[The year 2023 placed in perspective by hospital internists]. / Année 2023 mise en perspective par les internistes hospitaliers.

This article features a selection of ten topics chosen, reviewed, and commented for you by chief residents at the Department of Internal Medicine at Centre hospitalier universitaire vaudois (CHUV). This selection synthesizes the novelties and essential reminders of 2023 in internal medicine. By analyzing the standout publications of the year, it offers an overview of progress in diagnosis and patient management within the hospital and their transition to outpatient care. From oral anticoagulation to community-acquired pneumonias, encompassing the management of heart and kidney failure, each key aspect is explored. This compilation provides practitioners with an essential resource to remain at the forefront of current developments, thereby stimulating more informed and effective care for patients.

Cet article propose une sélection de dix sujets choisis, revus et commentés pour vous par les cheffes et chefs de clinique du Service de médecine interne du Centre hospitalier universitaire vaudois (CHUV). Cette sélection synthétise les nouveautés et rappels essentiels de 2023 en médecine interne. En analysant les publications phares de l'année, elle offre une vue d'ensemble des progrès dans le diagnostic et la prise en charge des patients intrahospitaliers et leur transition ambulatoire. De l'anticoagulation orale aux pneumonies communautaires en passant par la prise en charge des insuffisances cardiaque et rénale, chaque aspect clé est exploré. Cette compilation fournit aux praticiens une ressource essentielle pour rester à la pointe des développements actuels, stimulant ainsi des soins plus éclairés et efficaces pour les patients.

Implanted System for Orthostatic Hypotension in Multiple-System Atrophy.

Orthostatic hypotension is a cardinal feature of multiple-system atrophy. The upright posture provokes syncopal episodes that prevent patients from standing and walking for more than brief periods. We implanted a system to restore regulation of blood pressure and enable a patient with multiple-system atrophy to stand and walk after having lost these abilities because of orthostatic hypotension. This system involved epidural electrical stimulation delivered over the thoracic spinal cord with accelerometers that detected changes in body position. (Funded by the Defitech Foundation.).

Bariatric Surgery Induces a Differential Effect on Plasma Aldosterone in Comparison to Dietary Advice Alone.

Background and Objectives: The pathophysiological mechanisms linking weight loss to blood pressure (BP) reduction are not completely understood. The objective of this study was to compare the effect of weight loss after Roux-en-Y gastric bypass (RYGB) on BP, renin-angiotensin-aldosterone system (RAAS), and urinary electrolytes excretion to those of dietary advice. Methods: This was a case-control prospective study including obese patients referred for RYGB (cases) and obese receiving diet advice only (controls). Ambulatory BP, plasma renin activity (PRA), plasma aldosterone concentration (PAC), and urinary electrolytes were measured before (M0) and after intervention (M3: 3 months and M12: 12 months). Results: Twenty-five patients were included in the RYGB group and twelve patients in the control group. After 12 months, weight loss (-42 ± 11.5 vs -12.3 ± 6.3 kg in the control group, p=0.001) and decrease in PAC were more pronounced in the RYGB group (-34 ± 76 vs +14 ± 45 pg/ml in the control group, p=0.002). There was no difference in PRA between both groups (-0.08 ± 1.68 vs 0.01 ± 0.37 ng/ml/h, p=0.31). Sodium excretion was more marked in the RYGB group after 3 months only (-89 ± 14.9 vs -9.9 ± 27.9 mmol/day, p=0.009). The decrease in SBP was similar between both groups (-6.9 ± 9.9 vs -7.1 ± 11.9 mmHg in the control group, p=0.96). Conclusions: Bariatric-induced weight loss induces a progressive decrease in PAC independently of PRA and sodium excretion. Whether this decrease in PAC affects target organ damage in the long term remains to be determined. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT02218112.

[Severe asymptomatic hypertension and hypertensive emergency : From the ambulatory care to the emergency room]. / Hypertension artérielle sévère ou urgence hypertensive : du cabinet à l'hôpital.

High blood pressure levels are frequently encountered in medical practice, whether in an outpatient or inpatient setting. It is imperative to quickly differentiate severe hypertension associated with target organ damage, from severe hypertension without acute organ damage. In the latter situation, the management can be done on an outpatient basis by prescribing oral antihypertensive treatment with a close follow-up. On the other hand, in severe hypertension with acute target organ damage, patients should be admitted in an intensive care unit for close monitoring and, in most cases, treated with intravenous antihypertensive treatment. This article reviews the new definitions and management of these two entities and is addressed to both general practitioner and emergency doctor.

Les élévations sévères de la tension artérielle sont fréquemment rencontrées dans la pratique médicale, qu'elle soit ambulatoire ou hospitalière. Il est impératif de différencier rapidement une HTA sévère associée à un dommage d'organe(s) cible(s) d'une HTA sévère isolée. En effet, dans cette dernière situation, la prise en charge peut être gérée en ambulatoire par un traitement antihypertenseur oral tout en nécessitant un suivi rapproché par la suite. En revanche, l'HTA sévère avec atteinte aiguë d'organe(s) cible(s) nécessite une prise en charge hospitalière immédiate afin de rapidement baisser la tension artérielle à l'aide d'un traitement intraveineux. Cet article a pour but de passer en revue les nouvelles définitions et prises en charge de ces deux entités, et s'adresse autant au médecin praticien installé qu'au médecin hospitalier.

Assessment of a strategy combining ambulatory blood pressure, adherence monitoring and a standardised triple therapy in resistant hypertension.

PURPOSE: Poor adherence to drug therapy and inadequate drug regimens are two frequent factors responsible for the poor blood pressure (BP) control observed in patients with apparent resistant hypertension. We evaluated the efficacy of an antihypertensive management strategy combining a standardised therapy with three long acting drugs and electronic monitoring of drug adherence in patients with apparent resistant hypertension. MATERIALS AND METHODS: In this multicentric observational study, adult patients with residual hypertension on 24 h ambulatory BP monitoring (ABMP) despite the use of three or more antihypertensive drugs could be included. Olmesartan/amlodipine (40/10 mg, single pill fixed-dose combination) and chlorthalidone (25 mg) were prescribed for 3 months in two separated electronic pills boxes (EPB). The primary outcome was 24 h ambulatory systolic BP (SBP) control at 3 months, defined as mean SBP <130 mmHg. RESULTS: We enrolled 48 patients (36.0% women) of whom 35 had complete EPB data. After 3 months, 52.1% of patients had 24 h SBP <130 mmHg. 24 h SBP decreased by respectively -9.1 ± 15.5 mmHg, -22.8 ± 30.6 mmHg and -27.7 ± 16.6 mmHg from the tertile with the lowest adherence to the tertile with the highest adherence to the single pill combination (p = 0.024). A similar trend was observed with tertiles of adherence to chlorthalidone. Adherence superior to 90% was associated with 24 h systolic and diastolic blood pressure control in multiple logistic regression analysis (odds ratio = 14.1 (95% confidence interval 1.1-173.3, p = 0.039). CONCLUSIONS: A simplified standardised antihypertensive therapy combined with electronic monitoring of adherence normalises SBP in about half of patients with apparent resistant hypertension. Such combined management strategy enables identifying patients who need complementary investigations and those who rather need a long-term support of their adherence.

[Hypertension: novelties 2020]. / Hypertension artérielle.

Nowadays, hardly half of treated patients do not reach ideal blood pressure targets. New approaches could help, such as the creation of a multidisciplinary network of patients, doctors, pharmacists, with the favorable effects of telemonitoring on blood pressure control and cardiovascular outcomes. An excessive fall of blood pressure (BP) after a hemorrhagic stroke, when systolic BP is superior to 220 mm Hg, is deleterious. Improvement of renal denervation techniques, along with indications expansion, will complete the arsenal of care. Hypertensive pregnant women transmit BP values to their offsprings, leading to earlier prevention. Finally, visit-to-visit BP variability puts a considerable strain on the cognitive risk and dementia of hypertensive people.

De nos jours, la moitié des sujets hypertendus traités n'atteint pas les cibles tensionnelles idéales. De nouvelles approches pourraient aider comme la création d'un réseau multidisciplinaire entre patient, médecin, pharmacien, avec les bénéfices d'une télésurveillance sur le contrôle tensionnel et sur les issues cardiovasculaires. Un abaissement tensionnel trop marqué après un AVC hémorragique, même en cas de valeurs supérieures à 220 mm Hg, est délétère. L'amélioration des techniques de dénervation rénale, avec l'élargissement de ses indications, va compléter l'arsenal de prise en charge. La femme enceinte hypertendue transmet les valeurs tensionnelles à sa descendance, menant à une prévention plus précoce. Enfin, la variabilité tensionnelle d'une visite médicale à l'autre grève passablement le risque cognitif et de démence des malades hypertendus.

[Isolated diastolic hypertension : do we still have to care about it ?] / Hypertension artérielle diastolique isolée : faut-il encore s'en préoccuper ?

Isolated diastolic hypertension (IDH), defined as a diastolic blood pressure (DBP) > 90 mmHg and a systolic blood pressure (SBP) < 140 mmHg, is a common situation in medical practice. In the elderly, the cardiovascular risk is clearly associated with the level of systolic BP and pulse pressure. However, diastolic BP is also associated with an increased risk of cardiovascular event, in particular among young hypertensive patients (< 50 years old). Therefore, isolated diastolic hypertension should not be neglected. A careful follow-up of patients with IDH should be put in place with lifestyle changes. Sometimes, a pharmacological treatment must be started to control DBP.

L'hypertension artérielle diastolique (HTAD) isolée, définie par une élévation de la pression artérielle diastolique (PAD) > 90 mmHg et d'une pression artérielle systolique (PAS) < 140 mmHg est une entité parfois rencontrée en pratique médicale. Bien que dans la population âgée, le risque cardiovasculaire attribué à l'HTA soit le mieux corrélé à la PAS et à la pression pulsée (PP), il est aujourd'hui évident que l'HTAD isolée est également associée à un risque d'événement cardiovasculaire, particulièrement dans la population jeune (< 50 ans). Elle ne doit de ce fait pas être négligée. Un suivi rapproché de ces patients avec instauration de mesures d'hygiène de vie et parfois pharmacologiques est absolument nécessaire.

[Gut microbiota and kidney diseases : dangerous liaisons?] / Microbiote et maladies rénales : liaison dangereuse ?

Recent studies have found a relationship between the kidney and the intestinal microbiome, called the colo-renal axis. Mounting evidence suggests that patients suffering from chronic kidney disease (CKD) have an altered composition of gut microbiota. This leads to 1) the increased fermentation of intestinal proteins to uremic toxins such as p-cresyl sulphate and indoxyl sulphate, 2) an altered, more 'leaky' intestinal barrier, and 3) translocation of bacteria and toxins from the gut lumen to the circulation, inducing systemic inflammation. This may contribute to the increased morbidity and mortality in this population. Future studies are needed to confirm this hypothesis, and to assess whether manipulating the intestinal microbiota with pre-, pro-, or symbiotics may alter the development and course of CKD.

Des études récentes démontrent l'existence d'une relation entre le rein et le microbiote intestinal, parfois appelée « axe intestin-rein ¼. Les patients souffrant de maladie rénale chronique (MRC) ont une composition altérée du microbiote intestinal. Ces modifications conduisent à : 1) une augmentation de la fermentation de protéines intestinales en toxines urémiques comme par exemple le p-crésyl sulfate et l'indoxyl sulfate ; 2) une augmentation de la perméabilité de la barrière intestinale et 3) une translocation de bactéries et de toxines de la lumière intestinale vers la circulation sanguine, responsables d'une inflammation systémique. Ces mécanismes pourraient contribuer à l'augmentation de la morbi-mortalité dans cette population. Des études ultérieures sont nécessaires pour confirmer cette hypothèse, mais également pour évaluer si des modifications dans la composition du microbiote par des agents pré, pro ou symbiotiques pourraient avoir un effet bénéfique sur l'évolution de la MRC.