[Experimental cadaveric study assesing protection and osteotomy guide system (BARU) in hallux valgus surgery using Reverdin-Isham technic]. / Estudio experimental cadavérico para valorar el sistema de protección y guía de osteotomía (BARU) en cirugías de hallux valgus con técnica de Reverdin-Isham.

INTRODUCTION: Hallux valgus is a high frequency disorder, affecting the first ray. Operative correction techniques have grown popularity lately. One of them is the Reverdin-Isham technique (first metatarsal medial incomplete osteotomy). Recently, a protection and osteotomy cutting guide has been developed: the BARU system. OBJECTIVE: To test the usefulness of the BARU system as a protective factor for soft structures adjacent to the surgical site and guidance for osteotomy. MATERIAL AND METHODS: Experimental cadaveric study. Six cadaveric feet (two fresh-frozen and four in formaldehyde solution), unapproached. Feet were numbered and intervened with RI technique, three of them with BARU system and three without it. Afterwards, dissection by two dissectors who did not know whether the BARU system had been used or not, establishing a single-blinded model. 13 structures were evaluated in each foot. Data was recovered into Microsoft Office Excel and processed with SPSS. 2 test (significative if p value < 0.05) and relative risk were calculated. RESULTS: Approach using BARU system was satisfactory, with usual-size operation-ports. BARU system colocation was simple and radiological control showed adequate spatial location. The device contributed as reference for cutting direction and depth. 65 out of the 78 searched structures were found (83.3%). Six injuries were found among the assessed structures: plantar medial nerve (one injury), plantar medial artery (one injury), flexor brevis muscle (three injuries), abductor muscle (one injury). Five of these injuries occurred in non-utilizing BARU system feet. CONCLUSION: Promising results in terms of protection of nearby structures, cutting guide, and ease of intervention. Avoids X-rays exposure. Not significant statistical calculations, the sample should be enlarged.

INTRODUCCIÓN: El hallux valgus es una patología con alta prevalencia en la población. Técnicas de corrección quirúrgica han crecido en popularidad últimamente. Una de ellas es la de Reverdin-Isham (RI: osteotomía incompleta medial en primer metatarsiano), se desarrolló un dispositivo de protección y guía de corte para dicho procedimiento: el sistema BARU. OBJETIVO: Probar la utilidad del sistema BARU como factor protector de estructuras blandas adyacentes al sitio de abordaje y guía para osteotomía. MATERIAL Y MÉTODOS: Estudio cadavérico; seis pies (dos frescos y cuatro formolados) sin abordajes previos. Tres con el sistema BARU y tres sin éste. Posteriormente disección por dos disectores con enmascaramiento simple ciego. Se evaluaron 13 estructuras en cada pie. Los datos fueron recabados con Microsoft Office Excel y procesados en SPSS. Se realizó test de 2 (valor p < 0.05 significativo) y se calculó el riesgo relativo. RESULTADOS: El sistema BARU fue satisfactorio. Su colocación fue sencilla y el control radiológico mostró adecuada ubicación espacial. Ayudó como referencia para la dirección y profundidad del corte. Se encontraron 65 de las 78 estructuras buscadas (83.3%). En las estructuras evaluadas hubo seis lesiones: nervio plantar medial (uno dañado), arteria plantar medial (uno dañado), músculo flexor corto (tres dañados), músculo abductor (uno dañado). Cinco de estas lesiones ocurrieron en pies donde no se utilizó el sistema BARU. CONCLUSIÓN: Resultados prometedores en cuanto a protección de estructuras cercanas, guía de corte y facilidad para la intervención. Cálculos estadísticos no significativos, la muestra debería ampliarse.

Gemcitabine in the treatment of advanced transitional cell carcinoma of the urothelium.

M-VAC (cisplatin, methotrexate, adriamycin, vinblastine) combination chemotherapy has been for long time the standard of care in fit patient with advanced urothelial tumors. Gemcitabine/cisplatin with similar results and an improved toxicity profile has proved to be a new standard alternative. Whether or not we can improve survival with newer triplet regimens will depend upon the results of ongoing phase III trials. In addition to the new active drug combinations and targeted therapies, new approaches are emerging for treatment. Chemotherapy optimization using molecular markers predicting chemosensitivity are being applied. There is an obvious need to incorporate in clinical trials a systematic translational approach to explain both our successes and our failures.

A comparison of indapamide SR 1.5 mg with both amlodipine 5 mg and hydrochlorothiazide 25 mg in elderly hypertensive patients: a randomized double-blind controlled study.

OBJECTIVE: To analyse the efficacy of indapamide sustained-release (SR) 1.5 mg in reducing blood pressure versus amlodipine 5 mg and hydrochlorothiazide 25 mg, in elderly hypertensive patients. DESIGN: Double-blind, randomized, 12 week study using three parallel groups. SETTING: European teaching hospitals and general practices. PATIENTS: Randomized patients, (n = 524) including 128 patients with isolated systolic hypertension (ISH); mean age: 72.4 years; mean systolic/diastolic blood pressures (SBP/DBP): 174.5/97.9 mmHg. MAIN OUTCOME MEASURES: Clinic systolic and diastolic blood pressure variations. RESULTS: Indapamide SR 1.5 mg demonstrates a similar efficacy to that of amlodipine 5 mg, as well as to that of hydrochlorothiazide 25 mg (equivalence P < 0.001); the mean decreases in SBP/DBP were -22.7/-11.8 mmHg, -22.2/-10.7 mmHg and -19.4/-10.8 mmHg, respectively. In the ISH subgroup, indapamide SR 1.5 mg tends to have greater efficacy than hydrochlorothiazide 25 mg in reducing the SBP (-24.7 versus -18.5 mmHg, respectively; equivalence P = 0.117), while similar results are obtained with amlodipine 5 mg (-23 mmHg, equivalence P < 0.001). The normalization rate was relatively high for indapamide SR 1.5 mg (75.3%), when compared with amlodipine (66.9%) and hydrochlorothiazide (67.3%), especially in the subgroup of isolated systolic hypertensive patients: 84.2 versus 80.0% for amlodipine, and versus 71.4% for hydrochlorothiazide. CONCLUSIONS: Indapamide SR 1.5 mg shows similar antihypertensive efficacy to amlodipine 5 mg and hydrochlorothiazide 25 mg in elderly hypertensive patients, while in patients with isolated systolic hypertension, indapamide SR 1.5 mg shows a similar efficacy to amlodipine 5 mg but a greater efficacy than hydrochlorothiazide 25 mg.

Influence of renal function on the pharmacokinetics of ramipril (HOE 498).

The pharmacokinetics of ramipril (HOE 498) were studied after oral administration of a single 10 mg dose to 24 hypertensive patients with different degrees of renal function. The creatinine clearance ranged between 4.1 and 126 ml/min/1.73 m2 and was below 35 ml/min/1.73 m2 in 16 patients. Angiotensin converting enzyme activity and the concentrations of ramipril and its active diacid metabolite ramiprilat were measured in plasma up to 10 days after drug intake. Urine levels of ramipril, ramiprilat, their glucuronides and 2 major metabolites (a diketopiperazine and a diketopiperazine acid) were measured up to 4 days after medication. The plasma concentration-time curve of ramiprilat was polyphasic with an initial steep decline after the peak level and a subsequent very long terminal phase at low concentrations. Impaired renal function resulted in higher peak levels of ramiprilat, longer times to peak and a markedly slower decline of plasma ramiprilat levels. Hence, the duration of angiotensin converting enzyme inhibition was considerably prolonged in renal failure and depended on the severity of renal impairment. The urinary excretion of ramipril and its metabolites decreased with decreasing renal function and was linearly related to the creatinine clearance, suggesting an alternative pathway of elimination. The pattern of excretion rates of ramipril and its various metabolites was not affected by renal failure. In contrast to the marked changes in the renal elimination, no relevant differences were observed in the absorption of ramipril from the gastrointestinal tract. Systolic and diastolic blood pressure decreased in all groups. The single 10 mg dose of ramipril was well tolerated.

White coat hypertension and related phenomena. A clinical approach.

In this paper, several clinical problems associated with the diagnosis of hypertension are discussed. Blood pressure variability and reactivity are factors underlying the difficulties in the diagnosis of hypertension. These phenomena are interrelated and mixed. White coat hypertension (WCH), referring to the phenomenon of a high diastolic pressure at the doctor's office and a normal diurnal diastolic pressure when it is measured by ambulatory monitoring, is the most important clinical problem of diagnosis. Blood pressure variability is described, since it is essential to understand changes in pressure throughout the day, and its phasic and tonic components. Blood pressure differences between activity and rest, usually seen as daytime/night-time differences, allow for blood pressure control in most patients with moderate hypertension. Prevalence of WCH depends on the cut-off point used by the investigators for normal diurnal blood pressure; thus, between 53% and 12% of patients may have WCH. In our studies, a prevalence of 35% has been found. The alert reaction, labile and borderline hypertension and WCH result from a mix of both variability and reactivity, and patients with these conditions are at a higher cardiovascular risk than normotensive controls. Ambulatory blood pressure monitoring, which enables true hypertensives to be distinguished from false hypertensives, is the most useful technique available to date for the diagnosis of hypertension.

Mineralogical microanalysis of idiopathic pulmonary fibrosis.

A mineralogical analysis of lung tissue was conducted on 25 samples from patients who had been diagnosed as having idiopathic pulmonary fibrosis (IPF). Scanning electron microscopy (SEM) at low magnification and energy-dispersive x-ray analysis (EDXA) was used. In all samples, the surface silicon/sulfur (Si/S) ratio was calculated. The Si/S ratio for 25 samples of normal lung and 6 samples of pneumoconiotic lung was also determined (upper limit of normal Si/S ratio = 0.3). The difference between the Si/S ratio in the group with IPF and group with normal lung tissue was significantly significant (p less than .007, Wilcoxon test). Six of 12 patients with a previous diagnosis of IPF and a Si/S ratio greater than 0.3 had an exposure history that could imply inhalation of silica/silicates, and the correct diagnosis for these patients is most probably pneumoconiosis. The silica/silicate deposits detected in patients with IPF, and who had a ratio and no past exposure to dusts, could be either a cause or an effect of the disease.

[Variability of arterial pressure and of heart rate in essential arterial hypertension]. / Variabilidad de la presión arterial y de la frecuencia cardíaca en la hipertensión arterial esencial.

BACKGROUND: Blood pressure (BP) and heart rate (HR) show multiple oscillations. The aim of the present study was to evaluate their variability by means of a noninvasive device for the continuous recording of ambulatory BP. METHODS: A 24 hour recording was programmed (minimal interval 30 minutes) in 190 individuals: 35 normotensive individuals aged 46 +/- 20 years and 155 patients with essential hypertension aged 49 +/- 12 years. RESULTS: In the whole population a significant positive correlation was found between systolic BP (SBP) and its variability (r = 0.360; p less than 0.001). This correlation was found for both normotensive (r = 0.506; p less than 0.01) and hypertensive (r = 0.384; p less than 0.001) groups. There also was significant positive correlation between HR and its variability in the overall population (r = 0.374; p less than 0.001) and in the normotensive (r = 0.594; p less than 0.001) and hypertensive (r = 0.356; p less than 0.001) groups. There was a significant positive correlation between SBP and age in the whole population (r = 0.269; p less than 0.001) and in the normotensive (r = 0.448; p less than 0.001) and hypertensive (r = 0.193; p less than 0.05) groups. When the individuals were divided in those older than 65 years and those younger than 60 years, with same levels of SBP and DBP, it was found that the variability (given as standard deviation) of both SBP and DBP were higher in the older group (similar SBP: 19 +/- 7/13 +/- 4 mmHg vs 15 +/- 4/11 +/- 3 mmHg, p less than 0.01/p less than 0.01; similar DBP: 19 +/- 7/13 +/- 4 mmHg vs 15 +/- 5/11 +/- 3 mmHg, p less than 0.001/p less than 0.01). Multiple regression analysis showed that the most important determinant of this variability was the baseline SBP value, followed by age. CONCLUSIONS: SBP and HR show a greater variability with higher baseline values. The variability of both SBP and DBP are greater in elderly patients.

[Plasma renin activity, arterial blood pressure and response to beta-adrenergic blockade: a non-demostrated correlation. Practical view points (author's transl)]. / Actividad renina plasmática, presión arterial y respuesta al bloqueo beta-adrenérgico: una correlación no demostrada. Consideraciones prácticas.

Nineteen patients have been treated with timolol maleate (a non selective beta-blocking) and the decrease of their blood arterial pressure was correlated with the suppression of renine secretion. The patients which controlled their arterial pressure (63%) as well as those who did not (37%) showed a significative decrease of the plasmatic renine. The patients were diagnosed of essential hypertension, with normal renal function and formed an homogenous group. The sodium intake was similar in all of them. The results showed that although the beta-blocking can act in hypertensive patients through the suppression of the renine angiotensine system, this is not the only maintenance factor of the arterial pressure, nor its only way of action. A relevant point to be stressed in the possibility of ARP stimulation by walking, in spite of the beta-blocking, which means that this is not a total blocking or that there are other factors regulating the ARP secretion, and that act together with the autonomous nervous system.

[Paradoxical correlation between plasma renin activity and hypotensive effect of beta-adrenergic blocking (author's transl)]. / Correlación paradójica entre actividad renina plasmática y efecto hipotensor del bloqueo beta-adrenérgico.

A group of 39 patients has been divided in three categories according to their plasmatic renine activity and the correlation of the hipotensive answer to the Timolol Maleate (betadrenergic blocking). The control is more favourable in the normorreninemic than in the hiporreninemic patients and, paradoxically, even more than in the hyperreninemic. This unexpected answer is probably due to the lowest sodium intake of this last group. Hyperreninemia is more than a factor determining their basal hypertension: it is a regulation factor by hiposodic diet and probably, drug resistant. Nor quantitative neither qualitative correlation among the basal plasmatic renine activity and the hipotensive activity has been observed.

[Validation of a model of an automatic device for the ambulatory monitoring of blood pressure: the Spacelab 5200]. / Validación de un modelo de aparato automático de registro de la presión arterial ambulatoria: el Spacelabs 5200.

BACKGROUND: The aim of this study was to test two of the same models of portable automatic devices for monitoring blood pressure over 24 hours. These devices were the Spacelabs 5200 (Kontron 1 and Kontron 2). METHODS: A mercury shygmomanometer was used as reference measurer. To validate Kontron 1, 22 persons (10 males and 12 females) of 45 +/- 12 years of age were selected. For Kontron 2, 25 subjects (12 males and 13 females) of 44 +/- 17 years of age were chosen. RESULTS: The results expressed as arithmetic mean and standard deviation were (manual vs Kontron 1); systolic blood pressure (SBP) 139 +/- 19 mmHg vs 135 +/- 16 mmHg, p less than 0.05; diastolic (DBP) 96 +/- 12 mmHg vs 93 +/- 12 mmHg, p less than 0.05, heart rate (HR) 77 +/- 13 ppm vs 76 +/- 14 ppm, NS. The correlation between the two methods was: SBP r = 0.870; DBP r = 0.875 and HR r = 0.949. The results of Kontron 2 were: SBP 137 +/- 17 mmHg vs 130 +/- 15 mmHg, p less than 0.05; DBP 93 +/- 11 mmHg vs 94 +/- 11 mmHg, NS; HR 75 +/- 10 ppm vs 73 +/- 12 ppm, NS. The correlations were: SBPr = 0.820; DBP r = 0.877 and HR r = 0.847. CONCLUSIONS: The Spacelabs 5200 automatic blood pressure monitoring underestimates systolic blood pressure while diastolic blood pressure and heart rate are reliable according to international norms.

[Study of the clinically useful interval in ambulatory monitoring of blood pressure]. / Estudio del intervalo clínicamente útil para monitorizar la presión arterial ambulatoria.

BACKGROUND: Ambulatory blood pressure monitoring (ABPM) throughout 24 hours has been introduced for clinical practice, improving the diagnosis and treatment of hypertension. However, there is not an agreement concerning how often the blood pressure have to be measured. SUBJECTS AND METHODS: An ABPM was performed in 29 normotensive and hypertensive subjects (16-73 years) throughout 24 hours recording the blood pressure every 15 minutes. The average of systolic and diastolic blood pressure of the diurnal and nocturnal periods of the interval of 15 minutes, were compared with the two intervals of 30 minutes and the four of 60 minutes, according to Bland and Altman method. RESULTS: Between 90% and 100% of the differences of the interval 15 minutes versus 30 minutes, and 15 minutes versus 60 minutes, were within +2 and -2 standard deviation of the mean. However, only between 95% and 100% of the difference of the intervals 15 minutes versus 30 minutes were within the limits of agreement for systolic and diastolic blood pressure in the nocturnal period. CONCLUSIONS: A clinical satisfactory information using ABPM can be obtained monitoring the blood pressure every 15 minutes during the day and 30 minutes at night.

[The evaluation of a noninvasive monitor to record ambulatory arterial pressure: the DIASYS 200 Novacor]. / Validación de un monitor no invasivo de registro de presión arterial ambulatoria: el DIASYS 200 Novacor.

BACKGROUND: The aim of this study was to validate the measurement precision of the portable automatic non invasive monitor of blood pressure-Novacor DIASYS 200. METHODS: A mercury sphygmomanometer was used as the reference measurer. To validate the DIASYS 87 persons (45 males, 42 females--age range 17-76 years) with a systolic blood pressure between 90-225 mmHg and diastolic blood pressure of between 64-149 mmHg were selected. RESULTS: The differences between the two apparatus were: systolic blood pressure 6.1 +/- 12.2 mmHg (r = 0.909); diastolic blood pressure -1.9 +/- 6.8 mmHg (r = 0.929) and cardiac frequency -2.0 +/- 6.3 ppm (r = 0.942). In healthy subjects of under 31 years of age (n = 20) the differences for systolic and diastolic blood pressure and cardiac frequency were 0.2 +/- 8.0 mmHg; -1.3 +/- 5.8 mmHg and -0.1 +/- 8.0 ppm, respectively. For subjects over the age of 59 years (n = 29) the measurements were 9.2 +/- 12.0 mmHg, 2.5 +/- 6.0 mmHg, -1.5 +/- 4.4 ppm, respectively. With the sample subdivided according to blood pressure the differences found in the normotensive subgroup (n = 23) were: -1.7 +/- 7.8 mmHg, -2. +/- 4.9 mmHg, and -2.4 +/- 7.9 ppm, respectively; in the subgroup with slightly high blood pressure (n = 40) 6.4 +/- 14.0 mmHg, -2.8 +/- 6.0 mmHg and -2.3 +/- 5.1 ppm, and in the subgroup with moderate-severe high blood pressure (n = 24) 10.4 +/- 10.9 mmHg, 0.2 +/- 9.1 mmHg and -0.9 +/- 6.5 ppm, respectively. CONCLUSIONS: The DIASYS fulfills the criteria of validation and precision for the measurement of diastolic blood pressure and cardiac frequency in all the cases. However criteria for systolic blood pressure are only fulfilled in normotensive and young subjects (less than 31 years of age).

[A clinical study of the verapamil and captopril combination in hypertensive patients uncontrolled by monotherapy. An evaluation by recording the 24-hour ambulatory blood pressure]. / Estudio clínico de la asociación verapamilo y captopril en pacientes hipertensos no controlados con monoterapia. Valoración mediante el registro de presión arterial ambulatoria durante 24 horas.

BACKGROUND: By measuring ambulatory blood pressure monitoring (ABPM), the pharmacologic association of verapamil plus captopril in essential hypertensive patients not responding to isolated monotherapy of these drugs was studied since a synergism has been described between these two drugs. METHODS: A lineal clinical trial with a previous period of selection (PeSe) in which verapamil and captopril were administered in two consecutive phases was carried out in 57 essential hypertensive patients of 52 +/- 19 years of age with those controlling their blood pressure (BP) being excluded. Following a lavage phase the remaining subjects were included in the experimental period (ExPe) in wash out the association of verapamil 120 mg+captopril 25 mg was administered and if the BP was not controlled this was increased to 240 mg + 50 mg, respectively. ABPM was performed prior to and at the end of the ExPe. RESULTS: Of the 57 patients 21 were excluded in the SePe due to control or adverse effects. Of the 26 individuals who passed into the ExPe 20 presented mild-moderate HTA (M-HTA) and 6 severe HTA (S-HTA). In the M-HTA group, the reduction of BP (in mmHg) was 157 +/- 15/106 +/- 5 to 147 +/- 12/97 +/- 7 (p < 0.05/p < 0.001), five controlled BP, in the remaining subjects the reduction in the following phase was 150 +/- 11/100 +/- 6 at 136 +/- 11/93 +/- 6 (p < 0.01/p < 0.01). In the S-HTA group the BP descended in the ExPe from 184 +/- 15/121 +/- 6 to 167 +/- 24/107 +/- 10 (p < 0.05/p < 0.05). The 24 hour measurement of BP in the ExPe decreased from 140 +/- 13/96 +/- 8 to 124 +/- 10/86 +/- 7 (p < 0.001/p < 0.001). BP descended significantly in all the hours with the exception of the hours 24, 1, 6, 7, and 5. CONCLUSIONS: The association of verapamil-captopril demonstrates efficacy and synergism in hypertensive patients previously uncontrolled by monotherapy of these drugs.