[Placebo: real or imagined effect. What does the science say?] / Placebo : effet réel ou imaginaire, qu'en dit la science ?

The placebo effect is one of the mechanisms at work in the success of comprehensive care. It relies on psychological, biological and environmental mechanisms. If its effectiveness has been documented, it should be noted that its power of effect remains weak and that it depends on the context. Although real, the placebo effect is remembered to be associated with manipulation concerning the success of a treatment, we pose as an ethical defender of its use. This article aims to recall the psychobiological mechanisms at work and to replace the placebo effect in clinical practice.

L'effet placebo, un phénomène fréquemment évoqué dans la société, est souvent sous-estimé par la communauté médicale. Pourtant, il repose sur des mécanismes psychologiques, biologiques et environnementaux solidement documentés dans la littérature scientifique. Des études ont démontré son efficacité sur une vaste gamme de symptômes et de pathologies. L'objectif de cet article est de rappeler les mécanismes psychobiologiques impliqués, de réintégrer l'effet placebo dans la pratique clinique quotidienne et de fournir un aperçu des études consacrées à ce sujet.

Hand Hygiene Improvement and Sustainability: Assessing a Breakthrough Collaborative in Western Switzerland.

OBJECTIVE To assess hand hygiene improvement and sustainability associated with a Breakthrough Collaborative. DESIGN Multicenter analysis of hand hygiene compliance through direct observation by trained observers. SETTING A total of 5 publicly funded hospitals in 14 locations, with a total of 1,152 beds, in the County of Vaud, Switzerland. PARTICIPANTS Clinical staff. INTERVENTIONS In total, 59,272 opportunities for hand hygiene were monitored for the duration of the study, for an average of 5,921 per audit (range, 5,449-6,852). An 18-month Hand Hygiene Breakthrough Collaborative was conducted to implement the WHO multimodal promotional strategy including improved access to alcohol-based hand rub, education, performance measurement and feedback, reminders and communication, leadership engagement, and safety culture. RESULTS Overall hand hygiene compliance improved from 61.9% to 88.3% (P<.001) over 18 months and was sustained at 88.9% (P=.248) 12 months after the intervention. Hand hygiene compliance among physicians increased from 62% to 85% (P<.001) and finally 86% at follow-up (P=.492); for nursing staff, compliance improved from 64% to 90% (P<.001) and finally 90% at follow-up (P=.464); for physiotherapists compliance improved from 50% to 90% (P<.001) and finally 91% at follow-up (P=.619); for X-ray technicians compliance improved from 45% to 80% (P<.001) and finally 81% at follow-up (P=.686). Hand hygiene compliance also significantly increased with sustained improvement across all hand hygiene indications and all hospitals. CONCLUSIONS A rigorously conducted multicenter project combining the Breakthrough Collaborative method for its structure and the WHO multimodal strategy for content and measurement was associated with significant and substantial improvement in compliance across all professions, all hand hygiene indications, and all participating hospitals. Infect Control Hosp Epidemiol 2017;38:1420-1427.

[Ethics and the decision of cardiopulmonary resuscitation]. / Ne pas réanimer ou laisser mourir naturellement? Enjeux éthiques.

Following the guidelines of the Swiss Academy of Medical Science, most Swiss hospitals have implemented advanced directives that define what should be undertaken in case of cardiorespiratory arrest for every patient. This remains difficult to apply for physicians and difficult to understand for patients. From a medical perspective, some confusion occurs around medical directives. Difficulties include subjective misinterpretation of patient's quality of life, as well as decision making bias. In addition, patients overestimate the cardiopulmonary reanimation success rate, modify their choices with time and health status, and might lack their individual ability of discernment. Patient's autonomy must always be encouraged as long as it stays within the limits of medical indications.

Conformément aux recommandations de l'Académie suisse des sciences médicales (ASSM), la majorité des hôpitaux suisses ont mis en place une obligation de directives anticipées déterminant l'attitude à adopter en cas d'arrêt cardiorespiratoire pour chaque patient. En pratique, cela est souvent difficile à appliquer pour les médecins et à comprendre par les patients. Du point de vue médical, on observe notamment des problèmes de compréhension des attitudes, des interprétations subjectives erronées du pronostic de vie et de la qualité de vie, ainsi que des biais décisionnels. Le patient quant à lui surestime le taux de succès de la réanimation cardiopulmonaire, fait des choix inconstants, et n'a pas toujours sa capacité de discernement au moment de se prononcer. L'autonomie du patient doit être encouragée, toutefois dans les limites de l'éventail de propositions thérapeutiques jugées médicalement indiquées.

Patients' characteristics associated with the decision of "do not attempt cardiopulmonary resuscitation" order in a Swiss hospital.

BACKGROUND: According to Swiss legislation, do not attempt cardiopulmonary resuscitation (DNACPR) order can be made at any time by patients only, unless the resuscitation is considered as futile, based on the doctors' evaluation. Little is known about how this decision is made, and which are the factors influencing this decision. METHODS: Observational, cross-sectional study was conducted between March and May 2013 on 194 patients hospitalized in the general internal medicine ward of a Swiss hospital. The associations between patients' DNACPR orders and gender, age, marital status, nationality, religion, number and type of comorbidities were assessed. RESULTS: 102 patients (53%) had a DNACPR order: 27% issued by the patient him/herself, 12% by his/her relatives and 61% by the medical team. Patients with a DNACPR order were significantly older: 80.7 ± 10.8 vs. 67.5 ± 15.1 years in the "with" and "without" DNACPR order group, respectively, p < 0.001. Oncologic disease was associated with a DNACPR order issued by the medical team (37.5% vs. 16.9% in the "with" and "without" DNACPR order group, respectively, p < 0.05). Being protestant was associated with a DNACPR order issued by the patient (57.9% vs. 25.9% in the "with" and "without" DNACPR order group, respectively p < 0.01). CONCLUSIONS: Over half of the patients admitted to a general internal medicine ward had a DNACPR order issued within the first 72 h of hospitalization. Older age and oncologic disease were associated with a DNACPR decision by the medical team, while protestant religion was associated with a DNACPR decision by the patient.

[Non-neoplastic esophageal stenosis: not always so benign]. / Sténose œsophagienne non-néoplasique: pas toujours si bénigne.

Esophageal intramural pseudodiverticulosis is a rare pathology whose etiology is unknown, but which is frequently associated with three highly prevalent entities: esophageal reflux disease, esophageal candidosis and alcoholic esophagitis. With conservative treatment the course of these pathologies is usually benign. However, some severe cases are resistant to conservative treatment and may require more aggressive management. We here present the case of patient suffering from a severe esophagitis complicated by chronic mediastinitis with life-threatening repercussions, requiring esophagectomy as treatment.

La pseudodiverticulose œsophagienne intramurale est une pathologie rare, d'étiologie inconnue, mais fréquemment associée à trois entités hautement prévalentes: la maladie de reflux, la candidose œsophagienne et l'œsophagite alcoolique. L'évolution de ces pathologies est habituellement bénigne avec un traitement conservateur. Certains cas sévères nécessitent toutefois une prise en charge plus agressive. Nous présentons ici le cas d'un patient souffrant d'une œsophagite sévère compliquée d'une médiastinite chronique avec des répercussions menaçant sa survie, ayant nécessité une prise en charge chirurgicale agressive.

[Pulmonary hypertension and lung edema at high altitude. Role of endothelial dysfunction and fetal programming]. / Hipertensión y edema pulmonar de altura. Rol de la disfunción endotelial y de la programación fetal.

High altitude constitutes an exciting natural laboratory for medical research. While initially, the aim of high-altitude research was to understand the adaptation of the organism to hypoxia and find treatments for altitude-related diseases, over the past decade or so, the scope of this research has broadened considerably. Two important observations led to the foundation for the broadening of the scientific scope of high-altitude research. First, high-altitude pulmonary edema (HAPE) represents a unique model which allows studying fundamental mechanisms of pulmonary hypertension and lung edema in humans. Secondly, the ambient hypoxia associated with high-altitude exposure facilitates the detection of pulmonary and systemic vascular dysfunction at an early stage. Here, we review studies that, by capitalizing on these observations, have led to the description of novel mechanisms underpinning lung edema and pulmonary hypertension and to the first direct demonstration of fetal programming of vascular dysfunction in humans.

Hipertensión y edema pulmonar de altura: Rol de la disfunción endotelial y de la programación fetal / Pulmonary hypertensión and lung edema at high altitude: Role of endothelial dysfunction and fetal programming

La altura constituye un fascinante laboratorio natural para la investigación médica. Si bien al principio el objetivo de la investigación en la altura fue la comprensión de los mecanismos de adaptación del organismo a la hipoxia y la búsqueda de tratamientos para las enfermedades relacionadas con la altura, durante la última década el alcance de esta investigación se ha ampliado considerablemente. Dos importantes observaciones han generado las bases para el crecimiento del alcance científico de la investigación en la altura. Primero, el hecho de que el edema pulmonar agudo de la altura constituye un modelo único para estudiar los mecanismos fundamentales de la hipertensión pulmonar y el edema pulmonar en humanos. Segundo, que la hipoxia ambiental asociada con la exposición a la altura facilita la detección de disfunción vascular pulmonar y sistémica en un estadio precoz. Aquí revisaremos los estudios que, capitalizando estas observaciones, han llevado a la descripción de nuevos mecanismos subyacentes del edema pulmonar y de la hipertensión pulmonar, y a la primera demostración directa de la existencia de una programación fetal sobre la disfunción vascular en humanos.

High altitude constitutes an exciting natural laboratory for medical research. While initially, the aim of high-altitude research was to understand the adaptation of the organism to hypoxia and find treatments for altitude-related diseases, over the past decade or so, the scope of this research has broadened considerably. Two important observations led to the foundation for the broadening of the scientific scope of high-altitude research. First, high-altitude pulmonary edema (HAPE) represents a unique model which allows studying fundamental mechanisms of pulmonary hypertension and lung edema in humans. Secondly, the ambient hypoxia associated with high-altitude exposure facilitates the detection of pulmonary and systemic vascular dysfunction at an early stage. Here, we review studies that, by capitalizing on these observations, have led to the description of novel mechanisms underpinning lung edema and pulmonary hypertension and to the first direct demonstration of fetal programming of vascular dysfunction in humans.

Pulmonary and systemic vascular dysfunction in young offspring of mothers with preeclampsia.

BACKGROUND: Adverse events in utero may predispose to cardiovascular disease in adulthood. The underlying mechanisms are unknown. During preeclampsia, vasculotoxic factors are released into the maternal circulation by the diseased placenta. We speculated that these factors pass the placental barrier and leave a defect in the circulation of the offspring that predisposes to a pathological response later in life. The hypoxia associated with high-altitude exposure is expected to facilitate the detection of this problem. METHODS AND RESULTS: We assessed pulmonary artery pressure (by Doppler echocardiography) and flow-mediated dilation of the brachial artery in 48 offspring of women with preeclampsia and 90 offspring of women with normal pregnancies born and permanently living at the same high-altitude location (3600 m). Pulmonary artery pressure was roughly 30% higher (mean+/-SD, 32.1+/-5.6 versus 25.3+/-4.7 mm Hg; P<0.001) and flow-mediated dilation was 30% smaller (6.3+/-1.2% versus 8.3+/-1.4%; P<0.0001) in offspring of mothers with preeclampsia than in control subjects. A strong inverse relationship existed between flow-mediated dilation and pulmonary artery pressure (r=-0.61, P<0.001). The vascular dysfunction was related to preeclampsia itself because siblings of offspring of mothers with preeclampsia who were born after a normal pregnancy had normal vascular function. Augmented oxidative stress may represent an underlying mechanism because thiobarbituric acid-reactive substances plasma concentration was increased in offspring of mothers with preeclampsia. CONCLUSIONS: Preeclampsia leaves a persistent defect in the systemic and the pulmonary circulation of the offspring. This defect predisposes to exaggerated hypoxic pulmonary hypertension already during childhood and may contribute to premature cardiovascular disease in the systemic circulation later in life.

Exaggerated pulmonary hypertension during mild exercise in chronic mountain sickness.

BACKGROUND: Chronic mountain sickness (CMS) is an important public health problem and is characterized by exaggerated hypoxemia, erythrocytosis, and pulmonary hypertension. While pulmonary hypertension is a leading cause of morbidity and mortality in patients with CMS, it is relatively mild and its underlying mechanisms are not known. We speculated that during mild exercise associated with daily activities, pulmonary hypertension in CMS is much more pronounced. METHODS: We estimated pulmonary artery pressure by using echocardiography at rest and during mild bicycle exercise at 50 W in 30 male patients with CMS and 32 age-matched, healthy control subjects who were born and living at an altitude of 3,600 m. RESULTS: The modest, albeit significant difference of the systolic right-ventricular-to-right-atrial pressure gradient between patients with CMS and controls at rest (30.3 +/- 8.0 vs 25.4 +/- 4.5 mm Hg, P 5 .002) became more than three times larger during mild bicycle exercise (56.4 +/- 19.0 vs 39.8 +/- 8.0 mm Hg, P < .001). CONCLUSIONS: Measurements of pulmonary artery pressure at rest greatly underestimate pulmonary artery pressure during daily activity in patients with CMS. The marked pulmonary hypertension during mild exercise associated with daily activity may explain why this problem is a leading cause of morbidity and mortality in patients with CMS.

Consultoria em ética clínica na Suíça / Clinical ethics consultancy in Switzerland

A realização de Consultorias em Ética Clínica tem sido reduzida, muitas vezes, a uma simples aplicação de um método de análise de casos baseados em princípios. A consultoria seria reduzida a uma simples avaliação de um conflito entre princípios. A proposta de uma abordagem baseada em uma Deliberação de Caso Moral pode ser uma alternativa importante, onde o consultor atua como facilitador e não tomando decisões que cabem aos profissionais de saúde.

Clinical Ethics Consultancy, often, has been reduced as a simple method of case analysis based on principles. The consultancy would be reduced to a simple evaluation of a conflict between principles. The proposed approach based on a Moral Case Deliberation could be an important alternative, where the consultant acts as a facilitator and not as a decision maker.

[Defective nitric oxide homeostasis. Common underlying mechanism between insulin resistance, sympathetic overactivity and cardiovascular morbidity and mortality]. / Defecto en la homeostasis del oxido nítrico. Mecanismo común subyacente de la insulino-resistencia, la hiperactividad simpática y la morbi-mortalidad cardiovascular.

Obesity, insulin resistance and associated cardiovascular complications are reaching epidemic proportions worldwide and represent a major public health problem. Over the past decade, evidence has accumulated indicating that insulin administration, in addition to its metabolic effects, also has important cardiovascular actions. The sympathetic nervous system and the L-arginine-nitric oxide pathway are the central players in the mediation of insulin's cardiovascular actions. Based on recent animal and human research, we demonstrate that both defective and augmented NO synthesis represent a central defect triggering many of the metabolic, vascular and sympathetic abnormalities characteristic of insulin-resistant states. These observations provide the rationale for the use of pharmaceutical drugs releasing small and physiological amounts of NO and/or inhibitors of NO overproduction as a future treatment for insulin resistance and associated comorbidities.

Stimulation of peroxynitrite catalysis improves insulin sensitivity in high fat diet-fed mice.

Peroxynitrite synthesis is increased in insulin resistant animals and humans. Peroxynitirite-induced nitration of insulin signalling proteins impairs insulin action in vitro, but the role of peroxynitrite in the pathogenesis of insulin resistance in vivo is not known. We therefore assessed the effects of a 1-week treatment with the peroxynitrite decomposition catalyst FeTPPS on insulin sensitivity in insulin resistant high fat diet-fed (HFD) and control mice. FeTPPS normalized the fasting plasma glucose and insulin levels (P < 0.01), attenuated the hyperglycaemic response to an intraperitoneal glucose challenge by roughly 50% (P < 0.05), and more than doubled the insulin-induced decrease in plasma glucose levels in HFD-fed mice (P < 0.001). Moreover, FeTPPS restored insulin-stimulated Akt phosphorylation and insulin-stimulated glucose uptake in isolated skeletal muscle in vitro. Stimulation of peroxynitrite catalysis attenuates HFD-induced insulin resistance in mice by restoring insulin signalling and insulin-stimulated glucose uptake in skeletal muscle tissue.

Respiratory nitric oxide and pulmonary artery pressure in children of aymara and European ancestry at high altitude.

Invasive studies suggest that healthy children living at high altitude display pulmonary hypertension, but the data to support this assumption are sparse. Nitric oxide (NO) synthesized by the respiratory epithelium regulates pulmonary artery pressure, and its synthesis was reported to be increased in Aymara high-altitude dwellers. We hypothesized that pulmonary artery pressure will be lower in Aymara children than in children of European ancestry at high altitude, and that this will be related to increased respiratory NO. We therefore compared pulmonary artery pressure and exhaled NO (a marker of respiratory epithelial NO synthesis) between large groups of healthy children of Aymara (n = 200; mean +/- SD age, 9.5 +/- 3.6 years) and European ancestry (n = 77) living at high altitude (3,600 to 4,000 m). We also studied a group of European children (n = 29) living at low altitude. The systolic right ventricular to right atrial pressure gradient in the Aymara children was normal, even though significantly higher than the gradient measured in European children at low altitude (22.5 +/- 6.1 mm Hg vs 17.7 +/- 3.1 mm Hg, p < 0.001). In children of European ancestry studied at high altitude, the pressure gradient was 33% higher than in the Aymara children (30.0 +/- 5.3 mm Hg vs 22.5 +/- 6.1 mm Hg, p < 0.0001). In contrast to what was expected, exhaled NO tended to be lower in Aymara children than in European children living at the same altitude (12.4 +/- 8.8 parts per billion [ppb] vs 16.1 +/- 11.1 ppb, p = 0.06) and was not related to pulmonary artery pressure in either group. Aymara children are protected from hypoxic pulmonary hypertension at high altitude. This protection does not appear to be related to increased respiratory NO synthesis.

Defecto en la homeostasis del óxido nítrico: Mecanismo común subyacente de la insulino-resistencia, la hiperactividad simpática y la morbi-mortalidad cardiovascular / Defective nitric oxide homeostasis: Common underlying mechanism between insulin resistance, sympathetic overactivity and cardiovascular morbidity and mortality

La incidencia de la obesidad y de la resistencia a la insulina con sus complicaciones asociadas, como la hipertensión arterial y el aumento de la morbi-mortalidad cardiovascular, alcanzan hoy en día proporciones epidémicas y representan un problema mayor de salud pública. En los últimos años se ha demostrado que la administración de insulina, además de sus efectos metabólicos, posee efectos cardiovasculares importantes. El sistema nervioso simpático y el sistema L-arginina - óxido nítrico son los mediadores centrales de estas acciones cardiovasculares de la insulina. Mostramos, gracias a estudios realizados en animales y en humanos, que no sólo un déficit de la síntesis del óxido nítrico (NO), sino también un aumento exagerado en su producción representan un defecto subyacente central de las anomalías metabólicas, cardiovasculares y del sistema nervioso simpático que caracterizan a la insulino resistencia. Mostramos cómo estos resultados establecen el fundamento científico para la utilización de sustancias farmacológicas capaces de liberar de manera prolongada cantidades fisiológicas de NO o de inhibidores de su sobreproducción como futuros tratamientos para la resistencia a la insulina y sus complicaciones asociadas.

Obesity, insulin resistance and associated cardiovascular complications are reaching epidemic proportions worldwide and represent a major public health problem. Over the past decade, evidence has accumulated indicating that insulin administration, in addition to its metabolic effects, also has important cardiovascular actions. The sympathetic nervous system and the L-arginine-nitric oxide pathway are the central players in the mediation of insulin's cardiovascular actions. Based on recent animal and human research, we demonstrate that both defective and augmented NO synthesis represent a central defect triggering many of the metabolic, vascular and sympathetic abnormalities characteristic of insulin-resistant states. These observations provide the rationale for the use of pharmaceutical drugs releasing small and physiological amounts of NO and/or inhibitors of NO overproduction as a future treatment for insulin resistance and associated comorbidities.

Pulmonary-artery pressure and exhaled nitric oxide in Bolivian and Caucasian high altitude dwellers.

There is evidence that high altitude populations may be better protected from hypoxic pulmonary hypertension than low altitude natives, but the underlying mechanism is incompletely understood. In Tibetans, increased pulmonary respiratory NO synthesis attenuates hypoxic pulmonary hypertension. It has been speculated that this mechanism may represent a generalized high altitude adaptation pattern, but direct evidence for this speculation is lacking. We therefore measured systolic pulmonary-artery pressure (Doppler chocardiography) and exhaled nitric oxide (NO) in 34 healthy, middle-aged Bolivian high altitude natives and in 34 age- and sex-matched, well-acclimatized Caucasian low altitude natives living at high altitude (3600 m). The mean+/-SD systolic right ventricular to right atrial pressure gradient (24.3+/-5.9 vs. 24.7+/-4.9 mmHg) and exhaled NO (19.2+/-7.2 vs. 22.5+/-9.5 ppb) were similar in Bolivians and Caucasians. There was no relationship between pulmonary-artery pressure and respiratory NO in the two groups. These findings provide no evidence that Bolivian high altitude natives are better protected from hypoxic pulmonary hypertension than Caucasian low altitude natives and suggest that attenuation of pulmonary hypertension by increased respiratory NO synthesis may not represent a universal adaptation pattern in highaltitude populations.

[High altitude pulmonary edema. An experiment of nature to study the underlying mechanisms of hypoxic pulmonary hypertension and pulmonary edema in humans]. / Edema pulmonar de altura. Modelo de estudio de la fisiopatologia del edema pulmonar y de la hipertension pulmonar hipoxica en humanos.

High altitude constitutes an exciting natural laboratory for medical research. Over the past decade, it has become clear that the results of high-altitude research may have important implications not only for the understanding of diseases in the millions of people living permanently at high altitude, but also for the treatment of hypoxemia-related disease states in patients living at low altitude. High-altitude pulmonary edema (HAPE) is a life-threatening condition occurring in predisposed, but otherwise healthy subjects, and, therefore, allows to study underlying mechanisms of pulmonary edema in humans, in the absence of confounding factors. Over the past decade, evidence has accumulated that HAPE results from the conjunction of two major defects, augmented alveolar fluid flooding resulting from exaggerated hypoxic pulmonary hypertension, and impaired alveolar fluid clearance related to defective respiratory transepithelial sodium transport. Here, after a brief presentation of the clinical features of HAPE, we review this novel concept. We provide experimental evidence for the novel concept that impaired pulmonary endothelial and epithelial nitric oxide synthesis and/or bioavailability may represent the central underlying defect predisposing to exaggerated hypoxic pulmonary vasoconstriction and alveolar fluid flooding. We demonstrate that exaggerated pulmonary hypertension, while possibly a condition sine qua non, may not be sufficient to cause HAPE, and how defective alveolar fluid clearance may represent a second important pathogenic mechanism. Finally, we outline how this insight gained from studies in HAPE may be translated into the management of hypoxemia related disease states in general.

Edema pulmonar de altura: Modelo de estudio de la fisiopatología del edema pulmonar y de la hipertensión pulmonar hipóxica en humanos / High altitude pulmonary edema. An experiment of Nature to study the underlying mechanisms of hypoxic pulmonary hypertension and pulmonary edema in humans

La altura, fascinante laboratorio natural de investigación médica, provee resultados con importantes implicancias para la comprensión de enfermedades que afectan a millones de personas que viven en ella, asi como para el tratamiento de enfermedades ligadas a la hipoxemia en pacientes que viven en baja altitud. El edema pulmonar de altura (EPA) es una entidad que pone en peligro la vida y que ocurre en sujetos predispuestos pero sanos. Esto permite estudiar los mecanismos subyacentes del edema pulmonar en humanos, sin la presencia de factores que presten a la confusión como enfermedades concomitantes. El EPA resulta de la conjunción de dos defectos mayores: acumulación de líquido en el espacio alveolar debido a una hipertensión pulmonar hipóxica exagerada, y alteración en la eliminación del mismo por un defecto en el transporte transepitelial alveolar de sodio. En esta revisión, describimos brevemente las características clínicas y revisaremos este novedoso concepto. Proveemos evidencia experimental de como la síntesis alterada de óxido nítrico y/o la disminución de su biodisponibilidad representan el defecto central que predispone a la vasoconstricción pulmonar hipóxica exagerada y a la acumulación de líquido en el espacio alveolar. Mostramos que la hipertensión pulmonar hipóxica exagerada, per se, no es suficiente para producir un EPA, y que una alteración en la eliminación del fluido del espacio alveolar representa un segundo mecanismo fisiopatológico importante. Finalmente, describimos cómo los nuevos aportes obtenidos de los estudios del EPA pueden ser trasladados al manejo de otros estados patológicos ligados a la hipoxemia.

High altitude constitutes an exciting natural laboratory for medical research. Over the past decade, it has become clear that the results of high-altitude research may have important implications not only for the understanding of diseases in the millions of people living permanently at high altitude, but also for the treatment of hypoxemia-related disease states in patients living at low altitude. High-altitude pulmonary edema (HAPE) is a life-threatening condition occurring in predisposed, but otherwise healthy subjects, and, therefore, allows to study underlying mechanisms of pulmonary edema in humans, in the absence of confounding factors. Over the past decade, evidence has accumulated that HAPE results from the conjunction of two major defects, augmented alveolar fluid flooding resulting from exaggerated hypoxic pulmonary hypertension, and impaired alveolar fluid clearance related to defective respiratory transepithelial sodium transport. Here, after a brief presentation of the clinical features of HAPE, we review this novel concept. We provide experimental evidence for the novel concept that impaired pulmonary endothelial and epithelial nitric oxide synthesis and/or bioavailability may represent the central underlying defect predisposing to exaggerated hypoxic pulmonary vasoconstriction and alveolar fluid flooding. We demonstrate that exaggerated pulmonary hypertension, while possibly a condition sine qua non, may not be sufficient to cause HAPE, and how defective alveolar fluid clearance may represent a second important pathogenic mechanism. Finally, we outline how this insight gained from studies in HAPE may be translated into the management of hypoxemia related disease states in general.

[Prevalence of hypertension in an Indian community in the North of Argentina]. / Prevalencia de hipertension arterial en una comunidad aborigen del norte argentino.

The prevalence of hypertension among adults of both sexes was assessed as part of a primary medical attention program in an Indian Wichi-Chorote community in Santa Victoria Este, province of Salta, Argentina. Arterial blood pressure was measured after a five minutes rest in a sitting position in adults (over 18 years old) of both sexes with a calibrated sphygmomanometer. A total of 522 adults (318 women and 204 men) were evaluated with median age of 43.5 +/- 16.3. The mean systolic blood pressure (SBP) was 125.2 +/- 22.7 mm Hg, and the mean dyastolic blood pressure (DBP) was 76.3 +/- 12.8 mm Hg. Thirty five percent of the people evaluated had normal pressure values (SBP<80 and DBP<120), 37% prehypertensive (SBP 120-139 or DBP 80-89) and 28% hypertensive (SBP > or = 140 or DBP > or = 90). Thirty one percent of the men (mean age: 43.93 +/- 17.11, mean SBP: 126.81 +/- 22.61 and mean DBP: 77.80 +/- 13.33) and 27% of the women studied (mean age: 42.93 +/- 16.3, mean SBP: 124.92 +/- 24.02 and mean DBP: 75.28 +/- 12.57) were hypertense. Fifty nine percent of the people over 65 years of age (n:58) (mean age: 73.15 +/- 6.36, mean SBP: 144.81 +/- 28.72 and mean DBP: 79.68 +/- 13.17) had blood pressure values in the hypertense range. The prevalence of hypertension in the evaluated rural population, suffering extreme demographic and sanitary conditions, is similar to that reported for urbanized societies in the USA but lower than the one reported for other rural areas of our country.