[Endocrine hypertension in pregnancy]. / Hypertensions artérielles endocriniennes au cours de la grossesse.

Hypertension is a frequent complication of pregnancy and may compromise fetal and maternal outcome. Hypertension may be pregnancy-induced, essential or secondary to endocrine disorders. Most cases of endocrine hypertension are the consequence of adrenal diseases. Pheochromocytoma, hypercorticism, primary aldosteronism or glucocorticoid-remediable aldosteronism can be present or diagnosed at any term and may cause severe hypertension. The most hazardous form of endocrine hypertension during pregnancy is pheochromocytoma because it may involve paroxysmal arrhythmia and/or hypertension during labor. Clinical clues and biological tests are similar to those used in non-pregnant subjects. Tests for tumor location are limited to ultrasound and magnetic resonance scans in order to avoid maternal and fetal irradiation. Medication to prepare for pheochromocytoma surgery uses alpha- and beta-blockers. The timing of surgery depends on the term of pregnancy at the diagnosis of the tumor.

[Arterial hypertension secondary to curable causes in adults]. / Hypertensions artérielles secondaires à des causes curables chez l'adulte.

EXTENSIVE AND COSTLY INVESTIGATIONS: Are not warranted in the vast majority of hypertensive patients. Characteristics identifying the patients at risk for secondary hypertension can be used to define the small percentage of patients with hypertension who require more extensive diagnostic testing and management of their condition. Exposure to certain medicines, foods or drugs may cause reversible rises in blood pressure. Renovascular and adrenal diseases cause curable forms of hypertension. IN MANY CASES, THE PATIENT'S HISTORY: Examination and simple tests can detect such exposures and disorders. Checking for secondary hypertension is therefore an early step required for the management of all patients with hypertension, provided it is based on clinical signs and inexpensive tests. This primary screening cannot exclude the possibility of renovascular or adrenal disease in a small number of asymptomatic patients. The risk of missing a diagnosis is acceptable provided that blood pressure is normalized by non-specific antihypertensive treatment. However, more extensive etiologic investigation is required in patients who subsequently develop resistant hypertension. This secondary screening requires imaging and biochemical tests that are not required for primary screening. CORRECTION OF THE CAUSES: Of secondary forms of hypertension may restore blood pressure to normal. The patient's age affects the reversibility of renovascular and adrenal hypertension after etiologic treatment: the younger the patient, the higher the probability of blood pressure normalization.

[Revascularization of atherosclerotic stenosis of the renal artery. Indications and results]. / Revascularisation des sténoses athéroscléreuses de l'artère rénale. Indications et résultats.

RISKS: Atherosclerotic renal artery stenosis typically occurs in high risk patients with coexistent vascular disease elsewhere. Patients with atherosclerotic renal artery stenosis may develop progressive renal failure but have a much higher risk of dying with a stroke or a myocardial infarction than of progressing to end-stage renal disease. REVASCULARIZATION RESULTS: Recent controlled trials comparing medication to revascularization have shown that only a minority of such patients can expect hypertension cure, whereas trials designed to document the ability of revascularization to prevent progressive renal failure are not yet available. Percutaneous renal artery angioplasty is the first choice because it is simpler than and as effective as surgical reconstruction. INDICATIONS: Revascularization should be undertaken in patients with atherosclerotic renal artery stenosis and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition. Older age, long history of hypertension and a kidney size less than 8 cm are associated with little chance of blood pressure improvement or kidney function recovery. PRACTICAL ATTITUDE: With or without revascularization, medical therapy using antihypertensive agents, statins and aspirin is necessary in almost all cases. Blood pressure and plasma creatinine concentration should be measured every three months. Kidney size and renal artery patency should be assessed yearly.

Is primary aldosteronism underdiagnosed in clinical practice?

1. Primary aldosteronism is a syndrome consisting of hypertension, suppressed renin activity or concentration and high aldosterone levels in plasma or urine. The main steps in diagnosis are the determination of renin and aldosterone levels, the demonstration of renin-aldosterone dissociation and discrimination between idiopathic hyperplasia and Conn's adenoma, with only Conn's adenoma amenable to surgery. 2. Patients with resistant hypertension and/or hypokalaemia should be screened for primary aldosteronism with simple, redundant hormonal tests. The aldosterone to renin ratio is a logical initial screening test, a high ratio demonstrating renin-aldosterone dissociation. Criteria for a high ratio should be determined in each laboratory. 3. In patients with documented primary aldosteronism, computed tomography scan and adrenal vein sampling help to distinguish between idiopathic hyperplasia and Conn's adenoma. 4. Patients with low renin hypertension, idiopathic hyperplasia and Conn's adenoma have overlapping values for plasma concentrations of potassium, renin and aldosterone and the aldosterone to renin ratio. Because primary aldosteronism subtypes are quantitative diseases, the true prevalence of primary aldosteronism cannot be defined. 5. The use of sensitive screening tests (e.g. aldosterone to renin ratio) gives a higher prevalence of diagnosed cases of primary aldosteronism, but not of surgically correctable forms. Therefore, there is no clinical evidence that primary aldosteronism is underdiagnosed. 6. There is a need for tests to predict the postoperative blood pressure outcome of surgery in subjects with Conn's adenoma.

Intrapleural treatment with recombinant gamma-interferon in early stage malignant pleural mesothelioma.

BACKGROUND: This report presents the results of a prospective multi-institutional study of intrapleural treatment with gamma-interferon in patients with Butchart's Stages I and II epithelial or mixed malignant pleural mesothelioma. METHODS: Interferon was administered at a dose of 40 million units twice a week for 8 weeks intrapleurally via a catheter or an implantable port. Thoracoscopic or surgical biopsy was performed if computed tomography scan 2 weeks after the end of treatment demonstrated a reduction in tumor size. Survival was calculated after a follow-up of at least 18 months. Prognostic factors were identified by univariate and multivariate analyses (Cox model). RESULTS: Eighty-nine patients were included over 46 months. Eight histologically confirmed complete responses and nine partial responses with at least a 50% reduction in tumor size were obtained. The overall response rate was 20%. Most responses were achieved in patients with early stage disease. The response rate for patients with Stage I disease was 45%. Tolerance of interferon was good. Treatment was performed on an outpatient basis. The main side effects were hyperthermia, liver toxicity, neutropenia, and catheter-related infection. CONCLUSIONS: Gamma-interferon is effective mainly in Stage I mesothelioma, especially if the tumor is confined to the parietal or diaphragmatic pleura (Stage IA).

Activity of intrapleural recombinant gamma-interferon in malignant mesothelioma.

Twenty-two consecutive patients with malignant diffuse pleural mesothelioma were treated with recombinant gamma-interferon by the intrapleural route. Diagnosis was made by thoracoscopic examination and all cases were confirmed by the French Mesothelioma Panel of Pathologist. Patients were staged based on thoracoscopic examination and computed tomography (CT) scan: 12 patients were classified as Stage I and 10 were Stage II. A solution of gamma-interferon (40 X 106 U) was infused twice a week over 2 months. Every patient experienced fever. One patient had a Grade 2 leukopenia and one patient suffered from pleural empyema. Response evaluation was based on the following: (1) CT scan performed 2 weeks after treatment ended, and (2) repeat thoracoscopic examination with histopathologic verification in nine patients who had demonstrated a stabilization or a regression of the disease on CT scan. From the original group, 19 patients could be evaluated. Four complete thoracoscopic histopathologic responses and one partial response were observed in Stage I patients (56%). One partial response was observed in Stage II patients.

Severe respiratory syncytial virus pneumonia in an adult renal transplant recipient: successful treatment with ribavirin.

Respiratory syncytial virus (RSV) pneumonia may be a severe disease especially in immunocompromised patients. It is quite rare in adults. We report a case of severe RSV pneumonia in a 38-year-old male renal transplant recipient with successful outcome after ribavirin aerosol therapy.

[Critical study of methods for the diagnosis of allergic asthma]. / Etude critique des moyens de diagnostic de l'asthme allergique.

A search for an allergic cause in asthma is fundamental to the diagnosis. Typically it is based on: A clinical history. Specific cutaneous and inhaled provocation tests which can produce a possible reaction (early and delayed) which are of great pathophysiological and therapeutic interest. In vitro tests (which enable the different phases of the allergic reaction to be distinguished) to know the serum IgE antibody levels (total IgE, specific IgE and their fixation to cell receptors) cell tests on the degranulation of basophils and the dosage of chemical mediators: histamine, leukotrienes, prostaglandins, P.A.F. in the serum or in the bronchial alveolar lavage liquid, from the study of cells or tissue samples. In this regard the authors stress two recent techniques enabling direct access to bronchial tissue and the pulmonary parenchyma, which are bronchoalveolar lavage and bronchial biopsy, both are possible today by using a fibroscope. The broncho-alveolar lavage still remains in the research area, and is not always well tolerated in asthmatics. It already allows a better definition of the major allergic cytological and biochemical components in asthma (IgE, IgA, albumin, phospholipids, mast cells and eosinophils). Bronchial biopsies with ultra-structural studies, and above all immunopathology (by immunofluorescent techniques and peroxidase stains) enable groups of asthmatics to be uncovered who were considered as non-allergic by the unsuspected intervention of hypersensitivity mechanisms to IgE (the presence of cells carrying IgE); these biopsies enable the importance of inflammatory factors to be confirmed and equally to establish the prognosis in certain asthmatics by the degree of irreversibility of the lesions (fibronectin).(ABSTRACT TRUNCATED AT 250 WORDS)

[Tissue immunopathology methods for the diagnosis of bronchopulmonary diseases]. / Apport des méthodes d'immunopathologie tissulaire au diagnostic des maladies broncho-pulmonaires.

The authors draw attention to the diagnostic value of tissue immunopathology methods in numerous bronchopulmonary diseases. Having emphasized the strict technical requirements and difficulties of these methods--all obstacles that are necessary for an accurate evaluation of the lesion--they use concrete examples to demonstrate the usefulness of extra-thoracic, skin or muscle biopsies to diagnose some systemic diseases, such as lupus erythematosus or Churg and Strauss syndrome. They also refer to bronchial biopsies which provide information on the aetiology and pathogeny of adult asthma, and to the prognostic and therapeutic value of collagen studies in idiopathic pulmonary fibrosis.

[Protected distal aspiration in the identification of pathogenic microorganisms in pneumologic intensive care]. / Apport de l'aspiration protégée distale à l'identification de micro-organismes pathogènes en réanimation pneumologique.

To identify the micro-organisms responsible for bronchopulmonary infections in intensive care patients is an absolute prerequisite to successful treatment. Numerous techniques of specimen collection have been used to facilitate this bacteriological diagnosis. In this study, which involved 27 intensive care patients selected according to various criteria of infection, endotracheal aspiration (a commonly used but not very specific technique) was compared with protected distal brushing under fibroscopy and with protected distal aspiration. The latter method, still seldom used, proved as specific as protected distal brushing (hitherto regarded as the reference method), but it also presents the enormous advantages of being rapid, non-traumatic, devoid of side-effects and easily performed in hospital routine by paramedical staff.

[Intravascular bronchioloalveolar tumor or I.V.B.A.T. Apropos of a case and review of the literature]. / "Intravascular bronchioloalveolar tumor" ou I.V.B.A.T. A propos d'un cas et revue de la littérature.

Intravascular bronchioloalveolar tumor is a rare tumour of the lung. Having observed a case detected during systematic examination in a 44-year old woman, the authors compare the radiological, clinical, histological and evolutive signs of the disease with those reported in the 40 cases published since the first description by Dail and Liebow, in 1975.

[Hypercalcemic sarcoidosis and primary hyperparathyroidism disclosed by renal insufficiency]. / Sarcoïdose hypercalcémique et hyperparathyroïdie primaire révélées par une insuffisance rénale.

Primary hyperparathyroidism and sarcoidosis were found in one patient with hypercalcemia and renal failure. Cervicotomy disclosed a parathyroid adenoma and renal biopsy demonstrated interstitial nephropathy. Association of sarcoidosis with hyperparathyroidism, if not fortuitous, has not yet been clearly established.