Biomedical subjects
Publications and source records attributed to M Salvador.
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OBJECTIVE: To present the main results of the investigation of an outbreak of Legionnaire's disease that occurred in an inner city district of Barcelona between 15 October and 15 November 2000. METHODS: Epidemiological surveys of patients and environmental investigations were initiated on the day the first five cases were notified. Water samples and smears from cooling tower trays were taken for microbiological analysis. Maps of the distribution of cases and possible contamination foci were elaborated. Incidences were calculated for each census tract. RESULTS: A total of 54 patients related to the outbreak were identified, with a case fatality rate of 5.5%. Incidence rate in the area closest to the cooling tower (6.40/1000) was significantly higher than that of the rest of the neighbourhood (2.23/1.000, RR 2.87, 95%CI 1.37-6.12, P = 0.0035). Cultures positive for Legionella pneumophila serogroup 1, subtypes Pontiac, Philadelphia or Allentown, were obtained from eight patients. On the 39th day of the investigation it was found that the strain isolated in one of the cooling towers coincided with the serogroup, subtype and molecular profiles identified in clinical samples. CONCLUSIONS: Rapid coordination of clinicians, microbiologists, epidemiologists and environmentalists permitted the source of infection and the affected cases to be correlated within a few days.
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The authors report the case of an asymptomatic 32 year old man with no family history of sudden death but with ECG changes suggesting Brugada's syndrome. He underwent implantation of an automatic defibrillator after inducible syncope ventricular fibrillation had been demonstrated during electrophysiological investigation. The later occurrence of three episodes of ventricular fibrillation treated by the defibrillator confirmed a posteriori the logic of this therapeutic approach.
The aim of the study was to evaluate pulse wave velocity (PWV) and carotid intima-media thickness (IMT) in type 2 diabetics with microalbuminuria (mualb). The study concerned 37 patients type 2 diabetics, age: 53.4 +/- 6.6, years free of cardiovascular complications. HbA1C was 7.73 +/- 1.39%, waist circumference 104.2 +/- 11.7 cm. 19 patients with BP > 130/85 mmHg were identified as mild hypertensives (17/19 under treatment). All patients underwent ABPM, PWV and IMT measurements. The study population was separated into 2 subgroups according to median of mualb (mg/24 h): 18.9. [table: see text] In patients with mualb > 18.9 mg/24, IMT and PWV were significantly increased (p = 0.06; p < 0.01). After adjustment to BP and age, there was no significant difference in IMT and PWV in the subgroups. In this selected population of type 2 diabetics, microalbuminuria appears associated to a pressure-dependant vascular remodeling.
BLOOD PRESSURE CONTROL: More than half of all diabetic patients have high blood pressure. Even more so than in the general population, hypertension compromises the cardiovascular and renal prognosis. Optimal blood pressure control can limit the progression of microangiopathy and macroangiopathy as clearly demonstrated in the HOT and UKPDS studies. For the WHO, the goal is to control pressures < 130/85 mmHg. In this respect, there has been no demonstration of a J-curve relationship between pressure lowering with antihypertension drugs and incidence of cardiovascular events among patients with coronary artery disease included in the HOT study. MULTIPLE DRUG THERAPY: Regular long-term monitoring and, in most cases, multiple-drug regimens, are prerequisites for maintaining pressure figures below 130/85. When elaborating a blood pressure control protocol, it is important to consider the presence of coronary artery disease, suggesting use of beta blockers, or renal disease, which should lead to the use of angiotensin converting enzyme inhibitors. Diuretics play an important role in combination regimens and are indispensable in three-drug protocols or in case of altered renal function. SYSTOLIC HYPERTENSION: Subgroup analyses in the SHEP and SYST-EUR studies demonstrated the importance of treating pure systolic hypertension in diabetics. The protection obtained has the same or even more impact than in the general population. RISK FACTORS: Diabetes control must of course be maintained and coherent management requires taking into consideration all the risk factors, especially smoking and dylipidemia.
BACKGROUND: Cardiovascular (CV) complications are the leading cause of mortality in hemodialysis patients. The role of arterial hypertension on the prognosis of CV in hemodialysis patients is not as clear as in the general population. The purpose of this study was to investigate the prognostic role of ambulatory blood pressure (BP) on CV mortality in treated hypertensive hemodialysis patients. METHODS: Fifty-seven treated hypertensive hemodialysis patients (56.87 +/- 16.22 years, 30 men) were prospectively studied. All patients initially underwent an ambulatory BP monitoring between two dialysis sessions. The outcome event studied was CV death; kidney transplantation and deaths not related to CV disease were censored. RESULTS: The duration of follow-up was 34.4 +/- 20.39 months, during which 10 CV and 8 non-CV fatal events occurred. In the 10 patients who died from CV complications, age, previous CV events, ambulatory systolic BP, ambulatory pulse pressure (PP), and life-long smoking level were significantly higher, and the office diastolic BP was lower at the time of inclusion than in those who did not die from CV complications (N = 47). Based on Cox analysis and after adjustment for age, sex, and previous CV events, a low office diastolic BP [relative risk (RR) 0.49, 95% CI, 0.25 to 0.93, P = 0.03], an elevated 24-hour PP (RR 1.85, 95% CI, 1.28 to 2.65, P = 0.009), and an elevated nocturnal systolic BP (RR 1.41, 95% CI, 1.08 to 1.84, P = 0.01) were predictors of CV mortality (RR associated with a 10 mm Hg increase in BP and in PP). CONCLUSION: This study demonstrates that nocturnal BP and 24-hour PP are independent predictors of CV mortality in treated hypertensive hemodialysis patients. Randomized trials are needed to investigate whether nocturnal BP and 24-hour PP are superior to office BP as targets for antihypertensive therapy in this high-risk group.
Blood pressure (BP) elevations may correspond to different clinical situations. Hypertensives emergencies are situations that require immediate reduction in BP because of acute or rapidly progressing target organ damage: accelerated malignant hypertension, hypertensive encephalopathy, acute myocardial infarction, acute aortic dissection, acute left ventricular failure, and eclampsia. Hypertensive urgencies are those with marked elevated BP in which it is desirable to reduce BP progressively within few hours, such as severe hypertension, progressive target organ damage, perioperative hypertension. Cerebrovascular accidents have to be individualized. In most patients in the immediate post-stroke period, BP should not be lowered. Caution is advised in lowering BP in these patients because excessive falls may precipitate cerebral ischemia. In situations without symptoms or progressive target organ it is necessary to exclude proximate causes of elevated BP such as pain and elevated BP alone rarely requires antihypertensive treatment. Among parenteral antihypertensive (AH) drugs labetalol, nicardipine, urapidil, and nitroprussiate are generally used, and the choice of AH drug depends on the clinical situation. It is not required to normalize BP immediately but to reduce mean BP no more than 25%, then toward 160/100 mmHg as recommended by JNC VI, in order to avoid an impairment of renal, cerebral or coronary ischemia. Oral long-acting dihydropyridines are often subsequently administrated, except in myocardial ischemia. Therapeutic attitudes vary considerably according to the clinical situation: abstention, immediate decrease or progressive decrease in BP have to be decided.
OBJECTIVE: WHO management plan for mild hypertension recommends to take into account total cardiovascular risk in the decision treatment making process. However, despite a lower coronary risk in women than in men, hypertension awareness, treatment and control were higher in women than in men. This study was designed to evaluate the relationships between sex, coronary risk, awareness and treatment of hypertension in Haute-Garonne a south western French region. METHODS: 1,160 subjects aged 35-64, 600 men, were recruited between 1994 and 1996 by the Toulouse MONICA center. Subjects were selected by stratified randomization on age and size of home area. For each patient a score of coronary risk based on Framingham equation was calculated. RESULTS: 157 treated hypertensives (HT), 73 men and 84 women (G1) whom 046 adequately treated were identified, 16 men and 30 women. 60 known but untreated HT, 38 men and 22 women (G2), 171 newly diagnosed HT, 115 men and 53 women (G3). In men, the coronary risk score was higher in treated hypertensives compared with G2 and G3 (G1: 19.19 +/- 5.77 vs G2: 16.71 +/- 6.12 vs G3: 17.42 +/- 5.65) while no significant difference was observed in BP between these three groups (G1: 150.73 +/- 18.6/88.57 +/- 10.81 vs G2: 151.97 +/- 10.59/89.73 +/- 8.04 vs G3: 146.68 +/- 12.14/90.05 +/- 9.19) were observed between these three groups. In treated men, patients were older, total cholesterol was lower, intake of hypolipidemic drugs and diabetes were more prevalent than in the other two groups. In women, coronary risk score were not significantly different between the three groups. CONCLUSION: This study confirms the higher rate of awareness, treatment and control of hypertension in women. In men, treated hypertensives are at higher coronary risk than untreated and/or unawareness hypertensives: an improvement of hypertension control appears the prerequisite to decrease absolute cardiovascular risk in this group. In women, treated patients have a risk close to the level observed in untreated hypertensives.
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PURPOSE: Solitary fibrous tumour (SFT) of the orbit is a very rare lesion that may be misdiagnosed as fibrous histiocytoma, haemangiopericytoma, or other orbital tumour. We studied a case of SFT of the orbit in a 35-year-old woman. METHODS: The patient, with a 1-year history, reported a 'pressure' sensation behind her right eye, but no pain, vision changes, or other associated symptoms. Ocular examination was normal. Magnetic resonance imaging (MRI) showed a well-circumscribed medial mass in the right orbit. The tumour was excised. RESULTS: The tumour was a cellular spindle-cell neoplasm with a storiform pattern. The tumour cells were spindle-shaped with bland nuclei and rare mitoses. Immunostaining was positive for vimentin and CD34, but negative for cytokeratin (AE1-AE3), EMA, desmin, smooth muscle actin, S-100, CD31, CD45 and bcl-2. CONCLUSION: SFT can infrequently involve the orbit. The tumour must be removed entirely to avoid recurrences. Careful and continued follow-up is important because orbital recurrence may occur several years after the excision of the primary tumour.
OBJECTIVE: To determine the influence of ambulatory blood pressure monitoring (ABPM), carotid intima media thickness (IMT) and global cardiovascular risk on the therapeutic strategies issued from our hypertension unit. METHODS: All essential uncomplicated and never treated hypertensive patients referred to our hypertension unit between 1996 and 1997 for etiologic or target organ damage evaluation were considered eligible. We excluded diabetics and patients with renal disease who need a specific therapeutical approach. 54 patients (44.7 +/- 10.1 years) were included (40 men). All patients underwent an ABPM measurement. The right common carotid IMT measurement had been performed (0.06 +/- 09 mm). The global cardiovascular risks were assessed with the Framingham prediction chart taking into account age, sex, total cholesterol, smoking status and systolic office blood pressure. According to the therapeutic decision three groups were made up: group 1 lifestyle counselling (n = 13), group 2 single drug therapy (n = 31), and group 3 combination therapy (n = 10). RESULTS: No significant difference was found in age, sex ratio, prevalence of severe hypertension, office systolic blood pressure, body mass index, global cardiovascular risk between the three groups. In contrast ABP (24 h ABP mmHg: group 1: 128.23 +/- 6.91/79.7 +/- 6.4; group 2: 140.48 +/- 9.7/97.48 +/- 8.17; group 3: 152.4 +/- 15.35/99.4 +/- 12.14 p < .0001) and IMT (group 1: 10.55 +/- .09, group 2: .59 +/- .07, group 3: .66 +/- .11 p = .02), were significantly higher in group 3 than in group 2 and in group 1. The percentage of white coat hypertensives was higher in group 1 than in group 3 (group 1: 61.5%, group 2: 3.2%, group 3: 0%). In the whole population, the higher was the global cardiovascular risk, the higher was the common carotid intima media thickness. In this study the global cardiovascular risks are not related to therapeutic decisions. Therapeutic strategies are influenced by ABP level and by the vascular remodeling which depends partly on the global cardiovascular risk.
The efficacy and good safety of fosinopril, an angiotensin converting enzyme inhibitor recently made available to the medical profession in France, has been demonstrated by several controlled studies versus placebo and reference antihypertensives. A phase IV multicentre clinical trial was conducted among general practitioners in order to assess, on a larger scale and under conditions of daily practice, the results obtained in terms of blood pressure control and quality of life as well as the clinical and laboratory safety of the drug. This analysis was based on 19,435 hypertensive patients, 989 of whom were over the age of 75 years, followed for 12 weeks after introduction of fosinopril either as monotherapy or in combination with the antihypertensive treatment(s) already prescribed. Under these conditions, after 12 weeks of treatment, blood pressure was controlled in 79.8% of patients, with improvement of all items of the quality of life scale. The very low incidence of clinical and laboratory adverse events, even among the oldest patients, confirms the safety of use of fosinopril, predictive of good long-term compliance with treatment.
A prior diagnosis of multiple sclerosis (MS) has been considered a contraindication for performing epidural blocks due to the possible negative impact of the course of disease. For this reason, women with MS who given birth have rarely benefited from obstetric epidural analgesia. We report the case of a woman giving birth at full-term who had been diagnosed one year before the pregnancy of "probable" MS. She was given epidural analgesia with a mixture of bupivacaine and fentanyl at low doses. Both the birth and the immediate postpartum period transpired without complications and no new signs of disease were reported over the following years. We conclude that obstetric epidural analgesia with bupivacaine administered at a low concentration is safe for women with MS.
Recent epidemiological studies have reported an association between carotid intima media thickness (IMT), ambulatory blood pressure (ABP) and absolute cardiovascular risk. To study the relation between white coat effect and vascular changes in hypertensives (HT), 57 essential HT (office blood pressure (OBP) 152.2 +/- 19.5/93.7 +/- 12.4 mmHg) were recruited (46.4 +/- 11.8 years old, 49 men). After antihypertensive drugs withdrawal, an ABP was performed (Spacelabs 90207). The right common carotid artery IMT 3 cm proximal to the bifurcation was examined by ultrasonography. IMT (0.59 +/- 0.09 mm; Software lotec system) were measured by a reader blinded to the ABP data. White coat hypertension (WCH) was defined by a mean day-time ambulatory BP (d-ABP) lower than the 90th percentile of the distribution of daytime ABP of a normotensive population reported by Verdecchia et al. (131/86 mmHg in women and 136/87 mmHg in men). [table: see text] White coat hypertension was found in 8 from 57 (14%) subjects. IMT was significantly increased in ambulatory HT when compared with white coat HT while age, sex ratio, OBP, smoking status were not different. In stepwise regression age and systolic d-ABP were the only determinants of IMT (p < 0.05). In our hypertensive population. ABP appears more closely related to IMT than OBP and IMT in sustained is greater than in white coat hypertensive.
OBJECTIVE: To determine the links between circadian blood pressure rhythm and metabolic profile in overweight essential hypertensive men with an elevated waist: hip ratio (> 0.95). METHODS: Ambulatory blood pressure monitoring (ABPM) was performed in 53 patients (using a SpaceLabs 90207 device) after withdrawal of antihypertensive medication. All of the patients underwent an oral glucose-tolerance test. Blood lipids and lipoproteins were measured with standard techniques. The left ventricular mass index was determined by echocardiography according to American Society of Echocardiography (ASE) recommendations. According to the magnitude of the decrease in nocturnal blood pressure measured by ABPM two groups were defined: dippers (n = 27) and non-dippers (n = 26). RESULTS: The non-dipper group showed a higher diurnal and noctural pulse pressure, a greater left ventricular mass index and a higher level of 2 h glycaemia, in spite of their body mass index being almost identical to that of the dipper group. There were no differences in lipid parameters. In stepwise regression analysis, age and 2 h glycaemia appeared to be the only independent determinants of an altered circadian blood pressure pattern. In order to specify the potential influence of the metabolic profile independently of age on the circadian blood pressure pattern, two age-matched subgroups were constituted. Of the 53 hypertensive patients, 28 from the dipper and non-dipper groups were considered; for each non-dipper patient an age-matched (within 2 years) dipper patient was selected from the population. Despite their having the same age, body mass index and fasting glycaemia, a higher 2 h glycaemia (P < 0.01) and, to a lesser extent, a higher 3 h glycaemia (P = 0.06) were observed in the non-dipper group compared with the dipper group. CONCLUSION: It is suggested that, in overweight hypertensive men, a reduced nocturnal blood pressure decrease could be related both to age and to metabolic profile and that ABPM could be an effective tool for a global approach to cardiovascular risk in this population.
PURPOSE: To investigate in vivo the survival of retinal ganglion cells (RGC) 4 to 14 days after optic nerve (ON) transection alone or in combination wih a single intraocular injection of neurotrophin-4 (NT-4), neurotrophin-3 (NT-3), or brain-derived neurotrophic factor (BDNF). METHODS: In adult rats, RGCs were labeled with fluorogold (FG) applied to their main targets in the brain. Seven days later, the left ON was intraorbitally transected, and, in several groups of animals, the left eye received a sham injection or was injected with 5 microliters of 1% bovine serum albumin-phosphate-buffered saline alone or containing 5 micrograms of NT-4, NT-3, or BDNF. Four, 5, 7, 9, 12 and 14 days after ON transection, the retinas were examined under fluorescence microscopy to estimate RGC survival. RESULTS: In control retinas, the mean densities (cells/mm2+/-SEM) of FG-labeled RGCs were 2421+/-55 (n=20). Four days after axotomy, the densities of RGCs were similar to those observed in control retinas, but 5 and 7 days after axotomy, the mean densities had decreased to 2028+/-63 (n=6) and 1568+/-50 (n=6) respectively. In the group of retinas with sham injection, with vehicle alone or with NT-3, RGC densities also decreased by 7 days to 1261+/-71 (n=5), 1506+/-98 (n=10), and 1474+/-125 (n=4), respectively. However, similar densities to those observed in control retinas were observed 7 days after ON transection in the groups of retinas treated with NT-4 (2505+/-91; n=7) or BDNF (2380+/-74; n=7). Fourteen days after axotomy, RGC densities decreased to 521+/-39 (n=10). Comparable densities were found in groups that underwent axotomy and either sham injection (533+/-51; n=5), injection of vehicle (588+/-19; n=10), or NT-3 treatment (634+/-62; n=6). However, at this time, higher densities were observed in the groups treated with NT-4 839+/-39 (n=8) or BDNF 1321+/-120 (n=7). CONCLUSIONS: Axotomy-induced RGC death first appears by day 5 and reaches 80% of the original RGC population by day 12. NT-4 and BDNF administered intraocularly at the time of axotomy exert a neuroprotective effect on axotomy-induced RGC death, thus increasing the population of surviving RGCs and delaying the onset of RGC of axotomy-induced RGC death by approximately 3 days. Intraocular administration of NT-3 did not modify the survival of RGCs after injury.
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