Glaucomatous Optic Neuropathy Associated with Nocturnal Dip in Blood Pressure: Findings from the Maracaibo Aging Study.

PURPOSE: To determine which nocturnal blood pressure (BP) parameters (low levels or extreme dipper status) are associated with an increased risk of glaucomatous damage in Hispanics. DESIGN: Observational cross-sectional study. PARTICIPANTS: A subset (n = 93) of the participants from the Maracaibo Aging Study (MAS) who met the study eligibility criteria were included. These participants, who were at least 40 years of age, had measurements for optical tomography coherence, visual field (VF) tests, 24-hour BP, office BP, and intraocular pressure <22 mmHg. METHODS: Univariate and multivariate logistic regression analyses under the generalized estimating equations (GEE) framework were used to examine the relationships between glaucomatous damage and BP parameters, with particular attention to decreases in nocturnal BP. MAIN OUTCOME MEASURES: Glaucomatous optic neuropathy (GON) based on the presence of optic nerve damage and VF defects. RESULTS: The mean age was 61.9 years, and 87.1% were women. Of 185 eyes evaluated, 19 (26.5%) had signs of GON. Individuals with GON had significantly lower 24-hour and nighttime diastolic BP levels than those without. However, results of the multivariate GEE models indicated that the glaucomatous damage was not related to the average systolic or diastolic BP levels measured over 24 hours, daytime, or nighttime. In contrast, extreme decreases in nighttime systolic and diastolic BP (>20% compared with daytime BP) were significant risk factors for glaucomatous damage (odds ratio, 19.78 and 5.55, respectively). CONCLUSIONS: In this population, the link between nocturnal BP and GON is determined by extreme dipping effects rather than low nocturnal BP levels alone. Further studies considering extreme decreases in nocturnal BP in individuals at high risk of glaucoma are warranted.

Risk of tuberculosis in public transport sector workers, Lima, Peru.

SETTING: Delays from symptom onset to the diagnosis and treatment of smear-positive pulmonary tuberculosis (TB) produces possible new cases in persons in close contact with TB cases, especially in confined spaces such as overcrowded public transport, which puts other users and transport workers at risk. OBJECTIVE: To estimate TB incidence rates in patients of a health micro-network, and the percentage of transport sector workers among TB and multidrug-resistant TB (MDR-TB) patients. DESIGN: Crude and indirect standardised incidence rates of TB were calculated from an exhaustive analysis of all clinical histories of incident patients in a health micro-network between 1 January 2007 and 30 June 2008. The percentage of transport sector workers and the association between MDR-TB and working in the transport sector were analysed. RESULTS: Standardised incidence rates for transport sector workers are 2.7-4.5 times higher than those in the total working-age male and global population of the micro-network studied. The association between TB and transport occupation and MDR-TB and transport occupation is high (respectively OR 3.06, 95%CI 2.2-4.2 and OR 3.14, 95%CI 1.1-9.1). CONCLUSION: These results indicate that the use of informal public transport is a risk factor for TB infection and an occupational risk in countries with characteristics similar to those in Peru.

[New concepts in hypertension]. / Conceptos actuales en hipertensión arterial.

The management of arterial hypertension has experienced great changes during the past years, based on the knowledge of its pathophysiology, as well as the development of new antihypertensive drugs. Recent studies show the effect of the dysfunction of the endothelium in hypertension, sleep apnea and a higher prevalence of primary hyperaldosteronism. The Sixth report of the Joint Committee makes a new classification of this pathology, including a new concept of the stratification of risk for each stage of the disease, and according to it a new way of treatment. This fact marks a new and a more aggressive behaviour to treat the hypertense patient. With respect to the treatment, the emphasis has been on the non-pharmacological measures, and the development of new antihypertensive drugs of long action and high through/peek rate. Prevention continues to be an important goal and main challenge for the clinician, given the high morbidity and mortality rate caused by hypertension.

[Percutaneous mitral valvuloplasty and open mitral commissurotomy: comparison of 2 techniques in immediate results]. / Valvuloplastía mitral percutánea y comisurotomía mitral abierta: comparación de las dos técnicas en los resultados inmediatos.

The aim of this study was to assess the real usefulness of percutaneous mitral balloon valvuloplasty (PMV). Eighty patients aged less than 56 years old, with symptomatic pure mitral stenosis, with an hemodynamic and echocardiographic area < 1.5 cm2, without associated valvular or coronary lesions and without surgical contraindications were studied. These were randomized in two groups of similar age, sex, symptomatology, cardiac rhythm, severity of stenosis and valve anatomy, that were subjected to PMV (n = 38) using a double balloon technique or to mitral commissurotomy (n = 42) with extracorporeal circulation (MC). Mitral areas (calculated using modified Gorlin's formula) increased in 1.15 +/- 0.28 and 1.72 +/- 0.34 cm2 in patients subjected to PMV and MC respectively. No patient died, there was one technical failure with PMV and two patients subjected to MC had a surgical wound infection. Mitral regurgitation increased in more than one degree in two patients treated with PMV (5%) and in 6 patients treated with MC (15%). It is concluded that PMV and MC are highly effective and safe procedures for the treatment of mitral stenosis. Mitral areas obtained with MC are higher than with PMV, however a significant improvement of the disease is achieved with both procedures and MC produces mitral regurgitation with a higher frequency.

[Percutaneous mitral valvuloplasty as a treatment of choice for mitral stenosis. Immediate results and long-term follow-up]. / Valvuloplastía mitral percutánea como tratamiento de elección de la estenosis mitral. Resultados inmediatos y seguimiento alejado.

We evaluated 77 patients with symptomatic mitral stenosis for balloon valvuloplasty. Five patients were excluded from the procedure due to the presence of intra-atrial thrombi or mitral valve endocarditis as detected by 2D echocardiography. The mean age of the 72 treated patients was 38 +/- 11 years, 68 were NYHA functional class II or IV: only 6 patients had valvular calcification. Three patients had severe liver failure, 2 were chronic alcoholics, one had liver cirrhosis, 2 had severe weight loss and 13 had pulmonary hypertension at systemic levels. 69 patients had a technically adequate procedure, one patient died, 1 developed cardiac tamponade and 1 failed. Mitral valve area increased from 0.93 +/- 0.34 to 2.38 +/- 0.67 cm2. Mitral incompetence increased in only 16 patients. After a mean follow up period of 15 +/- 5 months (range 8 to 27), 56 patients remained in FC I or II. Mitral valve area remained satisfactory in 54 patients. Mitral valve anatomy evaluated by echocardiography is helpful to predict immediate and late outcome. We conclude that balloon mitral valvuloplasty is the first choice for patients with severe symptomatic mitral stenosis.

Significacion del bloqueo AV tipo Wenckebach en atletas. / Significance of atrioventricular block type Wenckebach in athletes

Se presenta el caso de un joven remero, seleccionado nacional, que participo en los ultimos Juegos Olimpicos, y que durante su preparacion desarrollo un bloqueo AV de segundo grado tipo Wenckebach. La arritmia guardo estrecha relacion con el grado de entrenamiento fisico, y desaparecio con el ejercicio, sugeriendo su etiologia funcional. Se revisa la literatura a proposito del caso

Tratamiento de la taquicardia paroxistica, del recien nacido con reflejo de la sumersion. / Treatment of paroxysmal tachycardia of the newborn infant with submersion reflex

Se presenta el caso de un recien nacido de 25 dias de edad con una taquicardia paroxistica supraventricular (TPSV), convertida a ritmo sinusal con el llamado "reflejo de sumersion". Este es el primer recien nacido con TPSV convertido con este eficaz y sencillo procedimiento que se comunica en nuestro medio

[Congenital abnormalities of the tricuspid valve and Ebstein's anomaly with pulmonary valvular stenosis]. / Malformaciones congénitas de la tricúspide y anomalía de Ebstein con estenosis pulmonar valvular.

We are reporting a case of Ebstein's anomaly of the tricuspid valve and another case of a congenital double tricuspid lesion, both associated with pulmonary valve stenosis and with similar hemodynamics and physiopathology. Given that there are few reported cases in the literature, we analyzed the clinical and electrocardiographic findings of both. The utility of the echocardiogram is discussed in the diagnosis of such abnormalities and the angiographic and hemodynamic data commented upon. It is emphasized that right ventricular hypertension (105 mm Hg, and 98 mmHg, respectively) modifies the cardiopathic hemodynamics and its natural history, that was favorably modified by isolated corrective surgery of the pulmonary obstruction. The postoperatory transvalvular gradients were measured at 27 and 11 mm Hg, respectively. After having revised the pertinent bibliographic literature, we commented upon the factors that give such a high mortality rate in Ebstein's surgery and the congenital abnormalities which are most frequently associated.

Malformaciones congenitas de la tricuspide y anomalia de Ebstein con estenosis pulmonar valvular. / Congenital malformation of tricuspid valve and Ebstein anomaly with pulmonary valvular stenosis

Informamos de um caso con anomalia de Ebstein tricuspidea y de otro con doble lesion tricuspidea congenita, ambos asociados a estenosis valvular pulmonar y con hemodinamica y fisiopatologia similares. Dado que existen pocos casos informados en la literatura, analizamos los hallazgos clinicos y electrocardiograficos de ambos; se discute la utilidad del ecocardiograma en el diagnostico de tales anormalidades y comentamos sus datos hemodinamicos y angiograficos. Se enfatiza que la hipertension ventricular derecha: de 105 mm Hg en uno y de 98 mm Hg en el otro, modifica la hemodinamica de la cardiopatia y su historia natural y que esta se ve favorablemente modificada por la cirugia correctiva aislada de la obstruccion pulmonar. El gradiente transvalvular en el postoperatorio se midio en 27 y 11 mm Hg respectivamente. Despues de hecha la revision bibliografica pertinente se comentan los factores de los que depende la elevada mortalidad de la cirugia del Ebstein y las anomalias congenitas con las que mas frecuentemente se asocia

[The radiologic "melting sign". Is it pathognomic of pulmonary infarct?]. / El signo radiológico del deshielo patognomónico de infarto pulmonar?

The "melting sign" can be seen in the radiologic resolution of pulmonary thromboembolism, but is also seen in pneumonia. It's not a pathognomonic radiologic sign and has a rather subjetive character.