[Carotid intima-media thickness distribution according to the stratification of cardiovascular risk by means of Framingham-REGICOR and score function charts]. / Distribución del grosor íntima-media carotídeo en función de la estratificación del riesgo cardiovascular según las funciones de Framingham-REGICOR y SCORE.

BACKGROUND: Carotid intima-media thickness (cIMT) has been suggested as a further tool for risk function charts. The aim of this study was to describethe relationship between cIMT and cardiovascular risk (CVR) estimation according to Framingham-REGICOR and SCORE equations. METHODS: Observational, cross-sectional cohort study from 362 hypertensive subjects. Demographic and clinical information were collected as well as laboratory, ultrasonographic and CVR estimation by the Framingham-REGICOR and SCORE functions. Statistical analysis was performed using SPSS software (version 20,0). To analyze the data, statistical tests such as Chi-square, T-test, ANOVA, and Pearson correlation coefficient were used. RESULTS: According to both functions, differences on mean cIMT were found between low CVR group and intermediate to high groups. No differences were found between intermediate and high risk groups (cIMT: 0,73mm low risk patients vs. 0,89 or 0,88mm respectively according to SCORE function and cIMT: 0,73 vs. 0,85 or 0,87mm respectively according to Framingham-REGICOR function). cIMT correlated positively with CVR estimation according to both SCORE (r=0,421; P<.01), and Framingham-REGICOR functions (r=0,363; P<.01). CONCLUSIONS: cIMT correlates positively with CVR estimated by SCORE and Framingham-REGICOR functions. cIMT in those subjects at intermediate risk is similar to those at high risk. Our findings highlight the importance of carotid ultrasound in identifying silent target-organ damage in those patients at intermediate CVR.

[Comparison of the cardiovascular predictive value of MDRD and CKD-EPI in estimating chronic kidney disease]. / Comparación del valor predictivo cardiovascular de MDRD y CKD-EPI en la estimación de la enfermedad renal crónica.

OBJECTIVE: To assess predictive value of the cardiovascular prognosis by comparing the two most used formulas for the estimation of glomerular filtration rate in hypertensive patients. MATERIAL AND METHODS: A retrospective cohort study was designed that included 405 patients diagnosed with essential hypertension. The patients were referred from Primary Care to the Hypertension and Vascular Risk Unit between January 1, 1998 and August 31, 1999. Blood pressure measurements, blood and urine analysis, and echocardiography were simultaneously performed. They were followed up for 12.5 years (mean [± IQR]: 10.61 [± 3.11] years) and 174 events were recorded. RESULTS: The study included 405 patients (53.8% women), with a mean age of 55.5 years. The estimated glomerular filtration rate according to the MDRD and CKD-EPI equations was 73.9±2.6 mL/min/1.73m(2) and 76.9±2.2 mL/min/1.73m(2), respectively. The prevalence of chronic kidney disease was 31.6% and 23.9%, respectively. Using the CKD-EPI equation led to the re-classification of 22.9% of patients. The incidence rate ratio (IRR [95%CI] for chronic kidney disease identified by the MDRD equation was 2.4 [1.8-3.3], and for the CKD-EPI calculation it was 2.5 [1.8 to 3.3]). CONCLUSIONS: Both equations estimate similar magnitudes of renal function, although the CKD-EPI equation has less false positives, and both have similar prognostic values in patients at high cardiovascular risk as well those at low risk.

Hipertrofia ventricular izquierda y variación circadiana de la presión arterial / Left ventricular hypertrophy and circadian variation in blood pressure

Antecedentes y objetivos: Son múltiples los estudios que avalan el papel pronóstico que han mostrado tanto la presión arterial (PA) ambulatoria como la hipertrofia ventricular izquierda (HVI) en el paciente hipertenso. Por ello, nos planteamos evaluar la correlación existente entre determinados parámetros de la PA ambulatoria y la masa ventricular izquierda (MVI) medida por ecocardiografía, en una muestra de pacientes hipertensos. Material y métodos Se diseñó un estudio transversal retrospectivo, que incluyó a 405 pacientes (53,8% mujeres), con una edad media de 55,5 años, diagnosticados de HTA esencial, remitidos a la Unidad de HTA y Riesgo Vascular, desde atención primaria, entre el 1 de enero de 1998 y el 31 de agosto de 1999. En todos los casos se realizó una evaluación clínica y biológica (según protocolo estandarizado), estudio ecocardiográfico y MAPA de 24 h (monitor Space Labs 90207).Resultados La MAPA demostró un mal control de la HTA en 320 pacientes (79%); la profundidad de la PA sistólica fue del 10,6 ± 0,9%. La prevalencia de perfil dipper fue del 43,8%, del dipper-extremo 13,4%, del no dipper 30,2% y del riser 12,6%. Se identificó a 248 pacientes (61,23%) con HVI. El aumento de la PA ambulatoria nocturna se asoció con un incremento de la MVI (p < 0,0001) y se objetivó una correlación estadísticamente significativa y negativa entre la disminución de la profundidad de la PA y el incremento del índice de MVI (p < 0,0001).Conclusión El incremento de la MVI se asocia con HTA nocturna y disminución de la profundidad nocturna de la PA (AU)

Background and objectives: Multiple studies support the prognostic role of both ambulatory blood pressure (BP) monitoring and left ventricular hypertrophy (LVH) in patients with hypertension. Consequently, we evaluated the correlation between certain ambulatory BP monitoring parameters and left ventricular mass (LVM) measured by echocardiography in a sample of hypertensive patients. Material and methods: A cross sectional, retrospective study was performed in 405 patients(53.8% women; mean age, 55.5 years), diagnosed with essential hypertension and referred to the Hypertension and Vascular Risk Unit by their primary care centers between 1 January,1998 and 31 August, 1999. All patients underwent clinical and biological evaluation (using a standardized protocol), echocardiography, and 24-hour ambulatory BP monitoring (SaceLabs90207).Results: Ambulatory BP monitoring revealed poor BP control in 320 patients (79%); the meandip in systolic BP was 10.6 ± 0.9%. The dipper pattern was observed in 43.8%, the extreme dipper pattern in 13.4%, the non-dipper pattern in 30.2%, and the riser pattern in 12.6%. Left ventricular hypertrophy was identified in 248 patients (61.23%). An increase in ambulatory nocturnal BP was associated with an increase in LVM (p < 0.0001) and a statistically significant negative correlation was observed between the drop in BP and the increase in LVM (P<.0001).Conclusion: An increase in LVM was associated with nocturnal hypertension and a decrease in the nocturnal drop in BP (AU)

Knowledge of likely time of ovulation and contraceptive use in unintended pregnancies.

This investigation analyzed social and demographic characteristics of women having an unwanted or mistimed pregnancy (unintended pregnancies at the current time) in South America. A sample of 5135 women having had a normal non-malformed live-born infant were interviewed immediately postpartum at 18 hospitals participating in the Latin American Collaborative Study of Congenital Malformations (Spanish acronym: ECLAMC). Half (2568/5135 = 50%) reported that their pregnancies had been unintended, and, of those, 59.3% (1522/2568 = 59.3%) declared that they were trying to avoid conception. The latter group (n = 1522) was the main sample for this study. Patients were asked about their knowledge of when during the menstrual cycle conception is most likely to occur, their biomedical and social characteristics, the type of contraceptive methods used, their opinion of reasons for contraceptive failure, and their reasons for not using contraceptive methods. Among women with unintended pregnancies who attempted to avoid conception, only 61.6% were using contraceptive methods. Reasons given for not using contraceptives included health problems, lack of knowledge and lack of access to contraception. Women with unintended pregnancies who had not attempted to avoid conception were younger, often primigravid, less educated, and less knowledgeable concerning when during the cycle pregnancy is most likely to occur. Thus, reproductive health policies should be aimed at this target group.

PIP: This study analyzes the social and demographic characteristics of women having an unwanted or unintended pregnancy in South America between 1992 and 1994. The study was conducted among 5135 women who had a normal non-malformed live-born infant and were interviewed at 18 hospitals participating in the Latin American Collaborative Study of Congenital Malformations. Patients were asked about their knowledge of when conception is most likely to occur during the menstrual cycle, their biomedical and social characteristics, the type of contraceptive methods used, their opinion and reasons for contraceptive failure, and their reasons for failing to use contraceptive methods. Results indicate that 50% of the respondents had unintended pregnancies, and about 59% declared that they were trying to avoid conception. However, among women with unintended pregnancies who attempted to avoid conception, only 61.6% were using contraceptive methods. Reasons for failure to use contraceptives include health problems, lack of knowledge, and lack of access to contraception. Meanwhile, women with unintended pregnancies who had not attempted to avoid conception were younger, often primigravid, less educated, and less knowledgeable concerning the likelihood that pregnancy will occur during menstrual cycle. This study implies that reproductive health policies should be aimed at this target group.

Unintended pregnancies in women delivering at 18 South American hospitals. NFP-ECLAMC Group. Latin American Collaborative Study of Congenital Malformations.

Unintended pregnancies are accepted as associated with social, maternal and perinatal risks, but few data exist in South America. In a selected network of hospitals participating in the ECLAMC (Spanish acronym for Latin American Collaborative Study of Congenital Malformations), the frequency of unintended pregnancies was 49.8% in 5155 mothers of normal liveborns, as interviewed in the post-partum period (1992-1994). Compared with the intended pregnancy group, these mothers were more frequently multiparous, conceived easily, had a surprisingly higher mean maternal age, lower educational level, and Black ancestors. The frequency of mistimed pregnancies was the highest among primiparae. No adverse perinatal outcome could be found with regard to low birthweight (< 2500 g), prematurity (< 37 weeks), and early neonatal death. The rates of Caesarean delivery, twinning and sex ratio were similar in intended and unintended groups. Logistic regression analysis showed that maternal education could be a confounding factor associated with other maternal variables. The rate of unintended pregnancies in the present study is significantly higher than that described for other regions. Knowledge of the characteristics of women experiencing unintended pregnancies would allow proper public health strategies.

Survival of children with Down syndrome in South America. ECLAMC-Downsurv Group. Latin American Collaborative Study of Congenital Malformations.

The first step of all healthcare actions aimed at promoting an appropriate quality of life for infants affected by Down syndrome (DS) is to ensure their survival. This investigation was aimed at estimating the infant mortality rate of infants affected with DS in urban populations of South America. Thirty-three hospitals included in the Latin American Collaborative Study of Congenital Malformations (ECLAMC) distributed in 23 cities of 5 South American countries followed 360 liveborn DS cases born during the 1988-1992 period. Families were recontacted after the infant should have reached the age of one year. The collected data included information about health status; i.e., frequency and dates of diagnosed illnesses and hospital admissions, and, in case of death, information on date, place and cause of death, and illness immediately before death. Information about the interviews included place, date, and name of the interviewer. A closed questionnaire was employed by the interviewers, mostly physicians, nurses, and social workers. Life table analysis up to the age of one year was performed by the actuarial survival method. The overall mean survival at age one year was 0.736 (SE=0.023). Thirty-three (9.2%) of the 360 cases died neonatally, and 62 (17.2%) within the remaining 2-to-12-month interval. The probability of survival at one year of age did not differ between public (209 cases; mean 0.718; SE=0.031) and private (151 cases; mean: 0.762; SE=0.035) (chi2:0.87; df:1; P >0.05) health systems. The 150 DS cases with a congenital heart defect (CHD) had a significantly lower P robability of survival at the age of one year (mean: 0.660; SE: 0.039) than did the 210 cases without CHD (mean: 0.790; SE: 0.028) (chi2:6.67; df:1; P <0.01). The death rate in the first year of life for DS cases without a detected cardiac defect (21%) is significantly higher than that reported in developed countries; namely, 16% from Italy, 11% from Canada, 10% from England, and 7% from Denmark.

VATERL: an epidemiologic analysis of risk factors.

This work analyzed the incidence of risk factors in 138 cases presenting two or more of five components defining VATERL, with no other recognized unrelated anomalies: vertebral anomalies, anal atresia, esophageal atresia with or without tracheoesophageal fistula, renal anomalies, and preaxial defects of the upper limbs, including polydactyly of the thumb. The 138 infants were ascertained among 1,811,461 births examined in the 1967-1994 period by the Latin-American Collaborative Study of Congenital Malformations: ECLAMC. One healthy and one malformed control newborn infant were matched to each VATERL case. The birth prevalence rates (per 100,000 births) for VATERL were significantly lower in Venezuela (3.1) than in the other eight countries (8.8) (P < 0.001). Venezuela also had lower rates for all five VATERL defects, even after excluding the 138 VATERL cases. VATERL cases were preferentially males (male proportion 0.6261) (P < 0.02), and, when compared with healthy controls, they had a higher perinatal mortality rate (63.7%) (P < 0.005), a higher frequency of fetal losses in previous pregnancies (12.6%) (P < 0.05), and lower mean birthweights (2,361.79 +/- 809.63 g) (P < 0.005). VATERL cases showed a higher rate than matched malformed controls for prenatal exposures to drugs and physical agents (P < 0.02 and P < 0.05, respectively), although no specific pharmacological or physical group was involved. The lower birth prevalence rates found in Venezuela, for VATERL as well as for each of the five congenital anomalies involved in this association, seem to be biologically meaningful. Since we could not identify a potential risk factor, nor a common cause of underascertainment unique to the Venezuelan subsample and common to all six hospitals, no hypothesis can be advanced here for this phenomenon. Nevertheless, this unequal geographic distribution strongly suggests a common etiopathogenicity for the five congenital anomalies involved in the VATERL association.

Hand and foot postaxial polydactyly: two different traits.

The aim of this work was to test whether postaxial hexadactyly had different clinical and epidemiological characteristics depending on hand or foot involvement. In the period 1967-1993, the Latin-American Collaborative Study of Congenital Malformations (ECLAMC) enrolled 1,582,289 births, and 2,271 cases with isolated (nonsyndromal) postaxial polydactyly (5th-digit hexadactyly). The prevalence was 14.3/10,000 births. Postaxial polydactyly (PP) of the hand (HPP) was the most frequent type (N:1,733; 76.3%; prevalence: 11.0/10,000), followed by foot PP (FPP=N:351; 15.5%; prevalence: 2.2), and hand and foot PP (BPP=N:187; 8.2%; prevalence: 1.2). Unlike HPP (55.0% bilateral; 77.2% left), FPP was less frequently bilateral (19.4%), with lower preference for the left side (55.5%). As expected, HPP was associated with African Black ethnicity, male sex, twinning, low maternal education, parental consanguinity, and there was frequent recurrence in 1st-degree relatives. Conversely, FPP was associated with Amerindian racial background, parental subfertility, and bleeding in the 1st trimester of pregnancy. BPP displayed the highest frequency of associated congenital defects (23.4%, vs HPP:6.6%, FPP: 15.4%). In its isolated form, BPP resembled HPP more than FPP with respect to left preference (90.9%), familial recurrence (11.0% of 1st degree relatives), and low maternal education. Although male sex preference and high frequency of twinning was observed in the 3 PP subtypes, statistical significance was present only in HPP. None of the 3 PP subtypes showed abnormal values for perinatal mortality, birth weight, length of gestation, parental ages, or parity. A logistic regression analysis showed Black race only to be associated with HPP, parental subfertility with FPP, parental consanguinity with BPP, and non-Black race with both FPP and BPP. The data presented here are the first indication that HPP and FPP are 2 different entities, with a larger genetic component in HPP than in FPP.

Uso de medicamentos y de presuntos teratógenos durante el primer trimestre de gestación en América Latina / Drugs use and teratogenic presumed during the first trimester of gestation in Latin America

El objetivo de esta investigación es definir el perfirl de consumo de medicamentos durante el primer trimestre del embarazo y detectar el uso de potenciales teratógenos

Prevención primaria de defectos de desarrollo fetal en poblaciones de Latinoamérica: análisis de un modelo para modificar la estructura etaria materna / Primary prevention of fetal development defects in Latinamerica: analysis of a model to modify the maternal age distribution

Evaluar el impacto que, posibles acciones sobre la estructura etaria materna que tiendad a transferir la ocurrencia de embarazos en los extremos del ciclo reproductivo hacia edades maternas asociadas a un menor riesgo perinatal, representarian en la frecuencia de diversas anomalias del desarrollo

Uso de medicamentos y de presuntos teratógenos durante el primer trimestre de gestación en América Latina / Drugs use and teratogenic presumed during the first trimester of gestation in Latin America

El objetivo de esta investigación es definir el perfirl de consumo de medicamentos durante el primer trimestre del embarazo y detectar el uso de potenciales teratógenos(AU)

Prevención primaria de defectos de desarrollo fetal en poblaciones de Latinoamérica: análisis de un modelo para modificar la estructura etaria materna / Primary prevention of fetal development defects in Latinamerica: analysis of a model to modify the maternal age distribution

Evaluar el impacto que, posibles acciones sobre la estructura etaria materna que tiendad a transferir la ocurrencia de embarazos en los extremos del ciclo reproductivo hacia edades maternas asociadas a un menor riesgo perinatal, representarian en la frecuencia de diversas anomalias del desarrollo(AU)

Thalidomide, a current teratogen in South America.

Thalidomide, mainly used for the treatment of leprosy, is a current teratogen in South America, and it is reasonable to assume that at present this situation is affecting many births in underdeveloped countries. Moreover, the potential re-marketing of thalidomide for the treatment of a large variety of diseases may extend the problem to the developed world. When the drug is available, the control of its intake during early pregnancy is very difficult since most pregnancies are unintended. The ongoing occurrence of thalidomide embryopathy cases went undetected by the ECLAMC, due to several factors: (1) low populational coverage through this monitoring system; (2) pre-existence of the teratogen with its effects present in both baseline (expected) and monitored (observed) materials; and (3) lack of a defined phenotype to be monitored. Thus, if thalidomide re-enters the market throughout the world, due to the wide range of new applications, occurrence of phocomelia alone might not be sufficient to detect its effects. By a case-reference approach, the ECLAMC registered 34 thalidomide embryopathy cases born in South America after 1965 whose birthplaces correspond to endemic areas for leprosy. Phocomelia was found in five of eleven fully described cases. Thus, phocomelia alone is neither specific nor sufficient to serve as a suitable phenotype to survey the teratogenic effects of thalidomide. Therefore, a thalidomide-like phenotype, defined as any bilateral upper and/or lower limb reduction defect of the preaxial and/or phocomelia types, should be included in the routine surveillance of birth defects in all programmes.

VACTERL association, epidemiologic definition and delineation.

This study departed from a preconceived definition of VACTERL, including more than one of these six anomalies in the same infant: V (vertebral anomalies), A (anal atresia), C (congenital heart disease), TE (tracheoesophageal fistula or esophageal atresia), R (reno-urinary anomalies), and L (radial limb defect). Under this definition, 524 infants were ascertained by ECLAMC from almost 3,000,000 births examined from 1967 through 1990. Observed association rates among VACTERL components as well as between VACTERL and other defects were compared against randomly expected values obtained from 10,084 multiply malformed infants (casuistic method) from the same birth sample. Conclusions were: 1) Cardiac defects are not a part of VACTERL. 2) Single umbilical artery, ambiguous genitalia, abdominal wall defects, diaphragmatic hernia, and anomalies that are secondary to VACTERL components (intestinal and respiratory anomalies, and oligohydramnios sequence defects) are frequent enough to be considered an "extension" of VACTERL, and cardiac defects should be included in this category. 3) Neural tube defects are negatively associated with VACTERL which could not be explained by selection bias or any other operational artifact. High embryonic lethality or mutually exclusive pathogenetic mechanisms could be suitable explanations. 4) Results were not clear enough to determine whether VACTERL should be defined by at least two or three component defects.

Estudio de la asociación entre la exposición a medicamentos de uso frecuente en primer trimestre de gestación y defectos del desarrollo fetal / Study of the association between medicaments of use during the first trimestre of gestation and deffects of fetal development

Desde el episodio de la talidomida en los '50, un número creciente de medicamentos y agentes químicos han sido imputados como agentes causales en la producción de teratogénesis y toxicidad fetal, situación que es conocida cada vez más por la opinión pública. Actulamente se recomienda evitar el uso de medicamentos durante el embarazo, mientras que aquellos que sean prescriptos necesariamente deben ser evaluados con respecto a sus potenciales beneficios y riesgos, tanto para la madre como para el feto. No obstante, distintos estudios indican que entre el 40 por ciento y el 90 por ciento de las mujeres embarazadas están expuestas a uno o más medicamentos durante el embarazo. Estos estudios están realizados sobre poblaciones con características socioculturales diferentes a la población hospitalaria latinoamericana, por lo que los resultados no son extrapolables. Una gran cantidad de fármacos se usan cuando se piensa que ésto potencialmente beneficiará a la madre y que este fármaco se encuentra en el mercado con suficiente tiempo para que se hubiesen producido un número importante de exposiciones no intencionadas. Esto puede producir en los médicos una falsa sensación de seguridad, especialmente con respecto a los medicamentos que producen efectos infrecuentes como los defectos congénitos. Los programas de monitoreo de defectos congénitos son una fuente importante de información sobre exposición a agentes ambientales y defectos presentes al nacimiento. Estos programas vigilan la variación de la frecuencia de base de defectos congénitos para detectar la aparición de nuevos teratógenos, y son útiles para dar algunas pistas en la asociación entre exposición a madicamentos y malformaciones. El objetivo de este trabajo es el de establecer la frecuencia y tipo de medicamentos a la que está expuesta la población en nuestro medio, y describir algunos de los datos contenidos en la base de datos del ECLAMC sobre exposición a medicamentos de uso común, usando métodos simples para buscar asociaciones entre medicamentos y malformaciones

Estudio de la asociación entre la exposición a medicamentos de uso frecuente en primer trimestre de gestación y defectos del desarrollo fetal / Study of the association between medicaments of use during the first trimestre of gestation and deffects of fetal development

Desde el episodio de la talidomida en los 50, un número creciente de medicamentos y agentes químicos han sido imputados como agentes causales en la producción de teratogénesis y toxicidad fetal, situación que es conocida cada vez más por la opinión pública. Actulamente se recomienda evitar el uso de medicamentos durante el embarazo, mientras que aquellos que sean prescriptos necesariamente deben ser evaluados con respecto a sus potenciales beneficios y riesgos, tanto para la madre como para el feto. No obstante, distintos estudios indican que entre el 40 por ciento y el 90 por ciento de las mujeres embarazadas están expuestas a uno o más medicamentos durante el embarazo. Estos estudios están realizados sobre poblaciones con características socioculturales diferentes a la población hospitalaria latinoamericana, por lo que los resultados no son extrapolables. Una gran cantidad de fármacos se usan cuando se piensa que ésto potencialmente beneficiará a la madre y que este fármaco se encuentra en el mercado con suficiente tiempo para que se hubiesen producido un número importante de exposiciones no intencionadas. Esto puede producir en los médicos una falsa sensación de seguridad, especialmente con respecto a los medicamentos que producen efectos infrecuentes como los defectos congénitos. Los programas de monitoreo de defectos congénitos son una fuente importante de información sobre exposición a agentes ambientales y defectos presentes al nacimiento. Estos programas vigilan la variación de la frecuencia de base de defectos congénitos para detectar la aparición de nuevos teratógenos, y son útiles para dar algunas pistas en la asociación entre exposición a madicamentos y malformaciones. El objetivo de este trabajo es el de establecer la frecuencia y tipo de medicamentos a la que está expuesta la población en nuestro medio, y describir algunos de los datos contenidos en la base de datos del ECLAMC sobre exposición a medicamentos de uso común, usando métodos simples para buscar asociaciones entre medicamentos y malformaciones (AU)