Hypertension and sleep apnea-hypopnea syndrome: changes in echocardiographic abnormalities depending on the presence of hypertension and treatment with CPAP.

INTRODUCTION: Sleep apnea-hypopnea syndrome (SAHS) is an emerging disease with high prevalence. There is controversy as to whether cardiac abnormalities are due to the disease itself or to the arterial hypertension frequently associated with this disease. OBJECTIVES: To analyze echocardiographic abnormalities in a population of SAHS patients depending on the presence or absence of hypertension at the time of diagnosis and after six months of treatment with continuous positive airway pressure (CPAP). METHODS: We studied 85 consecutive patients diagnosed with SAHS who required treatment with CPAP (Hypertensive: 43, nonhypertensive: 42). We performed a baseline echocardiogram after six months of treatment. We analyzed morphological (wall thickness, diameters, ejection fraction) and functional (peak E- and A-wave velocities, deceleration time, Tei index) parameters of the left and right ventricles. RESULTS: Hypertensive patients were older and had higher blood pressure values, but there were no differences between groups in other clinical parameters. The hypertensive group had greater septal thickness (hypertensive: 12.1+/-2.3; nonhypertensive: 10.8+/-2.1mm; p=0.01). There were also differences in impairment of left (hypertensiveHT: 92.9%, nonhypertensive: 65%, p=0.002) and right (hypertensive: 74.4%, nonhypertensive: 42.1%, p=0.006) ventricular filling. After six months of treatment, an improvement of the myocardial performance index was noted in nonhypertensive patients (baseline Tei: 0.55+/-0.1 vs. 6-month Tei: 0.49+/-0.1; p=0.01), whereas no significant change was observed in hypertensive patients. CONCLUSIONS: Cardiac abnormalities in SAHS patients are increased in the presence of associated hypertension. Treatment with CPAP for six months improves cardiac abnormalities in nonhypertensive patients but not in hypertensive patients.

Influence of immunosuppressive regimens on short-term morbidity and mortality in heart transplantation.

BACKGROUND: The goal of immunosuppressive therapy in heart transplantation is to maximize safety and efficacy while minimizing morbidity and mortality. We now have numerous drug combinations, but few have been compared with each other. AIM: To compare various immunosuppressive regimens assessing morbidity and mortality at one yr. METHODS: A total of 351 patients transplanted between 1989 and 2005 were included and grouped by immunosuppressive regimen into group 1 (n = 52): Muronomab (OKT3) 10 d, cyclosporine (CSA), azathioprine (AZA), steroids; group 2 (n = 193): OKT3 seven d, CSA, AZA, steroids; group 3 (n = 22): OKT3 seven d, CSA, mycophenolate mofetil (MMF), steroids; and group 4 (n = 84): interleukin-2 antagonists (IL-2), CSA, MMF, steroids. RESULTS: The incidence of acute graft failure and treated rejection was similar between groups (17% and 78% respectively). We found a statistically significant difference in the incidence of infections (p < 0.001), renal dysfunction (p = 0.011) and in diabetes mellitus (p = 0.023). There were no differences in survival at 30 d (97%), but differences were found at one yr (p = 0.011). The multivariate analysis showed a strong association between mortality and infection (p = 0.001) and between survival and the group 4 regimen (p < 0.001). CONCLUSION: There are differences in survival at one yr of heart transplant patients depending on the immunosuppressive regimen used. The best combination was induction with IL-2 antagonists, followed by CSA, MMF and steroids.

[Silent heart disease in patients with sleep apnea-hypopnea syndrome: usefulness of the myocardial performance index]. / Disfunción miocárdica silente en pacientes con síndrome de apneas-hipopneas durante el sueño. Valor del índice de rendimiento miocárdico.

OBJECTIVE: Sleep apnea-hypopnea syndrome (SAHS) is an emerging disease with considerable cardiovascular impact. The myocardial performance index (MPI) is an echocardiographic parameter that is useful in the assessment of global myocardial function. The purpose of this study was to identify any differences in the MPI between patients with and without SAHS. PATIENTS AND METHODS: We studied 120 consecutive patients referred to our department for suspected SAHS. Following the overnight sleep study and after excluding all patients with hypertension, heart disease, or invalid recordings, 54 patients with SAHS and 13 patients without the disease matched for age and body mass were analyzed. A blinded cardiologist performed Doppler echocardiography, measuring parameters related to ventricular hypertrophy, systolic function, diastolic function, and the MPI. The data were compared by chi(2) and analysis of variance. RESULTS: Mean (SD) ventricular mass was greater in patients with SAHS (183.17 [40.5] g) than in those without that diagnosis (149 [26] g) (P=.005). No differences were observed in systolic function (78.5% [8.95%] vs 81.6% [7%]) (P=.2), although a higher percentage of patients with SAHS had abnormal diastolic function (71.2% vs 38.5%) (P=.049). The MPI was significantly higher in SAHS patients (0.54 [0.12] vs 0.46 [0.07]) (P=.028). CONCLUSIONS: On its own, SAHS leads to left ventricular hypertrophy. Diastolic involvement is common in these patients, although a large number of healthy individuals who are obese also present it. The MPI is higher in SAHS and could be a useful parameter to identify patients with silent heart disease before it progresses.

Embryonic Cerebrospinal Fluid Increases Neurogenic Activity in the Brain Ventricular-Subventricular Zone of Adult Mice.

Neurogenesis is a very intensive process during early embryonic brain development, becoming dramatically restricted in the adult brain in terms of extension and intensity. We have previously demonstrated the key role of embryonic cerebrospinal fluid (CSF) in developing brain neurogenic activity. We also showed that cultured adult brain neural stem cells (NSCs) remain competent when responding to the neurogenic influence of embryonic CSF. However, adult CSF loses its neurogenic inductive properties. Here, by means of an organotypic culture of adult mouse brain sections, we show that local administration of embryonic CSF in the subventricular zone (SVZ) niche is able to trigger a neurogenic program in NSCs. This leads to a significant increase in the number of non-differentiated NSCs, and also in the number of new neurons which show normal migration, differentiation and maturation. These new data reveal that embryonic CSF activates adult brain NSCs, supporting the previous idea that it contains key instructive components which could be useful in adult brain neuroregenerative strategies.

[Impact of diabetes mellitus on heart transplant recipients]. / Impacto de la diabetes mellitus en el paciente con trasplante cardiaco.

INTRODUCTION AND OBJECTIVES: At present, there is some controversy about the impact of diabetes mellitus on heart transplant patients. The effect of the disease on mortality and on other complications, such as infection or rejection, is unclear. The objective of this study was to investigate these factors in our heart transplant patients. METHODS: We studied 365 consecutive patients who underwent heart transplantation between November 1987 and May 2003. We divided them in three groups according to whether they had pretransplantation diabetes (group 1), de novo diabetes (group 2), or no diabetes (group 3). Baseline variables and the development of complications were recorded, and findings were analyzed using Student's t test, chi squared test, and Kaplan-Meier survival analysis. RESULTS: There was no difference in the 1-year or 5-year survival rate between the groups (P=.24 and P=.32, respectively). Patients with pretransplantation and de novo diabetes were older (54.6 years vs 54.9 years vs 50.6 years, P=.04), had a higher prevalence of hypertension (48% vs 36% vs 23%, P=.001), and had more frequently been treated with tacrolimus (10% vs 12% vs 4%, P=.04) or steroids (92% vs 86% vs 70%, P=.001). The incidence of rejection during follow-up was greater in these two groups (64% vs 70% vs 45%, P=.001). CONCLUSIONS: Neither pretransplantation diabetes nor de novo diabetes had a negative impact on survival in our heart transplant patients. The disease's presence was associated with treatment with steroids and tacrolimus. In these patients it would be preferable to individualize immunosuppressive therapy.

Prognostic value of glomerular filtration rate 1 year after heart transplantation.

INTRODUCTION AND OBJECTIVES: The development of renal failure is one of the most important problems after heart transplantation (HT), but the wide range of definitions means that estimates of its prevalence vary considerably. Furthermore, its impact on mortality has not been adequately studied. The objective was to investigate the relationship between the glomerular filtration rate (GFR) 1 year after transplantation and mortality during follow-up. METHODS: The GFR was determined in 316 patients still living 1 year after transplantation using the abbreviated Modification of Diet in Renal Disease Study formula. Patients were divided into three groups according to GFR (i.e. <30, 30-59 and > or =60 mL/min per 1.73 m2) and pretransplant variables and rejection and infection rates within the first year were analyzed. The association between GFR at 1 year and mortality during follow-up was evaluated and reasons for the association were examined. RESULTS: There was no difference in the number of rejections or infections in the first year between the three groups. During a mean follow-up period of 6.3 years, 74% of patients with a GFR <30 mL/min per 1.73 m2 died, compared with 24% and 30% of those with a GFR > or =60 and 30-59 mL/min per 1.73 m2, respectively. Survival analysis (i.e. Cox regression analysis) demonstrated a significant difference between patients with a GFR <30 mL/min per 1.73 m2 and other patients (P< .001). A very low GFR at 1 year was the only independent predictor that remained statistically significant on multivariate analysis (hazard ratio =2.87; 95% confidence interval, 1.52-5.41). CONCLUSIONS: Severe renal dysfunction at 1 year was an independent predictor of long-term all-cause mortality in heart transplant patients.

[Analysis of echocardiographic alterations observed in sleep apnea-hypopnea syndrome and how they are influenced by hypertension]. / Análisis de las alteraciones ecocardiográficas del síndrome de apneas e hipopneas del sueño y su modificación con la presencia de hipertensión arterial.

INTRODUCTION AND OBJECTIVES: Sleep apnea-hypopnea syndrome (SAHS) is associated with significant effects on the heart, which can be assessed using noninvasive methods such as transthoracic echocardiography. However, it is not clear whether these effects are due to the condition itself or are influenced by associated factors, such as high blood pressure (HBP). The objective of this study was to investigate the echocardiographic alterations observed in SAHS patients and how they are affected by the presence of concomitant HBP. METHODS: The study involved 103 consecutive patients (49 with HBP and 54 without) with SAHS and an indication for continuous positive airways pressure treatment and 24 controls matched for age and body mass index. Doppler echocardiography was performed in a blinded manner. Both morphology (i.e., wall thickness, and diameters) and function (i.e., ejection fraction, peak E and A wave velocities, mitral deceleration time, and Tei index) were assessed. Results were compared using ANOVA and Bonferroni's test. RESULTS: Hypertensive patients had larger morphological changes characteristic of left ventricular hypertrophy (i.e., increased septal and posterior wall thicknesses) than nonhypertensive patients, who in turn had larger changes than controls (septal thickness: HBP-SAHS, 12 [2] mm; non-HBP SAHS, 11 [2] mm, and controls, 9.5 [5] mm; 1 vs. 2, P=.038; 1 vs. 3, P=.0001, 2 vs. 3, P=.034) (posterior wall thickness: HBP-SAHS, 11 [2] mm; non-HBP SAHS, 10 [1] mm, and controls, 9 [1.5] mm; 1 vs. 2, P=.5; 1 vs. 3, P=.0001; 2 vs. 3, P=.001). In addition, there were also greater changes in ventricular filling patterns on the left (HBP-SAHS, 92%; non-HBP SAHS, 72%, controls, 29%; P=.0001) and on the right (HBP-SAHS, 72%; non-HBP SAHS, 58%; controls, 25%; P=.001). There was a trend towards a larger left ventricular Tei index (HBP-SAHS, 0.56 [0.2]; non-HBP SAHS, 0.54 [0.12]; controls, 0.5 [0.1]; 1 vs. 2, P=.8; 1 vs. 3, P=.09; 2 vs. 3, P=.7). CONCLUSIONS: From the time of diagnosis, SAHS was associated with left ventricular hypertrophy and impaired biventricular filling, even in the absence of concomitant HBP. The abnormalities observed were more severe when HBP was present.

Heart transplantation in a patient with systemic mastocytosis.

Systemic mastocytosis is a hematologic disorder characterized by mast-cell proliferation and organ infiltration. A variety of stimuli and drugs can cause severe anaphylaxis in these patients. We report the case of a female patient diagnosed with systemic mastocytosis and advanced dilated cardiomyopathy in whom a heart transplant was successfully performed.

[Relationship between echocardiographic abnormalities and sleep apnea-hypopnea syndrome severity]. / Alteraciones ecocardiográficas asociadas al síndrome de apnea-hipopnea del sueño en función de su gravedad.

INTRODUCTION AND OBJECTIVES: Sleep apnea-hypopnea syndrome (SAHS) is a prevalent condition that has well-known cardiovascular repercussions. However, few published echocardiographic studies have investigated the abnormalities present at SAHS diagnosis or their relationship with syndrome severity. Our objective was to evaluate myocardial structural, functional and performance parameters in these patients. METHODS: In total, 110 consecutive patients diagnosed with SAHS between June 2005 and 2006 who required treatment with continuous positive airway pressure were divided into two groups according to SAHS severity. Baseline echocardiography was carried out to evaluate structural and functional variables. Findings in the two groups were compared by univariate and multivariate analysis. RESULTS: The patients' mean age was 54 (13) years, their body mass index was 32 (6), 51% had comorbidities, and 74% were male. Patients with severe SAHS (i.e., apnea-hypopnea index [AHI] > or = 30) smoked and drank alcohol more and had larger neck circumferences. There was no significant difference in any structural parameter between the two groups. Functionally, patients with severe SAHS had shorter aortic (AHI<30 277 [4] ms vs AHIé30 263 [4] ms; P=.02) and pulmonary (AHI < 30 287 +/- 5 ms vs. AHI > or = 30 268 +/- 5 ms; P=.01) ejection times, and a higher Tei index (Left: AHI<30 0.51 [0.01] vs AHIé30 0.57 [0.02] [P=.04]; Right: AHI<30 0.38 [0.02] vs AHIé30 0.49 [0.03] [P=.02]). There were correlations between SAHS severity and the right Tei index, and aortic and pulmonary ejection times (P=.0001, P=.01, and P=.0001, respectively). The pulmonary ejection time was an independent predictor of SAHS severity (odds ratio: 0.98, 95% confidence interval, 0.97-0.99; P=.01). CONCLUSIONS: Myocardial performance is poorer in patients with SAHS. The Tei index and ejection times are all associated with SAHS severity. The pulmonary ejection time is an independent predictor of disease severity.

[Clinical teams: planning and creating Institutes and Units in a Spanish National Health Service hospital]. / Areas clínicas: planificación y creación de institutos y unidades en un hospital del Sistema Nacional de Salud.

INTRODUCTION: Clinical Teams are framed within the New Organizational Models (1996) and Spanish national health system's Strategic Plan (1997). The objectives of the internal organization model are as follows: A) General: to implement health management systems in the health service. B) Specific: service, quality and financial improvement. MATERIAL AND METHOD: Methodology. 1. Jurisdiction. Self-managing despite having no separate legal status. 2. Creation: a) feasibility study and project viability. The drafting committee consisted of representatives of the Services' physicians, other health professionals and non-health employees (Representation and Participation Organizations), and explained the portfolio of specialty services and new diagnosis and treatment techniques to be implemented. Costs and a strategic analysis of the situation were evaluated. The project was approved by management and was sent to the Ministry of Health (formerly to the Territorial Health Agency (ratified) and to the Spanish national health system's General Directorate for Organization and Planning); b) homologation: institutional approval of health centers' self-management and the feasibility of the proposals. MATERIAL: 1. Resources. Resources of the assigned Services. 2. Structure. Horizontality, simplicity and operativity. 3. PURPOSE: a) clinical: role assigned to Specialized Care Services; b) management: responsibility for proper working order (actions), personnel performance (tasks), and custody and use of material resources (available resources), carried out with active and responsible participation of all departments. 4. Quality plan: patient-oriented care, evidence-based medicine (standards and protocols), evaluation of medical technologies (service corporation) and corporative quality guarantee. CONCLUSIONS: A voluntary, innovative, participative and decentralized management model.

Embryonic cerebrospinal fluid collaborates with the isthmic organizer to regulate mesencephalic gene expression.

Early in development, the behavior of neuroepithelial cells is controlled by several factors acting in a developmentally regulated manner. Recently it has been shown that diffusible factors contained within embryonic cerebrospinal fluid (CSF) promote neuroepithelial cell survival, proliferation, and neurogenesis in mesencephalic explants lacking any known organizing center. In this paper, we show that mesencephalic and mesencephalic+isthmic organizer explants cultured only with basal medium do not express the typically expressed mesencephalic or isthmic organizer genes analyzed (otx2 and fgf8, respectively) and that mesencephalic explants cultured with embryonic CSF-supplemented medium do effect such expression, although they exhibit an altered pattern of gene expression, including ectopic shh expression domains. Other trophic sources that are able to maintain normal neuroepithelial cell behavior, i.e., fibroblast growth factor-2, fail to activate this ectopic shh expression. Conversely, the expression pattern of the analyzed genes in mesencephalic+isthmic organizer explants cultured with embryonic cerebrospinal fluid-supplemented medium mimics the pattern for control embryos developed in ovo. We demonstrate that embryonic CSF collaborates with the isthmic organizer in regulation of the expression pattern of some characteristic neuroectodermal genes during early stages of central nervous system (CNS) development, and we suggest that this collaboration is not restricted to the maintenance of neuroepithelial cell survival. Data reported in this paper corroborate the hypothesis that factors contained within embryonic CSF contribute to the patterning of the CNS during early embryonic development.