The Radiologist Is in, but Was it Worth the Wait? Radiology Resident Note Quality in an Outpatient Interventional Radiology Clinic.

Preprocedural evaluation of patients in an interventional radiology (IR) clinic is a complex synthesis of physical examination and imaging findings, and as IR transitions to an independent clinical specialty, such evaluations will become an increasingly critical component of a successful IR practice and quality patient care. Prior research suggests that preprocedural evaluations increased patient's perceived quality of care and may improve procedural technical success rates. Appropriate documentation of a preprocedural evaluation in the medical record is also paramount for an interventional radiologist to add value and function as an effective member of a larger IR service and multidisciplinary health care team. The purpose of this study is to examine the quality of radiology resident notes for patients seen in an outpatient IR clinic at a single academic medical center before and after the adoption of clinic note template with reminders to include platelet count, international normalized ratio, glomerular filtration rate, and plan for periprocedural coagulation status. Before adoption of the template, platelet count, international normalized ratio, glomerular filtration rate and an appropriate plan for periprocedural coagulation status were documented in 72%, 82%, 42%, and 33% of patients, respectively. After adoption of the template, appropriate documentation of platelet count, international normalized ratio, and glomerular filtration rate increased to 96%, and appropriate plan for periprocedural coagulation status was documented in 83% of patients. Patient evaluation and clinical documentation skills may not be adequately practiced during radiology residency, and tools such as templates may help increase documentation quality by radiology residents.

Improved cardiac performance with human calcitonin gene related peptide in patients with congestive heart failure.

STUDY OBJECTIVE: The aim of the study was to assess the cardiovascular effects of human calcitonin gene related peptide (CGRP) in patients with congestive heart failure. DESIGN: The effects of CGRP II (or beta), 12.5 micrograms.h-1, given by intravenous infusion for 24 h to digitalised patients with congestive heart failure, were assessed by measurement of cardiac functional indices. PATIENTS: Five patients (four female) were studied. Age was 73-82 years. Three were in New York Heart Association phase III and two in phase IV. MEASUREMENTS AND MAIN RESULTS: The pre-ejection period to left ventricular ejection time ratio and the QT distance adjusted for heart rate were lowered by 21% and 4% respectively. The left ventricular shortening index was raised by 43%. The arterial pressure and heart rate did not change consistently. CONCLUSION: Calcitonin gene related peptide improves myocardial contractility in patients with congestive heart failure. This is the first time this has been shown.

24-hour blood pressure control by once-daily administration of irbesartan assessed by ambulatory blood pressure monitoring. Irbesartan Multicenter Investigators' Group.

OBJECTIVES: To compare 24 h ambulatory blood pressure and trough office blood pressure lowerings after 8 weeks of therapy with 75 mg irbesartan once a day, 150 mg irbesartan once a day , and 75 mg irbesartan twice a day versus placebo; and to assess safety and tolerability of irbesartan therapy. DESIGN: Multicenter, double-blind, randomized, placebo-controlled trial. SETTING: Sixteen centers in Italy. PATIENTS: Caucasian patients (n = 215) aged > or = 18 years with seated diastolic blood pressure 95-110 mmHg and ambulatory diastolic blood pressure (ADBP) > or = 85 mmHg. PRIMARY OUTCOME: Mean 24 h ADBP after 8 weeks of irbesartan therapy. RESULTS: Mean changes (value before treatment minus value after treatment) in ADBP for placebo, 75 mg irbesartan once a day, 150 mg irbesartan once a day, and 75 mg irbesartan twice a day were -0.2, -5.4, -7.2, and -7.2 mmHg, respectively; respective changes in ambulatory systolic blood pressure were +1.6, -8.3, -10.5, and -9.7 mmHg. All irbesartan regimens reduced trough office seated diastolic blood pressure and seated systolic blood pressure after 2 and 8 weeks of treatment (all P < 0.01, versus placebo except for seated systolic blood pressure in patients in the 75 mg irbesartan once a day group). Trough: peak ratios were > or = 55% with 150 mg irbesartan once a day. Percentages of patients whose blood pressures were normalized with 150 mg irbesartan once a day (45%) and 75 mg irbesartan twice a day (47%) were greater than those with placebo (14%, P < 0.01) and with 75 mg irbesartan once a day (19%, NS, versus placebo). Adverse events with irbesartan were similar to those with placebo. CONCLUSIONS: All irbesartan regimens significantly reduced mean 24 h ADBP and ambulatory systolic blood pressure, and were well tolerated. Administration of 150 mg irbesartan once a day provided significant reduction of blood pressure for 24 h, equivalent to that obtained with the same daily dose divided into two separate administrations.

Acute cardiovascular and renal effects of human calcitonin gene-related peptide.

Acute cardiovascular and renal effects of 25 micrograms IV human calcitonin gene-related peptide (hCGRP) have been studied in four normotensive and untreated subjects, in the absence and the presence of indomethacin, a prostaglandin synthesis-blocking agent. Intravenous infusion of hCGRP, alone, caused a transient but significant increase in heart rate (HR), hypotension, and facial flushing. Along with these effects, a positive inotropic action of hCGRP was documented by a noninvasive poligraphy. Furthermore, a significant increase in the catecholamines (norepinephrine and epinephrine), in the cyclic nucleotide (cyclic AMP and cyclic GMP) plasma levels, and a small decrease in total calcium with no change in inorganic phosphorus serum levels, occurred. Also acute renal hCGRP induced effects were observed, as a significant increase in urinary volume and in the urinary calcium, sodium, potassium, and chloride excretion. Indomethacin did not affect all the cardiovascular, metabolic, and renal hCGRP-induced effects. These results are in agreement with the hypothesis that hCGRP acts on the heart, vessels, and kidney, directly or indirectly, by the mediation of other vasodilating agents or systems excluding the prostaglandin system.

Aerobic exercise training fails to reduce blood pressure in nondipper-type hypertension.

To assess whether aerobic exercise training is an effective and an alternative method to control blood pressure (BP) in hypertension, 32 uncomplicated, never treated patients suffering from mild-to-moderate essential arterial hypertension (EAH) were included in an aerobic exercise training program using a regular standardized cycle ergometer exercise for 3 months. In all EAH patients, before and after the exercise training period, ambulatory BP monitoring (ABPM) was performed and several metabolic variables were assessed. Before exercise, in 20 EAH patients, a 48-h ABPM showed a normal day-night rhythm, with nocturnal BP decrease, according to a dipper-type hypertension, whereas in 12 EAH patients 48-h ABPM profile indicated a nondipper-type hypertension. After exercise, EAH dippers presented a significant decrease in the daytime systolic and diastolic BP, whereas EAH nondippers did not show any change in daytime and nighttime systolic and diastolic BP. Our study confirms the controversy about the postulated BP lowering effect of dynamic exercise in EAH patients, in the sense that only EAH dipper patients seem to obtain a beneficial diurnal lowering BP effect deriving from exercise, possibly through a reduction in sympathetic tone. On the contrary, physical activity seems to fail in reducing diurnal and nocturnal BP values in EAH nondippers, suggesting that in nondipper-type hypertension, other "masking" endogenous or exogenous factors could interfere with and prevail over the adrenergic-vagal balance that modulates the day-night BP synchronism.

Correlation between left atrial size, prothrombotic state and markers of endothelial dysfunction in patients with lone chronic nonrheumatic atrial fibrillation.

Atrial fibrillation is associated with a prothrombotic state and endothelial dysfunction. To understand whether the prothrombotic state was correlated with endothelial dysfunction and whether the latter was related to atrial dimension (endocardial damage), we studied systemic hemocoagulative activity and markers of endothelial dysfunction in 45 patients with chronic nonrheumatic atrial fibrillation and in 35 controls. We assessed fibrinogen, antithrombin III, protein C, markers of platelet activation (platelet factor 4 and beta-thromboglobulin) as markers of fibrinolysis, and D-dimer, tissue plasminogen activator, plasminogen activator inhibitor, von Willebrand's factor and soluble thrombomodulin as endothelial dysfunction. Plasma fibrinogen (P<0. 005), platelet factor 4 (P<0.001), thromboglobulin (P<0.001), D-dimer (P<0.03), tissue plasminogen activator (P<0.006), plasminogen activator inhibitor (P<0.04) and both von Willebrand's factor (P<0.0001) and soluble thrombomodulin (P<0.03) were significantly higher in the patients than in the controls. Positive significant linear correlations were found between fibrinogen and markers of endothelial dysfunction and left atrial volume and fibrinogen or markers of endothelial dysfunction. These findings confirm that chronic nonrheumatic atrial fibrillation is associated with a prothrombotic state but also suggest that there is a correlation between endothelial dysfunction, coagulation factors and left atrial dimension.

Acute antihypertensive, diuretic and metabolic effects of etozolin and chlorthalidone.

Etozolin, a new diuretic agent, has shown a dose-dependent diuretic and saluretic effect in both experimental and clinical studies. Etoxolin, when compared to furosemide or thiazides, exerts a similar effect on urinary excretion of water and Na+, but induces a lower urinary K+ and Cl- excretion and a smaller activation of the renin-angiotensin-aldosterone system. Furthermore, the E series of the prostaglandin system seems to play a role in the mechanism of action of the drug. Seven uncomplicated hypertensive patients were included in this double blind, placebo controlled study, according to a latin square design. Each patient received three single oral doses of etozolin (200 mg, 400 mg, 600 mg), of chlorthalidone (25 mg, 50 mg, 75 mg) and one dose of placebo. Etozolin and chlorthalidone caused a similar, dose-dependent antihypertensive and diuretic effect. However, several haemodynamic and metabolic differences were observed between the two drugs. Etozolin, unlike chlorthalidone, caused no increase of heart rate, no decrease of serum K+ levels and a marked rise plasma PGE2. Moreover, etozolin caused a significantly smaller decrease of serum Na levels compared to chlorthalidone, and a significantly lower increase of supine and standing PRA, of plasma aldosterone and of the urinary excretion of Na and K. These results confirm that the acute antihypertensive and diuretic activity of etozolin occur with little involvement of the RAA system and with a significant but still unclear activation of the prostaglandin system.

Evaluation of plasma levels of renin-aldosterone and blood pressure in women over 35 years treated with new oral contraceptives.

Increases in blood pressure and weight are consequences of increased fluid retention following oral contraceptives administration. Hypertension and weight increase are particularly frequent in women over 35 years of age. The aim of the present study was to evaluate the clinical and hormonal effects of a new extra-low dose oral contraceptive [15 microg ethinyl estradiol (EE) and 60 microg gestodene (GSD)] on the renin-aldosterone system in a group of women aged 35-39 years treated for 3 months compared with a formulation containing the same hormones at a higher dose. Eighteen healthy women, age 35-39 years, were divided into two groups. The first group (10 women) used Arianna, Schering, 15 microg EE/60 microg GSD (EE15/GSD60); the second group (8 women) used Fedra, Schering, 20 microg EE/75 microg GSD (EE20/GSD75). Blood samples were obtained before the study and after 3 months of contraceptive use for assay of renin and aldosterone. Blood pressure was also measured on both occasions. No significant changes in plasma renin activity (PRA) or plasma concentrations of aldosterone were observed between the two groups after 3 months of contraceptive use. The mean increase in body weight after 3 months of contraceptive use was 350 +/- 100 g for EE20/GSD75 and 300 +/- 50 g for EE15/GSD60. There was a mean increase of 4 mm Hg for systolic pressure and 2 mm Hg for diastolic pressure in women on EE20/GSD75 and corresponding increases of 3 and 2 mm Hg in women on EE15/GSD60. The changes were not significant in any case. The results of the present study show that the formulations were well tolerated and provided good control of the menstrual cycle in all 18 women. The contraceptive formulations EE20/GSD75 and EE15/GSD60 have no clinical impact on blood pressure, PRA, or aldosterone in this age group.

Prognostic value of dipyridamole stress echocardiography in hypertensive patients with left ventricular hypertrophy, chest pain and resting electrocardiographic repolarization abnormalities.

BACKGROUND: Hypertension is a major cardiovascular risk factor in the development of coronary artery disease (CAD); therefore, evaluating the presence of CAD is a primary clinical goal. However, the noninvasive tests that are commonly used have poor diagnostic specificity, particularly in patients with left ventricular hypertrophy. OBJECTIVES: To assess the prognostic value of dipyridamole stress echocardiography (DET) for ischemic events in a subset of patients with hypertension with left ventricular hypertrophy, chest pain and resting electrocardiographic repolarization abnormalities. PATIENTS AND METHODS: Eighty-two patients (48 men and 34 women; average age 65+/-7.2 years with left ventricular hypertrophy documented echocardiographically (left ventricular mass index greater than 50 g/h(2.7)), and resting ST segment shift of 0.1 mV or more from baseline at 80 ms after J point in at least two contiguous leads, were submitted to DET according to high-dosage protocol and coadministered with atropine. RESULTS: The follow-up period was 25.11+/-8.3 months. The stress test produced positive results in 30 patients (36.5%); 16 (53%) and three (5%) cardiac events occurred in positive and negative stress test groups, respectively. At multivariate analysis, only positive DET response (P=0.000002), left ventricular mass index (P=0.028) and a family history of CAD (P=0.037) were independent predictors. The two-year event-free survival rates were 95% and 47% (log-rank 21.093, P=0.00001) for negative and positive stress test results, respectively. CONCLUSIONS: DET is a useful tool in the prognostic assessment of coronary events in this particular subgroup of patients with hypertension.

Blood pressure and heart rate variability in elderly hypertensive patients.

In elderly hypertensive patients (HP) blood pressure (BP) and heart rate (HR) control and variability seem to be affected by a reduced baroreceptor sensitivity, or autonomic dysfunction, and concomitant cardiovascular diseases. Therefore, the aim of present study was to investigate the circadian profiles and variability of BP and HR, by means of a 24-hour ambulatory BP monitoring, in a group of 22 elderly HP compared with those of a group of 24 middle aged patients with essential hypertension. Many differences in BP and HR profile and variability were observed in elderly HP when compared to those of middle aged HP, such as significantly lower diurnal diastolic BP values, lower nocturnal BP fall, lower diurnal HR but with a greater diurnal variability. Conversely, in middle aged HP a significantly greater diurnal systolic BP variability was observed, and a significant correlation was found between hourly diastolic BP and hourly HR values, while in elderly HP this correlation was not detectable. The changes in BP and HR profile and variability observed in elderly HP may play a role as risk factors for cardiovascular complications and indicate a dysfunction of autonomic and nonautonomic factors in BP control.

Plethysmographic evaluation of the vascular effects of human calcitonin gene-related peptide in man.

Calcitonin gene-related peptide (CGRP) is a neuropeptide with potent cardiovascular effects that include positive inotropic and chronotropic actions systemic vasodilation, and hypotension in animals and in man. The mechanism of action of CGRP is still, however, not clear, and in particular it is not known whether vasodilation by CGRP occurs by changes in cutaneous or in muscular blood flow, or both. The aim of the study was, therefore, to evaluate the cutaneous and muscular blood flow, at rest and after ischemic test, induced by an IV bolus 25 micrograms human CGRP infusion in 5 healthy normotensive volunteers, using a strain gauge plethysmographic procedure with venous occlusion. Human CGRP provoked a transient but significant decrease in systolic and diastolic blood pressure, associated with tachycardia, marked flushing, a significant increase in plasma noradrenaline, adrenaline, and cyclic AMP levels, and a slight, but significant, decrease in serum total calcium. Moreover, a significant increase in the carpal cutaneous blood flow at rest was observed, with no significant change in the lower extremity muscular blood flow at rest and after ischemic test. Finally human CGRP produced a significant increase in the venous partial O2 pressure and in the hematocrit and a significant decrease in the venous partial CO2 pressure. The results of the present study confirm the acute cardiovascular and metabolic effects of CGRP. In fact, hypotension, tachycardia, flushing, and the increased cutaneous blood flow indicate a systemic vasodilation by the neuropeptide, with a secondary sympathetic response, as documented by the augmented catecholamine and cyclic AMP plasma levels.

[Role of aldosterone in essential arterial hypertension complicated by chronic renal insufficiency]. / Ruolo dell'aldosterone nell'ipertensione arteriosa essenziale complicata da insufficienza renale cronica.

The following parameters were studied in a group of patients suffering from essential arterial hypertension complicated by chronic renal insufficiency (CRI), mean age = 64.31 +/- 1.84, with creatinine clearance (CrC) ranging between 30 and 60 ml/min: blood pressure (systolic and diastolic arterial pressure), heart rate, plasmatic renin activity (PRA), plasma levels of aldosterone (ALDO) both in clino- and orthostatism, as well as some metabolic parameters. All parameters were compared with those in a group of age- and sex-matched patients with slight or moderate essential arterial hypertension. Before starting the study all patients completed a wash-out period of one week to annual the effects of other drugs which might interfere with the RAA system. PRA levels were within the norm, whereas plasma levels of ALDO were high both in clino- and orthostatism. ALDO levels were also found to be inversely correlated with those of CrC. From these data it emerges that hyperaldosteronism, as observed in these patients with CRI, is a relatively reliable marker of the extent of CRI and may occur independently of the activation of the RAA system, given that other factors, such as orthostatic stimulation, alterations in the acid-base equilibrium, and the degree of aldosterone hepatic and urinary clearance, contribute to its pathogenesis.

[Treatment of essential mild-to-moderate arterial hypertension with once-daily penbutolol. Controlled clinical study vs atenolol]. / Trattamento della ipertensione arteriosa essenziale di grado lieve-moderato con penbutololo "once daily". Studio clinico controllato vs atenololo.

The anti-hypertensive and tolerance of penbutolol, a non-selective beta-blocker of long duration and endowed with an ISA effect were compared with those of atenolol, a cardioselective beta-blocker without ISA effect, in two groups of 20 patients each suffering from slight-to-moderate essential primary hypertension selected on the basis of a clinico-experimental design of open randomised type. The two drugs presented a similar anti-hypertensive effect which attained its peak expression in the second week of treatment. As for side-effects, penbutolol during treatment presented better tolerance than atenolol. Further, both penbutolol administered once daily at a dose of 40 mg/die, and atenolol, administered once daily at a dose of 100 mg/die proved to possess satisfactory anti-hypertensive activity justifying its use in a single daily dose.

[Spironolactone combined with chlorthalidone in the treatment of essential arterial hypertension]. / Lo spironolattone associato al clortalidone nel trattamento dell'ipertensione arteriosa essenziale

The antihypertensive effect and the tolerance of the association of spironolactone and chlorthalidone were evaluated clinically and by numerous laboratory examinations in a group of 18 patients affected with non-complicated essential hypertension. All the patients were treated for 30 consecutive days with chlorthalidone (100 mg/day) and then for another 30 days with the two drugs administered contemporaneously (100 mg/day of spironolactone + 100 mg/day chlorthalidone). The balanced combination of the two drugs showed to be significantly more active than the treatment with just chlorthalidone and the margin of safety wider; the therapeutic activity showed to be independent from the variations of the plasma renin activity.

[Evaluation of the adrenergic and pressor response to the hand-grip test in young athletes]. / Valutazione della risposta adrenergica e pressoria all'"hand-grip test" nei giovani atleti.

Numerous factors may influence the sympathetic and pressure response to physical exercise, age, sex, type of activity carried on and training for example. Training, in particular is considered to reduce both adrenergic and pressure response. Plasma catecholamine levels and the haemodynamic response to the hand-grip test have therefore been evaluated in a group of young athletes, compared with a group of non-trained youths. The results confirmed that young athletes have a lower sympathetic and haemodynamic response to the isometric exercise and this is accompanied by improved cardiac performance. The value of the hand-grip test is underlined as a method of investigation able to evaluate the training level attained by the athlete.

[Antihypertensive effect of indapamide].

2.5 mg/day indapamide was administered to 16 hypertensive patients for 30 days. These was a gradual, significant reduction in systolic and diastolic pressure values with no significant changes in plasma and urinary electrolytes. The effect of the drug on ARP and renal performance was also examined. There were no alterations of other metabolic parameters. These data point to a safe and lasting hpotensive action on the part of indapamide.

[Evaluation of the hereditary component in patients with essential arterial hypertension]. / Valutazione della componente ereditaria nei pazienti affetti da ipertensione arteriosa essenziale.

As is well known, genetic factors play a decisive role in the pathogenesis of essential hypertension (EH), even if they are closely related to environmental factors; it is therefore not possible to quantify with any degree of certainty the role and importance of each in the onset of hypertensive disease. The aim of the present study was to ascertain the presence of hypertensive 1st and 2nd degree ascendant, collaterals and descendants in a group of 355 out-patients with EH (167 males, 188 females; mean age: 52.9 +/- 0.7 years) using an anamnestic analysis. The results of this study confirmed the high prevalence of the hereditary component in EH: familial hypertension was found in 60.6% of the group. From a detailed analysis of the group, with regard to hypertensive ascendant, the hereditary transmission of EH by the mother was significantly higher than that by the father, both the parents and the forefathers, even if it is worth pointing out that the penetration of the genetic character was not always sex-related and was equally distributed between male and female descendents. In addition, it was observed that patients with a familial pattern of hypertension in common with collateral relatives showed significantly enhanced levels of systolic and diastolic pressure in relation to those with another hereditary component. These findings serve to underline the importance of evaluating the effective incidence of EH with regard to an entire family nucleus and not only in individual terms, in order to identify the various means of genetic transmission and possible interactions with environmental factors.

[Metabolic changes in the patient with essential hypertension]. / Le alterazioni metaboliche nel paziente iperteso essenziale.

The aim of the present study was to evaluate a number of parameters in a group of patients with essential hypertension and then compare the results with those in a group of healthy normotensive subjects. One hundred and fifty-six patients with essential hypertension (EH) in the non-complicated form (73 males, 83) females; mean age: 54.8 +/- 0.9 years) were selected and compared with 150 normotensive subjects matched for age and sex. After a 2-week period of wash-out during which patients followed a diet with normal sodium and calorie content, body mass index, systolic and diastolic arterial pressure (AP), mean arterial pressure (MAP), heart rate in clino- and orthostatism were measured and blood was collected to assay glycemia, total cholesterolemia, LDL and HDL cholesterolemia and triglycerides. In the group of patients suffering from EH all the above parameters were found to be significantly higher than in normotensive control subjects. In particular, in the hypertensive population the prevalence of obesity was 21.3%, hyperglycemia 26.9%, hypercholesterolemia 65.1% and smoking 36.4%. When the possible relation between one or more risk factors and AP values was assessed, it was found that in hypertensive patients the presence of hyperglycemia alone or in association with other metabolic disorders led to the highest MAP findings. Moreover, having studied the correlation rate of the various parameters, it was seen that in both the hypertensive and normotensive populations systolic AP measured in clinostatism positively correlated with glycemia, total cholesterolemia, and age, whereas correlations were not found between clinostatic diastolic AP and the above parameters.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serum ionized calcium, parathormone and plasma renin activity in essential arterial hypertension]. / Calcio ionizzato sierico, paratormone, attività reninica plasmatica nell'ipertensione arteriosa essenziale.

Given the significance of the calcium ion in the pathogenesis of essential arterial hypertension, blood levels of total and ionised calcium, phosphorus, parathormone, blood renin activity as well as urinary calcium and phosphorus were assayed in a group of hypertensives and a comparable control group with normal blood pressure. The results showed reduced ionised calcium in the blood of the hypertensives together with hyperparathyroidism and increased calciuria. In addition, the link between parathormone and mean blood pressure levels suggests that parathormone itself play a primary role in the genesis of high blood pressure. Finally the connection between renin activity in the plasma and ionised calcium in the serum suggests that the two hormone systems are closely linked and may interact via the calcium ion.

[Incidence of the most frequent complications in hypertensive patients]. / Incidenza delle più comuni complicanze nel paziente iperteso.

The incidence of district (cardiac, cerebral, renal) and systemic vascular complications was studied in a population of 3992 hypertensive in-patients during the period from 1984 to 1988. The total number of male hypertensive patients was always higher (2355) than that of female hypertensive patients (1637). From the analysis of results it appears that 11.01% of male hypertensive patients and 15.85% of female hypertensive patients were diagnosed as being affected by uncomplicated essential arterial hypertension, whereas 88.97% of male and 84.12% of female hypertensive patients suffered from arterial hypertension with varying percentages of cardiac, cerebral, renal or systemic-type atheroarteriosclerotic complications. The prevalence of the male sex was particularly evident in the case of cardiac complications. Given the peak incidence of the various types of complications when analysed by decade of age, an earlier incidence of cardiac and renal complications was found in male hypertensive patients which anticipates the complications found in female hypertensive patients by approximately one decade. Lastly, the paper underlines the social importance of essential arterial hypertension and the need to develop efficacious primary and secondary prevention in order to reduce the incidence of complications which today represent the most severe aspect of hypertension.