[Medical expert consensus in AH on the clinical use of triple fixed-dose antihypertensive therapy in Spain]. / Consenso de médicos expertos en HTA sobre el uso clínico de la triple terapia antihipertensiva a dosis fija en España.

INTRODUCTION: The opinion of experts (different specialties) on the triple fixed-dose antihypertensive therapy in clinical practice may differ. MATERIALS AND METHODS: Online questionnaire with controversial aspects of the triple therapy answered by panel of experts in hypertension (HT) using two-round modified Delphi method. RESULTS: The questionnaire was completed by 158 experts: Internal Medicine (49), Nephrology (26), Cardiology (83). Consensus was reached (agreement) on 27/45 items (60%); 7 items showed differences statistically significant. Consensus was reached regarding: Predictive factors in the need for combination therapy and its efficacy vs. increasing the dose of a pretreatment, and advantage of triple therapy (prescription/adherence/cost/pressure control) vs. free combination. CONCLUSIONS: This consensus provides an overview of the clinical use of triple therapy in moderate-severe and resistant/difficult to control HT.

Correlation of asymptomatic hyperuricaemia and serum uric acid levels with arterial stiffness in women with systemic lupus erythematosus without clinically evident atherosclerotic cardiovascular disease.

The objective of this article was to evaluate whether serum uric acid (SUA) correlates with arterial stiffness and inflammation markers in a cohort of women with systemic lupus erythematosus (SLE) without overt atherosclerotic cardiovascular diseases, who attended a community hospital. One hundred and two women with SLE were assessed as part of this cross-sectional study. Carotid-femoral pulse wave velocity (PWV) was measured using an automatic device (Complior). C-reactive protein (CRP), fibrinogen and homocysteine levels as well as other metabolic results were recorded. Duration and activity of SLE, damage accrual and treatments were recorded. SLE women were categorized as having or not having hyperuricaemia (HU) according to SUA levels (greater than or up to 6.2 mg/dl, respectively). A multiple linear regression analysis was used to determine the independent link between SUA levels and other variables. Women with SLE and HU (n = 15, 15%) had a worse cardiovascular risk profile that included ageing, hypertension, obesity, higher total cholesterol levels, renal failure and presence of metabolic syndrome. Also, the duration of SLE was increased and damage accrual was greater. In the unadjusted analysis, SUA levels correlated with PWV, CRP, fibrinogen and homocysteine. However, in a multivariate linear regression analysis, SUA levels independently correlated with the duration of SLE, creatinine, total cholesterol and homocysteine levels but did not correlate with PWV. In conclusion, SUA was associated with arterial stiffness, but not independently of age and homocysteine levels. Nevertheless, SUA might be an ancillary indicator of subclinical atherosclerosis in SLE women without clinically evident atherosclerotic cardiovascular disease.

Extramedullary relapse in acute promyelocytic leukemia treated with all-trans retinoic acid and chemotherapy.

We analyzed the incidence, presenting features, risk factors of extramedullary (EM) relapse occurring in acute promyelocytic leukemia (APL) treated with all-trans retinoic acid (ATRA) and chemotherapy by using a competing-risk method. In total, 740/ 806 (92%) patients included in three multicenter trials (APL91, APL93 trials and PETHEMA 96) achieved CR, of whom 169 (23%) relapsed, including 10 EM relapses. Nine relapses involved the central nervous system (CNS) and one the skin, of which two were isolated EM relapse. In patients with EM disease, median WBC count was 26950/mm3 (7700-162000). The 3-year cumulative incidence of EM disease at first relapse was 5.0%. Univariate analysis identified age <45 years (P=0.05), bcr3 PML-RARalpha isoform (P= 0.0003) and high WBC counts (> or = 10,000/ mm3) (P<0.0001) as risk factors for EM relapse. In multivariate analysis, only high WBC count remained significant (P= 0.001). Patients with EM relapse had a poorer outcome since median survival from EM relapse was 6.7 months as compared to 26.3 months for isolated BM relapse (P=0.04). In conclusion, EM relapse in APL occurs more frequently in patients with increased WBC counts (> or = 10,000/mm3) and carries a poor prognosis. Whether CNS prophylaxis should be systematically performed in patients with WBC > or = 10,000/mm3 at diagnosis remains to be established.

Diversidad en la expresión clínica del carcinoma suprarrenal. Presentación de 7 casos / Diversity of the clinical presentation of adrenal carcinoma. Analysis of 7 cases

El carcinoma suprarrenal es un tumor extremadamente infrecuente, cuya incidencia es de 0,5-2 casos por millón de habitantes/año. La presentación clínica es variable, desde casos asintomáticos (incidentalomas) a manifestaciones clínicas de hiperfunción hormonal, sobre todo hipercortisolismo y androgenización. El gran tamaño de estos tumores, así como la rapidez de la aparición de la sintomatología hormonal, cuando aparece, son signos indicativos de malignidad. Es un tumor muy agresivo, con mal pronóstico. Se presentan 7 casos de carcinoma suprarrenal, diagnosticados en nuestro hospital entre los años 1985 y 2000, con el fin de ilustrar su forma de presentación clínica. Por su gran tamaño, las técnicas de imagen nos permitieron detectar sin problemas todos los casos. Seis de los casos se encontraban en estadio IV (AU)

Clinical significance of polymicrobial versus monomicrobial bacteremia involving Pseudomonas aeruginosa.

The objective of this study was to examine the clinical significance of polymicrobial bacteremia involving Pseudomonas aeruginosa. Two hundred forty-eight episodes of Pseudomonas aeruginosa bacteremia, 43 of which were polymicrobic, were studied prospectively over a 6-year period. Three sets of blood cultures were obtained for each patient. Positive results for all three blood cultures were found more frequently in patients with polymicrobial infection, who were older than those with monomicrobial infection. Patients with polymicrobial bacteremia also were worse clinically and developed shock more frequently. Crude mortality was higher in patients with polymicrobial infection. A multivariate analysis revealed three variables significantly and independently associated with polymicrobial Pseudomonas aeruginosa bacteremia: higher age, poor clinical status of the patient, and positive results for all blood cultures obtained.

Nontyphoidal salmonella intracranial infections in HIV-infected patients.

Salmonella focal intracranial infections are unusual in human immunodeficiency virus (HIV)-infected patients. Six such infections have been reported in the world literature. We report a case of salmonella subdural and epidural cerebral empyema with concomitant osteomyelitis of the frontal bone. Such a complication in the course of salmonellosis is reported for the first time. In previously published case reports, four patients had brain abscess and two had subdural empyema. Salmonella typhimurium was isolated from two patients, and different serotypes were recovered from the others. All patients had advanced HIV disease, and all but two had had opportunistic infections before the diagnosis of salmonella intracranial infection. Surgical drainage combined with systemic antibiotic therapy resulted in the recovery of four of five patients. No regression of the lesions occurred in one patient treated only with antibiotics for multiple cerebral abscesses.

[Utility of bronchoalveolar lavage in the diagnosis of respiratory infection in HIV patients]. / Utilidad del lavado broncoalveolar en el diagnóstico de la infección respiratoria en pacientes HIV.

From January 1, 1992, to December 31, 1995, we studied 52 bronchoalveolar lavages in 45 HIV-infected patients. All patients with pulmonary symptoms and/or new pulmonary infiltrates underwent bronchoalveolar lavage (BAL) when the results of blood cultures and mycobacterial smears of sputum and urine were negative. Lavage fluid was investigated for the presence of P. carinii, bacteria, mycobacteria, fungi and virus. BAL was diagnostic in 39 (75%) cases. The organisms more frequently isolated were P. carinii and M. tuberculosis. Only one pathogen was identified in 28 cases (54%); two in ten (19%); and three in one patient (2%). BAL was, generally, well tolerated by the patient and had a high diagnostic yield in the evaluation of patients with HIV infection and respiratory symptoms.

[Directional velocity of the arterial flow, systemic vascular resistance and urinary excretion of sodium in cirrhotic patients]. / Vitesse directionelle du flux artériel, résistance vasculaire systémique et excrétion urinaire du sodium chez les cirrhotiques.

OBJECTIVES: We have studied the vascular resistance at the posterior tibial artery utilizing the Doppler reverse/forward flow ratio, and its relationship to systemic vascular resistance and renal function in 32 nonazotemic cirrhotic patients. METHODS: Patients were divided into three groups. Group A comprised 10 patients without ascites or oedema; group B comprised 9 patients with ascites and a relatively high sodium excretion (40 +/- 34 mmol/day); and group C comprised 13 patients with ascites and very low sodium excretion (4.9 +/- 2 mmol/day). RESULTS: No significant differences were found in urine flow, creatinine or creatinine clearance between the three groups. Renin and aldosterone levels were found increased in group C. Systemic vascular resistance differed significantly in the three groups, being lower in group C. Significant higher values in the Doppler reverse/forward ratio were observed in patients with markedly increased sodium retention and less systemic vascular resistance (group C). The Doppler reverse/forward ratio showed significant correlations with systemic vascular resistance (r = 0.65; n = 32; p < 0.001), urinary sodium excretion (r = 0.53; n = 32; p < 0.01), renin (r = 0.474; n = 32; p < 0.01) and aldosterone levels (r = 0.589; n = 32; p < 0.001). CONCLUSIONS: These preliminary results suggest in patients with hepatic cirrhosis vascular resistance, assessed non-invasively, at the posterior tibial artery, increases with the severity of sodium retention and the impairment in systemic hemodynamics. Thus, this measurement may be useful for the evaluation and follow-up of patients with cirrhosis of the liver.

Interrelationships between systemic hemodynamics, urinary sodium excretion, and renin-angiotensin system in cirrhosis.

We studied the interrelationships between systemic hemodynamics, sodium excretion and the renin-angiotensin system in 28 nonazotemic cirrhotic patients on a sodium restricted diet. Renal hemodynamics were also assessed. The patients were divided into three groups. Group A comprised 9 patients without ascites or edema; group B comprised 8 patients with ascites and relatively high sodium excretion (41.9 +/- 12.9 mmol/day); and group C comprised 11 patients with ascites and very low sodium excretion (4.8 +/- 12.9 mmol/day). There were no significant differences in urine flow, glomerular filtration rate or effective renal plasma flow between the three groups of patients, although renin and aldosterone levels were significantly increased in group C. Groups A and B did not differ in hemodynamic parameters and no differences were found between the three groups in heart rate or in plasma volume. Group C, however, showed significantly higher cardiac index and lower arterial pressure and systemic vascular resistance. Plasma volume was inversely related to systemic vascular resistance, and natriuresis correlated significantly with both cardiac index (inversely) and systemic vascular resistance (directly). In addition, renin and aldosterone levels were inversely correlated with both mean arterial pressure and systemic vascular resistance. The systemic hemodynamic disturbances in nonazotemic cirrhotics is paralleled by the impairment in sodium homeostasis, suggesting that the decrease in systemic vascular resistance is the primary event leading to hypotension, high cardiac output and the activation of the renin-angiotensin system in these patients.

[Listeria monocytogenes infection in HIV patients: 2 new cases]. / Infección por Listeria monocytogenes en pacientes VIH: dos nuevos casos.

Two new cases of infection due to Listeria monocytogenes in two females with HIV are discussed, one of them with full blown AIDS and the other pregnant and without knowledge of her seropositivity until that moment. Its clinical manifestation as a meningeal manifestation and bacteremia, coincide with the few cases described until now; different hypothesis invoked until now are reviewed to justify this infrequent association HIV-Listeria.

[Comments with respect to 2 patients with anti-Jo 1 antibodies]. / Comentarios a dos enfermos con anticuerpos anti-Jo 1.

Anti-Jo 1 antibodies define a subgroup of patients with polymyositis, which are characterized by the presence of extra-muscular involvement as pulmonary fibrosis, although Raynaud's phenomena, arthritis, tenosynovitis, pleuritis and pericarditis may also be present. Given the fact that extra-muscular signs may precede the clinical diagnosis of polymyositis, as in the two cases that we present here, these antibodies may help us to diagnose the disease before the onset of myositis.