[Uncommon diagnosis in a patient with fever and new-onset cardiac murmur]. / Seltene Diagnose bei febrilem Patienten mit neu entdecktem Systolikum.

HISTORY AND PHYSICAL FINDINGS: A 34-year old man was referred because of persistent low-grade fever and a newly-diagnosed systolic murmur. He complained of atypical chest pain and dyspnoea on exertion for the past few weeks. STUDIES: Blood analysis revealed an elevated CRP level (67.7 mg/l) along with a hypochromic, microcytic anaemia (Hb 122 g/l). Transthoracic echocardiography showed an extracardiac tumour compressing the right ventricular outflow tract. Computed tomography (CT) localized the tumour in the anterior upper mediastinum. Subsequently, a biopsy was carried out and revealed a non-seminomatous germ-cell tumour. DIAGNOSIS, TREATMENT AND COURSE: The diagnosis having been made the patient received four cycles of chemotherapy according to the BEP-protocol (bleomycin-etoposide-cisplatin). The remaining tumour was then resected surgically. After additional cycles of chemotherapy two autologous stem cell transplantations were carried out. CONCLUSION: This patient presented initially with symptoms typical of endocarditis. However, the reason for his newly diagnosed systolic murmur and persistent fever was an extracardiac germ cell tumor compressing the right ventricular outflow tract.

[Are we treating coronary heart disease and heart failure appropriately in the clinic and ambulatory care? Secondary prevention and drug therapy 1998]. / Therapieren wir die koronare Herzkrankheit und die Herzinsuffizienz in der Klinik und ambulant konsequent? Sekundärprophylaxe und medikamentöse Therapie 1998.

We examined retrospectively 186 patients with acute coronary syndrome (ACS) and 163 patients with cardiac insufficiency (CHF) regarding secondary prevention in hospital or externally. Of the Inhospital-patients with ACS 99% had antithrombotic medicaments (AT), 73% betablockers and 73% a statin. CHF-patients had ACEH in 69%. Externally 120 patients with known coronary heart disease (CHD) received in 91% AT, 66% betablocker, 30% statins and 111 CHF-patients in 49% ACEH. Compared to other studies medical therapy ameliorated in CHD and CHF either stationary and ambulatory. The reasons for low prescription of statins may be due to short time since positive results occurred and to the expensive costs in the setting of pressure because of high cost in health system.

Evidence for age-based rationing in a Swiss university hospital.

AIM: To test the hypothesis that rationing of medical management mainly based on age exists in our health care system today. METHODS: We studied 303 consecutive patients hospitalised for acute coronary syndrome (ACS) and 163 consecutive patients hospitalised with congestive heart failure (CHF). They were divided into two age groups; patients aged less than 75 years and those equal to or older than 75 years. RESULTS: Our main findings were a significant underuse of stress tests (p < 0.001) and coronary angiography (p < 0.0001) in elderly patients with ACS and a significant underuse of echocardiography (p < 0.0001) in patients with CHF of the same age group. In patients with ACS, there was also a trend towards underuse of statins in elderly patients with hypercholesterolaemia. In addition, we noted that the use of beta-blockers in ACS and of ACE inhibitors in CHF was better than in previous published studies but that many patients were still not treated according to evidence based medicine. CONCLUSION: The lower rates of diagnostic tests performed and the lower statin use observed in elderly patients suggest "hidden" rationing of health care in elderly patients.

Protective effects of endothelin receptor antagonists in dogs with aortic cross-clamping.

Endothelin (ET) may play an important role in the pathogenesis of vasoconstriction and acute renal failure after aortic cross-clamping (ACC). However, the relative contribution of the ET(A) and ET(B) receptors to the physiopathology of ischemic acute renal failure is poorly understood. This study was carried out to evaluate the potential protective effect of a selective ET(A) antagonist versus combined ET(A)/ET(B) antagonist on altered systemic, pulmonary, and renal hemodynamics induced by cross-clamping the suprarenal aorta for 1 h, followed by 2-h reperfusion. Studies were performed in three groups of anesthetized mongrel dogs. After baseline measurements, treatment (3 mg/kg i.v. bolus + 3 mg/kg/h infusion) with either a selective ET(A) antagonist, Ro 61-1790 (n = 5), or a combined ET(A)/ET(B) antagonist, bosentan (n = 5) or vehicle (n = 8) was initiated 5 min before ACC. There were marked increases in total peripheral (TPR), pulmonary (PVR), and renal (RVR) vascular resistances, and significant decreases in cardiac output (CO) and glomerular filtration rate (GFR) and tubular sodium reabsorption after ACC in the vehicle group. Both Ro 61-1790 and bosentan prevented the marked increases in TPR, PRV, and RVR, and attenuated the declines in CO, GFR, and tubular sodium reabsorption. We concluded that the profound systemic, pulmonary, and renal vasoconstriction, as well as the impairments in glomerular and tubular functions associated with ACC, is mostly ET mediated and that the ET(A) receptor activation makes a major contribution to the ET-mediated impairments of hemodynamics and renal function after ACC.

Effects of nonpeptide endothelin receptor antagonists in rats with reduced renal mass.

This study was set up to evaluate the long-term effects of nonpeptide endothelin (ET) antagonists in rats with renal mass reduction (RMR). In the first series of experiments, rats were administered bosentan (100 mg/kg/day) or the angiotensin-converting enzyme inhibitor cilazapril (10 mg/kg/day) for 14 weeks beginning 24 h after RMR. As expected, cilazapril completely prevented the development of hypertension, proteinuria, and renal structural damage. In contrast, bosentan had no influence on the development of proteinuria and renal structural damage, although it had a moderate antihypertensive effect and improved creatinine clearance. A second set of experiments was performed to assess whether Ro 48-5695, a very potent ET antagonist optimized from bosentan, could prevent the development of renal damage and reverse established renal damage. Rats received Ro 48-5695 (30 mg/kg/day) beginning either 24 h (prevention) before for 8 weeks, or 4 weeks (reversal) after RMR. Ro 48-5695 attenuated the hypertension and the decline of creatinine clearance when treatment was started at 24 h, but not when started at 4 weeks. Ro 48-5695 had no effect on proteinuria. These observations suggest that ET-receptor activation does not play a major role in the progression of glomerular sclerosis in this model of chronic renal failure.

The endothelin ETB receptor mediates both vasodilation and vasoconstriction in vivo.

It has been suggested that the endothelin (ET) ETB receptor could mediate endothelium-dependent vasodilation to ET-1 or ET-3, but its in vivo role is still largely unknown. We used sarafotoxin S6C, a selective agonist of the ETB receptor, to study the in vivo effects of ETB stimulation. SRTX S6C induced a transient decrease in blood pressure, followed by a long-lasting pressor response accompanied by a marked renal and mesenteric vasoconstriction. No constriction was observed in isolated mesenteric arteries in vitro, indicating that the in vivo vasoconstrictor effect is most likely indirect. The pressor effect of SRTX S6C was not dependent on central stimulation of ETB receptors and was not mediated by catecholamines from the adrenal medulla, prostanoids or ET-1.

Is substance P the transmitter at the first synapse of the baroreceptor reflex in rats and cats?

1. Substance P, injected into a lateral brain ventricle of urethane-anaesthetized rats, caused dose-dependent increases in blood pressure and heart rate. 2. By contrast, exposure of the obex region of the medulla oblongata to pieces of filter paper soaked in substance P-containing solution resulted in falls of blood pressure and heart rate in both rats and cats. 3. A more precise application of substance P to the first synapse of the baroreceptor reflex by micro-injection into defined areas of the nucleus of the solitary tract also led to an activation of the baroreceptor reflex. 4. Capsaicin, which is known to release substance P from primary afferents, mimicked the sympatho-inhibitory and cardiovascular effects of substance P when applied locally to the nucleus of the solitary tract. 5. The results are compatible with a transmitter or neuromodulatory role for substance P at the first synapse of the baroreceptor reflex.

Evidence suggesting a transmitter or neuromodulatory role for substance P at the first synapse of the baroreceptor reflex.

There is evidence that the undecapeptide substance P is the transmitter released from pain fibres in the dorsal horn of the spinal cord. This, in turn, suggested to use the possibility of a similar role for substance P in another type of primary sensory structure, namely the baroreceptor neurones which terminate in the bulbar nucleus of the solitary tract (NTS). Substance P, injected into a lateral brain ventricle of urethane-anaesthetized rats, caused dose-dependent increases in blood pressure and heart rate. By contrast, local application of substance P to the region of the NTS, using small pieces of filter paper soaked in substance P-containing solution, resulted in hypotension and bradycardia. In cats anaesthetized with urethane, the same procedure also decreased blood pressure, heart rate and spontaneous sympathetic nervous activity. Release of substance P from nerve endings, through local application of capsaicin to the NTS, produced cardiovascular effects which were indistinguishable from those of substance P. A combined cannula-electrode with an uninsulated tip enabled identification of sites in the NTS of rats and cats, where electrical stimulation elicited decreases in blood pressure, heart rate and spontaneous sympathetic nervous activity. These sites were considered to contain the first synapse of the baroreceptor reflex. Subsequent microinjection of substance P through the cannula into these defined areas resulted in effects which were similar to those of the preceding electrical stimulation. The results suggest a transmitter or neuromodulatory role for substance P at the first synapse of the baroreceptor reflex in the NTS.

[The burden of a general medical clinic with patients after suicide attempts]. / Die Belastung einer internmedizinischen Klinik durch Patienten nach Suizidversuchen

All 125 patients who entered the "suicide ward" of the Medical Department of a large public hospital during 1974 were analyzed according to age and sex distribution, duration of hospital stay, motivation and method of committing suicide and fate after recovering from the acute phase of intoxication. Motivation to commit suicide was mainly due to conflicting interpersonal relations. Suicide attempts were 3 times more frequent in women than in men. 49% of all suicide attempts were considered to be of the "cry for help" variety and 29% were classified as obviously ineffective but serious attempts of self-killing. The remaining 22% of patients wanted to mark a "caesura" in their lives. Since the early phase of recovery is of utmost importance for the patient's future, medical and nursing staff have to be trained and experienced in coping with the suicide patient's numerous problems. The permanent collaboration of an experienced psychiatrist within the staff of larger acute-phase hospitals is highly desirable in order to analyze the underlying social and medical problems, assess the danger of a renewed suicide attempt, start early and appropriate therapy and train hospital staff and nurses.