 patients at early control and 8 among these at late contorl, with no relation with pulmonary artery pressure or other echocardiographic parameters. No clinical, angiographic or therapeutic data predicted these distinct echocardiographic and doppler patterns and the long-term prognosis was not different. At late control, among 12 RVIPR patients which PR-derived doppler parameters were normal at early control, two patients had still RVIPR pattern at late control and described ischemic recurrence. PR flow doppler analysis is a useful tool for diagnosis and outcome evaluation of RV involvement and shows a remnant diastolic dysfunction in half of the patients with acute RV involvement.

Neurocysticercosis (i.e. cerebral localization of the metacestode larvae of Taenia solium) is believed to be a major cause of late onset epilepsy in non-Muslim developing countries. To define its role in childhood epilepsy in Madagascar, analysis of serological markers of cysticercosis was performed in 256 children with unexplained epilepsy and in 113 controls. Sera were considered positive when high titres in ELISA were present together with at least one of the bands 13, 14, 18, 21, 24 or 32 kD on Western blot. Altogether, 17.6% of the patients versus none of the controls were seropositive using these criteria. When analysing the bands of the Western blot, those of 13, 14 and 18 were significantly more frequently detected in sera of epileptic children than in sera of controls. Neurocysticercosis can be considered the main cause of secondary childhood epilepsy in our country, Madagascar being one of the most important foci in the world.

Neurocysticercosis is the most frequent parasitosis of the central nervous system in the world. Due to the extension of the pandemy, and the importance of the migrations from endemic countries, this parasitosis is being diagnosed with increasing frequency in France. Epilepsy is the main revealing symptom. However, in endemic countries, neurocysticercosis should be suspected in patients with any neurological sign. Diagnosis is based upon imaging procedures (computed tomography and magnetic resonance imaging) and serology (Elisa and Western blot). The evolution is highly variable, from complete latency to severe encephalopathy with psychomotor regression. Praziquantel and albendazole are the main therapeutic agents. Although corticosteroids are usually very effective on symptoms of the acute phase of the disease, their place in the treatment remains to be clarified. Racemic and ventricular forms of the disease usually need neurosurgery. In endemic regions, the diminution of the frequency of the disease relies upon prevention through health education compaigns, pending the achievement of an efficient vaccine.

The authors report the case of a patient undergoing coronary angiography for angina who had an anomalous origin of the septal perforator artery from a separate ostium. Anomalies of the coronary arteries may consist not only of anomalous trajectories and coronary fistulae but also of anomalous origins of the main coronary arteries. The anomalous origin of a septal artery from a separate ostium is very rare accounting for 0.5% of cases in the medical literature. In some cases, this artery provides a collateral circulation for occluded main coronary vessels, thereby preserving left ventricular contractility.

Rarely seen in industrialised countries, ileo-caecal tuberculosis does not require surgery unless complications or diagnosis uncertainly occur. When laparotomy is contre indicated in presence of chronical respiratory disease, laparo-assisted ileo-caecal resection is an interesting alternative to classical surgery as it has less effect on ventilation. This laparo-assisted ileo-caecal resection appears to the first reported in presence of intestinal tuberculosis.

Unique physiological and immunological features of the brain, as previously presented, explain the limitation of local inflammatory reactions and the existence of intrathecal specific IgG production. In addition, some parasitic factors of recent knowledge are induced during neurocysticercosis, which could be involved in vivo in a modulation of the immune response by larval products (a soluble RNA-peptide, some metacestode surface sphingoglycolipids). These recent findings lead us to make a critical review of the antigenic profiles obtained by enzyme-linked immunoelectrotransfer blot (EITB) on samples collected from patients suffering from simple or multiple neurocysticercosis.

The authors report two cases of spontaneous paroxysmal atrial fibrillation closely followed by syncopal ventricular tachycardia resulting in cardiac arrest requiring defibrillation. Both patients, men aged 62 and 64 years, had a past history of myocardial infarction without arrhythmias; atrial fibrillation occurred during severe myocardial ischaemia; coronary arteriography showed tight stenoses of the left main coronary artery with normal left ventricular function. Ventricular tachycardia (or fibrillation) during spontaneous paroxysmal atrial fibrillation is a rare occurrence. This sequence of events has been described in patients with accessory conduction pathways or in hypertrophic cardiomyopathy. It is an exceptionally rare complication of ischemic heart disease with only a very few previously reported cases. Myocardial ischaemia is probably the cause of the arrhythmia in together with irregularity of the ventricular contractions responsible for long cycle-short cycle sequences which are particularly arrhythmogenic and changes in sympathetic tone.

Coronary by-pass surgery and percutaneous transluminal angioplasty (PTCA) have changed the prognosis and life quality of patients with stable angina. Medical treatment and myocardial revascularisation are both useful and most often complementary. Coronary by-pass surgery is indicated in the treatment of coronary left main disease and three-vessel disease with poor left ventricular function. PTCA is the best choice in patient with one-vessel disease resulting in myocardial ischaemia. Discussion remains open in other cases mainly in stenosis of proximal left anterior descending artery. Often the ultimate choice results from the limits of each technique: sapheneous by-pass occlusion or coronary artery restenosis after PTCA. New techniques and devices in revascularization are expected to improve prognosis:use of arterial by-pass grafts, gene transfer, local drug delivery.

This retrospective study reviews 211 patients having sustained a bilateral groin hernia repair during a 3 year period. The procedure was the same for all the patients: via a Pfannensteil approach, a pre peritoneal prosthetic repair is performed, using two ePTFE patches, after resection of the hernial sacs and closure of the parietal gaps. The mean follow up was 2 years. During the post operative course, thirty seven of 211 patients sustained 10 local complications, 9 urethral catheter related complications and 11 residual pain. No prostheses infection or testicular atrophy was observed. Nine patients had recurrences (2.2% of 422 repairs). All the recurrences were due to incorrect technique, eight were successfully re operated on--Expanded PTFE is a reliable prosthetic material, easy to handle and well adapted to preperitioneal hernia repair.

The authors report two cases of cystic adventitial disease of the popliteal artery. Both patients complained of calf claudication and presented a thrombosis of the popliteal artery. In one case, magnetic resonance imaging exhibited a specific preoperative diagnosis. In both cases, at least one communication between the cysts and the capsule of the knee joint was demonstrated, supporting the congenital hypothesis of the disease. The two cases have been treated by vein graft replacement of the occluded popliteal arteries. Both patients have remained asymptomatic and the two grafts have remained patent during the ninth and twelfth month follow-up periods.

By examining the sera from 1,408 healthy individuals in all six provinces of Madagascar with ELISA methods, we were able to demonstrate a very high prevalence for cysticercosis: 18%. The serologic markers for cysticercosis among 1,132 patients with neurologic symptoms was even higher: 36%. Furthermore, of 241 patients with neurocysticercosis, 82% of the serums recognized, in Western Blot test, the 14-20 Kd "evolutivity proteins". Cysticercosis is thus highly implicated in the neurologic syndromes found in Madagascar. Only adequate prophylaxis will permit a reduction in the incidence of this disease.

The authors report a case of severe constrictive pericarditis occurring 6 weeks after coronary bypass surgery and in the absence of any other predisposing factor. The diagnosis was confirmed by CT scan and cardiac catheterisation which showed signs of a diastole. The patient died despite early surgical reoperation because of the severity of the pericardial fibrosis.

The aim was to find an objective indicator in order to evaluate white coat effect (WE). The first hour average values after placing an ambulatory blood pressure recorder (15 mn intervals) were compared to those of the 4 following hours of diurnal activity. A first hour systolic arterial blood pressure (SBP 1H) increase of 10 mmHg or more was considered as an ambulatory WE positive (AWE+) and was compared to clinical WE (CWE). CWE+ was observed in 78 pts and AWE+ in 72 among a group of 172 unselected pts referred for hypertension.the correlation between AWE and CWE is weak (r = 0.49) but significant (p0.001). There was no difference between the two groups in age, sex, clinical blood pressure, heart rate or ambulatory BP after the first hour (table). There was a significant difference in SBP between the 2 groups (p0.001) during the first hour only. [table: see text]Ambulatory blood pressure recording is able to recognize and evaluate the white coat effect. We suggest to consider independently the first hour of each recording and to compare it with the mean pressure measured during the period of diurnal activity.

Benign non-parasitic splenic cysts are uncommon. Their diagnosis can benefit from ultrasounds and computed tomography. However, it may be difficult, before surgery, to distinguish between true cysts, which are congenital with epidermal lining, and false cysts, which are consecutive to a trauma, inflammatory or degenerative, without epidermal lining. We report nine cases of non-parasitic splenic cysts and try to determine the preoperative diagnostic approach. To prevent the overwhelming post-splenectomy infection syndrome, conservative surgical treatment is mandatory. Various surgical methods are discussed.

Twenty patients aged 56.8 +/- 10 years, hospitalised for unstable angina (12 cases) or infarct without Q wave (8 cases) were treated with IV heparin, aspirin and oral verapamil. The clinical syndrome was controlled by verapamil in 16 cases out of 20 (80% of cases) at the dosage of 360 mg/d in 14 patients and of 480 mg/d in two. An exercise ECG, limited by symptoms, was obtained in 18 patients (90%) between the 8th and 12th day. Coronary arteriography was considered to be indicated in three sets of circumstances: recurrence of angina resistant to nitroglycerin, positive exercise ECG with verapamil, persisting despite triple therapy or strongly positive exercise ECG (total duration less than or equal to 6 minutes). An infarct complicated the early course in 4 patients (20%): twice following angioplasty, once following exercise ECG (spastic angina) and once during triple therapy (refractory angina). Hospital and mid-term (18 +/- 6 months) mortality was nil. With verapamil, the absence of recurrence of angina together with a negative exercise ECG enabled the identification of a large group of patients (40%) with a low risk of a subsequent major accident and in whom early and routine coronary arteriography is probably not indispensable.

The great diversity of injuries after abdominal wound, need an adapted treatment. When laparotomy is indicated in uncontrollable hemorrhage, peritoneal lavage associated with C.T. scan seems to be interesting in the management of hemoperitoneum with a moderate injury severity score and stable arterial and venous pressures. Three patients were recently managed non operatively with good results. The authors draw up these three cases with inclusion criterias and limits of the method.

Many traditional ointments are utilized in Senegal because of their local effects. We report the case of a new born girl deeply burned by the application of "Touloucouna" (Carapa Procera) on her skin. The berries of the tree contain cyclic terpens (Meliacine) well known for inducing inflammation by contact with the skin. They are most likely responsible for that burn until now, such injuries have never been described with Touloucouna.

Four premature infants presenting with episodes of bradycardia in the first weeks of life were given diphemanil. One of them received an overdose accidentally. Paradoxically, this induced a permanent bradycardia leading to the discovery of a grade II A-V block as well as a prolonged QT interval. Discontinuation of the drug resulted in a prompt normalization of these changes. It is felt that this anticholinergic therapy may have caused a prolongation of the QT interval and, therefore, a partial A-V block in case of sinus tachycardia. Thus, such a therapy should not be given to young premature infants without having checked the QT interval on a ECG tracing and having made sure that it is adapted to the actual heart rate. It is also advised to reduce usual doses.

Percutaneous transluminal balloon aortic valvuloplasty was introduced in 1985 and, owing to its sometimes dramatic short-term results, it has rapidly become a useful procedure in the management of aortic stenosis in elderly subjects. The purpose of this study was to determine its clinical results at medium-term and to identify possible prognostic factors in order to improve the selection of patients suitable for this technique. Between January 1986 and December 1987, 78 patients (30 men, 48 women, aged from 60 to 93 years, mean 80 +/- 6.7 years) totalling 85 procedures were selected among 102 dilatations on the basis of a primary success without complications. Dilatation was performed by a technique similar to that described by Cribier et al. The follow-up period was 10 +/- 5.7 months (range: 1 to 27 months). The aortic valve area increased from 0.47 +/- 0.15 cm2 to 0.77 +/- 0.23 cm2, i.e. from 0.29 +/- 0.09 cm2/m2 to 0.48 +/- 0.13 cm2/m2 as regards the indexed area. The hospital mortality rate was 3.3 p. 100. At the end of the follow-up period 55 p. 100 of the patients were in NYHA class I or II; 29 p. 100 had died, 10 p. 100 had undergone a second dilatation and 13 p. 100 had had aortic valve replacement. This distribution into functional classes and major cardiac events was not significantly different in the subgroup of patients with an aortic valve area greater than 0.9 cm2 or in the subgroup of primary failure. The patients who died for cardiac reasons were older (p less than 0.01), had a lower cardiac output before and after dilatation (p less than 0.001) and a lower ejection fraction after dilatation (p less than 0.05) or even before in case of early death (p less than 0.05). Mortality and morbidity therefore were high at medium-term and unrelated to the haemodynamic effect of dilatation. On the other hand, the left ventricular systolic function was determinant, mainly because it could improve or remain stable when initially altered. These results suggest that only patients for whom aortic valve replacement is truly contra-indicated and who have a limited alteration of left ventricular function should be selected for aortic valvuloplasty.

A new case of late bacterial endocarditis caused by Cardiobacterium hominis is reported. The infection developed on an aortic valve prosthesis and responded favourably to medical treatment. The main characteristics of the micro-organism and of the oslerian graft are reviewed in the light of published data. The problem of endocarditis with negative blood cultures is discussed since C. hominis is reputed difficult to cultivate, although this was not the case in our patient.