Bone and renal components in hypercalcemia of malignancy and responses to a single infusion of clodronate.

Increased bone resorption (BR) and increased renal tubular reabsorption of calcium (TRCa) may both be involved in the pathogenesis of hypercalcemia of malignancy (HM). We have evaluated the relative importance of these two mechanisms in 33 patients with HM after extracellular volume expansion and after single infusion of clodronate (C12MDP: 500 mg iv over 8 h). The fasting urine Ca/creatinine ratio was taken as an index of BR (BRI). An index of TRCa was calculated (TRCaI) from a nomogram based on the relationship between urine Ca excretion per unit of glomerular filtration rate and plasma Ca (PCa). Mean (+/- SEM) PCa fell from 3.29 +/- 0.07 to 2.69 +/- 0.05 mmol/l three days after C12MDP (n = 33, p less than 0.001), a response similar to that obtained with repeated daily iv injections of 500 to 1000 mg C12MDP. The pathogenesis of hypercalcemia varied according to the type of neoplasm. BRI was the highest in multiple myeloma and breast tumors. TRCaI was markedly increased in squamous-cells lung, bladder, kidney and liver carcinomas, reaching levels observed in primary hyperparathyroidism. TRCaI was normal in most cases of multiple myeloma. Breast tumors appeared to be heterogeneous with respect to TRCaI. The fall in PCa in response to a single infusion of C12MDP was usually most marked in cancer patients with elevated BRI and normal TRCaI. It was very modest in patients with high TRCaI and slightly elevated BRI. In conclusion, this study confirms that stimulation of bone resorption is not the only mechanism of the maintenance of hypercalcemia of malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Lumbar erosive intervertebral osteochondrosis. Anatomico-radiological study of a case.

A radiological and anatomical case study of intervertebral osteochondrosis is presented. X-rays reveal its evolution from an isolated Schmorl's node to a more diffuse lumbar intervertebral osteochondrosis. Macroscopical and microscopical post-mortem examination shows various degrees of disc deterioration with cartilaginous plate flaw and localized or diffuse intravertebral disc herniation. A discussion on the origin of this cartilaginous plate weakness and on the respective significance of the X-ray and biopsy in the differential diagnosis between intervertebral osteochondrosis and infectious spondylitis follows.

[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.

[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.

[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.

[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.

[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.

[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.

Bilateral osteochondritis dissecans of the carpal scaphoid. A radiological and anatomical study of one case.

The results of an anatomical and radiological study of one unusual case of bilateral osteochondritis dissecans of the carpal scaphoid are reported. On both sides, histological examination of the excised surgical specimen showed previous remodelling of the bone and marrow which had been followed by further aseptic necrosis. On the painful left side the sequestrum itself was fractured and appeared to be involved in a localised cystic remodelling reaction. The observations are discussed as an example of the histological changes in aseptic bone necrosis as well as an unusual type of pathology affecting the carpal scaphoid.

[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.

[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.

[Non-specific chronic obstructive bronchopneumopathy and nutrition]. / Bronchopneumopathie obstructive chronique non spécifique (BPCO) et nutrition.

Malnutrition is often observed in patients with chronic respiratory failure, particularly during acute episodes. In this short review, we discuss the nutritional status of patients suffering from chronic obstructive pulmonary disease (COPD) in the stable and acute phases, and the consequences of malnutrition for some components of the respiratory system (respiratory muscles, pulmonary tissue and ventilation control). Finally we propose a realimentation protocol, although at present time there is no proof that renutrition influences short or long term prognosis in such patients.