Impacto del índice tobillo-brazo sobre la estratificación de riesgo cardiovascular de pacientes hipertensos / Importance of ankle-arm index in cardiovascular risk factor stratification for hypertensive patients

Introducción. El índice de presión arterial tobillo-brazo (ITB) es una prueba diagnóstica eficiente en la detección de vasculopatía periférica y predice la morbimortalidad cardiovascular. El objetivo de este estudio fue evaluar el impacto de la realización de ITB en la estratificación de riesgo de sujetos sin enfermedad cardiovascular (ECV) clínica. Material y métodos. Se incluyeron pacientes con hipertensión arterial esencial, mayores de 65 años, de ambos sexos y al menos con un factor de riesgo cardiovascular. A todos ellos se les calculó los ITB pedios y tibiales de ambos miembros inferiores, determinando la presión arterial sistólica en dichos territorios mediante un detector continuo de pulso por sistema doppler (Vasculascope Model 500, Hayashi Denki Co., Ltd). Se consideró diagnóstico anormal un ITB inferior a 0,9 o superior a 1,3. Se recogieron datos sobre presión arterial, peso, talla, antecedentes personales y familiares, uso de fármacos y hábitos tóxicos. También se tomaron muestras sanguíneas para la valoración del perfil lipídico, bioquímica sanguínea y hemograma. Se incluyeron 130 pacientes hipertensos (62 por ciento varones), con una edad media de 68 ñ 5 años, y un valor de presión arterial sistólica media en brazo dominante de 146 ñ15 mmHg. Resultados. Según la clasificación del riesgo cardiovascular, 59 (45 por ciento) pacientes presentaban un riesgo medio y 71 (55 por ciento) mostraban un riesgo cardiovascular elevado. De los 130 pacientes, 9 (6,9 por ciento; IC 95 por ciento: 2,6 por ciento-11,4 por ciento) presentaron un ITB anormal, dos (3,4 por ciento) en el grupo de riesgo medio y 7 (9,9 por ciento) entre los pacientes de riesgo elevado. Conclusión. La medición del ITB en pacientes hipertensos libres de ECV clínica y diabetes, con riesgo medioalto, no parece ser clínicamente útil debido al escaso número detectado de pacientes con ITB anormal y que podrían obtener beneficios de esta intervención al ser reclasificados como de riesgo muy alto (AU)

Criterios de derivación de pacientes hipertensos a una Unidad de Hipertensión Arterial / Criteria for referral of hypertensive patients to a Hypertension Unit

Al inicio del siglo XXI ha quedado extensamente documentada la relevancia de la hipertensión arterial como uno de los principales componentes de múltiples síndromes relacionados con el aumento del riesgo cardiovascular. Las complicaciones de la hipertensión afectan los principales órganos diana, entre ellos corazón, cerebro, vasos y riñones. La diversidad de estas complicaciones y el gasto en salud que demanda el cuidado de estos pacientes exige mejorar la comunicación entre los diferentes componentes del sistema de salud. Sobre estas bases surge la necesidad de desarrollar criterios de derivación de pacientes hipertensos a unidades especializadas de riesgo cardiovascular para un correcto diagnóstico y estratificación de riesgo, con el fin de optimizar el tratamiento y control de esta patología. En la última guía de la SEH-LELHA se publican los principales criterios de derivación de los hipertensos a centros especializados. En esta revisión se desarrollan brevemente cada uno de estos puntos, haciendo hincapié en los signos y síntomas característicos de cada patología. Además, se agregan algunas situaciones especiales en la práctica clínica. El principal objetivo de este trabajo es proveer una orientación a los profesionales de la salud en la toma de decisión sobre la derivación de pacientes o la realización de pruebas especializadas para el diagnóstico y tratamiento. Finalmente se realizó un análisis de los pacientes enviados a la Unidad de Hipertensión del Hospital 12 de Octubre, entre octubre de 2002 y enero de 2003 que ilustran las principales pautas de proceder (AU)

Acute interhemispheric subdural hematoma: two case reports and analysis of the literature.

Interhemispheric subdural hematoma (ISH) had been considered extremely rare until identification with imaging studies. Its natural history is still quite unknown in terms of potential origin and course. As a consequence of various controversies, there is still no clearly established treatment, particularly in regard to medical or surgical management. The best decision requires tailoring treatment to the individual patient according to his or her clinical condition. Two patients with acute interhemispheric subdural hematomas are reported, the controversial management of this rare entity is analysed. In reviewing current published cases of interhemispheric subdural hematoma, it seems that the outcome of an individual patient is not related to the therapeutic approach, but to the level of consciousness and the neurological condition on admission. Surgical and medical treatment indications are taken into account for management. A patient with ISH developed an extension of the hematoma to the convexity at 2 weeks of his clinical course, with a decline of his neurological condition. The hematoma was then evacuated through a parietal craniotomy with an uneventful postoperative course. Another case of ISH presented as headache and TIA, with spontaneous clinical improvement at 12 hours and with no decline in the patient's neurological condition. Management was conservative. In both cases the neurological examination was normal after 6 months. As in previously reported cases, the clinical and neurological condition of the patient on admission is crucial for the course of an ISH. Treatment strategies are based on the individual neurological response of each case and the risk-benefit ratio to decide on a medical or surgical approach.

[Control of arterial pressure: experience at a hospital monographic unit arterial hypertension]. / Control de la presión arterial: experiencia de una Unidad monográfica de Hipertensión Arterial hospitalaria.

OBJECTIVE: To analyse the evolution of blood pressure control in patients referred to our centre for study, proportion of controlled hypertensive patients, changes in the characteristics of hypertensive patients and in therapeutic guidelines in the last twenty years. MATERIAL AND METHODS: A total of 4,103 patients were referred to study of hypertension. The analysed variables year by year included sex, age, weight, systolic blood pressure (SBP) and diastolic blood pressure (DBP). Cross sections at five-year intervals were performed to collect basal SBP and DBP and the evolution of BP in the following five years. RESULTS: From 1977 to 1997 the following changes were observed: basal mean age changed from 67 +/- 9 down to 56 +/- 10 years among males and from 68 +/- 8 down to 52 +/- 9 years among females; basal mean weight changed from 71 +/- 7 up to 81 +/- 8 kg among males and from 69 +/- 12 up to 73 +/- 13 years among females. Males showed a decrease in basal mean values of SBP/DBP from 176 +/- 25/112 +/- 20 mmHg down to 154 +/- 21/94 +/- 12 mmHg. In women, the corresponding values changed from 182 +/- 36/105 +/- 19 mmHg down to and 154 +/- 23/93 +/- 12 mmHg. In the early 1980's, 62% of patients received one or no antihypertensive drug. In the last few years such percentage has been 36% and 64% have been treated with two or more drugs. CONCLUSIONS: A decrease in age and an increase in weight of hypertensive patients referred to study have been observed in the last twenty years. Such patients show a less severe hypertension compared with referred patients in the early years. The use of new hypertensive drugs and their combined use are measures that contribute to improve the percentage of controlled hypertensive patients.

Coartación de aorta del adulto / Coartation of aorta in adult patients

Se presenta un caso de coartación aórtica del adulto en un paciente remitido a nuestra consulta por presentar cifras tensionales persistentemente elevadas en el marco de una hipertensión arterial (HTA) de 14 años de evolución. Se procede al interrogatorio y exploración fisica, donde se sospecha la coartación aortica, confirmándose ésta por las pruebas complementarias, realizándose su correción quirúrgica. Tras la misma, el paciente se presenta asintomático con muy buen control de presión arterial. Se plantea la importancia de realizar interrogatorio y examen físico concienzudo en un paciente joven con HTA, por el rendimiento que presenta una adecuada anamnesis, para orientar el correcto diagnóstico y tratamiento de la HTA secundaria (AU)

Control de la presión arterial: experiencia de una Unidad monográfica de Hipertensión Arterial Hospitalaria / Blood pressure control: experience in a monographic Hospital Hypertension Unit

Fundamento. Analizar la evolución del control de la hipertensión arterial (HTA) en la población remitida para estudio en nuestro centro, la proporción de hipertensos controlados, los cambios de las características del hipertenso y de las pautas terapéuticas en los últimos 20 años. Pacientes y métodos. Se incluyeron 4.013 pacientes remitidos para estudio de su HTA. Las variables analizadas año por año fueron sexo, edad, peso, presión arterial sistólica (PAS) y diastólica (PAD). Se realizaron cortes transversales cada 5 años para recoger la PAS y PAD basal y la evolución de dichos valores de PA en los 5 años siguientes. Resultados. Entre 1977 y 1997 se observaron los siguientes cambios: la edad basal media pasó de 67 ñ 9 a 56 ñ 10 años en varones y de 68 ñ 8 a 52 ñ 9 años en mujeres; el peso basal medio pasó de 71 ñ 7 a 81 ñ 8 kg en los varones y de 69 ñ 12 a 73 ñ 13 kg en las mujeres. Los varones mostraron una reducción de los valores medios basales de PAS/PAD de 176 ñ 25/112 ñ 20 mmHg a 154 ñ 21/94 ñ 12 mmHg. En las mujeres dichos valores pasaron de 182 ñ 36/105 ñ 19 mmHg a 154 ñ 23/93 ñ 12 mmHg. A principios de los ochenta el 62 por ciento de los pacientes recibían uno o ningún fármaco antihipertensivo. En los últimos años dicho porcentaje es del 36 por ciento y un 64 por ciento son tratados con 2 o más fármacos. Conclusiones. Se observa una disminución de la edad e incremento del peso de los hipertensos remitidos para estudio en los últimos 20 años. Dichos pacientes muestran una HTA menos severa en comparación con los pacientes remitidos en los primeros años. La utilización de nuevos fármacos antihipertensivos y el uso combinado de los mismos son medidas que contribuyen a mejorar el porcentaje de pacientes hipertensos controlados (AU)

Crystal structure of the ectodomain of Methuselah, a Drosophila G protein-coupled receptor associated with extended lifespan.

The Drosophila mutant methuselah (mth) was identified from a screen for single gene mutations that extended average lifespan. Mth mutants have a 35% increase in average lifespan and increased resistance to several forms of stress, including heat, starvation, and oxidative damage. The protein affected by this mutation is related to G protein-coupled receptors of the secretin receptor family. Mth, like secretin receptor family members, has a large N-terminal ectodomain, which may constitute the ligand binding site. Here we report the 2.3-A resolution crystal structure of the Mth extracellular region, revealing a folding topology in which three primarily beta-structure-containing domains meet to form a shallow interdomain groove containing a solvent-exposed tryptophan that may represent a ligand binding site. The Mth structure is analyzed in relation to predicted Mth homologs and potential ligand binding features.

[Mobilization of alpha-glutathione S-transferase in the anesthetized patient]. / Movilización de la enzima alfa glutatión S-transferasa en el paciente anestesiado.

OBJECTIVE: To measure and assess changes in plasma concentrations of alpha glutathione S-transferase (alpha-GST) during and after anesthesia with isoflurane, desflurane and propofol. PATIENTS AND METHODS: Study of 90 ASA I and II patients scheduled for lumbar back surgery under general anesthesia assigned randomly to one of three groups to receive anesthetic maintenance with isoflurane, desflurane or propofol. We measured plasma levels of alpha-GST, aspartate aminotransferase aspartate, alanine aminotransferase, alkaline phosphatase, pseudocholinesterase, gamma glutamyltransferase and total bilirubin at baseline and several times during and after surgery. RESULTS: Changes in plasma levels of alpha-GST were detected in all three groups, the tendency to increase reaching its peak with the sample taken at the end of anesthesia. The ranges considered normal were not exceeded in any of the patients studied. CONCLUSIONS: By measuring alpha-GST changes in plasma, we have detected signs of disturbance in hepatocellular integrity after anesthesia with all three maintenance agents used. However, the slight and transitory nature of the events confirms the scarce hepatotoxic potential of isoflurane, desflurane and propofol.

[Pheochromocytoma: a motley tumor]. / Feocromocitoma: un tumor abigarrado.

Four patients admitted to our hospital with different symptomatology are studied: a 9-years-old boy with hyperhidrosis; a 47-years-old woman with arterial hypertension and two young males, 25 and 36-years-old, respectively, with thoracic pain. In all cases, the presence of pheochromocytoma was suspected. One of them died due to left ventricular failure with acute lung edema. The other three patients were diagnosed by hormonal determinations, detecting a supra-renal body with abdominal echography and computerized axial tomography and undergoing surgery. Currently, they are asymptomatic.

Intraluminal crystalloids in struma ovarii. Immunohistochemical, DNA flow cytometric, and ultrastructural study.

We recently encountered a unique case of follicular variant of papillary carcinoma arising in struma ovarii that contained numerous intrafollicular crystalloids. There was no evidence of capsular or vascular invasion or metastases, though the DNA content of the papillary carcinoma was aneuploid. In contrast, diploid DNA was manifested in the histologically benign thyroid tissue. The nature of the crystalloids and the significance of aneuploid DNA content are discussed.

Effects of captopril on diabetic nephropathy in hypertensive women.

The effects of the angiotensin converting enzyme inhibitor captopril on blood pressure, proteinuria, creatinine clearance and metabolic control in diabetic nephropathy have been evaluated. Captopril 144 mg per day was given to 8 longstanding, insulin-dependent, diabetic females with nephropathy. The blood pressure was significantly reduced (systolic 45.4, diastolic pressure 30.6 and mean arterial pressure 33.8 mm Hg after 24 weeks of treatment). Plasma renin activity rose significantly from a basal value of 1.60 to 6.71 ng.ml-1.h-1, and so did serum potassium (from 4.57 to 4.83 mEq.1-1). Serum aldosterone fell from 161 to 70.9 pgm.ml-1 and from 27.3 to 15.3 micrograms.24 h-1 in plasma and urine, respectively, after 6 months on captopril therapy. Urinary protein excretion was decreased by about 48% and creatinine clearance remained unchanged throughout the study. Plasma triglycerides and cholesterol also remained unchanged, and glycosylated haemoglobin was significantly reduced from 13.8 to 10.2% after captopril. The results suggest that captopril is a useful drug to treat hypertension in patients suffering from diabetic nephropathy, as the decline in kidney function can be reduced without impairing glucose tolerance or the lipid profile.

[Evidence of abnormal kidney processing of uric acid in patients with insulin-dependent diabetes mellitus]. / Evidencia del manejo renal anormal de ácido úrico en pacientes diabéticos insulinodependientes.

Renal uric acid handling in 62 insulin dependent diabetic (IDD) patients of both sexes, without clinical or biochemical signs of nephropathy or hypertension was studied and compared to healthy age matched control groups. IDD adults (n = 38, age 45-64) presented uremia similar to controls (n = 9 age 45-64). Neither, the tubular charge or filtration charge (CFU) or the uric acid excretion fraction showed statistically significant differences. Young IDD (n = 24, age 13-37) presented levels uric acid than significantly (p less than 0.001) lowers to young controls (n = 10, age 13-38) and adults IDD (p less than 0.001). The CFU is lower in both, young and adult IDD when compared to young controls (p less than 0.02). Nevertheless, the CFU is higher in young IDD than in controls of the same age (p less than 0.001) or in adult IDD (p less than 0.001). In summary, we conclude the existence of an abnormal (uric acid) renal management caused by a tubular defect probably lying on the proximal tubular segment where the uric acid secretion is carried out.

Expression of sialylated Leu-M1 antigen in histiocytosis X.

The purpose of this study is to determine the versatility of the monoclonal antibody anti-Leu-M1 in histiocytosis X diagnosis. This antibody recognizes an unsialylated lacto-N-fucopentaose III (hapen X) carbohydrate moiety that is linked to the cell membrane protein in interdigitating reticulum cells and Langerhans' cells. Previously, the authors have shown that anti-Leu-M1 can be used to stain Reed-Sternberg cells, which are likely related to interdigitating reticulum cells. In this study, the authors tested the usefulness of anti-Leu-M1 in staining formalin-fixed and paraffin-embedded tissue sections from eight patients with histiocytosis X. For staining of histiocytosis X cells, unlike Reed-Sternberg cells in Hodgkin's disease, neuraminidase treatment was required for removal of sialic acid residues from the Leu-M1 antigen. The staining characteristics of anti-Leu-M1 in histiocytosis X cells resembled those of normal Langerhans' cells and lymphocyte and histiocyte variants (L & H cells) in the lymphocyte-predominant type of Hodgkin's disease. The significance of sialylation of Leu-M1 antigen in histiocytosis X cells has yet to be determined in order to correlate the prognosis of the disease. The authors suggest that anti-Leu-M1 used together with neuraminidase treatment is a valuable tool in the diagnosis of histiocytosis X when electron microscopy or frozen sections for OKT6 immunostaining are not available.

Bone involvement in hairy cell leukemia.

Four patients with a diagnosis of hairy cell leukemia complicated by bone involvement are described. This is an uncommon complication of the disease. Manifestations included osteolytic lesions, severe osteoporosis, and aseptic necrosis of the femoral head. The osseous complications do not seem to bear on the prognoses for these patients. Radiotherapy or chemotherapy provides symptomatic relief and may prevent further morbidity from the bone lesions.

Metastases from transitional cell carcinoma of urinary bladder.

In 107 patients who died of metastatic transitional cell carcinoma, the most common sites for metastases at necropsy were the lymph nodes, liver, lung, bone, and adrenal gland. Metastases first were documented clinically in multiple-organ sites in one third of the patients; solitary metastases were present in only 9 patients at necropsy. The mean duration of survival for patients was thirteen months from the diagnosis of the primary tumor. The metastatic lesion(s) generally were evident clinically within eleven months of the primary diagnosis; death ensued usually within three months. Our finding that the majority of patients presented initially with high-grade tumors suggests that a high-grade lesion, regardless of its clinical stage, warrants early aggressive therapy.