Prevalence of renal artery stenosis in type 2 diabetes.

Renal artery stenosis (RAS) was searched for in a Type 2 diabetes population (n =208) with severe hypertension (SHT) and/or renal deficiency (RD) and/or severe macroangiopathy (MA), using arteriography and/or duplex colour scan (with confirmation by arteriography or magnetic resonance angiography). Thirty-four (16.3 %) cases had significant RAS >=70% (83% unilateral, 17% bilateral; 11.7% with total thrombosis). High significance (P<0.01) (34 RAS vs 174 subjects without RAS) was found for male predominance (sex ratio 0.8), smoking (47%), insulin requirement (65%), prevalence and severity of decreased renal function (65%), severe hypertension (53%), and prevalence of macroangiopathy (82%), especially in association with coronary heart disease (65%). RAS prevalence was low in subjects with only 1 (8%) diagnostic criterion and high when 2 (21%) or 3 (41%) signs were present, regardless of the criterion (HT/RD/MA). A high increase of RAS prevalence was found in males, smokers and patients with heart disease or macroalbuminuria when 2 or 3 diagnostic criteria were present (no increased prevalence for only 1 criterion). RAS screening should be performed in a Type 2 diabetic population with HT, RD, or MA by opacification of the renal arteries at the same time as arteriography for control of another vessel, or by duplex colour scan when 2 or 3 diagnostic criteria are present. This attitude allows a diagnostic score of 85 % of RAS in this Type 2 diabetic population.

The effect of maternal hypothermia on the fetal heart rate.

Fetal bradycardia is a recognized response to maternal hypothermia but has not previously been reported in conjunction with diabetes. A 30-year-old insulin-dependent diabetic was admitted at 35 weeks gestation for control of her diabetes. She developed maternal hypothermia and hypoglycemia and the fetal heart rate fell to 100 beats per minute (b.p.m.). However, the fetal heart rate gradually returned to normal after rewarming the patient.

[Renal artery stenosis and chronic renal failure in NIDDM]. / Sténose de l'artère rénale et insuffisance rénale chronique chez le diabétique de type II.

The NIDDM patient, willingly with high blood pressure and atheroma, has frequently an abnormal renal function. Must a renal artery stenosis (RAS) be searched as a determining or favorising cause? We have searched RAS by color duplex scan, in 60 consecutive NIDDM patients with altered renal function (creatinine clearance < or = 60 mL/min). Metabolic blood pressure (ABPM), cardiovascular and renal investigations have been realised. The population was composed of 22F/38M with middle age: 70.7 +/- 6.2 yrs, diabetic duration: 11.6 +/- 8 yrs, the plasma creatinine was: 161 +/- 78 mumol/L and clearance: 40 +/- 13 mL/min. Thirty eight had albuminuria, 28 had plasma creatinine > or = 150 mumol/L. All patients had high blood pressure. Significative RAS (> or = 70%) was detected in 15 patients (25%) by color duplex scan and proved with arteriography (n = 10) or angio NMR (n = 5). Twelve (80%) had unilateral stenosis (4 thrombosis), 3 (20%) bilateral stenosis. Renal US lead the diagnosis in 10 patients (66%): unilateral or bilateral hypotrophy. Those 15 patients had these following characteristics: 4F/11M (sex R : 0.36), middle age: 70.8 +/- 7.2 yrs, diabetic duration: 14.3 +/- 7.5 yrs, HbA1c was at 8.4 +/- 2%, 8 (53%) patients require insuline and 5 have retinopathy, plasma creatinine was at 169 +/- 6 mumol/L; 32% of patients with plasma creatinine > or = 150 mumol/L had RAS (n = 9/60%), creatinine clearance was at 38 +/- 12 mL/min (7/47% < or = 30 mL/min), 9 (60%) had macroalbuminuria and 5 (33%) microalbuminuria. All hypertensive patients were treated (mean SBP: 148 +/- 16, mean DBP: 82 +/- 7 mmHg) and had 62 +/- 28% SBP escape and 33 +/- 19% DBP escape. Ten had severe hypertension (at least 3 hypotensive drugs), 12 received CEI; 8 (53%) were smokers; 14 (93%) had one or more macroangiopathies (10/66% coronary heart diseases, 7/46% lower limbs arteritis, 6/40% carotid atheroma); 13 of these macroangiopathies are severe. In conclusion, renal failure (especially evolutive and/or treated with CEI) in NIDDM must call up a RAS (25%) specially in elderly males with a long diabetes duration, severe hypertension and macroangiopathies. This patient profile must lead to a color duplex scan to confirm the diagnosis already suspected by the renal echography.

Nine year survey of 138 ectopic pregnancies.

During the nine years (1986-1994), 138 women underwent surgery for ectopic pregnancies (One for every 213 deliveries). The commonest presenting symptom was abdominal pain (96%) followed by vaginal bleeding (83%). Four patients were asymptomatic and were diagnosed at a routine antenatal ultrasound scan. The most frequent physical findings were abdominal tenderness (87%) and followed by adnexal tenderness (57%). Histories of infertility in 17%, use of intrauterine contraceptive device (13%), and previous ectopic pregnancy in 11% were elicited. Eleven patients (8%) had a false negative urinary pregnancy test and subsequently required surgery. The ectopic pregnancies were tubal in 97% of the cases. There were 3 ovarian ectopics and one cervical ectopic.

[Prevalence and profile of renovascular disease in type II diabetic patients with severe hypertension]. / Prévalence et profil d'une atteinte rénovasculaire chez le diabétique de type II hypertendu sévère.

The aim of this study was to determine the prevalence and profile of renal artery stenosis (RAS) in NIDDM population with severe hypertension. 60 consecutive NIDDM with severe HT (> or = 3 hypotensive drugs), 42 F/18 M (SR: 2.8), mean age: 66.6 +/- 6.5 years, diabetes duration: 14.1 +/- 6 years have had metabolic, ABPM and renal investigations: color duplex scan (CDS) (with renal us): n = 60, and/or arteriography: n = 17). 13 (21.5%) renal artery stenosis > or = 70%: 8 unilateral/5 bilateral were proved by arteriography. We compared classic HT (n = 47) versus renovascular HT (n = 13). There was no difference for age (years): 64.8 +/- 8 versus 70.6 +/- 6.4, HT duration (years): 11.6 +/- 6.8 versus 12.3 +/- 6. B.M.I.: 31.5 +/- 6 versus 27.6 +/- 3.3, HBA1C (%): 8.9 +/- 2.2 versus 8.8 +/- 0.9, cholesterol (mmol/L): 5.7 +/- 1.3 versus 5.5 +/- 0.6. Significant difference (p < 0.05) was noticed for S.R. (F/M): 2.9 versus 1.16, diabetes duration (years): 11.7 +/- 5 versus 16.5 +/- 8, frequency of retinopathy (%): 30 versus 61, smoking (%): 10 versus 40, triglycerides (mmol/L): 1.9 +/- 1.1 versus 2.6 +/- 1.1, and (p < 0.01) for blood pressure level (mmHg) (SBP: 142 +/- 20 vs 155 +/- 7, DBP: 81 +/- 13 vs 87 +/- 10, MBP: 103 +/- 16 vs 111 +/- 6), frequency (%) of HT escape (> or = 140/SBP, > or = 90/DBP) on ABPM: 40 versus 75 and 24 versus 40, insulin requirence (%): 36 versus 69, macroangiopathy (%): 51 versus 100 (coronaropathy: 34 vs 61, legs arteritis: 21 vs 69, carotid stenosis: 17 vs 30) and for renal function: frequency (%) of micro-macroalbuminuria: 36 versus 92 creatinaemia (mmol/L): 80 +/- 24 versus 124 +/- 44, creatinaemia clearance (mmL/min): 65 +/- 30 versus 40 +/- 12 while are found 5 renal insufficiencies (> or = 120 mmol/L). In NIDDM population with severe HT, renovascular HT is frequent (21.5%), and RAS must be evocated in unstable HT and/or renal injury with macro angiopathy, old NIDDM (> 15 years), requiring insulin. Colour duplex scan (+ renal US) mays lead to arteriography to confirm renal artery stenosis.

[Prevalence and aspects of arteriopathies in non-insulin-dependent diabetes mellitus with severe hypertension]. / Prévalence et aspects des artériopathies du diabétique non insulino-dépendant hypertendu sévère.

UNLABELLED: Severe hypertension may lead to macroangiopathy complications especially when a major vascular risk factor as diabetes exists. We have studied the prevalence of macroangiopathy in a group of 40 consecutive NIDDM patients with severe hypertension (> or = 3 hypotensive drugs) (grS) that we have compared to 80 consecutive NIDDM patients with controlled hypertension (1 or 2 hypotensive drugs) (grC). All patients have had metabolic, blood pressure (ABPM) and vascular (color duplex) investigations. The two groups were similar for age (years): 61.9 > or = 9 versus 65.2 +/- 9.5, diabetes duration (years): 10.7 +/- 7 versus 12.1 +/- 8 and hypertension duration: (years) 8.9 +/- 8 versus 11.7 +/- 7.3. The mean level of blood pressure was the same in all patients (mmHg): SBP = 138 +/- 14 versus 144 +/- 20; DBP = 80 +/- 9 versus 83 +/- 13; MBP = 100 +/- 10 versus 105 +/- 15. The frequency (%) of escape SBP (> 140): 50 versus 80, p < 0.01), and DBP (> 90): 29 versus 35, p < 0.05 was significantly higher in grS. Twenty (25%) patients in grC and 20 (50%) in grS had one or more macroangiopathy which was dispatched as follow: coronary heart disease n = 8 (7%) versus 13 (32.5%), p < 0.01; lower limb arteritis n = 12 (15%) versus n = 9 (22%), NS; carotid atheroma n = 5 (25) versus n = 6 (15%), NS. All significant renal artery stenosis (RAS) n = 8 (20%) were found in grS (p < 0.001). Only plasma triglyceride level (mmol/L) was statistically higher in grS 2.5 +/- 1.2 versus +/- 1 while BMI, plasma cholesterol, HbA1C, and creatininemia were NS. The sex-ratio (F/M) 1.28 versus 3, insulin requirement (%): 11 versus 42.5, retinopathy (%) 14 versus 45 and micromacroalbuminuria were statistically significant p < 0.01. CONCLUSION: macroangiopathy is frequent in severe hypertension (50%) versus controlled hypertension (25%) in NIDDM patients especially coronary heart disease (32.5%); the prevalence of RAS is high in grS (20%). The following criteria are frequently noticed in high risk patients: insulin requirement, micro or macroalbuminuria and high plasma triglyceride.

A review of granulosa cell tumours and thecomas of the ovary.

This review is a retrospective study of granulosa cell tumours and thecomas encountered in one hospital between 1970 and 1995. There were 16 granulosa cell tumours and 17 thecomas. The size of the granulosa cell tumours varied from 3 to 30 cms in diameter and no correlation was found between size and evidence of invasion. There was also no correlation between either mitotic counts or histological pattern and evidence of invasion. Evidence of oestrogen production was found in 11 of the sixteen granulosa cell tumours (2 with endometrial carcinoma and 9 with endometrial hyperplasia) and in 9 out the seventeen thecomas (2 with endometrial carcinoma and 7 with endometrial hyperplasia). Thecomas are regarded as benign tumours but granulosa cell tumours are characterised by a long natural history with a significant capacity to recur years after an apparent clinical cure. It is therefore important that patients with these tumours are followed up indefinitely.

A five-year review of ectopic pregnancy.

During the five years from 1990-1994, 98 women underwent surgery for ectopic pregnancy. For every 167 deliveries, one patient underwent surgery for ectopic pregnancy. The incidence is 0.59 per cent with a rising trend. The commonest presenting symptom was abdominal pain (97%) followed by vaginal bleeding (79%). Four patients were asymptomatic and were diagnosed at routine antenatal ultrasound scan. The most frequent physical findings were abdominal tenderness (91%), followed by adnexal tenderness (54%). Histories of infertility (15%), use of intrauterine contraceptive devices (14%), and previous ectopic pregnancy (11%) were elicited. Five patients had a false negative urinary pregnancy test and subsequently required surgery. The ectopic pregnancies were tubal in 98 per cent of the cases. The diagnosis and management of ectopic pregnancy has changed significantly over the last decade. The increasing use of quantitative BHCG assay and vaginal ultrasonography have made early diagnosis possible, allowing conservative tubal surgery when indicated.

Sex cord-stromal tumours of the ovary- a 25 year review.

We present a retrospective study of granulosa cell tumours and thecomas encountered in one hospital between 1970 and 1995. There were 17 granulosa cell tumours and 17 thecomas. The size of the granulosa cell tumours varied from 3 cm to 30 cm in diameter, and no correlation was found between size and evidence of invasion. There was also no correlation between either mitotic counts or histological pattern and evidence of invasion. Evidence of oestrogen production was found in 12/17 granulosa cell tumours (two with endometrial carcinoma and 10 with endometrial hyperplasia) and in 9/17 of the thecomas (two with endometrial carcinoma and seven with endometrial hyperplasia). Thecomas are regarded as benign tumours, but granulosa cell tumours are characterised by a long natural history with a significant capacity to recur years after an apparent clinical cure. It is therefore important that patients with these tumours are followed up indefinitely.

Adult granulosa cell tumours of the ovary.

This review is a retrospective study of granulosa cell tumours encountered in one hospital between 1970 and 1995. There were 16 granulosa cell tumours. The size of the granulosa cell tumours varied from 3 to 30 cms in diameter and no correlation was found between size and evidence of invasion. There was also no correlation between either mitotic count or histological pattern and evidence of invasion. Evidence of oestrogen production was found in 11 of the 16 granulosa cell tumours (2 with endometrial carcinoma and 9 with endometrial hyperplasia). Granulosa cell tumours are characterised by a long natural history with a significant capacity to recur years after an apparent clinical cure. It is therefore important that patients with these tumours are followed-up indefinitely.

Primary aldosteronism in pregnancy--should it be treated surgically?

We report a case of primary aldosteronism in pregnancy that was treated surgically by removal of the adenoma in the 2nd trimester. Only a few cases have been reported in the English literature due to the rarity of the condition. Primary aldosteronism follows a variable course in pregnancy. In the majority of cases the hypertension and hypokalaemia are made worse, necessitating antihypertensive medication to control the blood pressure. Some of the drugs required for treatment are known to affect the fetus. In a minority of cases the hypertension improves with pregnancy. This is thought to be due to the high levels of progesterone which is an aldosterone antagonist. Primary aldosteronism invariably gets worse in the post partum period, irrespective of the antenatal course of the disease. Surgery seems to be the treatment of choice for this condition, provided the adenoma is localised. It has the advantage of offering an immediate solution, avoids fetal complications of medical treatment and possible deterioration in the post partum period.

[Treatment of pulmonary thromboembolism with extrinsic plasminogen activator. A case report]. / Tratamento do tromboembolismo pulmonar com ativador extrínseco do plasminogênio. Relato de caso.

A 49 year-old woman with acute pulmonary thromboembolism and severe hemodynamic impairment was successfully treated with tissue-type plasminogen activator (r-TPA). She did not have previous pulmonary or cardiac diseases. Thirty days after immobilization of the right ankle, she had a sudden onset of dyspnea, epigastrial pain and syncope. As heparin therapy was unsuccessful, 90 mg of IV r-TPA was administered. There was rapid clinical and hemodynamic improvement of her condition. Pulmonary scanning one week later was normal and she was discharged without symptoms 12 days after the acute episode.