[Early pregnancy termination: what the generalist should know]. / L'interruption de grossesse précoce: ce que le praticien doit savoir.

Termination of pregnancy before 12 weeks after the last menstrual period is requested by an important number of women. We review the legal framework of abortion in Switzerland and the most used methods for medical abortion precising their contra-indications and most frequent complications. Very rare but fatal cases of infection following medical abortion (with mifepristone and misoprostol) were recently described. We present their clinical characteristics and discuss the related physiopathological process.

[Cancer and fecundity]. / Cancer et fécondité.

The overall increase in relative survival rates of adult and childhood cancer patients is related to improved chemotherapy and radiotherapy treatment protocols. However, this success is tempered by gonadotoxic effects and uterine damage. The reduced fertility and possible premature menopause can have a profound impact on patients self-esteem and quality of life. Consequently, preservation of fertility or treatments to protect the ovarian function, become a more relevant issue. Advances in assisted reproduction techniques have focused on the following: embryo cryopreservation which is restricted by time and constrains such as, sexual maturity and the presence of a stable partner. Cryopreservation of immature ovarian tissue, the most promising option, with restoration of natural fertility following auto-transplantation or maturation of oocytes in vitro in combination with assisted reproduction.

[Family planning, what's new?]. / Quoi de neuf en matière de contraception?

Women rely on complete and precise information given by doctors and family planning consultants for choosing a suitable contraceptive. Available hormonal contraceptives in Switzerland are presented. Personal and family history are essential for evaluating medical contraindications to combined hormonal methods. Combined pills, vaginal hormonal rings and combined patches share the same contraceptive effects, contraindications and overall cardiovascular risks. Prescribers should prefer second generation pills because of lower risks of venous thromboembolic disease. Non oral methods are generally associated with improved compliance and in the case of vaginal rings, with fewer side effects. Progestogen only contraceptives (pills, implants and intrauterine devices) can be used in patients with known intolerance and/or contraindications to estrogens.

[Menopause: where are we three years beyond WHI?]. / Menopause: où en sommes-nous trois ans après la WHI?

The WHI triggered a great debate on Menopausal Hormonal Therapy. We now know that HT should not be used in cardio-vascular prevention. Many studies have yet been published regarding it's influence on breast cancers. Risks should be modulated in respect with the type of treatment and the targeted population. Only recently menopaused women or women suffering from invalidating menopausal symptoms should benefit from HT. When an HT is needed, the authors recommend the use of trans-cutaneous estrogens combined with natural oral progesterone. Every HT should be prescribed individually, according to the patient's aspirations and expectations.

Acute and chronic effects of lisinopril on renal and systemic hemodynamics in hypertension.

Acute and chronic effects of the converting enzyme inhibitor lisinopril on renal and systemic hemodynamics were studied in 12 patients with mild to moderate essential hypertension. After a washout period, cardiac output (measured by Doppler echography), renal plasma flow, and glomerular filtration rate (measured by isotopic techniques) were determined before and after oral administration of 20 mg lisinopril (visit 1). The same protocol was repeated after 3 months of lisinopril therapy 20 mg once daily (visit 2). Acute administration of lisinopril, both in untreated hypertensive patients (visit 1) and during long-term treatment (visit 2), decreased blood pressure (p < 0.05) and increased renal plasma flow (p < 0.05), while cardiac output and glomerular filtration rate were unchanged. Comparison of baseline parameters between visits 1 and 2 showed that chronic treatment with lisinopril decreased blood pressure and renal vascular resistance and that these effects were still significant 24-hours postdosage. We conclude that lisinopril is an effective antihypertensive agent with favorable renal hemodynamic effects.

Myocardial depression characterizes the fatal course of septic shock.

The relationship between cardiac and vascular abnormalities was studied in 68 patients with established septic shock. At time of hemodynamic evaluation, after initial resuscitation, there was no significant difference in arterial pressure, pulmonary artery pressure, cardiac filling pressures, and cardiac index between the 38 survivors of shock and the 30 patients who died of shock, but the left ventricular stroke work index and the right ventricular (RV) stroke work index were higher in survivors than in those who died (mean +/- SD: 25.0 +/- 9.1 vs 20.1 +/- 9.4 gm/m2 [p less than 0.05] and 6.6 +/- 3.6 vs 4.8 +/- 2.8 gm/m2 [p less than 0.05], respectively). Survivors had also higher thermodilution RV ejection fraction and lower RV end-diastolic volumes than had those who died (43.9% +/- 16.3% vs 31.1% +/- 13.7% [p less than 0.01] and 82 +/- 30 vs 99 +/- 31 ml/m2 [p less than 0.05], respectively). Calculated systemic vascular resistance was similar in the two groups, but vasopressors had been required in 22 (58%) of 38 survivors and 25 (83%) of 30 patients who died (p less than 0.01). Moreover, when the patients were separated into two groups according to their cardiac output, higher or lower than 3 L/min/m2, in both subgroups patients who died had lower blood pressure than had survivors. Blood lactate levels were significantly lower in survivors than in nonsurvivors (5.1 +/- 2.1 vs 8.1 +/- 4.7 mEq/L, p less than 0.01). Final data obtained before recovery of shock or death indicated that the survivors had higher arterial pressure, lower pulmonary artery pressure and right atrial pressure, higher stroke volume, and higher RV ejection fraction than had the patients who died. No survivors but all patients who died had been treated with vasopressors. These data therefore indicate that death as a result of septic shock is characterized by both myocardial depression and altered vascular tone and both are probably interrelated.

Measurements of right ventricular volumes during fluid challenge.

The effects of fluid loading on RV function were studied in 41 acutely ill patients monitored with a modified pulmonary artery catheter equipped for measuring RVef. Hemodynamic evaluation was performed before and after infusion of 300 ml of 4.5 percent albumin solution in 30 min. Changes in SI did not correlate with Pra or Ppao but did with RVEDVI. For the entire group, RVef was unchanged (27 +/- 9 vs 27 +/- 9 percent). In the eight patients with an initial RVEDVI greater than 140 ml/m2, the fluid challenge increased Pra and Ppao and reduced LVSWI without any other significant effect. There was no significant correlation between RVEDVI and Pra and only a weak correlation between RVESVI and Ppa. However, there was a highly linear correlation between both RVEDVI and RVESVI and changes in RVEDVI and in RVESVI, suggesting that in the absence of severe pulmonary hypertension RV output is primarily dependent on RV preload.

Bretylium tosylate versus lidocaine in experimental cardiac arrest.

Bretylium tosylate has been shown effective in the treatment of ventricular fibrillation and in the prevention of its recurrence. However, lidocaine is generally preferred because bretylium could have adverse hemodynamic effects related to its antiadrenergic action. To explore further the differences between these two antiarrhythmic agents, the authors compared the effects of bretylium, lidocaine, and saline on a standardized dog model of ventricular fibrillation followed by electromechanical dissociation (EMD). The protocol included three successive episodes of cardiac arrest in each animal. Three minutes before each episode of ventricular fibrillation, 5 mg/kg of bretylium tosylate (n = 11), 1 mg/kg of lidocaine (n = 9) or saline (n = 12) were administered blindly. There was no difference in the duration of cardiac arrest (bretylium, 8 min 18 sec; lidocaine, 7 min 54 sec; saline, 8 min 20 sec) or the total doses of epinephrine required to resuscitate the animals. Both bretylium and lidocaine appeared to preserve cardiac function 5 minutes after recovery, as stroke volume increased from 17.8 +/- 6.7 to 18.7 +/- 6.7 mL (NS) after bretylium and from 17.7 +/- 7.7 to 19.0 +/- 7.0 mL (NS) after lidocaine, but decreased from 19.0 +/- 5.3 to 14.6 +/- 6.0 mL (P less than .05) after saline. During the first 10 minutes of EMD, ventricular fibrillation or ventricular tachycardia recurred in 4 dogs treated with lidocaine, 3 dogs treated with saline, but no dog treated with bretylium (P less than .05 between bretylium and saline).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute subdural hematoma of the posterior fossa. A case report and a review of the relevant literature.

Acute subdural hematoma of the posterior fosa (ASDH-PF) is a clinical rarity with a poor prognosis in teenagers or adults (mortality rate: 71%). We report the third case operated upon with success. The relevant literature is analysed and the characteristics of ASDH-PF are discussed, particularly in connection with the patient's age.

Administration of dopexamine, a new adrenergic agent, in cardiorespiratory failure.

The short-term effects of dopexamine hydrochloride, a new synthetic adrenergic agent with predominant beta 2-adrenergic and dopaminergic properties, were studied in nine patients with inadequate cardiac output during the course of an episode of respiratory failure associated with lung infection. Dopexamine at doses up to 5 microgram/kg/min had no significant effect on arterial pressure or cardiac filling pressures, but increased cardiac index from 2.0 +/- 0.2 to 2.6 +/- 0.2 L/min.m2. Left ventricular stroke work increased from 17.3 +/- 15 to 22.1 +/- 2.4 g.m/m2 (p less than 0.01) and systemic vascular resistance index decreased from 3,792 +/- 1,035 to 2,194 +/- 823 dynes.s.cm5.m2 (p less than 0.01). The increase in cardiac output was in part related to an increase in heart rate from 91 +/- 6 to 102 +/- 7 beats/min. Under a mean inspiratory oxygen fraction of 0.48, the PaO2 decreased from 105 +/- 12 to 91 +/- 11 mm Hg (p less than 0.05) as venous admixture increased from 15.8 +/- 1.0 to 18.1 +/- 1.4 percent (p less than 0.05). Accordingly, the combination of inotropic, afterload-reducing and renal vasodilating effects of dopexamine can be useful acutely to increase cardiac output in critical conditions. However, its administration can be limited by a dose-related increase in heart rate. Dopexamine, like other catecholamines, alters blood oxygenation and increases venous admixture.

Right ventricular dysfunction in septic shock: assessment by measurements of right ventricular ejection fraction using the thermodilution technique.

Right ventricular ejection fraction (RVEF) was measured by the thermodilution technique in a series of 127 consecutive critically ill patients monitored with a modified pulmonary artery (PA) catheter equipped with a fast response thermistor. Thermodilution RVEF was significantly lower in septic shock (23.8 +/- 8.2%, 93 measurements) than in sepsis without shock (30.3 +/- 10.1%, 118 measurements) or in the absence of sepsis or cardiopulmonary impairment (32.5 +/- 7.1%, 62 measurements). Both myocardial depression and pulmonary hypertension could account for this impairment of RV function. RVEF decreased from 35.1 +/- 9.8 to 24.2 +/- 10.4% (P less than 0.01) during development of septic shock and increased from 25.0 +/- 7.6 to 29.8 +/- 8.5% (P less than 0.05) during recovery (14 patients). Initial RVEF in septic shock was 27.8 +/- 8.6% in 11 patients who survived but only 20.9 +/- 6.7% (P less than 0.02) in the 23 patients who eventually died. Thus, RV dysfunction is common during septic shock, is directly related to its severity, and can easily be recognized in patients monitored with a PA catheter.

Effects on right ventricular function of a change from dopamine to dobutamine in critically ill patients.

In 15 critically ill patients requiring adrenergic support, right ventricular ejection fraction (RVEF) and right ventricular (RV) volumes were measured by the thermodilution technique receiving 5 micrograms/kg.min of dopamine and after replacement by the same dose of dobutamine. Shift from dopamine to dobutamine resulted in significant increases in stroke index from 28.1 +/- 3.6 to 31.0 +/- 3.8 ml/m2 (p less than .01) and significant decreases in pulmonary artery balloon-occluded pressure from 15.1 +/- 1.0 to 13.9 +/- 1.2 mm Hg (p less than .05) and right atrial pressure (RAP) from 14.0 +/- 1.3 to 12.2 +/- 1.1 mm Hg (p less than .05). RVEF increased slightly but significantly from 21.5 +/- 2.7% to 23.7 +/- 2.9% (p less than .01) so that RV end-diastolic volume (RVEDVI) was unchanged (140 +/- 12 vs. 141 +/- 12 ml, nonsignificant). RVEDVI/RAP ratio increased from 11.3 +/- 1.0 to 12.9 +/- 1.1 ml/mm Hg (p = .037). These results support the view that dobutamine has more favorable effects on RV function than dopamine in critically ill patients in the absence of profound hypotension and also indicates that higher filling pressures under dopamine administration can be related to changes in ventricular pressure/volume relationship.

Preserved renal perfusion during beta blockade by tertatolol with and without cyclooxygenase inhibition in normal humans.

The systemic and renal hemodynamic effects of tertatolol, a new noncardioselective beta blocker without partial agonist activity, given alone or in combination with cyclooxygenase inhibition by acetylsalicylic acid (aspirin), were investigated in eight healthy volunteers. Tertatolol 5 mg, aspirin 1 g, tertatolol 5 mg together with aspirin 1 g and placebo were administered at 1-week intervals in a random order and in a double-blind fashion. Cardiac output was measured by Doppler echography and renal blood flow and glomerular filtration rate (GFR) by constant infusion techniques using (123I) iodohippurate and (51Cr) EDTA, respectively. Measurements were performed before and then successively 2 and 4 hours after oral intake of drugs or placebo. Tertatolol decreased cardiac output by 22% (P less than .05) and heart rate by 17% (P less than .05) without change in blood pressure, renal blood flow, and GFR. The same effects occurred when tertatolol was given together with aspirin. Either placebo or aspirin alone had no effect on systemic and renal hemodynamics. These results suggest that cardiac output is redistributed to the kidneys after tertatolol intake in normal humans. This favorable effect on renal hemodynamics is probably not mediated by a local release of vasodilating prostaglandins.

Vasoconstrictive effect of portal blood in isolated dog kidney.

Humoral vasoactive substances coming from portal blood have been considered as a possible cause of renal dysfunction in cirrhotic patients. We have thus investigated the effect of perfusion of portal blood from anesthetized dogs on the isolated kidney functions. Both kidneys of a dog were simultaneously perfused on 2 Nizet's pump oxygenators, one kidney serving as control for the other. Renal blood flow was decreased in kidneys perfused with portal blood, as compared to the paired control kidneys perfused with sus-hepatic blood (group A experiments). Addition of polymyxin B to the portal blood restored the renal blood flow to the control level (group B experiments). No significant changes appeared between experimental and control kidneys for glomerular filtration rate, urine output, sodium and water excretion, renin activity, angiotensin II levels, plasmatic PGE2 levels, in group A as well as in group B. We conclude that portal blood of dogs contains vasoactive substances reducing renal blood flow; their action is mediated neither by the renin-angiotensin system nor by changes in renal PGE2 production. The complete abolition of this effect by Polymyxin suggests that these substances may be endotoxins.

Ischemic pancreatitis and hepatitis secondary to ergotamine poisoning.

Acute ergotamine intoxication in a 29-year-old man was complicated by peripheral ischemia, pancreatitis, and hepatitis. The patient was treated with sodium nitroprusside infusion. Complications and treatment of ergotamine poisoning are discussed.

Discrepancy between thermodilution and radionuclide right ventricular ejection fraction measurements: the importance of tricuspid regurgitation.

Measurement of right ventricular ejection fraction (RVEF) by the thermodilution technique has become routinely available at the bedside of the critically ill. We describe 2 patients with tricuspid regurgitation in whom RVEF values were considerably lower by thermodilution than by radionuclide techniques. Discrepancies could be due to the regurgitation of the thermodilution signal and possibly to the different nature of the two measurements (forward stroke volume with the thermodilution technique and total stroke volume with the radionuclide technique). We suggest that lower RVEF measurement by the thermodilution technique could be related to unrecognized tricuspid regurgitation. Measurement of an unexpectedly low RVEF by the thermodilution technique should suggest the presence of tricuspid regurgitation.