[Hepatitis C: from pathogenesis to treatment]

Hepatitis C virus (HCV) belongs to the greater family of Flaviviridae. It is probably responsible for the majority of NANB hepatitis. Serologic evidence in the term of antibodies against certain parts of HCV persists in 60 to 100% of patients with NANB hepatitis after blood transfusion. The evidence for the existence of a second virus responsible for NANB has not been excluded as inactivation-studies would suggest. HCV is also a common cause for sporadic acute hepatitis. It is the purpose of this article to present diagnosis, course and treatment of this form of hepatitis.

[Psychiatric morbidity in the medical service of a non-university general hospital]

The aim of this study was to assess the nature and extent of psychiatric pathology in the internal medicine service of a small general hospital. During a three months' period, 315 consecutive patients were enrolled in this prospective study. 92 persons (29% of the admitted patients) exhibited a psychiatric disorder which was recognized by the internists and then discussed with the psychiatric team. The disorders were diagnosed according to the DSM-III-R classification. The age of the patients with psychiatric disorders was lower (median 56 years versus 63 years) and women were more numerous. In 75% of cases the psychiatric problem influenced medical management. A psychiatric consultation was indicated in 12%. Concerning the nature of this pathology, 29% of the 120 diagnoses established in these 92 patients were linked to the use of psychoactive substances; alcohol and male sex predominated. Among the women, anxio-depressive and personality disorders predominated. Two-thirds of the patients were sent to a general practitioner following their discharge from the hospital. The role of the general hospital as a site of care for these patients is discussed. It can be considered positive if a good climate of cooperation exists with the psychiatric team.

[Blood pressure measurement during tachyarhythmia: validation of a graduated measuring technique with an intra-arterial technique]

Use of the usual technique to measure blood pressure is known to be unsatisfactory in tachyarrhythmia. An easy and non-invasive technique, called the stage by stage method, has therefore been proposed. The aim of the present study is to verify the precision of this method by comparison with intraarterial measurements. The study was performed in 9 tachyarrhythmic patients with heart rate over 90/min and wide systolic pulse amplitude variations. For systolic pressure, the results show an excellent correlation between the blood pressure values obtained by the stage by stage method and those obtained by intraarterial measurements (r = 0.99; p > 0.01). For diastolic pressure, the best practical approximation is the value of the last stage before all sounds have disappeared plus 5 mm Hg. We conclude that the bedside stage by method is worth performing in patients presenting with tachyarrhythmia and wide systolic pressure variations from one systole to the other.

Historia morbi atrocis--2 new cases of spontaneous rupture of the esophagus (Boerhaave syndrome)

We report the case of two patients hospitalized within a few weeks of each other and both presenting with spontaneous rupture of the esophagus whose evolution proved fatal. We take the opportunity of drawing attention to this rare and challenging disease, which is often diagnosed too late.

Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain

In a prospective study of 278 consecutive patients admitted to an emergency ward for chest pain, the 115 clinical and paraclinical parameters available at the time of admission were evaluated by computer comparison with the final diagnoses. The most valuable items for making the diagnosis were classified according to their sensitivity, specificity and predictive value. Among the 278 patients, 100 individuals had myocardial infarctions (MI), 47 had unstable angina, 25 had stable angina and 106 patients had a non-coronary disease. The twelve most sensitive items for distinguishing MI from other conditions were the following: sudden onset of pain (70%); duration of more than 60 min (88%); constriction and squeezing (79%); oppression (75%); prior anginal attacks (61%); sex male (72%); age over 60 years (74%); abnormal heart auscultation (62%); abnormal electrocardiogram (ECG) (98%); segment (ST) disturbances (86%); increased glucose level (77%); CKMB fraction greater than 6% of total creatine kinase (CK) level (63%). Among the twelve most specific items, also with the best positive predictive value, irradiation in the right arm is of most importance; among the 51 patients with right arm involvement, 48 suffered from a coronary disease and 41 from a myocardial infarction. The largest extension of pain was reported in the latter group. It is concluded that chest pain with a wide irradiation involving the right arm strongly suggests that a myocardial infarction is ongoing.

Cerebrospinal fluid lactate in 78 cases of adult meningitis

In a retrospective study of 78 cases of adult meningitis, the CSF lactate was measured on the first spinal tap (ST); 25 had a bacterial meningitis, 28 a viral meningitis; 22 other cases had been on antibiotics prior to admission; 3 cases had meningitis of rare aetiology. The median CSF lactate level among the 25 bacterial cases amounted to 13.6 mmol/l (range: 3.5-24.5) whereas it remained low in the 28 viral cases: 2.7 mmol/l (range: 1.4-4.2). These differences are highly significant. The comparison of the CSF lactate level with the other tests routinely performed showed that the CSF lactate level had the highest sensitivity, specificity and predictive values. The CSF lactate level on the first ST had no prognostic value, but a rapid decrease of the CSF lactate during the treatment is indicative of good prognosis. Among the pretreated cases, a high lactate level could be an indication that bacteria were the causal agents. In conclusion, the measurement of the CSF lactate, quickly performed and inexpensive, is worth performing when a meningitis is suspected, as it appears to be the best way of distinguishing bacterial from non-bacterial meningitis.

[Practical consequences of ambulatory registration of blood pressure]

Ambulatory recorded blood pressure (BP) has been shown to correlate better with secondary target-organ damage than casual blood pressure, and has demonstrated that ambulatory BP cannot be predicted on the basis of casual BP measurements by the physician. To assess whether these recordings have practical repercussions on diagnosis and treatment, 182 patients (74 female/108 male) aged 16 to 84 years (mean 51.9 +/- 14.8 SD), all referred by their physicians to the investigation unit of the hospital, underwent ambulatory BP measurements using the portable Remler M2000 BP recorder. The mean systolic blood pressure was above 140 mm Hg in 96 patients (53%) and the mean diastolic blood pressure above 90 mm Hg in 81 (45%). -3 to 9 months later, multiple choice questionnaires were sent to the 34 physicians who had referred patients and had meanwhile received recording results without comments. The questions were designed ascertain the indication for BP recording in each patient and the changes undertaken in the light of the results. In 27% of the cases the assumed diagnosis was not confirmed and in 40.8% of the cases the planned or prescribed treatment was obviated or withdrawn. This percentage corresponds to the data previously published describing 30 to 40% of patients as hypertensive only in the physician's office. This latter percentage shows that ambulatory BP recordings contribute to the practical assessment of patients with mild to moderate elevation of office BP.

[Pressure determination in tachycardia. Improved approximation using a stage-by-stage technic]

In heart arrhythmia, and especially tachyarrhythmia, blood pressure measurements are known to be approximate. The current recommendations proved to be unsatisfactory in a group of 23 patients in whom they were tested systematically. A simple atraumatic bedside method, developed from the standard method of measuring blood pressure by sphygmomanometer and called the "stage by stage" measurement method, is presented.

[Syncope of undetermined origin]

A 48-year-old man with no significant medical history suddenly suffered, when walking, a sensation of thoracic pressure and severe dyspnea, soon followed by loss of consciousness without seizure. On hospitalization the following abnormal features were found: moderate cyanosis and cutaneous erythematous lesions; a blood gas analysis with moderate hypoxemia and slight compensated metabolic acidosis; and on chest X-ray a small band of atelectasis of the left lower lobe. An ECG, a continuous 24 hours Holter ECG recording and pulmonary scintigraphy were within normal limits. During the next few days the patient had several syncopal attacks without detectable cause. Two biopsies were then performed which established the diagnosis.