Maternal lifestyle characteristics during pregnancy, and the risk of obesity in the offspring: a study of 5,125 children.

BACKGROUND: To investigate the association between gestational weight gain, maternal age and lifestyle habits (e.g., physical activity, smoking, and alcohol consumption) during pregnancy, with Body Mass Index of the offspring at the age of 8. METHODS: Α random sample of 5,125 children was extracted from a national database and matched with their mothers. With the use of a standardised questionnaire, telephone interviews were carried out for the collection of information like: maternal age at pregnancy, gestational weight gain (GWG), exercise levels, smoking and alcohol consumption. The Body Mass Index (BMI) status of the offspring at the age of 8 was calculated from data retrieved from the national database (e.g., height and weight). RESULTS: The odds for being overweight/obese at the age of 8 for 1 kg GWG, for smoking, and for mild exercise during pregnancy compared to sedentary was 1.01 (95%CI: 1.00, 1.02), 1.23 (95%CI: 1.03, 1.47) and 0.77 (95%CI: 0.65, 0.91), respectively. Further analysis revealed that offspring of women who exceeded the Institute of Medicine (IOM) maternal weight gain recommendations were at an increased risk of obesity (OR: 1.45; 95%CI, 1.26, 1.67) compared with offspring of women with GWG within the recommended range. Maternal age and alcohol consumption were not associated with the outcome (p > 0.05). CONCLUSION: GWG, physical activity and smoking status during pregnancy were significantly associated with obesity for the offspring at the age of 8. Health care professionals should strongly advise women to not smoke and to perform moderate exercise during pregnancy to prevent obesity in the offspring in later life.

Clinical implications of congenital uterine anomalies: a meta-analysis of comparative studies.

The clinical implications of congenital uterine anomalies (CUA), and the benefits of hysteroscopic resection of a uterine septum, were evaluated. Studies comparing reproductive and obstetric outcome of patients with and without CUA and of patients who had and had not undergone hysteroscopic resection of a uterine septum, were evaluated. Meta-analysis of studies indicated that the pregnancy rate was decreased in women with CUA (RR 0.85, 95% CI 0.73 to 1.00; marginally significant finding, P = 0.05). The spontaneous abortion rate was increased in women with CUA (RR 1.68, 95% CI 1.31 to 2.15). Preterm delivery rates (RR 2.21, 95% CI 1.59 to 3.08), malpresentation at delivery (RR 4.75, 95% CI 3.29 to 6.84), low birth weight (RR 1.93, 95% CI 1.50 to 2.49) and perinatal mortality rates (RR 2.43, 95% CI 1.34 to 4.42) were significantly higher in women with CUA. Hysteroscopic removal of a septum was associated with a reduced probability of spontaneous abortion (RR 0.37, 95% CI 0.25 to 0.55) compared with untreated women. Presence of CUA might be associated with a detrimental effect on the probability of pregnancy achievement, spontaneous abortion and obstetric outcome. Hysteroscopic removal of a septum may reduce the probability of a spontaneous abortion.

Metabolic syndrome in adolescence: can it be predicted from natal and parental profile? The Prediction of Metabolic Syndrome in Adolescence (PREMA) study.

BACKGROUND: There are well-established predisposing factors for the development of metabolic syndrome (MetS) in childhood or adolescence, but no specific risk profile has been identified as yet. The Prediction of Metabolic Syndrome in Adolescence (PREMA) study was conducted (1) to construct a classification score that could detect children at high risk for MetS in adolescence and (2) to test its predictive accuracy. METHODS AND RESULTS: In the derivation cohort (1270 children), data from natal and parental profile and from initial laboratory assessment at 6 to 8 years of age were used to detect independent predictors of MetS at 13 to 15 years of age according to the International Diabetes Federation definition. In the validation cohort (1091 adolescents), the discriminatory capacity of the derived prediction score was tested on an independent adolescent population. MetS was diagnosed in 105 adolescents in the derivation phase (8%), whereas birth weight <10th percentile (odds ratio, 6.02; 95% confidence interval, 2.53-10.12, P<0.001), birth head circumference <10th percentile (odds ratio, 4.15; 95% confidence interval, 2.04-7.14, P<0.001), and parental overweight or obesity (in at least 1 parent; odds ratio, 3.22; 95% confidence interval, 1.30-5.29, P<0.01) were independently associated with diagnosis of MetS in adolescence. Among adolescents in the validation cohort (86 [8%] with MetS), the presence of all these 3 predictors predicted MetS with a sensitivity of 91% and a specificity of 98%. CONCLUSIONS: The coexistence of low birth weight, small head circumference, and parental history of overweight or obesity may be useful for detection of children at risk of developing MetS in adolescence.

Staple line reinforcement in laparoscopic bariatric surgery: does it actually make a difference? A systematic review and meta-analysis.

BACKGROUND: Staple line leaks represent a major concern in all laparoscopic operations but are particularly important in bariatric surgery, where leak complications carry significant morbidity and mortality. Therefore, several means of staple line reinforcement have been described, but none is totally accepted. In this study, we attempt to illuminate any clear benefit of staple line reinforcement through a systematic review and meta-analysis of reported articles. METHODS: Two major databases (PubMed and Cochrane) were searched and assessed by two reviewers. Inclusion criteria were: detailed description of operative technique, especially concerning staple line reinforcement, and possible existence of proven staple line leak. Selected studies were evaluated by systematic review and meta-analysis according to their eligibility. The study population was finally divided into two groups: reinforcement (of any type) and no reinforcement. RESULTS: In the initial search, 126 studies were obtained. Then, 17 full papers, both randomised controlled trials (RCTs) and non-RCTs, were included in the systematic review. Seven studies, comprising 3,299 patients, were examined for evaluation of population odds of leak (7.69), which was considered clinically significant. Meta-analysis of three studies comprising 1,899 patients revealed no clear benefit of reinforcement group, though with marginal significance. CONCLUSIONS: Although several drawbacks exist, this study illustrates two important aspects: that current staplers may not be uniformly reliable, and that staple line reinforcement does not seem to have any clear benefit, at least concerning leak rate.

Association between the administration of phenylbutazone prior to racing and musculoskeletal and fatal injuries in Thoroughbred racehorses in Argentina.

OBJECTIVE: To examine the association between prerace administration of phenylbutazone and the risk of musculoskeletal injury (MSI) and fatal injury in Thoroughbred racehorses that raced between 2006 and 2015 at 2 of the 4 official racetracks in Argentina. SAMPLE: Data from racetrack databases and veterinary reports on 283,193 race starts. PROCEDURES: Data were collected relating to race performance and injury outcomes for starts at these tracks. The incidence of MSI and fatal injury was calculated for each year, stratified by the declared prerace administration of phenylbutazone. Univariable logistic regression, followed by multivariable logistic regression, was used to identify significant risk factors for both MSI and fatal injury. RESULTS: Analyses identified associations between the declared prerace administration of phenylbutazone and the risk of MSI and fatal injury during racing. Horses with declared prerace phenylbutazone administration had greater odds of MSI (OR, 1.45 [95% CI, 1.03 to 2.04]) and fatal injury (OR, 1.59 [95% CI, 1.1 to 2.27]) than did horses racing without prerace phenylbutazone administration. These associations remained significant when other risk factors were accounted for in both multivariable models. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested an association between the prerace administration of phenylbutazone and the risk of MSI and fatal injury in Thoroughbred racehorses during racing. Although these results did not imply a direct causal relationship between prerace phenylbutazone administration and injury, they may be considered in the development of more conservative medication policies to optimize racehorse welfare in North and Latin America.

Assessing personal exposure to PM using data from an integrated indoor-outdoor experiment in Athens-Greece.

An integrated indoor-outdoor 15-day PM sampling campaign in a general area close to the centre of Athens, targeted to examine personal exposure. All microenvironments (MEs) (second and fourth floor flats, cafes, cars, restaurants, underground metro, outdoor etc.) frequented by the residents were included in the study. The instrumentation used was both stationary (low volume samplers) and portable/wearable to be able to measure continuously PM10, PM2.5, PM1 and analyze chemically PM2.5 and PM1 samples. The study showed that the residences' air quality was determined by the type and intensity of outdoor sources and their vertical distance from the street. Indoor activities such as cooking, cleaning further increased PM levels and formulated the air quality, while particulate accumulation was evident. In general, PM2.5 concentrations were higher outdoors, 11-43 µg/m3, than in the second floor flat as well as on days within different MEs, 13-33 µg/m3 and 8-35 µg/m3, respectively and finally in the fourth floor 10-18 µg/m3. PM2.5 chemical composition was typical of a Mediterranean urban area predominantly composed on average of OC/EC (33%), sulfate (13%), ammonium (9%), nitrate (5%) and crustal material (Cl-, Na+, K+, Mg2+ and Ca2+) (5%). On days when other MEs were visited crustal material increased on average to 16%. The PM levels measured with the portable instrumentation at all mEs showed that the persons were exposed to higher PM10 concentrations in the subway (avg. 218 µg/m3) due to the resuspension of crustal material, while maximum PM2.5 and PM1 were experienced in cafes where smoking was allowed (avg. 126 and 108 µg/m3, respectively). Using the car resulted to the lowest PM10, PM2.5 and PM1 exposure (58, 10 and 6 µg/m3, respectively). Total exposure to particulates depended both on the time spent in each ME and on the mixture of MEs visited in 24 h.

Prognostic significance of plasma resistin levels in patients with atherothrombotic ischemic stroke.

BACKGROUND: Resistin (RSN) is an adipocytokine involved in insulin resistance, obesity and atherosclerosis. This study aimed to investigate the association between plasma RSN and outcome after ischemic stroke. METHODS: RSN measured within 24 h after the event was related to functional outcome and 5-year survival in 211 subjects with first-ever atherothrombotic ischemic stroke. Prognosis was assessed by the Kaplan Meier and the Cox techniques. RESULTS: The probabilities of death were 80.4%, 46.2% and 15.7% (p<0.001) for patients stratified according to tertiles of RSN (>30 ng/mL, 20-30 ng/mL and<20 ng/mL, respectively). The proportion of dependency (modified Rankin Scale score>or=3) was greater in 5-year survivors with RSN in the upper tertile (6/11 [54.5%]) compared to the middle (20/56 [35.7%]) and the lowest tertile (8/43 [18.6%]; p<0.01). C-reactive protein levels (hazard ratio [HR] 3.96 [95% CI 2.06, 8.91]; p<0.001), coronary heart disease (2.69 [1.62, 6.23]; p<0.001), RSN levels (2.12 [1.31, 5.08] p<0.001), National Institute of Health Stroke Scale score (2.02 [1.23, 4.49]; p<0.01) and age (1.84 [1.19, 3.93]; p<0.01) were independent predictors of death. CONCLUSIONS: High plasma RSN appears to be associated with increased risk of 5-year mortality or disability after atherothrombotic ischemic stroke, independently of other adverse predictors.

Arterial stiffness: determinants and relationship to the metabolic syndrome.

This study aimed to investigate independent determinants of arterial stiffness and evaluate the association of arterial stiffness with the presence of metabolic syndrome (MS). Demographic characteristics, hemodynamic parameters, and cardiovascular (CV) risk factors were assessed in Greek food industry employees with no history of diabetes or CV disease in order to isolate multiple correlates of arterial stiffness as assessed by pulse wave velocity (PWV). Subsequently, logistic regression analysis was performed using as end point the presence of MS, defined according to the National Cholesterol Education Program. Data from 424 participants (mean age 45.3 -/+ 15.5 years, 298 [70.3%] males, average PWV 8.5 -/+ 3.6 m/s) were analyzed. PWV was higher in men (8.8 -/+ 3.1 m/s) compared to women (7.7 -/+ 2.9 m/s, p < 0.01). Age, systolic blood pressure, and heart rate were isolated as multivariate determinants of PWV (adjusted R2 0.511 [p < 0.0001] in men and 0.538 [p < 0.0001] in women). The overall prevalence of the MS was 14.6%, being similar in both genders. Four variables were shown to be independent predictors of the presence of MS: waist circumference >102 cm (men)/88 cm (women) (OR 8.6, [95% CI 2.8, 20.6], p < 0.001), insulin resistance (homeostasis model assessment >4) (6.3, [2.1, 17.6], p < 0.001), total cholesterol >240 mg/dL (5.5, [1.7, 12.4], p < 0.01), PWV >9 m/s (4.1, [1.5, 9.9], p < 0.01). High PWV, which was found to be mostly determined by advanced age, elevated systolic BP, and accelerated heart rate, appeared to exhibit a strong independent association with the presence of MS together with adiposity and insulin resistance. This index should be considered as a useful marker for CV risk stratification.

Risk factors associated with fatal injuries in Thoroughbred racehorses competing in flat racing in the United States and Canada.

OBJECTIVE To identify risk factors associated with fatal injuries in Thoroughbred racehorses in the United States and Canada. DESIGN Retrospective study. ANIMALS 1,891,483 race starts by 154,527 Thoroughbred racehorses at 89 racetracks in the United States and Canada from 2009 to 2013. PROCEDURES Data were extracted from the Equine Injury Database, which contained information for 93.9% of all official flat racing events in the United States and Canada during the 5-year observation period. Forty-four possible risk factors were evaluated by univariate then multivariable logistic regression to identify those that were significantly associated with fatal injury (death or euthanasia of a horse within 3 days after sustaining an injury during a race). RESULTS 3,572 race starts ended with a fatal injury, resulting in a period incidence rate of 1.9 fatal injuries/1,000 race starts. Twenty-two risk factors were significantly associated with fatal injury. Risk of fatal injury was greater for stallions than for mares and geldings and increased as the number of previous nonfatal injuries and race withdrawals and level of competitiveness (eg, horse's winning percentage and race purse) of the horse or race increased. CONCLUSIONS AND CLINICAL RELEVANCE Results identified several risk factors associated with fatal injuries in Thoroughbred racehorses. This information can be used as a guideline for the identification of racehorses at high risk of sustaining a fatal injury and in the design and implementation of preventative measures to minimize the number of fatal injuries sustained by horses competing in flat racing in the United States and Canada.

Plasma adiponectin levels and five-year survival after first-ever ischemic stroke.

BACKGROUND AND PURPOSE: This study aimed to investigate the association between plasma adiponectin levels and 5-year survival after first-ever ischemic stroke. METHODS: Plasma adiponectin measured within 24 hours after first-ever ischemic stroke was related to 5-year outcome. The Kaplan-Meier technique was applied in survival analysis, and the Cox proportional hazards model was used to evaluate the relationship between risk factors and prognosis. RESULTS: The probabilities of death were 92.8%, 52.5%, and 10.5% (P<0.001) for patients stratified according to tertiles of adiponectin (<4 microg/mL, 4 to 7 microg/mL, and >7 microg/mL, respectively). The relative risk of death was 8.1 (95% CI, 3.1, 24.5; P<0.001) for individuals with adiponectin levels in the lowest tertile compared with the upper tertile. Adiponectin <4 microg/mL (hazard ratio [HR], 5.2; 95% CI, 2.1, 18.4; P<0.001), score >15 in the National Institutes of Health Stroke Scale (HR, 3.6; 95% CI, 1.7, 15.9; P<0.001), and coronary heart disease (HR, 2.9; 95% CI, 1.5, 12.3; P<0.001) were independently associated with mortality. CONCLUSIONS: Low plasma adiponectin is related to an increased risk of 5-year mortality after first-ever ischemic stroke, independently of other adverse predictors.

Intraindividual blood pressure responses to angiotensin-converting enzyme inhibition and angiotensin receptor blockade.

This study aims to test the hypothesis that in some hypertensive subjects the blood pressure (BP) response to angiotensin-converting enzyme inhibition differs from that to angiotensin receptor blockade (ARB); a responder to angiotensin-converting enzyme inhibition may not respond to ARB or the opposite. A randomized, open-label, crossover, comparative trial of lisinopril 20 mg compared with telmisartan 80 mg (5 weeks per treatment period) was conducted in 32 untreated hypertensives using 24-hour ambulatory BP monitoring. Subjects were classified as "responders" and "nonresponders" using an arbitrary threshold of ambulatory BP response (> or =10 mm Hg systolic or > or =5 diastolic) or the median response achieved by each drug. No difference was detected between the drugs in their effect on ambulatory BP (mean difference 1.2+/-7.1/0.7+/-5.1 mm Hg, systolic/diastolic). Significant correlations were found between the antihypertensive responses to the two drugs (r=0.77, p<0.001). Using the arbitrary response criterion, there was a difference between the drugs in the responses in 28%/13% of subjects (9/4 patients) for systolic/diastolic BP (19%/25% using the median response criterion). These data suggest that in some hypertensive patients the BP response to angiotensin-converting enzyme inhibition may fail to predict the response to ARB. It appears that there are differences in the antihypertensive action of angiotensin-converting enzyme inhibitors and ARBs that may be clinically important.

Acute pyelonephritis in adults: prediction of mortality and failure of treatment.

BACKGROUND: To formulate a classification tool for early recognition of patients admitted with acute pyelonephritis (AP) who are at high risk for failure of treatment or for death. METHODS: A retrospective chart review of 225 patients (102 men) admitted with AP. We considered 13 potential risk factors in a multivariate analysis. RESULTS: Recent hospitalization, previous use of antibiotics, and immunosuppression were found to be independent correlates of the prevalence of resistant pathogens in both sexes. Additional predictors included nephrolithiasis in women and a history of recurrent AP in men. Prolonged hospitalization should be expected for a man with diabetes and long-term catheterization who is older than 65 years or for a woman of any age with the same characteristics, when the initial treatment was changed according to the results of urine culture. For mortality prediction, we derived an integer-based scoring system with 6 points for shock, 4 for bedridden status, 4 for age greater than 65 years, and 3 for previous antibiotic treatment for men and 6 points for shock, 4 for bedridden status, 4 for age greater than 65 years, and 3 for immunosuppression for women. Among patients with at least 11 points, the risk for in-hospital death was 100% for men and 91% for women. CONCLUSIONS: Simple variables available at presentation can be used for risk stratification of patients with AP. The additional identification of certain risk factors by means of a carefully obtained history could contribute to early recognition of patients infected by resistant bacteria and optimize the selection of antimicrobial agents.

Home or self blood pressure measurement? What is the correct term?

OBJECTIVE: Blood pressure measurements taken by patients at home (HBP) are usually referred to as 'self' or 'home' measurements. To demonstrate the most appropriate term we compared self-home measurements (S-HBP), with home measurements taken by relatives (R-HBP), clinic measurements taken by physicians (P-CBP) and self-measurements in the clinic (S-CBP). PATIENTS AND METHODS: Thirty treated hypertensives were randomized to an initial clinic BP (CBP) monitoring period (week 1, P-CBP followed by S-CBP measurements, or the opposite; 1 visit each), then to a HBP monitoring period (weeks 2-3, S-HBP followed by R-HBP or the opposite; 3 workdays each), and finally to a second CBP monitoring period (week 4, S-CBP followed by P-CBP, or the opposite). Triplicate morning trough measurements were taken per occasion using the same fully automated device. RESULTS: There was no difference between S-CBP and P-CBP (mean difference -1.9 +/- 6.1 mmHg, 95% confidence interval (CI) -4.2, 0.4/-1.6 +/- 4.7, 95% CI -3.3, 0.2, systolic/diastolic), or between S-HBP and R-HBP (-0.9 +/- 6.9, 95% CI -3.5, 1.8/-0.4 +/- 4.3, 95% CI -2.0, 1.2). S-CBP was higher than S-HBP (mean difference 9.3 +/- 9.0/4.9 +/- 5.4 mmHg, systolic/diastolic, P < 0.001) and R-HBP (8.4 +/- 9.1/4.5 +/- 5.0, P < 0.001). P-CBP was also higher than S-HBP (11.2 +/- 11.9/6.5 +/- 6.8, P < 0.001) and R-HBP (10.3 +/- 11.2/6.1 +/- 6.5, P < 0.001). CONCLUSIONS: Self-measurements provide similar BP levels to measurements taken by relatives or physicians, provided that measurements are taken in the same setting. 'Self-BP' is a misnomer because self-measurement has no impact on the difference between home and clinic BP. Given that this difference can be exclusively attributed to the effect of the different setting, the term 'home BP' represents a more appropriate term.

Comparison of the smoothness index, the trough : peak ratio and the morning : evening ratio in assessing the features of the antihypertensive drug effect.

OBJECTIVE: To provide a direct comparison of the trough : peak ratio (TPR), the morning : evening home blood pressure ratio (MER) and the smoothness index (SI) in assessing the features of the antihypertensive drug effect. PATIENTS AND METHODS: A total of 27 untreated hypertensives were randomized to receive lisinopril 20 mg o.d. or losartan 50 mg o.d. for 5 weeks and were subsequently crossed-over to the alternative treatment for a second 5-week period. Twenty-four hour ambulatory and 5-day home blood pressure were monitored before randomization and at the end of each treatment period. TPR, MER and SI were calculated for each drug for the total study population and for responders only. RESULTS: When all patients were considered, lisinopril provided higher values of TPR [0.63/0.66 for systolic/diastolic blood pressure (SBP/DBP)], MER (1.02/0.77) and SI (1.01/0.87) than losartan (0.35/0.51, 0.60/0.60 and 0.64/0.53, respectively). Analysis of responders only, again showed a clear advantage of lisinopril over losartan in TPR (0.77/0.67 versus 0.44/0.47, respectively) and MER (0.86/0.87 versus 0.48/0.61), whereas there was no difference in SI (1.25/1.13 for lisinopril versus 1.11/1.12 for losartan). CONCLUSIONS: These data suggest that the assessment of the duration of the antihypertensive drug effect provided by the MER is consistent to that by the TPR and that two drugs with different levels of TPR and MER may have the same level of SI. It appears that the SI is not simply a more reliable index of the features of the antihypertensive drug effect, but offers a different type of information complementary to that provided by the TPR and the MER, in regard to the homogeneity and the magnitude but not the duration of the antihypertensive effect.

Clinic, home and ambulatory pulse pressure: comparison and reproducibility.

OBJECTIVE: Recent evidence suggests that pulse pressure (PP) is an independent predictor of cardiovascular risk. The objective of this study was to compare mean values and reproducibility of PP obtained in the clinic (CPP), at home (HPP) and with ambulatory monitoring (APP) and to evaluate potential implications for trials aiming to assess drug effects on PP. METHODS: A total of 393 hypertensive subjects [mean age 51.5 +/- 11.5 (SD) years, 59% men, 35% treated] measured CPP (two visits), HPP (6 days) and APP (24 h). The reproducibility of PP was assessed using the SD of differences (SDD) between measurements in 133 untreated subjects who had repeated CPP (five visits), HPP (6 days) and APP measurements (two occasions). RESULTS: There was no difference between mean CPP (51.0 +/- 13.3 mmHg) and HPP (50.2 +/- 11.0) whereas APP (48.8 +/- 8.4) was lower than both CPP [mean difference 2.3 +/- 10.3 mmHg; 95% confidence interval (CI), 1.2, 3.3; P < 0.01] and HPP (1.5 +/- 7.8; 95% CI, 0.7, 2.3; P < 0.01). The SDD between repeated measurements was about 10 mmHg for CPP (one visit), 5.2 mmHg for HPP (2 days) and 4 mmHg for APP (24-h). For a parallel comparative trial aiming to detect a difference of 3 mmHg PP in the effect of two drugs, 415 subjects would be required when using CPP, compared to 127 using HPP and 63 using APP. CONCLUSIONS: These data suggest that although differences among mean values of CPP, HPP and APP are small, differences in their reproducibility are important and should be taken into account in the design of trials assessing drug effects on PP.

White coat effect in treated versus untreated hypertensive individuals: a case-control study using ambulatory and home blood pressure monitoring.

BACKGROUND: Some studies have shown a significant white coat effect (WCE) (i.e., difference between clinic blood pressure [CBP] and awake ambulatory blood pressure [ABP]) to be present not only in untreated but also in treated hypertensive individuals. This study aims to assess 1) the prevalence and the magnitude of the WCE in treated versus untreated hypertensive persons, and 2) the usefulness of home blood pressure (HBP) versus ABP in the detection of this phenomenon. METHODS: A case-control study was conducted in 138 treated hypertensive patients and same number of sex- and age-matched untreated hypertensive subjects who had measurements of CBP (at least three visits), HBP, and ABP. Subjects with a WCE of >20/10 mm Hg (systolic/diastolic) were classified as clinic reactors. RESULTS: There was a trend for a larger WCE assessed by ABP monitoring in the untreated group (mean difference in systolic WCE, 1.8 +/- 22.2 mm Hg, 95% CI -2.0 to 5.5; diastolic 1.8 +/- 11.9 mm Hg, 95% CI -0.2 to 3.8) and for more untreated clinic reactors (27% untreated v 20% treated, odds ratio 1.5, 95% CI 0.9 to 2.7). The sensitivity, specificity, and positive and negative predictive values of HBP to detect clinic reactors correctly were 56%/62% (treated/untreated), 87%/84%, 52%/59%, and 89%/86%, respectively, with moderate agreement between HBP and ABP (kappa 0.42/0.46). CONCLUSIONS: In treated hypertensive patients, WCE seems to be reduced compared with that in untreated hypertensive persons but is not eliminated. In both untreated and treated hypertensive individuals HBP monitoring appears to be useful in the detection of the WCE, but it may not be appropriate as an alternative to the ABP method.

Effect of estrogen receptor modulator tamoxifen on blood pressure, plasma renin activity, and renal sodium excretion.

BACKGROUND: Adjuvant treatment with the estrogen receptor modulator tamoxifen is a well established long-term therapy in breast cancer. This study investigated the effect of tamoxifen on blood pressure (BP) and on factors by which it might be influenced. METHODS: Normotensive postmenopausal women on > 12 months adjuvant tamoxifen therapy were randomized to withdraw or continue tamoxifen for 6 weeks and then to crossover to the alternative regimen for a second 6-week period. Measurements of clinic and ambulatory BP, plasma renin activity (PRA), and fractional sodium excretion (FE(Na)) were performed at baseline and at the end of each study period. RESULTS: Twenty-three women completed the study (mean age 60.6 +/- 8.3 years). There was no effect of tamoxifen on clinic BP (mean difference between withdrawal and continuation for systolic BP, 0.4 +/- 8.4 mm Hg, 95% confidence interval [CI] -4.0 to 3.2, and diastolic 0.6 +/- 4.7, 95%CI -1.4 to 2.7) or 24-hour ambulatory BP (systolic 0.7 +/- 7.4 mmHg, 95%CI -2.6 to 3.9; diastolic BP, 1.9 +/- 5.5, 95% CI -0.5 to 4.2). Furthermore, no effect of tamoxifen on PRA (mean difference between withdrawal and continuation 0.03 +/- 0.5 ng/mL/h, 95% CI -0.3 to 0.2) or FENa (0.05 +/- 0.5, 95% CI -0.2 to 0.2) was detected. CONCLUSIONS: Tamoxifen seems to have no effect on BP, PRA, or FE(Na) in normotensive postmenopausal women.

Differentiation between patients with acute upper gastrointestinal bleeding who need early urgent upper gastrointestinal endoscopy and those who do not. A prospective study.

OBJECTIVE: To differentiate, among patients presented at the emergency department with acute upper gastrointestinal bleeding, those who need early urgent upper gastrointestinal endoscopy from those who do not. METHODS: Seventeen variables for each patient presenting with upper gastrointestinal bleeding were prospectively recorded and considered in a multivariate analysis. We used the presence of active bleeding during early urgent upper gastrointestinal endoscopy within 12 h from admission as the end point. The derived score was validated with data from the next consecutive patients presenting with upper gastrointestinal bleeding. RESULTS: Among 190 consecutive patients (mean age 63.7 +/- 16 years; 64.7% men), active bleeding was observed in 51 patients (26.8%). Four variables were identified as independent predictors (P < 0.05) of active bleeding in early urgent upper gastrointestinal endoscopy and were used for the derivation of the following integer-based scoring system: number of points = 6 (fresh blood in nasogastric tube) + 4 (haemodynamic instability) + 4 (haemoglobin < 8 g/dl) + 3 (white blood cell count > 12 000/microl). The validation study consisted of 110 patients (71 men; mean age 66.1 +/- 14 years; 28 patients [25.5%] with active bleeding). In this study, a cut off of < 7 points indicated absence of active bleeding and >/= 11 points indicated presence of active bleeding; this gave a sensitivity of 96%, specificity of 98%, positive predictive value of 96% and negative predictive value of 98%. CONCLUSIONS: Simple clinical and laboratory variables available at presentation can be used to differentiate patients with upper gastrointestinal bleeding who do not need an early urgent upper gastrointestinal endoscopy from those who do.

Angiomyofibroblastoma of the spermatic cord: a case report.

INTRODUCTION: Angiomyofibroblastoma is a benign soft tissue tumor with tendency to arise in the vulva. CASE PRESENTATION: We report a 36-year-old Greek Caucasian man presenting with a left inguinal painless mass. This is the second case of angiomyofibroblastoma of the spermatic cord. At operation, a 4.5 cm well-circumscribed solid tumor was found adherent to the spermatic cord. The tumor consisted of spindle-shaped cells proliferating in short fascicles between numerous medium-sized blood vessels with thin and hyalinized walls. Neoplastic cells had eosinophilic cytoplasm with neither mitotic figures nor nuclear atypia. The stroma included abundant mast cells and few mature lypocytes. Immunostaining showed positivity for vimentin, CD34, desmin and smooth muscle actin. Our patient was treated by simple excision and was followed up for five years with clinical examination and ultrasonography, revealing no evidence of local recurrence or metastasis. CONCLUSION: This unusual neoplasm should be distinguished from aggressive angiomyxoma and other myxoid malignant tumors with widespread metastatic potential.