3D Echocardiography - A Useful Method for Cardiovascular Risk Assessment in End-Stage Renal Disease Patients.

Patients with chronic kidney disease (CKD) have an increased risk of premature mortality, mainly due to cardiovascular causes. The association between hemodialysis and accelerated atherosclerosis has long been described. The ankle-brachial index (ABI) is a surrogate marker of atherosclerosis and recent studies indicate its utility as a predictor of future cardiovascular disease and all-cause mortality. The clinical implications of ABI cut-points are not well defined in patients with CKD. Echocardiography is the most widely used imaging method for cardiac evaluation. Structural and functional myocardial abnormalities are common in patients with CKD due to pressure and volume overload as well as non-hemodynamic factors associated with CKD. Our study aimed to identify markers of subclinical cardiovascular risk assessed using ABI and 2D and 3D echocardiographic parameters evaluating left ventricular (LV) structure and function in patients with end-stage renal disease (ESRD) (patients undergoing dialysis), patients after kidney transplantation and non-ESRD patients (control). In ESRD, particularly in hemodialysis patients, changes in cardiac structure, rather than function, seems to be more pronounced. 3D echocardiography appears to be more sensitive than 2D echocardiography in the assessment of myocardial structure and function in CKD patients. Particularly 3D derived end-diastolic volume and 3D derived LV mass indexed for body surface appears to deteriorate in dialyzed and transplanted patients. In 2D echocardiography, myocardial mass represented by left ventricular mass/body surface area index (LVMI) appears to be a more sensitive marker of cardiac structural changes, compared to relative wall thickness (RWT), left ventricle and diastolic diameter index (LVEDDI) and left atrial volume index (LAVI). We observed a generally favorable impact of kidney transplantation on cardiac structure and function; however, the differences were non-significant. The improvement seems to be more pronounced in cardiac function parameters, peak early diastolic velocity/average peak early diastolic velocity of mitral valve annulus (E/e´), 3D left ventricle ejection fraction (LV EF) and global longitudinal strain (GLS). We conclude that ABI is not an appropriate screening test to determine the cardiovascular risk in patients with ESRD.

3D Echocardiography - A Useful Method for Cardiovascular Risk Assessment in End-Stage Renal Disease Patients.

Patients with chronic kidney disease (CKD) have an increased risk of premature mortality, mainly due to cardiovascular causes. The association between hemodialysis and accelerated atherosclerosis has long been described. The ankle-brachial index (ABI) is a surrogate marker of atherosclerosis and recent studies indicate its utility as a predictor of future cardiovascular disease and all-cause mortality. The clinical implications of ABI cut-points are not well defined in patients with CKD. Echocardiography is the most widely used imaging method for cardiac evaluation. Structural and functional myocardial abnormalities are common in patients with CKD due to pressure and volume overload as well as non-hemodynamic factors associated with CKD. Our study aimed to identify markers of subclinical cardiovascular risk assessed using ABI and 2D and 3D echocardiographic parameters evaluating left ventricular (LV) structure and function in patients with end-stage renal disease (ESRD) (patients undergoing dialysis), patients after kidney transplantation and non-ESRD patients (control). In ESRD, particularly in hemodialysis patients, changes in cardiac structure, rather than function, seems to be more pronounced. 3D echocardiography appears to be more sensitive than 2D echocardiography in the assessment of myocardial structure and function in CKD patients. Particularly 3D derived end-diastolic volume and 3D derived LV mass indexed for body surface appears to deteriorate in dialyzed and transplanted patients. In 2D echocardiography, myocardial mass represented by left ventricular mass/body surface area index (LVMI) appears to be a more sensitive marker of cardiac structural changes, compared to relative wall thickness (RWT), left ventricle and diastolic diameter index (LVEDDI) and left atrial volume index (LAVI). We observed a generally favorable impact of kidney transplantation on cardiac structure and function; however, the differences were non-significant. The improvement seems to be more pronounced in cardiac function parameters, peak early diastolic velocity/average peak early diastolic velocity of mitral valve annulus (E/e´), 3D left ventricle ejection fraction (LV EF) and global longitudinal strain (GLS). We conclude that ABI is not an appropriate screening test to determine the cardiovascular risk in patients with ESRD.

Comparing student and staff perceptions of the "Educational Climate" in Spanish Dental Schools using the Dundee Ready Education Environment Measure.

OBJECTIVE: To compare the perceptions of students and teachers of the "Educational Climate" (EC) in Spanish public dental schools. METHODS: A group of 1064 students and 354 teachers from six Spanish public dental schools responded to the DREEM questionnaire. This has 50 items grouped into five subscales: perception of learning (Learning); perception of teachers (Teachers); academic self-perceptions (Academic); perception of the atmosphere in the faculty (Atmosphere); and social self-perceptions (Social). The DREEM scale provides results for each item, each subscale and the overall EC. RESULTS: The EC scores were 123.2 (61.6%) for the students and 134.1 (67.0%) for the teachers (P<.001). The scores of the students and teachers for the subscales were, respectively: 27.9 (58.1%) and 30.2 (63.0 %) for Learning (P<.001); 26.8 (60.9%) and 32.6 (74.1%) for Teachers (P<.001); 20.7 (64.7%) and 20.5 (64.0%) for Academic (P=.333); 29.9 (62.3%) and 33.7 (70.3%) for Atmosphere (P<.001); and 17.9 (64.0%) and 16.9 (60.5%) for Social (P<.001). The students identified six problematic items (12.0 %) compared to only two (4.0 %) highlighted by the teachers. CONCLUSION: The students and teachers considered the EC to be "more positive than negative" in Spanish public dental schools; and the different subscales to be "positive and acceptable." The teachers did, however, evaluate the EC, and specifically the learning-teaching process, more positively than their students, identifying fewer problematic educational aspects. Both groups agreed on the need to: improve support systems for students who suffer from stress and reduce teaching based on "factual learning."

Predictors of blood pressure control in patients with resistant hypertension.

BACKGROUND: Uncontrolled resistant hypertension (RH) defined by the mean 24-hour ambulatory blood pressure (ABPM) represents an independent risk factor in hypertensive patients. Predictors of blood pressure (BP) control in RH are not yet clearly defined. OBJECTIVES: To evaluate the predictors of BP control in RH patients with repeated ABPM measurements. METHODS: 114 consecutive patients from outpatient cardiology office fulfilling criteria for RH (office BP ≥ 140 and/or 90 mmHg, with treatment of ≥ 3 antihypertensive drugs, including diuretic, or controlled BP with > 3 drugs), with two consecutive ABPM studies were compared in clinical characteristics according to BP control assessed by ABPM RESULTS: After the second ABPM, BP was controlled in 25.4 % of patients; the remaining 74.6 % were classified as uncontrolled. In the uncontrolled BP group, systolic office BP was 140.91±16.71 mmHg, diastolic 81.26 ± 10.92 mmHg. In ABPM, systolic was 145.11 ± 13.65 mmHg, diastolic 81.26 ± 10.92 mmHg. Compared to the controlled BP group, in the uncontrolled group the age was higher 72.32 ±10.89 years (p = 0.047), baseline average real variability of systolic BP was lower 12.66 ± 3.08 vs. 14.52 ± 3.53 (p = 0.013), no significant difference in baseline standard deviation of systolic BP changes was found. CONCLUSION: Higher office BP, older age, and increased short term BP variability were associated with an uncontrolled hypertension. Stronger association was found with baseline average real variability rather than standard deviation. No significant differences were found in the dipping status and other clinical characteristics (Tab. 6, Fig. 1, Ref. 28).

Psychometric validation of the Spanish version of the Dundee Ready Education Environment Measure applied to dental students.

AIM: To carry out a psychometric evaluation of the Spanish-language version of the Dundee Ready Education Environment Measure (DREEM) applied to dental students. METHODS: A total of 1,391 students from nine Spanish public schools of dentistry responded to the DREEM questionnaire. To analyse the reliability of the DREEM questionnaire, the internal consistency was assessed and a 'test-retest' carried out. Validity was evaluated through analysis of item response rate, floor and ceiling effects, corrected item-total and item-subscale correlations and factor structure. A confirmatory factor analysis was performed to analyse the structure of the original DREEM scale. RESULTS: Cronbach's alpha coefficient for the 'Educational Climate' (EC) global scale was 0.92. In the subscales, the 'observed' Cronbach's alpha coefficients ranged between 0.57 and 0.79 and were higher than the 'expected' ones; except for the Social subscale. In the DREEM questionnaire, all of the corrected correlation coefficients between the items and the EC global scale, and the items and their corresponding subscales, were >0.2; except for items 50 and 17. All goodness-of-fit indices of confirmatory factor analysis showed acceptable values (close to one or zero, depending on the case), and there was consistency in the results. CONCLUSIONS: The Spanish-language version of the DREEM questionnaire is a reliable and valid instrument for analysing the EC for dental students and its factor structure is supported by the data. Although our findings indicate that the DREEM may be as culturally independent as was originally stated, more research should be directed at verifying the factor structure in various languages and cultural environments.

Analysis of the 'Educational Climate' in Spanish Public Schools of Dentistry using the Dundee Ready Education Environment Measure: a multicenter study.

AIM: To analyse the 'Educational Climate' (EC) of dental students in Spain. METHODS: The study group consisted of 1391 students from nine Spanish Public Schools of Dentistry, who responded to the questionnaire based on 'Dundee Ready Education Environment Measure' (DREEM). This questionnaire has 50 items that are grouped into five domains: Learning, Teachers, Academic, Atmosphere and Social. RESULTS: The global score on the EC was 123.1 (interpretation: 'EC more positive than negative'). The scores obtained in the different domains were: 28.0 in Learning (interpretation: 'a generally positive perception of learning'), 26.8 in Teachers (interpretation: 'teachers are going in the right direction'), 20.8 in Academic (interpretation: 'feeling more on the positive side'), 29.7 in Atmosphere (interpretation: 'a generally positive atmosphere') and 17.7 in Social (interpretation: 'social perception acceptable'). In seven items (14%), an average of <2 was detected, showing that there are some educational problem areas. Regarding the EC in the different Schools of Dentistry, an average of >100 was achieved in all of them, although there were two centres that showed significantly higher values of EC. CONCLUSIONS: Spanish dental students felt that their EC was more positive than negative and considered that the different domains were positive and acceptable. However, they pointed out the existence of several educational problem areas associated with the development of a traditional curriculum. Accordingly, and in parallel with the implementation of an innovative curriculum in all Spanish Dental Schools in the coming years, immediate educational goals must address the problem areas identified, thereby further promoting a more positive perception of EC.

Identification of Kir2.1 channel activity in cultured trabecular meshwork cells.

PURPOSE: To study the presence of inwardly rectifying K(+) (Kir) channels in cultured bovine (BTM) and human (HTM) trabecular meshwork cells. METHODS: Cultures of BTM and HTM cells were obtained by an extracellular matrix digestion technique. Whole-cell patch-clamp recordings of BTM cells were performed with the appropriate solutions to detect K(+) currents. Also, Western blot analysis of Kir2.1 protein expression was performed on both cultured BTM and HTM cells. RESULTS: A strong inwardly rectifying current at negative potentials to the equilibrium potential for K(+) (E(K+)) and highly selective for K(+) was detected in 60% of cultured BTM cells. The slope conductance of the inward rectification was more pronounced when the extracellular [K(+)] was increased and was proportional to [K(+)](0.45). The current was blocked by Ba(2+) and Cs(+) in a voltage- and concentration-dependent manner, with K(d) at 0 mV, of 74.7 microM and 45.6 mM, respectively. Current amplitude was reduced by increasing extracellular [Ca(2+)]. The current was insensitive to 10 microM glibenclamide and 10 nM tertiapin. The application of 100 microM 8-Br-cAMP reduced the current by 50%. Kir2.1 channel expression was detected in confluent monolayers of BTM and HTM cells by Western blot analysis. CONCLUSIONS: A population of cultured BTM cells expressed an inwardly rectifying K(+) current that illustrates the biophysical and pharmacologic characteristics of the detected Kir2.1 channel protein. Kir2.1 channels are also thought to be present in HTM cells. Kir2.1 channels could be related to TM physiology, because they are involved in contractile and cell volume regulatory responses, two mechanisms that modify TM permeability.

Bradykinin decreases outflow facility in perfused anterior segments and induces shape changes in passaged BTM cells in vitro.

PURPOSE: To investigate the effects of bradykinin (BK) on the outflow facility (C) of human and bovine perfused anterior segments, the [Ca2+]i of cultured bovine trabecular meshwork (BTM) cells, and the area and major axis of BTM cells. METHODS: Cellular studies were performed using first- through third-passage cultures of BTM cells. For [Ca2+]i and shape change assessment, BTM cells were loaded with fura-2 acetoxymethyl ester, and individual fluorescence images were analyzed after the different experimental manipulations. C studies were performed in vitro using human and bovine anterior segments perfused at constant pressure. RESULTS: Bradykinin at 10(-6) M elicited a [Ca2+]i increase of 8 to 10 times the basal levels in 90% of the studied cells. From the responder cells, 60% elicited a 15%+/-1% reduction of the initial cell area, and 37% showed a 13%+/-2% reduction of their major axis. Bradykinin failed to induce any effect in the presence of the BK-B2 receptor antagonist HOE-140. Zero [Ca2+]o the depletion of intracellular stores with thapsigargin, or the presence of the calmodulin antagonist W13, decreased the BK response significantly (P < 0.001; P < 0.001; and P < 0.05). A second application of BK elicited a significantly lower (P < 0.001) response than the previous one. Perfusion with 10(-6) M BK decreased CD, calculated as the area under the curve, by 13%+/-4% (P < 0.05) in human anterior segments and 12%+/-4% (P < 0.05) in bovine anterior segments. The presence of 10(-6) M HOE-140, a BK-B2 receptor antagonist, completely blocked the decrease in C after perfusion with BK. CONCLUSIONS: The C of human and bovine trabecular meshwork (perfused anterior segments) is decreased by BK, acting through BK-B2 receptors. Primary cultured BTM cells respond to BK stimulation by increasing their [Ca2+]i by mobilization of extracellular and intracellular Ca2+. Moreover, these cells are reduced in area and their major axis shortened after the [Ca2+]i peak elicited by BK through BK-B2 receptors. The [Ca2+]i mobilization and shape changes are calmodulin dependent. Taking into account the [Ca2+]i mobilization, the BTM shape changes, the decrease of C, and the temporal sequence of these parameters, a contraction of trabecular meshwork cells related to the functional role of trabecular meshwork is discussed.

Effects of time of storage, albumin, and osmolality changes on outflow facility (C) of bovine anterior segment in vitro.

PURPOSE: To analyze the influence of time of storage, the presence of albumin at physiological concentrations, and the perfusion with anisosmotic media on the aqueous humor outflow facility (C) of isolated bovine anterior segments (AS). METHODS: Anterior segments dissected from cow eyes were perfused at a constant pressure of 10 mm Hg with Dulbecco's modified Eagle's medium (DMEM; osmolality 300 mOsm/kg), with hyposmotic media (150, 210, and 270 mOsm/kg), or with hyperosmotic media (360, 420, and 480 mOsm/kg). Outflow facility was calculated every 5 seconds as the ratio between average inflow from the reservoir (in microliters per minute) and the perfusion pressure (in millimeters of mercury). Three groups were studied: a 0-hour group, with AS perfused with DMEM 1 to 3 hours after enucleation; a 0-hour alb-group, with AS perfused with DMEM plus 0.1 mg/ml albumin 1 to 3 hours after enucleation; and a 24-hour group, with AS perfused after storage for 24 hours in DMEM. In the 0-hour groups, perfusion with increasingly hyposmotic or hyperosmotic media was also made in 30-minute steps, followed by a return to isosmotic medium for 90 minutes. RESULTS: Perfusion of AS with DMEM for 9 hours caused a progressive increase in C that was statistically significant at 225 minutes in the 0-hour group perfused with DMEM and at 195 minutes in the 24-hour group perfused with DMEM. The 0-hour alb-group perfused with DMEM did not show changes in C throughout the 9-hour perfusion period. Perfusion with increasingly hyposmotic media induced a progressive decrease in C that did not recover on return to isotonic medium. Hyperosmotic media caused a progressive increase in C that returned to control values when isotonic medium was again perfused. CONCLUSIONS: Preservation of tissue for C measurements is best achieved with short storage time (1 to 3 hours). Physiological concentrations of albumin (0.1 mg/ml) prevent development of washout, suggesting that albumin or an albumin-bound factor in aqueous humor may play a role in the maintenance of outflow resistance. Outflow facility also may be influenced by volume changes in the trabecular meshwork.

Facility changes mediated by cAMP in the bovine anterior segment in vitro.

The aim of this study was to investigate the influence of substances that increase intracellular cAMP levels on the aqueous humor outflow facility (C) of isolated bovine anterior segments. Anterior segments were perfused in vitro at a constant pressure of 10 mmHg for 270 min with a general protocol as follows: 90 min control perfusion with DMEM, 90 min of experimental perfusion with DMEM containing the test drug(s), and 90 min of postdrug-perfusion with DMEM. C was calculated as the ratio between the rate of medium inflow (microliter/min) and the perfusion pressure (mmHg). Anterior segments can be perfused in vitro for up to 5 hr without significantly modifying their C. The addition of epinephrine, forskolin, dibutyryl-cAMP or isobutylmethylxanthine to the control perfusion medium elicited a significant increase of C. If, during isobutylmethylxanthine perfusion, forskolin or epinephrine was added, C increased significantly. Finally, perfusion with indomethacin prior to addition of epinephrine prevented the increase of C induced by epinephrine. Epinephrine, the adenylate cyclase activator forskolin, the cAMP analog dibutyryl-cAMP, and the phosphodiesterase inhibitor isobutylmethylxanthine all increase aqueous facility. It seems reasonable to suspect that the cAMP system is involved in epinephrine's effects on bovine trabecular meshwork cells. Moreover, the complete inhibition by indomethacin of the outflow facility increase induced by epinephrine suggests that prostaglandins may be involved in the outflow facility mechanisms related to adrenoreceptor stimulation of trabecular meshwork cells.

Active and problem-based learning: two years' experience in physiology at the Medical School of the University of Barcelona.

Traditional educational methods are used in most medical schools. The introduction of new methods including active and problem-solving learning in traditional medical schools is difficult. The aims of this experiment were: (1) to introduce a self-learning system with a problem-solving approach in physiology; (2) to promote active student participation; (3) to introduce early clinical exposure; (4) to evaluate the response of the students to this experiment; and (5) to evaluate the feasibility and usefulness of a self-learning and problem-solving approach in only one discipline. Our experience has shown that it is possible to change the learning system in a traditional medical school, with good acceptance by the students and with a high level of satisfaction on the part of the teachers.

Effects of dihydropyridines and inorganic calcium blockers on aggregation and on intracellular free calcium in platelets.

[Ca2+]i increase is necessary in physiological platelet activity, particularly aggregation and release. The increase of [Ca2+]i observed during platelet activation depends in part on Ca2+ influx from the extracellular medium. The participation of voltage-operated Ca2+ channels as a pathway for Ca2+ entry is controversial. In the present study we have attempted to reinvestigate this problem by measuring aggregation and [Ca2+]i changes in platelets activated by ADP or thrombin and incubated with organic or inorganic blockers of calcium channels. The main findings of the present paper can be summarized as follows: (i) Ni2+, Co2+ and Mn2+, well known inorganic blockers of Ca2+ channels, inhibited platelet aggregation induced by ADP or thrombin in a dose-dependent manner, Ni2+ being the most effective agent. (ii) Thrombin induced a rise in free [Ca2+]i in platelets incubated both in 1 mmol/l Ca(2+)-containing medium and in nominally Ca(2+)-free medium; the rise of free [Ca2+]i was in the first case up to 370 +/- 31 nmol/l and in the second case up to 242 +/- 26 nmol/l, indicating that this observed difference was due to Ca2+ entry from the extracellular medium. Co2+ and Ni2+ abolished that difference by inhibiting Ca2+ influx. (iii) Nisoldipine, nitrendipine and nimodipine (10-50 nmol/l) inhibited in a dose-dependent manner platelet aggregation induced by either ADP or thrombin in platelets incubated in normal-Ca2+ normal-K+ medium, also, aggregation was inhibited to a similar extent in platelets incubated in normal-Ca2+ high-K+ medium. (iv) Nisoldipine--the most effective dihydropyridine to inhibit platelet aggregation--also inhibited Ca2+ influx in platelets incubated in normal-Ca2+ medium, either in normal-K+ or high-K+ media. Our data support the existence of voltage-operated, dihydropyridine-sensitive calcium channels (L-type) and a physiological role for them in platelet function.

Influence of sodium conductances on platelet activation.

The effects of extracellular Na+ and tetrodotoxin on resting membrane potential, cytosolic free Ca2+ levels and aggregation of human platelets have been studied. Neither the decrease in extracellular Na+-concentration (from 140 mmol/l to 0 mmol/l) nor the addition of tetrodotoxin (10(-7) to 10(-5) mol/l) modified the platelet membrane potential. Zero extracellular Na+ concentration or the presence of tetrodotoxin in the medium inhibited platelet aggregation; however, K+-depolarized platelets showed an unchanged aggregation induced by ADP or thrombin in media with zero or low extracellular Na+ concentrations or in the presence of tetrodotoxin. Moreover, zero extracellular Na+ concentration or tetrodotoxin inhibited calcium mobilization in platelets during activation induced by thrombin. Hence, voltage-dependent activation linked to Na+ influx appears to be necessary for ADP- and thrombin-induced platelet aggregation under control conditions. Mechanisms for the role of Na+ conductances in platelet function are discussed.

Platelet membrane potential as a modulator of aggregating mechanisms.

The membrane potential of platelets suspended in physiological medium and membrane potential changes induced by high potassium concentrations, ouabain and cooling have been measured using a cyanine fluorescent dye (3,3'-dipropylthiodicarbocyanine) [corrected]. The membrane potential of platelets suspended in physiological medium was -63.8 mV. High potassium concentrations, ouabain and cooling induced depolarization of platelet membrane. Depolarization using the above procedures enhanced platelet aggregation induced by ADP, adrenaline and collagen. These results suggest that the membrane potential could modulate platelet activity.

Inhibitory effect of peak 2-4 of uremic middle molecules on platelet aggregation.

It is well-known that uremic patients present prolonged bleeding times as a common complication. Factors responsible for this disorder have been extensively investigated. In order to elucidate the possible role of uremic middle molecules as responsible for the bleeding tendency observed in uremia, we have studied the effect on platelet aggregation of middle molecules obtained from uremic plasma by Sephadex and ion-exchange chromatography. Our results show that some purified middle molecular fractions have a specific inhibitory activity on platelet aggregation and suggest an important role for these compounds in the pathogenesis of uremic bleeding.

Effects of polyamines on platelet aggregation.

Polyamines, spermine and spermidine in the micromolar range (1-100 mumol/l) increase ADP and epinephrine-induced platelet aggregation in vitro. The possible rôle of polyamines as regulating factors of platelet aggregation in physiological and pathological states is discussed.