False positive in fluorodeoxyglucose-F18 positron emission tomography computed tomography scan of inferior vena cava leiomyoma in patient with a suspected paraganglioma. / Falso positivo en estudio de tomografía de emisión de positrones con fluorodesoxiglucosa-F18 de un leiomioma de vena cava inferior en paciente con sospecha de paraganglioma.

Leiomyomas are benign tumors derived from smooth muscle tissue that rarely present outside the uterus. These tumors do not usually show FDG uptake. We present the case of a patient with hypertension refractory to treatment and a lesion arising from inferior vena cava, that shows intense FDG uptake in PET/CT scan, suggestive of paraganglioma, with a final histological diagnosis of leiomyoma.

[Baroreflex activation therapy: One more step in the treatment of resistant arterial hypertension and chronic heart failure]. / La terapia de activación de barorreceptores, un paso más en el tratamiento de la hipertensión arterial resistente y la insuficiencia cardiaca.

The number of patients who suffer refractory arterial hypertension and chronic heart failure in advanced stages is currently increasing. The case is presented of a patient with an implantable cardioverter defibrillator, and with the dual indication of chronic heart failure and refractory arterial hypertension, who required the implanting of a baroreceptors activation therapy device of the carotid sinus. As far as it is known, it is the first case reported in Spain?

Clinical trials. A pending subject. / Ensayos clínicos. Una asignatura pendiente.

Clinical trials are essential tools for the progress of clinical medicine in its diagnostic and therapeutic aspects. Since the first trial in 1948, which related tobacco use with lung cancer, there have been more than 150,000 clinical trials to date in various areas (paediatrics, cardiology, oncology, endocrinology, etc.). This article highlights the importance for all physicians to participate, over the course of their professional career, in a clinical trial, due to the inherent benefits for patients, the progress of medicine and for curricular prestige. The authors have created a synthesis of their experience with clinical trials on hypertension, diabetes, dyslipidaemia and ischaemic heart disease over the course of almost 3 decades. Furthermore, a brief reference has been made to the characteristics of a phase I unit, as well as to a number of research studies currently underway.

Monitorización ambulatoria de presión arterial y enfermedad renal crónica en pacientes hipertensos diabéticos tipo 2 y en pacientes hipertensos / Ambulatory blood pressure monitoring and chronic kidney disease in type 2 diabetic hypertense patients and hypertense patients

Objetivos. La valoración del perfil circadiano de la presión arterial (PA) y la estimación adecuada de la presencia de enfermedad renal crónica constituyen nuevas aproximaciones en la evaluación del riesgo cardiovascular. En este estudio hemos pretendido conocer las características del patrón circadiano y la enfermedad renal de los pacientes diabéticos tipo 2 e hipertensos con respecto a los pacientes únicamente hipertensos. Pacientes y método. En una unidad especializada de riesgo cardiovascular se estudiaron 180 pacientes, 146 hipertensos y 34 hipertensos diabéticos tipo 2 con edades comprendidas entre 18 y 80 años. Se realizó historia clínica, bioquímica, electrocardiograma y se descartó la existencia de causa secundaria de hipertensión. A todos se les determinó el grado de enfermedad renal y se les realizó monitorización ambulatoria de presión arterial (MAPA) durante 24 horas. Resultados. La edad media del los pacientes hipertensos (H) fue de 47,9 ± 13,6 años, y la de los hipertensos diabéticos (H-D) fue de 57,2 ± 8,5 años. Las PA clínicas fueron más alta en los pacientes H-D que en los pacientes H (165 ± 15,1/99,7 ± 9,4 mmHg frente a 153,4 ± 23,6/96,7 ± 12,0 mmHg), respectivamente. En MAPA la presión arterial sistólica (PAS) de 24 h diurna y nocturna también eran más elevadas en los pacientes H-D que en los H. El 82,4 % de los pacientes H-D fueron non dipper frente al 71,2 % de los H (p = 0,28). El filtrado glomerular (FG) en los pacientes H-D fue de 66,7 ± 10,1 ml/min frente a 74,8 ± 3,2 ml/min (p < 0,0001) de los pacientes H. Conclusiones. Es preciso valorar con atención la enfermedad renal y el patrón circadiano de presión arterial de los pacientes hipertensos diabéticos tipo 2

Objectives. Evaluation of the circadian blood pressure (BP) profile and adequate calculation of the presence of chronic renal disease make up new approaches in evaluation of cardiovascular risk. In this study, we have aimed to know the characteristics of the circadian pattern and kidney disease of type 2 diabetic and hypertense patients in regards to patients who are only hypertense. Patients and methods. In a specialized cardiovascular risk unit, 180 patients were studied, with 146 hypertense and 34 type 2 diabetic hypertense subjects aged 18 and 80 years. A clinical, biochemical and electrocardiogram history was obtained and secondary cause of hypertension ruled out. The degree of kidney disease was determined in all of them and 24 hour ambulatory blood pressure monitoring (ABPM) was performed. Results. Mean age of the hypertense patients (H) was 47.9 ± 13.6 years and of diabetic hypertense (D H) subjects was 57.2 ± 8.5 years. The clinical BPs were higher in D-H patients than in H patients (165 ± 15.1/99.7 ± 9.4 mmHg versus 153.4 ± 23.6/96.7 ± 12.0 mmHg), respectively. In ABPM the daytime, nighttime, and 24 hour SBP were higher in D-H patients than in H ones. A total of 82.4 % of the D-H patients were non dipper versus 71.2 % of the H (p = 0.28). Glomerular filtration (GF) in D-H patients was 66.7 ± 10.1 ml/min versus 74.8 ± 13.2 ml/min (p < 0.0001) of the H patients. Conclusions. Renal disease and the circadian blood pressure pattern of type 2 diabetic hypertense patients must be evaluated carefully

[Study of the circadian blood pressure profile in patient with arterial hypertension]. / Estudio del patrón circadiano de la presión arterial en pacientes hipertensos.

In arterial hypertension besides reducing blood pressure, we should think about the circadian pressure profile that the patient presents, since the patients non depressors (not descent of arterial pressure during the night with regard to the day) (non-dipper) they associate to a worse cardiovascular prognosis. The purpose of the present study was to determine the circadian pressure profile in patient treated arterial hypertension and never previously treated with antihypertensive medication; and its relationship with the organic damage. They were included in the study to 702 patients with clinical indication for 24 hour ambulatory blood pressure monitoring. The 39% was dipper, 2% extreme dipper, 49.6% non-dipper and 9.4% riser. The patient non dipper had bigger levels of 24 hours systolic blood pressure, night blood pressure and bigger organic damage. The main factors associated to this pattern were the clinic systolic blood pressure, obesity and overalls a filtrate smaller glomerular to 60 ml/min.

Estudio del patrón circadiano de la presión arterial en pacientes hipertensos / Study of the circadian blood pressure profile in patient with arterial hypertension

En pacientes hipertensos además de reducir la presión arterial, debemos plantearnos el patrón circadiano que presenta el paciente, dado que los pacientes no depresores (no descenso de presión arterial durante la noche con respecto al día) (non-dipper) se asocian a un peor pronóstico cardiovascular. El propósito de este estudio fue determinar el patrón circadiano de presión arterial en pacientes hipertensos tratados y no tratados y su relación con la afectación orgánica. Se incluyeron en el estudio a 702 pacientes con indicación clínica para monitorización ambulatoria de la presión arterial de 24 horas. El 39% fue dipper, 2% dipper extremo, 49,6% non-dipper y 9,4% riser. Los pacientes non dipper tenían mayores niveles de presión arterial sistólica de 24 horas, nocturna y mayor repercusión orgánica. Los factores principales asociados a este patrón fue la presión arterial sistólica clínica, obesidad y sobretodo un filtrado glomerular menor a 60 ml/min

In arterial hypertension besides reducing blood pressure, we should think about the circadian pressure profile that the patient presents, since the patients non depressors (not descent of arterial pressure during the night with regard to the day) (non-dipper) they associate to a worse cardiovascular prognosis. The purpose of the present study was to determine the circadian pressure profile in patient treated arterial hypertension and never previously treated with antihypertensive medication; and its relationship with the organic damage. They were included in the study to 702 patients with clinical indication for 24 hour ambulatory blood pressure monitoring. The 39% was dipper, 2% extreme dipper, 49.6% non-dipper and 9.4% riser. The patient non dipper had bigger levels of 24 hours systolic blood pressure, night blood pressure and bigger organic damage. The main factors associated to this pattern were the clinic systolic blood pressure, obesity and overalls a filtrate smaller glomerular to 60 ml/min

Patrón no reductor de presión arterial y enfermedad renal crónica en pacientes hipertensos / Non-reducing pattern of blood pressure and chronic kidney disease in hypertensive patients

Introducción. La monitorización ambulatoria de la presión arterial (MAPA) se correlaciona mejor con el daño orgánico que la presión arterial (PA) casual. La MAPA también ha permitido dividir a los pacientes en dipper y non-dipper. Los pacientes non-dipper parecen tener un peor pronóstico en morbimortalidad cardiovascular. Nosotros presentamos los datos del patrón circadiano de PA y la afectación renal en pacientes hipertensos. Pacientes y método. Se incluyeron en el estudio 702 pacientes con criterio para realizar MAPA. A todos ellos se les midió el filtrado glomerular (FG) según la ecuación MDRD (Modification of Diet in Renal Disease) corregida para el sexo. Todos los resultados se registraron en base de datos ACCESS y se realizó estudio estadístico mediante el programa SPSS versión 12.0. Resultados. Los pacientes con FG menor de 60 ml/ min/m2 eran varones, de mayor edad, diabéticos y con niveles más elevados de colesterol, triglicéridos y ácido úrico. Las PA clínicas y de la MAPA fueron significativamente más elevadas en los pacientes con FG menor de 60 ml/min/m2. Un FG menor de 60 ml supone un riesgo estimado de 2,86 (IC al 95 %: 1,29-6,36) para presentar un patrón non-dipper. Conclusiones. En nuestro estudio el 15,8 % de los pacientes presenta un FG menor de 60 ml/min/m2. Los pacientes con FG reducido tienen más edad, son varones, diabéticos y con cifras de PA más elevadas. Un FG reducido se asocia a patrón non-dipper

Introduction. Ambulatory blood pressure monitoring (ABPM) correlates better with body damage than with casual blood pressure (BP). The ABPM has also made it possible to divide the patients into dipper and non-dipper. Non-dipper patients seem to have a worse prognosis in cardiovascular morbidity-mortality. We present the data of the circadian pattern of BP and kidney involvement in hypertensive patients. Patients and methods. A total of 702 patients with criterion to perform ABPM were included in the study. Glomerular filtration (GF) rate was measured in all of them according to the MDRD (Modification of Diet in Renal Disease) equation corrected for gender. All the results were recorded in the ACCESS database and statistical study was done with the SPSS version 12.0 program. Results. Patients with GF < 60 ml/min/m2 were male, of greater age, diabetics and with higher levels of cholesterol, triglycerides and uric acid. Clinical BP and those of ABPM were significantly higher in patients with GF < 60 ml/min/m2. A GF under 60 ml meant an estimated risk of 2.86 (95 % CI: 1.29-6.6) to have a NRP. Conclusions. In our study, 15.8 % of the patients showed a glomerular filtration less than 60 ml/m2. Patients with reduced GF are older, males, diabetics and with higher blood pressure values. A reduced GF is associated to a non-dipper pattern

Características clínicas y grado de presión arterialde los pacientes atendidos por primera vez en una unidadhospitalaria específica de hipertensión arterial / Clinical manifestations and level of blood pressure in patients evaluated for the first time in a Hypertension Clinic

Objetivo. Analizar las características clínicas, grado de presión arterial y factores condicionantes del grado de control en los pacientes remitidos por los médicos de Atención Primaria vistos por primera vez en una Unidad especializada en Hipertensión Arterial (HTA).Método. Se incluyeron de forma consecutiva 1.317 pacientes enviados por primera vez a la consulta de HTA por su médico de Atención Primaria entre enero de 1997 y noviembre de 2000. Se aplicó el siguiente protocolo inicial de estudio: anamnesis y exploración física, analítica de sangre y orina, radiografías de tórax y abdomen, fondo de ojo y electrocardiograma. En función de la orientación clínica inicial y de los resultados de las pruebas complementarias descritas, el estudio se completó o no con otros estudios complementarios. Los datos obtenidos se registraron en una base de datos informática y posteriormente se analizaron en el programa estadístico SPSS 9.0.Resultados. De los 1.317 pacientes, 741 (56,3 por ciento) fueron mujeres. La edad media fue de 54,58ñ14,4 años (rango: 14-91 años). La presión arterial sistólica (PAS) y la presión arterial diastólica (PAD) medias fueron de 152,6 ñ 22,7 mmHg y 94,2ñ11,6 mmHg, respectivamente. El 71,6 por ciento (943 pacientes) presentaron al menos dos factores de riesgo cardiovascular (FRCV), tres FRCV el 50,5 por ciento (665 pacientes) y cuatro FRCV el 10,4 por ciento (137 pacientes). El 43,6 por ciento (575 pacientes) presentaba un grado I de HTA, el 33,2 por ciento (438 pacientes) un grado II y el 23,1 por ciento (304 pacientes) un grado III de HTA. El grado de HTA se asoció con la edad, el tiempo transcurrido desde el inicio de la HTA, el índice de masa corporal (IMC) y los niveles en sangre de glucosa, colesterol total y colesterol LDL. Un modelo de regresión logística para clasificar a los pacientes como grados I o II-III identificó como variables independientes la edad, el tiempo transcurrido desde el inicio de HTA, el IMC, el padecimiento de diabetes mellitus (DM) y un nivel plasmático de colesterol LDL mayor de 160 mg/dl. Conclusiones. La mitad de los pacientes enviados por primera vez por su médico de Atención Primaria a nuestra Unidad de HTA presentaba al menos tres FRCV. Asimismo, el 56,4 por ciento presentaba una HTA moderada severa (grados II-III). Por último, el grado de HTA de los pacientes dependía de la edad, del tiempo transcurrido desde el inicio de la HTA, del índice de Quetelet y de la existencia de DM e hipercolesterolemia (AU)

[Clinical manifestations and level of blood pressure in patients evaluated for the first time in a Hypertension Clinic]. / Características clínicas y grado de presión arterial de los pacientes atendidos por primera vez en una unidad hospitalaria específica de hipertensión arterial.

OBJECTIVE: To analyze the clinical manifestations, blood pressure level, and determinants of the degree of hypertension (HT) control in the patients referred by the Primary Care physicians and evaluated for the first time in a Hypertension Clinic. METHOD: The participants were 1,317 consecutively referred patients for the first time to the Hypertension Clinic by their Primary Care physician, between January 1997 and November 2000. The following initial study protocol was applied: case history and physical exploration, blood and urine biochemistry, chest and abdomen x-rays, fundus oculi and electrocardiogram. According to the initial clinical orientation and the results of the complementary tests described, the study was supplemented or not with other complementary studies. Results were registered in a computer dabatase and subsequently were analyzed with the statistical program SPSS 9.0. RESULTS. 741 (56.3%) of the 1,317 patients were women. The average age was 54.58 14.4 years (range: 14-91 years). Average systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 152.6 22.7 mmHg and 94.2 11.6 mmHg, respectively. 71.6% (943 patients) presented at least two cardiovascular risk factors (CVRF), 50.5% (665 patients) three CVRF and 10.4% (137 patients) four CVRF. 43.6% (575 patients) presented a degree I, 33.2% (438 patients) a degree II and 23.1% (304 patients) a degree III HT. The degree of HT was associated with the age, the time elapsed from the beginning of the HT, the body mass index (BMI) and the levels of blood glucose, total cholesterol and LDL cholesterol. A model of logistic regression to classify the patients as HT degrees I or II-III identified as independent variables the age, the time elapsed from the beginning of HTA, the BMI, the presence of diabetes mellitus (DM) and the plasma LDL cholesterol level greater of 160 mg/dl. CONCLUSIONS: Half of the patients sent for the first time by its Primary Care physician to our Hypertension Clinic presented at least three CVRF. Furthermore, 56.4% presented a moderate-severe HTA (degrees II-III). Finally, the degree of HTA of the patients was related to the age, the time elapsed from the beginning of the HTA, the Quetelet's index, and the existence of DM and hypercholesterolemia (HC).

[Clinical characteristics of 47 patients with primary hyperparathyroidism surgically treated]. / Características clínicas de 47 casos de hiperparatiroidismo primario intervenidos quirúrgicamente.

BACKGROUND: The primary hyperparathyroidism is usually an asymptomatic disease. Actually, specialists are attempting to consider to what extent it can be necessary to undergo surgery in this disease. In this article, we are going to describe the clinical and biochemical characteristics of our patients with primary hyperparathyroidism as well as the diagnostic procedures and the results after operation. METHODS: Firstly, we have analysed 47 records of patients with primary hyperparathyroidism and intervened in our hospital during the last 5 years. Secondly, we assessed the biochemical results before and after the surgical intervention, the outcome of parathyroid echography, thoracico-cervical tomography, technietium-99-mm-sestamibi gammagraphy and bone densitometry. Finally, we followed up the assessment of the operation of the patients with hyperparathyroidism. RESULTS: 47 patients were intervened of hyperparathyroidism. 89.4% were women and average the age was 61.4 +/- 12.8 years. Most of them were asymptomatic (45.7%). The gammagraphy was the procedure with best sensibility and specificity, 75 and 100%. Bone densitometry showed that there were no patients with diminished calcification of the bones. The principal diagnostic of pathologic anatomy was adenoma (85.1%). Excluding one single case, the rest of patients healed of their illness after intervention. CONCLUSIONS: Primary hyperparathyroidism is asymptomatic in most of the cases. It is mainly an adenoma process. The best diagnostic procedure is technietium-99-mm-sestamibi gammagraphy. The most appropriate and successful treatment is surgery.

Características clínicas de los pacientes hipertensos esenciales respecto al consumo de sal / Clinical characteristics of patients with essential hypertension regarding salt intake

Numerosos estudios epidemiológicos y experimentales han puesto de manifiesto la estrecha relación entre el consumo de sal y la presión arterial. El objetivo de este estudio fue conocer la ingesta de sodio en 293 pacientes hipertensos no tratados previamente e identificar las características clínicas de los mismos que nos permitiera definir el perfil de los pacientes que consumen mayor cantidad de sodio. Se seleccionaron los pacientes hipertensos que acudían por primera vez a una consulta especializada de hipertensión arterial (HTA) y no tratados farmacológicamente, al menos durante el mes anterior. Se determinó la excreción urinaria de sodio en orina de 24 horas en dos ocasiones como índice del consumo de sodio. El 13 por ciento de los pacientes presentó un consumo inferior a 100 mEq/24 h y un 35 por ciento superior a 200 mEq/24 h.El consumo de sodio fue mayor en los hombres, en los pacientes más jóvenes, los que tenían un índice de Quetelet mayor, fumadores, estrato social más alto y menos años de duración de la HTA. No encontramos diferencias en el consumo de sal en los pacientes hipertensos con diabetes o hiperlipidemia asociada. El análisis de regresión lineal múltiple identificó como variables independientes en el consumo de sal al índice de Quetelet, sexo, edad y tabaco. No se encontró correlación entre el consumo de sal y la presión arterial. En conclusión, destacamos el alto consumo de sodio en nuestro medio en pacientes hipertensos que previamente se les había indicado la necesidad de moderar el consumo de sal. El consumo más elevado se observa entre los hombres, jóvenes, obesos y fumadores (AU)

[Usefulness of the clonidine test for the diagnosis of pheochromocytoma]. / Utilidad de la prueba de clonidina en el diagnóstico de feocromocitoma.

BACKGROUND: The clonidine test has been proposed as diagnostic biochemical test for patients with clinical suspicion of pheochromocytoma. METHODS: The clonidine test was used in 80 patients with suspicion of pheochromocytoma (on account of suggestive clinical findings, increased levels of metanephrines, increased plasma or urinary levels of catecholamines, or suggestive images by ultrasonography or CT). RESULTS: Surgery confirmed the diagnosis of pheochromocytoma in 16 patients. The highest sensitivity (62%) and specificity (46%) of the clonidine test corresponded to a brake degree of 5%, with a predictive negative value of 83%. The test was most useful in patients with increased basal plasma values of catecholamines (sensitivity, 62%; specificity, 66%). CONCLUSIONS: The clonidine test can be useful for the diagnosis of pheochromocytoma in patients with increased basal plasma levels of catecholamines and a brake degree lower than 5% at 180 minutes.

Utilidad de la prueba de clonidina en el diagnóstico de feocromocitoma / Utility of the clonidine test for the diagnosis of pheochromocytoma

Fundamento. La prueba de clonidina se ha propuesto como prueba bioquímica diagnóstica en pacientes con sospecha clínica de feocromocitoma. Método. Hemos realizado dicha prueba a 80 pacientes con sospecha de feocromocitoma (por datos clínicos sugestivos, metanefrinas elevadas, catecolaminas plasmáticas o urinarias elevadas, imágenes en eco o tomografía axial computarizada sugerentes del mismo).Resultados. Se confirmó quirúrgicamente el diagnóstico de feocromocitoma en 16 pacientes. La prueba de clonidina mostró la mayor sensibilidad (S = 62 por ciento) y especificidad (E = 46 por ciento) para un punto de corte de frenación del 5 por ciento, con un valor predictivo negativo del 83 por ciento. La prueba mostró mayor utilidad en los pacientes con valores plasmáticos basales elevados de catecolaminas (S, 62 por ciento; E, 66 por ciento).Conclusiones. La prueba de clonidina puede ser útil en el diagnóstico de feocromocitoma en pacientes que presentan catecolaminas plasmáticas basales elevadas y una frenación a los 180 minutos menor del 5 por ciento (AU)

[Clinical characteristics of patients with essential hypertension regarding salt intake]. / Características clínicas de los pacientes hipertensos esenciales respecto al consumo de sal.

A number of epidemiologic and experimental studies have revealed the close relationship between salt intake and blood pressure. The objective of this study was to know the salt intake among 293 not previously treated hypertensive patients and to identify their clinical characteristics that would allow us to define the profile of patients with high sodium intake. Hypertensive patients who first attended a specialized high blood pressure (HBP) clinic not previously treated with drugs, at least for the last month were selected. Sodium 24 h urinary excretion was determined on two occasions, as sodium intake index. Thirteen percent of patients had a salt intake lower than 100 mEq/24 h and 35% of patients higher than 200 mEq/24 h. Sodium intake was higher among men, younger patients, those with a higher Quetelet index, smokers, higher socioeconomic status, and less years with IBP. No differences were observed between salt intake among hypertensive patients with associated diabetes or hyperlipidemia. The Quetelet index, sex, age and smoking were identified as independent variables for salt intake by the multiple linear regression analysis. No correlation was found between salt intake and blood pressure. In conclusion, a high sodium intake was observed in our setting among hypertensive patients who had previously been advised to moderate salt intake. The highest salt intake was observed among men, youths, obese and smokers.

Amiloidosis nodular pulmonar. Diagnóstico por biopsia transbronquial / Nodular pulmonary amyloidosis. Diagnosis by transbronchial biopsy

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[Liver abscess caused by Klebsiella pneumoniae in diabetic patients]. / Absceso hepático por Klebsiella pneumoniae en pacientes diabéticos.

Pyogenic liver abscess are macroscopic collections of pus within the hepatic parenchyma after a bacterial infection. These infections are usually polymicrobial in nature, and in most occasions due to biliary tract diseases or cryptogenetic in origin. Monomicrobial hepatic abscess caused by Klebsiella pneumoniae are uncommon lesions in western countries. These lesions are associated with underlying diseases, particularly diabetes mellitus, and are frequently complicated with septic metastasis. We report here three cases of monomicrobial liver abscess caused by Klebsiella pneumoniae in diabetic patients, without septic metastasis and a favourable outcome.