Assessment of enlarged perivascular spaces and their relation to target organ damage and mild cognitive impairment in patients with hypertension.

BACKGROUND AND PURPOSE: Enlarged perivascular spaces (EPVS) have been recently considered a feature of cerebral small vessel disease. They have been related to aging, hypertension and dementia but their relationship with hypertension related variables (i.e. target organ damage, treatment compliance) and mild cognitive impairment (MCI) is not fully elucidated. Our aims were to investigate the relation between basal ganglia (BG) and centrum semiovale (CSO) EPVS with vascular risk factors, hypertension related variables and MCI. METHODS: In all, 733 hypertensive individuals free of stroke and dementia from the Investigating Silent Strokes in Hypertensives, a magnetic resonance imaging Study (ISSYS) underwent brain magnetic resonance imaging and cognitive testing to diagnose MCI or normal cognitive aging. RESULTS: The numbers of participants presenting high grade (>10) EPVS at the BG and CSO were 23.3% and 40.0%, respectively. After controlling for vascular risk factors, high grade BG EPVS were associated with age (odds ratio 1.68; 95% confidence interval 1.37, 2.06), poor antihypertensive compliance (1.49; 1.03, 2.14) and the presence of microalbuminuria (1.95; 1.16, 3.28), whereas in the CSO only age (1.38; 1.18, 1.63) and male sex were associated with EPVS (1.73; 1. 24, 2.42). MCI was diagnosed in 9.3% of the participants and it was predicted by EPVS in the BG (1.87; 1.03, 3.39) but not in the CSO. This last association was greatly attenuated after correction for lacunes and white matter hyperintensities. CONCLUSIONS: Basal ganglia EPVS are associated with the presence of microalbuminuria and poor adherence to antihypertensive drugs. The BG EPVS relation with MCI is not independent of the presence of other cerebral small vessel disease markers.

Cognitive assessment protocol design in the ISSYS (Investigating Silent Strokes in hYpertensives: a magnetic resonance imaging Study).

Hypertension and silent cerebrovascular lesions (SCL) detected by brain magnetic resonance imaging (MRI) are associated with an increased risk of cognitive decline. In a prospective observational study in 1000 hypertensive patients, aged 50-70 years, with no prior history of stroke or dementia, we will study the presence of mild cognitive impairment (MCI) and the relationship between SCL and cognition. All participants will be assessed by means of the Dementia Rating Scale-2 (DRS-2) and will undergo a brain MRI. In order to better characterize MCI and future dementia risk in our cohort, those patients that are suspected to be cognitively impaired according to the DRS-2 results will have a further neurological evaluation and complete neuropsychological testing. Follow-up for the entire cohort is planned to last for at least 3 years.

Hyperkalemic distal renal tubular acidosis caused by immunosuppressant treatment with tacrolimus in a liver transplant patient: case report.

Nephrotoxicity is one of the most common side effects of long-term immunosuppressive therapy with calcineurin inhibitors. We describe a case of distal renal tubular acidosis secondary to tacrolimus administration. A 43-year-old man with end-stage liver disease due to hepatitis C and B virus infections and alcoholic cirrhosis received a liver transplantation under immunosuppressive treatment with tacrolimus and mycophenolate mofetil. In the postoperative period, the patient developed hyperkalemic hyperchloremic metabolic acidosis, with a normal serum anion gap and a positive urinary anion gap, suggesting distal renal tubular acidosis. We excluded other causes of hyperkalemia. Administration of intravenous bicarbonate, loop diuretics, and oral resin exchanger corrected the acidosis and potassium levels. Distal renal tubular acidosis is one of several types of nephrotoxicity induced by tacrolimus treatment, resulting from inhibition of potassium secretion in the collecting duct. Treatment to correct the acidosis and hyperkalemia should be promptly initiated, and the tacrolimus dose adjusted when possible.

[Hypertension in hemodialysis: prevalence and associated factors in Catalonia. The PRESDIAL study]. / Prevalencia y factores asociados a hipertensión arterial en hemodiálisis en Cataluña. Estudio PRESIDIAL.

OBJECTIVE: To evaluate the prevalence of hypertension (HT) in prevalent hemodialysis (HD) patients in our region, and to analyze the associated clinical and biochemical variables. METHODS: Observational, cross-sectional and multicentric study including a representative sample of prevalent and stable (> 6 months) HD patients from all the HD centers (in and out of Hospitals) in Catalonia, Spain. Clinical and biochemical variables were recorded and predialysis blood pressure (BP) was determined (x3) in each dialysis session during 1 month, as well as the pre/post weight weekly. HT was defined as having at least one of these criteria: a mean (12 determinations) systolic BP > or = 140 mmHg or diastolic BP > or = 90 mmHg or antihypertensive treatment for at least 3 months. RESULTS: The sample comprised 387 patients from 32 of the 40 centers included, 231 of whom where men, with mean age of 63 +/- 14 years. The prevalence of HT in this sample was 67.4%, varying according to the etiology of End-Stage Renal Disease: diabetic 81%, vascular 81%, glomerulonephritis 61%, PKD 52%, unknown and others 64%. The prevalence of additional CV risk factors was 83%. One of each hypertensive 4 patients were treated, of whom 58% had systolic BP > or = 140 or dyastolic > or = 90, in contrast to 28% of untreated patients. The proportion of individuals according to the number of antihypertensive agents was 21% (no agents), 48% (1 agent), 20% (2 agents), 11% (3 agents). Blood pressure was higher among patients receiving higher number of antihypertensive agents. No differences according HT were found in age (64 +/- 13 in hypertensive patients versus 60 +/- 15 in normotensives), time on dialysis (4 +/- 4 vs 4 +/- 4 years), interdialysis weight gain (2.1 +/- 0.8 vs 2.1 +/- 0.8 kg), proportion of weight gain (3.3 +/- 1.4 vs 3.1 +/- 1.4%) or proportion of patients with > 5% weight gain with respect to dry weight (32.5 vs 27.3%). While 84% of hypertensive patients had an additional CV risk factor, this value was 67% in the patients without HT (p < 0.001). CONCLUSION: In HD patients HT has a high prevalence in our region and is poorly controlled. The causes of this poor control may be multiple, and weight gain parameters seem not to be a main factor in these stable patients. Due to the aggregation of risk factors in these patients, strategies in order to improve BP control in HD are mandatory.

Predictors of poor renal outcome in patients with lupus nephritis treated with combined pulses of cyclophosphamide and methylprednisolone.

Lupus nephritis remains a major cause of morbidity and mortality in patients with systemic lupus erythematosus. Although the renal prognosis has improved, the optimal therapeutic regime has not been definitively established, and significant challenges remain in the management of disease progression and recurrent renal relapse. We performed a prospective study to evaluate the outcome of 38 patients with severe lupus nephritis treated with standard cyclophosphamide and methylprednisolone pulse therapy, and to determine the variables associated with poor outcome. Five patients developed end-stage renal disease (ESRD) (13%), 10 (26%) developed persistent proteinuria (> 1 g/24h) and 15 (39%) suffered at least one relapse after 8 years of follow-up. A high chronicity index, interstitial fibrosis (P = 0.04), persistent hypertension (P < 0.0001) and hypocomplementaemia (P = 0.002) after treatment were the major variables associated with ESRD. Tubular atrophy (P = 0.01), persistent hypertension (P = 0.0001) and hypocomplementaemia after treatment (P = 0.0281) were associated with persistent proteinuria. Persistence of anti-dsDNA antibodies and hypocomplementaemia after treatment (P = 0.0118) were associated with renal relapse. Our data suggest that the group of patients with persistence of hypocomplementaemia and raised anti-dsDNA antibodies titres are at high risk of renal relapse and may be candidates for continuation of immunosuppressive treatment. Patients with persistent proteinuria alone or a high chronicity index are less likely to respond to immunosuppression, and strict control of the hypertension may be the best approach.

[Pheochromocytoma associated with multiple endocrine neoplasia 2A and sporadic: differential characteristics]. / Feocromocitoma asociado a neoplasia endocrina múltiple 2A y esporádico: características diferenciales.

BACKGROUND: To study distinctive clinical features of pheochromocytoma in the setting of multiple endocrine neoplasia type 2A (MEN 2A) in comparison with sporadic pheochromocytoma. PATIENTS AND METHOD: All patients diagnosed of sporadic pheochromocytoma (n = 29) and in the setting of MEN 2A (n = 16) between 1976 and 1998 in a tertiary hospital were included in the study. The following variables were compared: age at diagnosis, symptoms, presence and characteristics of hypertension, size of the tumor, localization and malignancy. The accuracy of diagnostic tests was also evaluated. RESULTS: The pheochromocytoma associated to MEN 2A had a higher prevalence in our study (35.5%) and the diagnosis was performed earlier than for sporadic pheochromocytoma (29.1 [7.8] vs. 47,5 [10. 9] years; p < 0.001). Other distinctive features in comparison with sporadic pheochromocytoma were: bilaterality (81.25 vs. 3.44%; p < 0. 001), absence of symptoms (44 vs 11%; p < 0.05) and paroxysmal hypertension. Concerning the diagnostic tests, it must be noted the low sensitivity (60%) of vanillylmandelic acid in MEN 2A. CONCLUSIONS: The pheochromocytoma in the setting of MEN 2A is diagnosed at younger age and frequently asymptomatic and bilateral. In view of the high prevalence of MEN 2A in our country, a genetic analysis should be performed in all patients with pheochromocytoma, especially when it is bilateral.

[Treatment of the rise in arterial pressure during the acute phase of stroke. Recommendation of Catalan Societies of Arterial Hypertension and Neurology]. / Tratamiento del aumento de presión arterial en la fase aguda del ictus. Recomendaciones de las Sociedades Catalanas de Hipertensión Arterial y de Neurología.

INTRODUCTION: Changes in arterial pressure (PA), especially arterial hypertension, are frequent during the acute phase of a stroke and the best therapeutic approach is controversial since although high blood pressure is associated with a poor prognosis, excessive or too rapid drop in blood pressure may also be associated with progression of the neurological deficit. OBJECTIVE: To reach agreement as to the correct therapeutic approach when the PA is high during the acute phase of a stroke, based on the published data and experience of a group of experts from the Catalan Societies of Neurology and Hypertension. METHODS: Review of the main recommendations published in the literature and discussion in joint study sessions. RESULTS: During the acute phase of a stroke moderate increases in blood pressure should not be treated. Antihypertensive treatment is recommended when the PA figures are of maintained levels of more than 220 mmHg of systolic or 120 mmHg of diastolic pressure in ischemic stroke, and over 180 mmHg of systolic or 105 mmHg of diastolic pressure in hemorrhagic stroke. CONCLUSIONS: Modifications of arterial pressure, especially of arterial hypertension, should be carefully treated during the acute phase of stroke, because of the risk of causing worsening of the neurological lesion. When treatment is indicated, it is best carried out in a Stroke Unite where this is possible.

Trough to peak ratio of once-daily lisinopril and twice-daily captopril in patients with essential hypertension.

The objective of this study was to assess the antihypertensive effect and the trough to peak (T:P) ratio of lisinopril and captopril, in patients with essential hypertension. After 2 weeks of placebo, 69 of 115 eligible patients had office diastolic blood pressure (DBP) between 90 and 114 mm Hg and daytime average DBP above 85 mm Hg during a 25-h ambulatory BP monitoring (ABPM) and were randomised to receive lisinopril (20 mg once daily) or captopril (50 mg twice daily) for 4 weeks. Office and ambulatory BP were then repeated. Indices of 24-h BP and T:P ratios were calculated and compared. Both drugs significantly reduced both office and ambulatory BP. The final BP obtained with lisinopril was less than with captopril. On office measurement, 75% of the patients treated with lisinopril and 44% on captopril were controlled (P < 0.001), but responses by ABPM were not significantly different. T:P ratios calculated in all patients were 0.75 and 0.66 for lisinopril and captopril respectively, but in patients who responded to each drug the corresponding ratios were 0.78 and 0.73. In conclusion both 20 mg once-daily lisinopril and 50 mg captopril twice-daily achieve a favourable T:P ratio in patients with essential hypertension.

[Isotopic renogram after captopril administration: clinical experience in the assessment of the hypertensive patient]. / Renograma isotópico después de la administración de captopril: experiencia clínica en la valoración del paciente hipertenso.

BACKGROUND: Isotopic renogram allows renal function to be estimated in both kidneys independently. The glomerular filtrate in ischemic kidneys is largely dependent on the tone of the efferent glomerular arteriolae and therefore on the concentration of circulating angiotensin II. METHODS: In 42 patients with severe high blood pressure in whom renal angiographic study was carried out for suspicion of vasculo-renal hypertension, an isotopic renogram using 99m Tc-DTPA as a tracer was performed in basal conditions and following the administration of 50 mg of oral captopril. RESULTS: In 21 patients both the angiographic examination and the post-captopril renogram were normal. In 16 patients in whom uni or bilateral stenosis higher than 50% of the lumen of renal artery was observed on angiographic examination, the post-captopril renogram showed changes. In 5 patients the angiography was normal while the renogram showed evaluable changes. No false negatives were observed in the post-captopril renogram, however the basal renogram was not demonstrative in 6 patients with stenosis of the renal artery. Sensitivity of the test was thus 100% and specificity 80%. The positive predictive value was 76% and the negative predictive value 100%. CONCLUSIONS: The post-captopril renogram may be a useful test in the functional study of renal behaviour in patients with vasculo-renal hypertension.

Rat myocardial tissue lipids and their effect on ventricular electrical activity: influence on dietary lipids.

OBJECTIVE: The aim was to investigate the effect of diets with different lipid content on rat myocardial tissue lipid composition and their possible influence on myocardial electrical activity. METHODS: 60 male Sprague-Dawley rats were randomised in three dietary feeding groups. Half the animals were used for the myocardial lipid study and the other half for the ventricular refractory period and ventricular conduction velocity measurements. Synthetic diets of low fat, high fat (predominantly lard fat), and high fat plus marine oil, the last two with cholesterol, were supplied ad libitum for five weeks. After 2-propanol myocardial lipid extraction, lipid fractions were separated by thin layer chromatography and their esterified fatty acids by gas-liquid chromatography. Ventricular refractory period was obtained according to the extrastimulus technique and maximum conduction velocity by ventricular pacing. RESULTS: The experimental diets induced marked changes in fatty acid composition of myocardial phospholipids and in esterified cholesterol content. The high fat group showed a significant decrement in oleic and linoleic acids, with an increment in arachidonic and docosahexaenoic acids in their phospholipid composition. This dietary group had the highest esterified cholesterol content. These changes were related to lowering of maximum ventricular paced heart rate and lengthening of ventricular refractory period, and were partly corrected by marine oil supplement. CONCLUSIONS: Saturated fat diets cause profound changes in myocardial fatty acyl composition which are linked to sustained differences in myocardial electrical activity. These changes can be partly corrected by a moderate fish oil supplement.

[Pheochromocytoma: clinical review of 21 cases]. / Feocromocitoma: revisión clínica de 21 casos.

BACKGROUND: To review the series of patients with pheochromocytoma diagnosed in this institution from 1976 to 1990. METHODS: The main clinical features and presentation of 21 patients (13 women and 8 males) with mean age 40 +/- 13 years were reviewed. Urinary excretion of vanillylmandelic acid (VMA) and total catecholamines had been measured. Abdominal echography, computed tomography (CT), adrenal scintigraphy and magnetic resonance (MR) had been used as localizing techniques. RESULTS: The main clinical feature was hypertension (86%), which was paroxysmal in 57% of patients. 9% were totally asymptomatic at the time of diagnosis. The following diseases were associated: thyroid medullary carcinoma (TMC) in one case, diabetes mellitus (5), cholelithiasis (3), contralateral nonfunctioning adrenal adenoma (2), and renal artery stenosis (1). The values of urinary catecholamines were high in all cases, while that of VMA was falsely negative in 33%. Echography localized the tumor in 10 of the 13 cases where it was carried out, and so did CT in 15 out of 15, scintigraphy in 6 out of 9 and MR in 5 out of 5. CONCLUSIONS: Hypertension, either paroxysmal or not, and increased perspiration were the most remarkable clinical features. VMA measurement has a small diagnostic value. Among the localizing techniques that were used, CT and MR had the highest yield.

[Intraoperative autotransfusion in massive hemorrhage following thoracic-abdominal trauma]. / Intraoperative Autotransfusion bei Massivblutungen nach Thorax-Bauch-Traumen.

In the University Hospital of Granada (Spain), 359 surgical trauma patients underwent intraoperative autotransfusion. The patients were divided into 2 groups, according to their blood loss: group I (blood loss less than or equal to 2000 ml) and group II (blood loss greater than 2000 ml). Patients from group I did not require homologous blood transfusion. So the high risk involved in this type of transfusion was avoided. Macroscopic haemoglobinuria was only found in those patients where the Solcotrans, Viavae type of autotransfusion system was used; with the Bentley ATS system, no macroscopic haemoglobinuria was registered. With patients from group II, however, that is, those with a blood loss of more than 2000 ml, we had to fall back on homologous transfusion in addition to retransfusing autologous blood. When the transfusion exceeds 4000 ml there is increasing bleeding, which requires treatment with fresh frozen plasma, platelets and/or fibrinogen. The mortality rate of patients in group II was very high but the patients died from the severity of their injuries or from postoperative complications which were not due to autotransfusion in itself with the exception of 3 patients who underwent massive autotransfusion (12,000 to 25,000 ml) and died from acute renal failure. The main indication for intraoperative autotransfusion is without doubt abdominal and thoracic trauma which lead to high blood loss.

[Complications in bland struma surgery. A retrospective study based on 2,035 personal cases]. / Die Komplikationen bei blander Strumenoperation. Retrospektive Studie anhand von 2035 eigenen Fällen.

In the present retrospective study we examine the complications arising from simple goiter operations based on the analysis of 2,035 cases. The mortality rate is extremely low (0.3%). The most typical intraoperative complications - such as unilateral vocal cord paralysis (1.6%) and permanent parathyroprival hypocalcemia (0.4%) were observed to occur much more frequently in cases of subtotal thyroidectomy than in those of partial resection. - As a result of the introduction of synthetic reabsorbent sewing materials, healing problems have been drastically reduced (0.4%). Hypothyreosis and goiter recurrence can be avoided in cases of subtotal thyroidectomy by life-long and individually adjusted administration of thyroid hormones (rate of incidence in our study 3.1%). - In our view a subtotal thyroidectomy is indicate in cases where malignity is suspected (one or more cold nodules).