Renin angiotensin system blockage associates with insertion/deletion polymorphism of angiotensin-converting enzyme in patients with hypertensive emergency.

Hypertensive crisis (HC) stands out as a form of acute elevation of blood pressure (BP). It can manifest itself as hypertensive emergency (HE) or hypertensive urgency (HU), which is usually accompanied with levels of diastolic BP ≥120 mmHg. Angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism may influence manifestations of HC. Thus, this study evaluated the influence of ACE I/D polymorphism in individuals with HC. A total of 187 patients admitted with HC (HU [n=69] and HE [n=118]) and 75 normotensive individuals were included in the study. Peripheral blood was drawn for a biochemical and genetic analysis of the ACE I/D polymorphism by Polymerase Chain Reaction. HC group showed higher systolic BP, body mass index (BMI), glycemia, creatinine, and lower high-density lipoprotein (HDL) cholesterol compared with normotensive individuals. The use of renin-angiotensin system (RAS) blockers was more frequent in the HU group than in the HE group (p=0.020). The II genotype was more predominant in normotensive and HU individuals than among HE individuals (18.7%, 11.6%, and 2.5%, respectively; p=0.004). Higher BMI and glycemia were associated with HC in the logistic regression model. ACE II genotype (odds ratio [OR] 0.14; 95% confidence interval [CI] 0.04-0.51) and HDL cholesterol were protective for the development of HE. ACE II genotype was present in the HU group, compared with the HE group (OR 0.18; 95% CI 0.04-0.88). This study shows an association between the low prevalence of ACE I/D polymorphism II genotype and a greater occurrence of HE in Brazilian individuals. The lower blockage of RAS, which was detected in the HE group, may interact with the low frequency of II genotype, conferring an increased risk for HE.

Mid-esophagus unresectable cancer treated with a low cost stent. First experience.

BACKGROUND: In the cancer of the esophagus, with recent technologic advances, self-expanding metal stents (SEMS) are at the forefront of the armamentarium for re-establishing luminal patency. Weighed against the numerous advantages of stents are the import conditions and the cost. In light of this, we tested new low cost prostheses having the basic needs and characteristics to aim a significant benefit to poor people having advanced esophageal cancer, in a Brazilian regional public hospital. METHODS: This initial experience included fifteen patients (eleven men and four women, 55 ± 6.17 years old), presenting esophageal cancer, located at the medium third of the thoracic esophagus, extending for 5.5-8 cm long, not suitable for surgical procedure because they had been staged on fourth grade of the disease, two of them having fistula communicating esophagus to respiratory tree. The stents were placed under endoscopic and fluoroscopic guidance, after attempting an esophageal dilatation. An appropriate covered stent was then deployed, twelve of 10 cm and three of 13 cm in length. A chest X-ray was done 2 h after the procedure and a barium swallow was performed within 12 hours. Seven days and monthly until complete a six month follow-up after the procedure the patients were questioned about presence of pain, regurgitation, heartburn, cough, and their alimentary behavior. RESULTS: There were no severe complications and transient mild chest pain resolved until the seventh day after the stent deployment. Chest X-ray demonstrated expansion of the stent in all patients. In 2 cases of fistula, a barium swallow showed its complete sealing. The completion of the proposed follow-up was not achieved in three cases, limited by the patient's death until the third month, due to cancer progression. Recurrent dysphagia to paste food accounted for by tumor overgrowth proximal or distal to the stent and stent migration were not observed in the series. CONCLUSIONS: The new low cost endoprostheses is effective and forthcoming increased experience and prospective trials including questionnaires to analyze quality of life will allow for more informed decisions tailoring to a particular patient situation or to unexpected complications.

Evaluation of the awareness, control and cost-effectiveness of hypertension treatment in a Brazilian city: populational study.

OBJECTIVES: Hypertension is a highly prevalent disease worldwide, constituting one of the main risk factors for cardiovascular morbidity and mortality. The aims of this study were to evaluate the level of awareness and control of hypertension comparing sex, socioeconomic and educational level, BMI and drug therapy in over 40-year-old patients. The cost-effectiveness of the main pharmacologic classes of antihypertensives, as monotherapy and combination therapy, was also assessed. METHODS: In this randomized and cross-sectional populational study, a sample of 738 hypertensive adults with ages at least 40 years were evaluated. Of these, 345 (46.7%) were men and 393 (53.3%) were women. RESULTS: A total of 72.9% of the hypertensives knew about their disease. Women in the 40-49 and 50-59 age groups and obese individuals had a higher rate of awareness of their hypertensive status. The rates of awareness were similar in different social classes and educational levels, however, blood pressure control varied. beta-Blockers were the most effective drugs to control blood pressure with no differences being observed between monotherapy and combinations. Diuretics were the most cost-effective. CONCLUSION: Approximately half of the participants received monotherapy. The best percentage of control with monotherapy was obtained with beta-blockers but the diuretics treatment was the most cost-effective. The levels of awareness and control were high compared with developed countries, most evident in the higher social classes and higher education levels.

Pharmacologic treatment for prehypertension: to treat or not to treat?

The Seventh Joint National Committee on the Prevention, Detection, Evaluation and Treatment of Hypertension (VII JNC) introduced the term "prehypertension" to designate individuals whose systolic blood pressure (BP) levels are in the range of 120 to 139 mm Hg and diastolic BP between 80 and 89 mm Hg. The decision to establish this new BP category was based on a rate of progression to hypertension, its prevalence and association with other cardiovascular disease (CVD) risk factors, its relationship to the development of CVD, and its therapy. So, the prehypertension term was established to focus attention on a segment of the population who is at higher-than-normal CVD risk and in whom therapeutic approaches to prevent or delay the onset of hypertension would be of value. The VII JNC report has recommended the adoption of healthy lifestyles to achieve BP goals except in prehypertensive subjects with diabetes or chronic renal disease in whom drug treatment is also advocated. The treatment with antihypertensive drugs to prehypertension has been the subject of recent debate. The decision to use antihypertensive drug treatment should be based on global CVD risk rather than on specific levels of BP alone. This review article discusses the background, risk factors, treatment options and some recent patents related to hypertension.

Low insulin-like growth factor-1 and hypocholesterolemia as mortality predictors in acute kidney injury in the intensive care unit.

OBJECTIVE: To assess the role of insulin-like growth factor-1 and cholesterol as predictors of acute kidney injury mortality in intensive care unit patients. DESIGN: Prospective cohort study. SETTING: Multidisciplinary adult intensive care unit (24 beds). PATIENTS: Adult patients with acute kidney injury at intensive care unit admission for an 11-month period were considered and a total of 56 patients were admitted in the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: At intensive care unit admission serum insulin-like growth factor-1 (ng/mL), total cholesterol (mg/dL), albumin (g/dL), transferrin (mg/dL), total lymphocyte count, triceps skinfold thickness, arm muscle area, and Subjective Global Nutritional Assessment were evaluated. Insulin-like growth factor-1 was significantly lower in nonsurviving as compared with surviving patients (48.5 +/- 24.4 vs. 70.8 +/- 39.9; p = 0.044), as well as cholesterol (80.3 +/- 35.7 vs. 147.4 +/- 53.1; p < 0.001) and albumin (1.9 +/- 0.4 vs. 2.4 +/- 0.7; p = 0.018). Groups were similar regarding transferrin, lymphocyte, triceps skinfold thickness, arm muscle area, and subjective global nutritional assessment. A binary logistic regression model based on insulin-like growth factor-1 < or = median (50.6 ng/mL), presence of sepsis, oliguria, and cholesterol < or = median (96 mg/dL) identified insulin-like growth factor-1 (odds ratio = 7.73; 95% confidence interval 1.19-49.87; p = 0.032), sepsis (odds ratio = 7.28; 95% confidence interval 1.29-40.89; p = 0.024), oliguria (odds ratio = 8.7; 95% confidence interval 1.10-68.77; p = 0.040) and cholesterol (odds ratio = 10.94; 95% confidence interval 1.89-63.29; p = 0.008) as independent covariate for death. CONCLUSIONS: Decreased levels of insulin-like growth factor-1 and cholesterol were clearly related to higher mortality. The close correlation of insulin-like growth factor-1 with nutritional status, its serum stability, and short-half life makes it a suitable candidate for an early and sensitive marker for intensive care unit acute kidney injury mortality.

Avaliação do ensino de Bioética nas faculdades de medicinado estado de São Paulo / Evaluation of the Bioethics teaching at medical colleges of São Paulo state

Introdução: Durante muito tempo focada apenas no ensino de questões pertinentes à Deontologia e Medicina Legal, a educação ética nas escolas Médicas brasileiras passa por um momento de grandes mudanças. Devido ao descompasso entre o enorme progresso da tecnologia e a maturidade das reflexões morais sobre suas conseqüências, surge uma crescente necessidade da inserção da Bioética nos cursos médicos, a fim de despertar no graduando um maior conteúdo humanístico. Objetivo: Caracterizar como é realizado o ensino da Bioética no Estado de São Paulo, avaliar como os alunos atuam tendo esta disciplina no currículo e se houve alguma mudança no comportamento dos acadêmicos em relação ao seu ingresso no curso. Materiais e Métodos: Foi realizado com 179 alunos, segregados em 23 Faculdades de Medicina do Estado de São Paulo. Os alunos responderam um questionário contendo treze perguntas fechadas e sete questões sob modelo de um caso clínico. Resultados: Este trabalho constou com 70,7% de participação dos alunos no estudo. Cento e sessenta e seis alunos (92,7%) responderam que a disciplina de Bioética estava presente na sua grade curricular. A forma com que tal disciplina é ensinada aos alunos predominou-se nas aulas teóricas em 72,3% dos casos. O tema das questões que apresentaram maior porcentagem de erros foi transfusão sanguínea em Testemunha de Jeová e portador de Vírus da Imunodeficiência Adquirida que não aceita contar tal fato à companheira. O último ano da graduação foi o que mais acertou as questões. Conclusões: As atividades relacionadas à Bioética se dão na grande maioria das vezes sob a forma de aulas teóricas, podendo ser uma das responsáveis pelo grande desinteresse que os alunos da graduação de medicina têm pela referida disciplina. Este desinteresse dos alunos contribui para a formação de médicos menos humanizados no futuro, com substancial distanciamento médico-paciente.

Introduction: For a long time focused only on teaching pertinent questions to Deontology and Medical jurisprudence, the ethical education in Brazilian Medical Schools has been through a dramatic breakthrough.Due to the unbalance between the out standing development of technology and the maturity of moral reflections upon its consequences, the insertion of Bioethics in medical courses appears to be an increasing requirement in order to arouse a higher humanistic interest in undergraduate students. Objective: To characterize how Bioethics has been taught in the State of São Paulo; to evaluate the students behavior regarding the insertion of this subject as part of the curriculum; and to evaluate if there has been changes, if any, in students behavior in relation to their admission in the course. Materials and Methods: The study was carried out with 179 students, gathered in 23 Medical Colleges of São Paulo State. A questionnaire with 13 closed questions and seven questions concerning a clinical case as a model were answered by the students. Results: The study comprised 70.7% of the student population. The answers obtained were as follows: 166 (92.7%) students reported that Bioethics was present as a component of the formal curriculum. The predominant modality of teaching Bioethics is theoretical in 72.3% of the courses. The questions which presented greater percentage of errors were Jehovah’s Witness blood transfusion and AIDS patients who do not accept sharing the burden of the disease with his/her partner. The seniors have given the most accurate answers. Conclusions: Most of the times, the activities related to Bioethics are only performed theoretically. This modality of teaching is hold responsible for the great indifference showed by the undergraduate medicalstudents. This indifference showed by the students contributes for the education of less humanized physicians, substantially jeopardizing the doctor/patient relationship.

Comparison of azithromycin and oral hygiene program in the treatment of cyclosporine-induced gingival hyperplasia.

BACKGROUND: It has been shown that azithromycin improves cyclosporine-induced gingival hyperplasia (GH), but its efficacy was never compared against an efficient oral hygiene program (OHP). The aim of this study was to analyze the effects of azithromycin plus OHP versus OHP alone in patients with cyclosporine-induced GH. METHODS: After periodontal evaluation, 20 renal transplant recipients received detailed oral hygiene instructions and a complete OHP, and were randomized to control (OHP) or azithromycin groups (OHP plus azithromycin). Patients were re-evaluated after 15 and 30 days. Both groups were similar in time after transplant, age, gender, cyclosporine dose, and cyclosporine through level and serum creatinine. The control group had fewer patients using calcium cannel blockers (10% vs. 70%, p = 0.02). RESULTS: All patients improved in pain, halitosis, and gum bleeding after OHP. The control group did not improve plaque index (PI) or GH. In contrast, baseline PI decreased from 1.52 +/- 0.28 to 0.50 +/- 0.16 on day 15 (p < 0.01) and to 0.46 +/- 0.14 on day 30 (p < 0.01) in the azithromycin group, and the GH score decreased from 1.9 +/- 0.27 to 0.90 +/- 0.27 on day 15 (p < 0.05) and to 0.70 +/- 0.21 on day 30 (p < 0.01). CONCLUSION: Azithromycin associated to efficient OHP induced a striking reduction in cyclosporine-induced GH, while efficient OHP alone improved oral symptoms but did not decrease cyclosporine-induced GH.

Fluxo sangüíneo arterial do pênis em homens com disfunção erétil: O uso do Doppler de fluxo contínuo - registro impresso / Penile arterial flow in men with erectile dysfunction: The use of Continuous Wave Doppler (CWD) - a statement of printing press

Ainda não há um método propedêudico de consenso para diagnosticar a disfunção erétil (DE). O uso isoladode drogas vasoativas intracavernosa não é um método capaz de demonstrar objetivamente se a resposta erétilfármaco-induzida nos pacientes é fisiológica ou funcional (não fisiológica). A associação do Doppler de fluxocontínuo, representado pela sigla CWD (continuous wave Doppler), com o teste de ereção fármaco-induzida(TEFI), adiciona um parâmetro diagnóstico hemodinâmico de velocidade de fluxo sangüíneo arterial do pênis.Esse parâmetro, utilizado nos estudos com o Doppler convencional PSV (Peak Systolic Velocity), é medidopela unidade PK=cm/s padronizado em nosso estudo. No presente trabalho foram avaliados cinqüenta pacientescom disfunção erétil de etiologia desconhecida, com seis meses ou mais de evolução. Para realização doTEFI foi aplicada uma injeção intracavernosa de 0,5 ml de prostaglandina (40µg) e fentolamina (0,33 mg) deuma solução padronizada em 6,0 ml de água bidestilada. A ereção foi avaliada 15 minutos após e classificadade acordo com a resposta (ereção com rigidez persistente ou ereção com rigidez não persistente ou incompleta).Com o equipamento SMART-DOP modelo ES-1000-PM e transdutor de 10 MHz (Doppler de fluxo contínuo) foram realizados registros gráficos correspondentes nas quatro fases do ciclo erétil (flacidez, pré-tumescência, tumescência e rigidez) sendo registrados gráficos em intervalos de 5 minutos cada um. As médias dasvelocidades de fluxo sangüíneo (PKm) e o desvio padrão (SD) foram analisados e relacionados somente coma primeira, terceira e quarta fases do ciclo erétil. A avaliação da DE, com Doppler de fluxo contínuo no presenteestudo, é realizada de modo fácil e objetivo pelo urologista. Concluiu-se que na flacidez peniana a média dasvelocidades de fluxo sangüíneo (PKm) foi compatível com um adequado suprimento arterial, independentementeda resposta erétil no final, não garantindo uma ereção rígida persistente. Na quarta fase d...

Crise hipertensiva: atualização clínico-terapêutica / Hypertensive crisis: clinical-therapeutic updating

Crise hipertensiva é uma situação clínica comum caracterizada por elevação sintomática da pressão arterialque apresenta alta taxa de morbidade e mortalidade e é classificada em emergência e urgência hipertensiva. Oquadro clínico de emergência hipertensiva difere do quadro de urgência por apresentar risco de morte iminentedecorrente de lesão em órgãos-alvo instalada ou em evolução, em particular coração, cérebro e rins. Essa condição requer uma abordagem clínica criteriosa que permita o diagnóstico rápido e correto do comprometimentode órgão-alvo. A intervenção terapêutica deve ser imediata, eficiente e individualizada para cada sistema comprometido, em geral com uso de anti-hipertensivos por via endovenosa em uma unidade de terapia intensiva. Por outro lado, o paciente com urgência hipertensiva não apresenta envolvimento de órgãos-alvo e nem se encontra com risco de morte maior, por isso o tratamento pode ser feito com anti-hipertensivos por via oral na própria sala de urgência. Este artigo revisa as principais causas de crise hipertensiva, a sua fisiopatogênese e a epidemiologia, bem como a sua abordagem clínica e terapêutica com os anti-hipertensivos utilizados e suas indicações.