[Changes in medications acting on the cardiovascular system during hospitalization]. / Changements de médications agissant sur le système cardiovasculaire en cours d'hospitalisation.

The present study was conducted to assess the extent to which the treatment of patients who take one or more cardiovascular drugs regularly is changed during hospitalisation and over the course of the subsequent two months after release from hospital. In order to elucidate the question more exactly, data was collected on 107 patient after a hospital stay on the internal medicine ward of a university hospital and on 107 patients who had been hospitalised in two non-university hospitals. The average number of changes in medication in patients in the university setting was 2.7 and in patients in the non-university setting it was 2.2. The treatment of patients who were hospitalised for cardiovascular complications was switched more often than that of patients whose circulation was stable at admission. Over the course of the subsequent two months after release, the attending general practitioners (GP) switched the medication at a much lower frequency than the hospitals had done. Within one specific drug class there was no more frequent changes in medication during the hospital stay as afterwards. A drug was discontinued in 107 patients in the university setting and in 124 cases in the two non-university hospitals. The same drug was prescribed again by the treating GP in 30 and 40 patients, respectively, after release. The results of the study show that treatment with drugs that have an effect on the patient's understanding of his illness with regard to its severity may be likely to cause doubts about the effectiveness of the drug and whether the therapeutic decisions that were made by the doctors for medical or other reasons were correct. Therefore, it makes more sense to avoid unnecessary changes in medication whenever possible and only then in unavoidable cases with a clear medical indication.

[Diabetic nephropathy with nephrotic syndrome--apropos of 2 cases. Advantages of combined conversion enzyme inhibitor and non-dihydropyridine calcium antagonist treatment]. / Néphropathie diabétique avec syndrome néphrotique--a propos de deux cas. Avantages de l'association d'un inhibiteur de l'enzyme de conversion et d'un antagoniste du calcium non dihydropyridinique.

The inhibitors of the angiotensin-converting-enzyme (ACEI) are considered as the best pharmacological class for the treatment of patients with diabetic nephropathy. Independently of lowering the arterial blood pressure they reduce the proteinuria and slow the evolution of the renal failure. Calcium-channels blockers not belonging to the dehydropyridine-type (verapamil-diltiazem) possess some of these features, too, contrarily to the rest of calcium-antagonists (nifedipine-like). Two clinical studies dealing with type-II diabetic-patients whose nephropathy was complicated by a nephrotic syndrome and a rapid progressive renal failure showed that the combination of verapamil with an ACEI, further dietetic measures (protein restriction, saltless diet), permitted a significant decrement of the proteinuria as well as a stabilisation of the kidney function. This effect could not be shown under treatment with only ACEI. Thus the proteinuria-inhibiting and kidney-protecting effects of the combination of theses two substances-groups should be known when the physician is confronted at this clinical situation that determines the prognostic of the kidney function in such a dramatic way and short laps of time.

[Treatment of arterial hypertension and sexual dysfunctions. Is it a certain cause of poor treatment compliance?]. / Le traitement de l'HTA et les dysfonctions sexuelles. Une cause certaine de mauvaise observance du traitement?

The great interest risen by sildenafil (Viagra) resulted in talking again about erectif dysfunction and sexual disorders. Its commercial introduction has already renewed speech and social representation about sexuality. Each of the antihypertensive drug classes is know to generate sexual disorders. In reducing or normalising blood pressure, they decrease intracavernous perfusion pressure, already compromised by vascular disease of the hypertensive patient. This is due less to a side effect than to the logical consequence of treatment. Analysing last 15 years' medical publications shows little interest in searching for sexual side effects of hypertensive medication, in both sexes. In its every day practice, the physician can more easily have an opinion about their repercussions, than by reading studies, with mention of erectile dysfunction percentages often lower then the known prevalence in general population. However, if we want to improve therapeutic observance, whereas nearly half of the hypertensive patients are not compliant, we need to remedy. The solution would be improving patient-physician communication and relationship, and preventing potentially harmful effects of each antihypertensive agent by proceeding, if possible, to a sexually oriented history taking and physical examination before and during the treatment. This article reviews the works especially about sexual side effects of antihypertensive drug therapy.

[Cardiac fibrosarcoma discovered by cerebral metastases]. / Fibrosarcome cardiaque découvert par métastases cérébrales.

Primary heart tumors are rare, and the fibrosarcomas are exceptional. We present the findings in a 78 year old female who has been hospitalized in April 1997 with a history of 4 months of malaise, headaches and weight loss. Clinical examination showed a right lateral homonymous hemi-anopsia. Computed tomography (CT-Scan) of the brain showed two lesions in the occipital and temporal lobe, consistent with metastasis. Thoracic and abdominal-pelvic CT-Scan revealed a voluminous mass of the left auricle that has been interpreted as a probable sarcoma. Biopsy specimen of one of the cerebral lesions, performed at the Centre hospitalier universitaire vaudois (CHUV) on April 29th 1997, revealed fragments of a poorly differentiated sarcoma. After referral back to Neuchâtel, the patient suffered suddenly three weeks later from a cerebral vascular insult with instant onset of deep coma. She deceased on May 27. At autopsy we found a neoplastic lesion of the left auricle with invasion of the pulmonary veins. The histological appearance is similar to the appearance of the cerebral metastasis, showing a proliferation of spindled cells with a partial positivity for Vimentine. It was classified as a fibrosarcoma. Metastasis were found only in the brain with postoperative ischemic left occipitotemporal necrosis and neoplastic emboli.--We are discussing the various incidences of cardiac neoplasms in autopsies or biopsies.

[Arterial hypertension in the elderly. Is there still room for diuretics?]. / Hypertension artérielle du sujet âgé. Quelle place reste-t-il pour les diurétiques?

Hypertension (HTA), whether systolic and diastolic or as isolated systolic hypertension, has been firmly established as a major risk factor of morbidity and cardiovascular mortality in elderly patients. Despite recent controversies that have appeared in the literature on the metabolic disturbances caused by diuretics, especially hypokalemia, and the absence of a significant advantage on coronary mortality, these drugs should nevertheless be considered as extremely important in the treatment of HTA. Prescribed at small doses, their long-term effects are by far the best documented of all antihypertensive drugs. Their mechanisms as well as their main side effects are described below. Finally, the authors give some simple guidelines on their use, more specifically in elderly patients.

[Treatment of arterial hypertension. Re-emergence of diuretics]. / Traitement de l'hypertension artérielle. La renaissance des diurétiques.

Recent epidemiological studies on the management of arterial hypertension confirm the need to reserve special attention to diuretics in our prescription routine. The author analyzes briefly the eight essential points in favour of a first-intention treatment of hypertension. The cost-efficiency ratio of diuretics remains extremely favourable, and the success in a reduction of arterial blood pressure is still comparable to that of other classes of antihypertensives.

[Behçet's disease and renal amyloidosis]. / Maladie de Behçet et amyloïdose rénale.

We report the case of an 29-year-old male Turkish patient suffering from generalized Behçet's disease. After an evolution of twelve years, he suddenly presented a nephrotic syndrome, a terminal renal insufficiency and thrombosis of the renal veins as well as the inferior vena cava. A percutaneous renal biopsy showed amyloidosis of the AA type, characteristic of secondary amyloidosis. Attempts to install an arterio venous shunt of the arm and to set up a peritoneal dialysis catheter were complicated by septic thrombosis. The patient died of renal failure. The association of renal amyloidosis and Behçet's disease is rare. It is, as far as we know, the first case reported in Switzerland.

[Inflammatory myopathy: unusual presentation of a case of Wegener disease]. / Myopathie inflammatoire: présentation inhabituelle d'un cas de maladie de Wegener.

The case is presented of a 66-year-old man who developed an inflammatory myopathy picture predominantly consisting in leg weakness. Wegener's granulomatosis was diagnosed on the basis of suggestive thoracic imaging, microhematuria and necrotizing arteritis with granulomas in muscular biopsy. An increasing titer of anti-neutrophilic cytoplasm auto-antibodies (ANCA) confirmed the diagnosis. Rapid resolution was obtained by classic immunosuppressor treatment (cyclophosphamide and corticoids), without worsening of renal function. In discussion we emphasize the importance of ANCA measurement for diagnosis and follow-up.

[Drug-induced calculi]. / Les lithiases médicamenteuses.

Drug-induced urinary calculi are rarely observed. However, it is useful to know this etiology. A complete anamnesis of drugs and dosages is mandatory if a patient presents with lithiasis, since some pharmacotherapies may carry an enhanced lithogenic risk. The list of lithogenic drugs is discussed. In order to yield preventive data, infrared, spectrophotometry is the best available analytic method.

[Converting enzyme inhibitors and acute renal insufficiency--precautions to be taken]. / Inhibiteurs de l'enzyme de conversion et insuffisance rénale aiguë--précautions à prendre.

Inhibitors of angiotensin-converting enzyme are used commonly nowadays for the treatment of hypertension and cardiac failure. Over the past two years, shortly after the introduction of this type of drug the occurrence of acute renal failure mainly in elderly patients has been reported. The authors have insisted that strict control of renal function and electrolytes are necessary before and after administration of an ACE inhibitor. Particular caution is needed in patients with severe atherosclerotic disease, especially if bilateral (or unilateral in patients with a single kidney) renal arterial stenosis is present or suspected. Considering these limitations ACE inhibitors remain well tolerated and beneficial cardiovascular drugs.

Recurrent adult respiratory distress-like syndrome associated with propylthiouracil therapy.

We report a patient who presented with an association between propylthiouracil treatment and recurrent episodes of an adult respiratory distress-like syndrome (ARDS). The bouts of ARDS were associated with a generalized reaction suggestive of systemic lupus erythematosus (SLE), responsive to corticosteroid therapy.

[Arterial hypertension and obesity]. / Hypertension artérielle et obésité.

Overweight and arterial hypertension have been found to be associated in most studies in diverse populations. Several possible mechanisms for this association have been proposed: hemodynamic modifications, glucose and lipid metabolism alterations, hyperinsulinemia, neuroendocrine abnormalities. However, it seems difficult to explain the relation obesity-hypertension by a single mechanism. The search for a physiopathological explanation including the diverse abnormalities found in obese hypertensive subjects must go on.

[Modifications in the urinary excretion of gamma-carboxyglutamic acid induced by vitamin K]. / Modifications de l'excrétion urinaire de GLA (acide gamma-carboxyglutamique) induite par la vitamine K.

To evaluate urinary GLA excretion, a marker of vitamin K metabolism, the effect of an oral calcium load was studied in 8 volunteers under three conditions: (1) after 1.5 g elementary calcium (calcium carbonate), (2) after 1.5 g calcium (Ossopan, a preparation containing 1 mg osteocalcin per g) and (3) after 1.5 g calcium but with pretreatment of 10 mg vitamin K1 orally for 3 days. No differences in blood calcium, osteocalcin concentration of calciuria were observed. However, GLA excretion was significantly higher with Ossopan or after pretreatment with vitamin K1.