Effect of verapamil on home self-measurement of blood pressure and heart rate by hypertensive patients. Verapamil-Frequency Research Group

BACKGROUND

Achievement of a controlled blood pressure and improvement of cardiovascular risk profile are the mainstays of therapy for hypertension.

OBJECTIVE

To assess the responses of heart rate and blood pressure in hypertensive patients to 240 mg/day sustained release verapamil.

METHODS

We assessed the effect of 240 mg/day sustained released verapamil on blood pressure and heart rate, measured in the office and at home, in 1395 hypertensive outpatients with mild-to-moderate hypertension, who were using an Omron HEM 705 CP automatic device for self-measurement. The period of observation was 3 months.

RESULTS

Blood pressure decreased both in the medical office and at the patient's home, the measurements obtained at home being lower than those found in the office. Heart rate decreased in a significant and particular way. The decrease was greatest among those patients with histories of myocardial infarction and among relatively young patients, who exhibit a tendency towards higher than normal baseline heart rates. Overall, there was a shift of the heart-rate curve towards more controlled levels clustered around heart rates between 65 and 75 beats/min. Home self-measurement showed that the data gathered by the patients at home are reliable and that, when cut-off values of 140/90 mm Hg for blood pressure are used, the percentage of patients with controlled blood pressures is 62%, whereas the percentage obtained in the medical office by the physician is 56%. If cut-off values of 135/85 mm Hg are considered for self-measurements at home, according to the VI JNC recommendations, the percentage of patients with controlled blood pressures is 25.4%.

[Prostatic benign hypertrophy: review of effectiveness, tolerance, and impact on quality of life of prolonged treatment with alfuzosin]

OBJECTIVES

To evaluate the effectiveness of Alfuzosin in terms of long term effect in BHP patients. To analyze the effectiveness according to the observer, the treatment compliance and the tolerance of alfuzosin, and specifically, cardiovascular and sexually adverse events. Also, to define the clinical profile of the BPH patients that spontaneously seek medical treatment in Spain.

DESIGN OF THE STUDY

Observational, descriptive, multicentric and 6-month retrospective study. DATA SOURCES AND COLLECTION: From the patient reports of BPH patients treated with alfuzosin during more than 6 months, data gathered were, along with usually anamnesic data and physical exploration (age, symptoms, blood pressure, e.g.), those related to treatment response, effectiveness, compliance and tolerance of Alfuzosin in the first and second quarter. Data of the 1635 patients initially recruited were considered to define the clinical profile of this population. Effectiveness and tolerance analysis were undertaken with the 911 patients who followed the treatment during the 6-month study.

RESULTS

After 6 months of treatment an improvement of the mean intensity of each of the urinary symptoms were statistically significant (p < 0.005). Also, the mean score of each of the analyzed variables and of the I-PSS global score were reduced significantly (p < 0.005). After 6 months of treatment the effectiveness evaluated by the observer was good or very good for the 88.5% of the patients. Treatment compliance was very good; from the 911 patients finishing the study, 96.4% continued with the initially prescribed treatment. Just 16 patients (3%) developed adverse events; measures undertaken were to modify the dosage or to interrupt the treatment (2 cases). The specific study of cardiovascular adverse events showed a mild reduction in the systolic (142 mmHg versus 137.86 mmHg) and diastolic blood pressure (83.53 mmHg) versus 80.72 mmHg), and the heart rate (76.80 l/m versus 76.04 l/m). The mean score of sexual life showed an improvement in all the items studied, although very slight.

CONCLUSIONS

The usefulness, effectiveness and tolerance of a long term treatment with alfuzosin in HPB patients was confirmed. Alfuzosin is considered a first choice treatment in patients with the clinical profile described.

Somatostatin modulates voltage-gated K(+) and Ca(2+) currents in rod and cone photoreceptors of the salamander retina

We investigated the cellular localization in the salamander retina of one of the somatostatin [or somatotropin release-inhibiting factor (SRIF)] receptors, sst(2A), and studied the modulatory action of SRIF on voltage-gated K(+) and Ca(2+) currents in rod and cone photoreceptors. SRIF immunostaining was observed in widely spaced amacrine cells, whose perikarya are at the border of the inner nuclear layer and inner plexiform layer. sst(2A) immunostaining was seen in the inner segments and terminals of rod and cone photoreceptors. Additional sst(2A) immunoreactivity was expressed by presumed bipolar and amacrine cells. SRIF, at concentrations of 100-500 nM, enhanced a delayed outwardly rectifying K(+) current (I(K)) in both rod and cone photoreceptors. SRIF action was blocked in cells pretreated with pertussis toxin (PTX) and was substantially reduced by intracellular GDP(beta)S. Voltage-gated L-type Ca(2+) currents in rods and cones were differently modulated by SRIF. SRIF reduced Ca(2+) current in rods by 33% but increased it in cones by 40%, on average. Both effects were mediated via G-protein activation and blocked by PTX. Ca(2+)-imaging experiments supported these results by showing that 500 nM SRIF reduced a K(+)-induced increase in intracellular Ca(2+) in rod photoreceptor terminals but increased it in those of cones. Our results suggest that SRIF may play a role in the regulation of glutamate transmitter release from photoreceptors via modulation of voltage-gated K(+) and Ca(2+) currents.

[Descriptive analysis (clinical and functional characteristics) of an asthmatic population in a health care district]

OBJECTIVE

To determine the social, demographic, clinical and lung function characteristics of the population of asthmatics living in Health Care District 2 of Madrid.

STUDY DESIGN

Transversal (initial visit) phase of a primary care community intervention study. The target population consisted of all asthmatics in District 2 of Madrid who were registered at the public health clinics, were older than 14 and had experienced asthma symptoms within the past year. The selection of patients for the study was systematic (not probabilistic), such that all registered asthmatics seeking care and/or scheduled for check-ups were enrolled. Participation was 96.6% of those on file. We recorded social, demographic, clinical, and lung function variables as well as results of allergy studies, family histories of asthma and/or atopy and type of treatment.

RESULTS

Six hundred fifty patients were enrolled, 238 men (36.7%) and 412 women (63.3%). Mean age was 45 +/- 28.1 yr, mean FEV1% was 87.2 +/- 26%. Mean course of disease was 16 +/- 14.6 yr and age of onset was 26 +/- 20 yr. Family history of asthma was present in 34% of cases and a family history of atopy was reported by 21%. Half had allergic rhinitis as an associated factor, with respiratory infections (62.4%) being the most common trigger, followed by pollen (25.3%) and exposure to tobacco smoke (20%). Active smokers accounted for 9.1% of the group, and ex-smokers for 21.6%. Short-term beta-adrenergic drugs on demand were used by 64% of patients, whereas 83.2% reported daily and long-term use of beta-2 drugs and 77% used inhaled steroids. Severity of disease differed significantly by age of patient, age at onset and predominance of perennial asthma (with older age and age of onset and greater seasonality observed among severely asthmatic patients).

CONCLUSIONS

a) Most symptomatic asthmatic have mild disease. b) Rationally adjusted, appropriate drug treatment should be graded according to level of disease severity.

The impact of different echocardiographic diagnostic criteria on the prevalence of left ventricular hypertrophy in essential hypertension: the VITAE study. Ventriculo Izquierdo Tension Arterial España

BACKGROUND

The prevalence of echocardiographic left ventricular hypertrophy in essential hypertension ranges from 12 to 96% depending on the threshold values used to define it, and on the selection bias.

OBJECTIVE

To estimate the prevalence of echocardiographic left ventricular hypertrophy by different criteria in essential hypertensives seen in primary care centres.

METHODS

Cross-sectional study in a population-based sample of 946 essential hypertensives randomly selected in 39 primary care centres across Spain. Echocardiographic studies were performed in reference hospitals by trained observers (concordance Cohen kappa index > 0.7) and analysed by a single observer.

RESULTS

Prevalence of left ventricular hypertrophy ranged from 59.2% [95% confidence interval (CI) 56.1 -62.3] by Framingham criteria to 72.7% (95% CI 69.9-75.6) using the criteria of De Simone et al. (J Am Coll Cardiol 1995; 25: 1056-1062). Prevalence was higher in males by the Cornell-Penn criteria, but higher in females when using Framingham or De Simone et al. criteria. Eccentric hypertrophy was more frequent (51.3-54.1%) independently of the criteria used, particularly when adjusting wall-thickness-ratio for age (56.2-58.9%). Concentric remodelling was present in 6.5-11.4% and only 20.8-29.7% of patients had no evidence of left ventricular structural alterations. Factors independently associated with left ventricular hypertrophy in the logistic regression analysis were age, gender, systolic blood pressure, pulse pressure and body mass index.

CONCLUSION

Prevalence of echo left ventricular structural alterations among essential hypertensives seen in primary care centres in Spain ranged from 70.3 to 79.2% depending on the threshold values used. Left ventricular hypertrophy ranged from 59.2 to 72.7% and age-adjusted concentric remodelling ranged from 6.5 to 11.4% depending on the criteria used. Only one-quarter of hypertensive patients were free from morphological alterations.

Detecting symmetric patterns in EEG data: a new method of analysis

Theoretical models of higher cognitive function predict that cortical activity will exhibit families of spatial-temporal patterns of activity whose individual members are related to each other by specific symmetry transformations. In the trion model, it is suggested that these inherent symmetries play a vital role in how we think and reason. We have developed a method of analysis (SYMMETRIC analysis), which detects families of patterns in EEG data, and characterizes the symmetry relationships between members of those pattern families. Using this analysis, significant symmetry families have been found in EEG and single unit spike train data. If symmetry is a crucial aspect of brain function, it is possible that different pathologies are associated with specific types of symmetry relationships in brain activity that could be detected in EEG data by a SYMMETRIC analysis.

Hybrid Capture II-based human papillomavirus detection, a sensitive test to detect in routine high-grade cervical lesions: a preliminary study on 1518 women

Hybrid Capture II (HC-II) is a commercial human papillomavirus (HPV) detection test designed to detect 18 HPV types divided into high-risk and low-risk groups. We have tested 1647 scrapes from 1518 unselected women attending routine cytological screening by this assay for the detection of histologically proven high-grade lesions. The reliability of this test was also evaluated on 117 fresh cone biopsy samples. HPV DNA has been detected in 400 scrapes (24.3%), 296 containing a high-risk HPV (18.0%). All the smears evocative of high-grade lesions were positive for high-risk HPV, and high-risk HPV were detected in all the 34 cases presenting a histologically proven high-grade lesion and in 68 (97.1%) of the 70 cone biopsy samples showing a high-grade lesion or an invasive carcinoma. Thus, the sensitivity was superior to the sensitivity of cytology (85.3%). Nevertheless, the quantitative approach provided by the HC-II assay for the assessment of the viral load could not clearly distinguish among cases with or without high-grade lesions. Thus this assay is recommended for the screening of high-grade lesions on a large scale, in association with classic cytology.

[Epidemiological study of chronic obstructive pulmonary disease in Spain (IBERPOC): prevalence of chronic respiratory symptoms and airflow limitation]

The prevalence of chronic respiratory symptoms and chronic airflow limitation (CAFL) was determined in a multicentric epidemiological study carried out in seven different areas of Spain. Based on a target population of 236,412 persons, a random census sample of 4,035 individuals between 40 and 69 years of age was chosen. Subjects answered several questionnaires and performed spirometric tests followed by a bronchodilation test if bronchial obstruction was detected. Respiratory symptoms were reported by 48% of the population (95% CI: 46.4-49.5%) with greater frequency of symptoms among men than women (55.2% versus 41%, p < 0.001). The following levels of prevalence of chronic symptoms were found: cough, 13.5% (95% CI: 12.5-14.6%); expectoration, 10.7% (95% CI: 9.7-11.6%); dyspnea after one flight of stairs, 10.4% (95% CI: 9.5-11.4%); and wheezing, 40.2% (95% CI: 38.7-41.7%). The prevalence of chronic bronchitis (CB) was 4.8% (95% CI: 4.1-5.4%) and was more frequent among men than among women (8.3% and 1.4%, respectively; p < 0.001). Asthma had been diagnosed previously in 4.9% (95% CI: 4.2-5.5%), more often in women than in men (5.8% and 3.8%, respectively; p < 0.003). CAFL was found in 10.6% (95% CI: 9.6-11.5%), 15.8% in men and 5.5% in women (p < 0.001). All respiratory symptoms except asthma were more frequent among smokers than among ex-smokers, and in turn were more common among ex-smokers than non-smokers. The frequency of symptoms increased in accordance with accumulated smoking. The prevalence of CB and CAFL was vastly different from one region to another. Multivariate analysis showed that factors associated independently with the appearance of CB were smoking, age over 60 years, male sex and having worked in industry. In conclusion, respiratory symptoms, including CB and CAFL, are common in the Spanish population. Smoking and amount of smoking are directly related to the frequency of such symptoms. Substantial differences were found in the prevalence of CB and CAFL among the regions where the study was performed.

[Epidemiological study of chronic obstructive pulmonary disease in Spain (IBERPOC): recruitment and field work]

Chronic obstructive pulmonary disease (COPD) is a large-scale social and health problem. Because prevalence studies have been performed only in certain areas of Spain, the Spanish Society of Pneumology and Chest Surgery initiated the IBERPOC study with the aim of determining the prevalence of COPD in several parts of the country. IBERPOC is a multicenter, population-based epidemiological study in which subjects have been selected randomly. Seven full-time pneumologists work full-time in seven different areas of Spain. A study of this nature involves a series of difficulties that should be taken into account at the time of planning studies of a similar nature. After 5,827 attempts to reach subjects, a total of 4,967 useful contacts were made, to provide 97.3% of the 5,104 contacts expected. Of those 4,967 useful contacts, 4,035 subjects completed interviews. Among the 932 refusals, 882 (94.6%) agreed to answer a short telephone questionnaire. The field work took 13 months to complete, 30% more time than had been anticipated. The rates at which subjects could not be traced differed from one zone to another, ranging between 5% and 30%; higher rates were attributable to the absence of telephone data in the corresponding census report. In one zone, the dispersion of the census population over a very large area supposed greater difficulty and delay in carrying out the study. In conclusion, the rate of participation and the time required for recruitment can be considered satisfactory. The performance of field work by trained, full-time pneumologists has been essential to the development and quality of the study. Similar epidemiological studies should consider problems derived from the lack of adequate census data, as well as to avoid defining areas of extreme population dispersion in order to facilitate field work.

[A comparison between 2 abbreviated Spanish versions of mental status assessment in the diagnosis of dementia. Study data on elderly community residents]

BACKGROUND

There are several Spanish versions and adaptations of the Mini-Mental State Examination (MMSE), the most used abbreviated test for screening of the cognitive decline in clinical and epidemiological setting. Among them, the Mini-Examen Cognoscitivo (MEC) is highlighted. The aim of this study was to compare the diagnostic usefulness between the Spanish translation of the MMSE (the MMSE1 which incorporates the proof of serial "sevens" and the MMSE2 which includes spelling "world" backward) and the MEC for the diagnosis of dementia.

PATIENTS AND METHODS

A sample of elderly persons (65 years or over), included in a population-based study of dementia prevalence. The diagnosis of dementia was assessed through exhaustive neuropsychological evaluation. The diagnosis of dementia (according to the standardized DSM-III-R criteria) was carried out by expert neurologists, who were independent and blind to the scores obtained in the MMSE and MEC.

RESULTS

79 subjects underwent both tools and neuropsychological assessment. The MMSE1 obtained the highest accuracy (92%), followed by the MEC (90%) and the MMSE2 (83%). The analysis of the areas under receiver operating characteristic curves did not show significant statistical differences between the MMSE1 and MEC (p = 0.38), but significant differences were observed between those and the MMSE2 (p = 0.01).

CONCLUSIONS

The diagnostic usefulness of Spanish translation of the MMSE is similar to the MEC. The proof of spelling "world" backward obtained poorer results than serial "sevens". The Spanish versions of the MMSE should be improved to be adapted to our cultural characteristics.

[Amnio-infusion during labor: experience and review of the literature]

OBJECTIVES

Evaluation of amnioinfusion results during labour in case of thick meconial amniotic fluid or in case of oligo-hydramnios associated with variable deceleration of the fetal heart response.

PATIENTS AND METHODS

Prospective non randomized study. Amnioinfusion was applied to 47 cases of thick meconial amniotic fluid and to 18 cases of variable fetal heart decelerations associated with oligo-hydramnios. Obstetrical and neonatal data were compared with a similar group without amnioinfusion (n = 32).

RESULTS

Comparing both groups shows that amnioinfusion offers a better fetal well-being during labour, according to Kreb's fetal heart evaluation during labour (8.53 +/- 1.06 vs 6.56 +/- 0.35--p < 0.01), lows the cesarean section rate (8.5% vs 31.2%--p < 0.01). Amnioinfusion is also associated with a higher Apgar's score at one minute after delivery (9.4 +/- 0.8 vs 8.7 +/- 1.7--p = 0.01) and a lower rate of thick meconium inhalation (13.7% vs 40.7%--p < 0.01). There was no difference for children's first days of life. We found no serious complication following amnioinfusion.

CONCLUSION

We confirm general agreement about amnioinfusion, according to international literature. Amnioinfusion needs an acute care to prevent classically described complications. In case of thick meconial amniotic fluid or variable decelerations associated with oligo-hydramnios, amnioinfusion during labour offers a better fetal well-being.

Ecological assessment of the environmental impacts of the kerosene burning in jet turbines and its improvement assessment

The burning of kerosene in jet turbines is investigated for two reference flights with a Boeing 747-400 and an Airbus A320-200, representing the typical Lufthansa planes for long and middle distance. The ecological evaluation is performed by Life Cycle Assessment (LCA). Formation of condensation trails, which is a specific environmental impact caused by air traffic, has to be considered in addition to established LCA impact categories. Based on the ecological assessment, an improvement assessment is performed. Environmental performance of diesel fuel during the combustion in car engines is analysed based on available publications. The relevant parameters for the environmental impact of the combustion of diesel (aromatics content, reduction of sulphur content, the reduction of the density and raising of the cetane number) are discussed with regard to improvements of the exhaust qualities of kerosene. A reduction of the aromatics content promises to improve the emission of soot which should be further investigated.

[Ambulatory blood pressure monitoring in the aged. The EPICARDIAN study. The EPICARDIAN Work Group]

OBJECTIVE

To determine reference values for ambulatory blood pressure in a random sample of Spanish elderly population, and their correlations with office blood pressure measurements.

METHODS

A representative random sample was obtained, stratified by sex and age, of 1,227 elderly subjects aged > 65 years, residents in an urban district, Barrio de Salamanca, or Madrid, Spain. In a random subsample (n = 420), two different blood pressure measurement approaches were performed: Office blood pressure and twenty-four hour ambulatory blood pressure (spacelabs 90207) were recorded, and two periods were defined: awake and sleeping, on the basis of the daily activities. Hypertension was defined if the average of casual blood pressure was > or = 140/90 mmHg or if there was current use of antihypertensive drugs.

RESULTS

Among the 420 participants, 333 ambulatory blood pressure monitorings were performed, 301 with valid registers, of whom 105 were receiving antihypertensive drug treatment. Office, 24 hour, awake and sleeping pressures averaged 147/84 mmHg, 128/72 mmHg, 132/77 mmHg and 122/66 mmHg respectively. Differences between whole sample and no treated group were not significant (p = 0.2), nor between the whole sample and the treated group (p = 0.7). Office blood pressure was markedly higher than 24 hour and awake averages (20 and 15 mmHg for systolic and 12 and 7 mmHg for diastolic, respectively). The differences between clinic and awake average blood pressures were significantly higher in females (p = 0.001) and increased, in both genders, as age (p = 0.001) and clinic blood pressure values (p < 0.000) increased. Correlation coefficients between office and the average awake period of the ambulatory blood pressures were of 0.60 and 0.48 for systolic and diastolic respectively. The ambulatory blood pressure value equivalent to 140/90 mmHg when obtained by causal measurement, was 15 mmHg lower when considering the 24 h average, or 10 mmHg lower when the awake averages.

CONCLUSION

Ambulatory systolic and diastolic blood pressure values in the elderly are markedly lower than office values, specially in the case of systolic blood pressure. Differences in results between the two methods increase with age and with clinic blood pressure values, and are bigger in females. The cut-off point for ambulatory blood pressure monitoring equivalent to 140/90 mmHg in the casual measurement is of 125/75 mmHg for the 24 hour average and of 130/80 mmHg for awake average.

[Epidemiology of cardiovascular diseases in the Spanish elderly population]

This paper is a comprehensive and critical review of the updated information available in Spain for the elderly population on the epidemiology of cardiovascular diseases. Clinical (coronary heart disease, heart failure, and cerebrovascular disease) and subclinical (left ventricular hypertrophy, carotid stenosis) cardiovascular diseases are reviewed. Prevalence and distribution of major classical cardiovascular risk factors such as hypertension, hyperlipidemia, diabetes mellitus and smoking and information on new risk factors such as microalbuminuria or abdominal obesity are also presented. The article is also focused on the high rates of morbidity, mortality and the burden of handicap in this age group in comparison with middle-aged people. Finally we call attention to the few and inconsistent population data available for some of the mentioned topics in our country, particularly the lack of specific figures of incidence and risk rates from cohort studies of elderly people in Spain.

Hybrid capture II, a new sensitive test for human papillomavirus detection. Comparison with hybrid capture I and PCR results in cervical lesions

AIM

To test a new assay for the detection of human papillomavirus (HPV) DNA, hybrid capture II (HC II), compared with the previous commercialized hybrid capture I (HC I) and polymerase chain reaction (PCR) results on cervical scrapes from fresh cone excision biopsy samples.

METHODS

The three methods were used on cervical scrapes from 42 fresh cone excision biopsy samples. There were nine metaplastic and inflammatory lesions, five low grade lesions, and 28 high grade lesions. PCR was performed using the general primers GP5+/GP6+. The viral load of high risk HPV DNA was estimated by the ratio of relative light units to positive control values in the samples.

RESULTS

The sensitivity of HC I for the detection of high grade lesions was 71.4%, while it was 92.8% for HC II and 96.4% for the PCR. Considering only the absence of detectable cervical in situ neoplasia, the specificity was 88.9% for HC I, 66.7% for HC II, and 66.7% for PCR. With HC II, for a ratio of cervical sample to normal control of > 200, the sensitivity for the detection of high grade lesion was only 34.6% with a specificity of 66.7%.

CONCLUSIONS

HPV detection with the HC II assay is more sensitive than the previous HC I and represents a more convenient and easier test than PCR for routine use. Nevertheless the viral load estimated with this test cannot be a reliable predictive indicator of high grade lesions.

Calcium released from intracellular stores inhibits GABAA-mediated currents in ganglion cells of the turtle retina

We studied spiking neurons isolated from turtle retina by the whole cell version of the patch clamp. The studied cells had perikaryal diameters > 15 microns and fired multiple spikes in response to depolarizing current steps, indicating they were ganglion cells. In symmetrical [Cl-], currents elicited by puffs of 100 microM gamma-aminobutyric acid (GABA) were inward at a holding potential of -80 mV. All of the GABA-evoked current was blocked by SR95331 (20 microM), indicating that it was mediated by a GABAA receptor. The GABA-evoked currents were unaltered by eliciting a transmembrane calcium current either just before or during the response to GABA. On the other hand caffeine (10 mM), which induces Ca2+ release from intracellular stores, inhibited the GABA-evoked current on average by 30%. The caffeine effect was blocked by introducing the calcium buffer bis-(o-aminophenoxy)-N,N,N',N'-tetraacetic acid (BAPTA) into the cell but was unaffected by replacing [Ca2+]o with equimolar cobalt. Thapsigargin (10 microM), an inhibitor of intracellular calcium pumps, and ryanodine (20 microM), which depletes intracellular calcium stores, both markedly reduced a caffeine-induced inhibition of the GABA-evoked current. Another activator of intracellular calcium release, inositol trisphosphate (IP3; 50 microM), also progressively reduced the GABA-induced current when introduced into the cell. Dibutyryl adenosine 3'5'-cyclic monophosphate (cAMP; 0.5 mM), a membrane-permeable analogue of cAMP, did not reduce GABA-evoked currents, suggesting that cAMP-dependent kinases are not involved in suppressing GABAA currents, whereas calmidazolium (30 microM) and cyclosporin A (20 microM), which inhibit Ca/calmodulin-dependent phosphatases, did reduce the caffeine-induced inhibition of the GABA-evoked current. Alkaline phosphatase (150 micrograms/ml) and calcineurin (300 micrograms/ml) had a similar action to caffeine or IP3. Antibodies directed against the ryanodine receptor or the IP3 receptor reacted with the great majority of neurons in the ganglion cell layer. We found that these two antibodies colocalized in large ganglion cells. In summary, intracellular calcium plays a role in reducing the currents elicited by GABA, acting through GABAA receptors. The modulatory action of calcium on GABA responses appears to work through one or more Ca-dependent phosphatases.

[Delayed deliveries in multiple pregnancies: is this reasonable?]

Delivery of viable fetus with a long interval delay is an unusual occurrence. There is no clear attitude among obstetricians for such cases. We report a case of retention of the second and the third triplet after the delivery of the first one at 24 weeks of amenorrhea and 3 days. The duration of the retention was 6 days. Only the third infant survived. We attempt to outline the difficulties in managing such pregnancies.

Effects of consanguineous marriage on reproductive outcome in an Arab community in Israel

Intrafamilial marriage is favoured by the Arab community in Israel, almost all of whom live in villages populated by a few (< 20) founding families. A previous study in Taibe, a large Arab village located 30 km from Tel Aviv, showed a significantly high malformation rate among infants of consanguineous parents. The present study examines the reproductive consequences of parental consanguinity in 610 families from the same village, selected retrospectively through infants routinely seen in the local well baby clinic. All mothers were interviewed with regard to previous pregnancy outcomes, including abortions, stillbirths, and neonatal or infant deaths, as well as the degree of consanguinity. In addition, we analysed the anthropometric measurements of the probands. The incidence of infant deaths was significantly higher in the inbred group (p < 0.001). No significant increase in fetal loss between the inbred and outbred groups was observed. There were no differences in anthropometric features, except for a lower birth weight in the consanguineous group (p < 0.035). This study, combined with our previous studies of the same population, indicates a prominent public health problem associated with consanguineous marriage in the Arab community and a need for specific genetic counselling.

[Evidence-based medicine]

This paper presents the origins and the concepts in which the paradigm of a new line of clinical reasoning "Evidence Based Medicine", is based. We describe its basic components such as: problem-oriented clinical policy formulation; information retrieval distillation and synthesis of the medical literature; critical appraisal of the evidence and clinical application. Additionally, we describe them already well established, for promoting and Evidence Based Clinical Practice. We particularly focus on the so called "Cochrane Collaboration", an international initiative whose mission is to prepare, maintain and disseminate systematic and updated reviews of the effects of health care.

Clinicopathological features of Zimbabwean patients with sustained proteinuria

OBJECTIVE

To describe clinico-pathological features of patients admitted with significant proteinuria.

DESIGN

Hospital based prospective survey conducted from 1982 to 1987.

SETTING

Paediatric and medical wards at both tertiary referral hospitals in Harare.

SUBJECTS

119 patients who presented with significant proteinuria were investigated.

RESULTS

Of the primary nephritides, diffuse mesangial proliferative glomerulonephritis was the most common finding (25/119); IgM was the dominant or sole immunoglobulin identified in 17/25. Minor glomerular abnormalities were common (19/119); there were 11 patients with minimal change disease and this number accounted for 42% of the children aged three to 12 years who were nephrotic. This incidence is higher than previously reported from Africa. Diffuse membranous nephropathy was frequent (18/119); hepatitis B surface antigen was present in only five of these patients. Focal sclerosing glomerulo-sclerosis was as frequent as diffuse membranous nephropathy (18/119) and appeared to be idiopathic. Diffuse mesangiocapillary glomerulonephritis (membranoproliferative) was present in 15/119 patients; no causal association was made.

CONCLUSION

The pattern of primary glomerulonephritis is described from 1982 to 1987. We describe a slightly higher number of patients with minimal change disease and minor glomerular abnormalities than previously reported and a surprisingly small number of patients with diffuse endocapillary glomerulonephritis. In common with other African series, no patient with IgA nephropathy was found.

Prevalence of stroke in two samples (rural and urban) of old people in Spain. A pilot door-to-door study carried out by health professionals

The aim of this study was to present the prevalence of stroke from a pilot study in old people. The urban site sample (Madrid) was made up of 397 subjects and the rural site sample (Arévalo, Avila) of 862 subjects. The study was performed with a door-to-door methodology. In the urban sample, the prevalence of stroke was 8.5% (CI 95% = 5.5-11.5%) and that of TIA was 2.1% (CI 95% = 0.6-3.6%). In the rural location the prevalence of stroke was 7.1% (CI 95% = 5.4-8.8%). This prevalence of stroke is higher than in other Spanish studies. These results need to be confirmed in a wider investigation.

Loss of sequences 3' to the testis-determining gene, SRY, including the Y pseudoautosomal boundary associated with partial testicular determination

The condition termed 46,XY complete gonadal dysgenesis is characterized by a completely female phenotype and streak gonads. In contrast, subjects with 46,XY partial gonadal dysgenesis and those with embryonic testicular regression sequence usually present ambiguous genitalia and a mix of Müllerian and Wolffian structures. In 46,XY partial gonadal dysgenesis gonadal histology shows evidence of incomplete testis determination. In 46,XY embryonic testicular regression sequence there is lack of gonadal tissue on both sides. Various lines of evidence suggest that embryonic testicular regression sequence is a variant form of 46,XY gonadal dysgenesis. The sex-determining region Y chromosome gene (SRY) encodes sequences for the testis-determining factor. To date germ-line mutations in SRY have been reported in approximately 20% of subjects with 46,XY complete gonadal dysgenesis. However, no germ-line mutations of SRY have been reported in subjects with the partial forms. We studied 20 subjects who presented either 46,XY partial gonadal dysgenesis or 46,XY embryonic testicular regression sequence. We examined the SRY gene and the minimum region of Y-specific DNA known to confer a male phenotype. The SRY-open reading frame (ORF) was normal in all subjects. However a de novo interstitial deletion 3' to the SRY-ORF was found in one subject. Although it is possible that the deletion was unrelated to the subject's phenotype, we propose that the deletion was responsible for the abnormal gonadal development by diminishing expression of SRY. We suggest that the deletion resulted either in the loss of sequences necessary for normal SRY expression or in a position effect that altered SRY expression. This case provides further evidence that deletions of the Y chromosome outside the SRY-ORF can result in either complete or incomplete sex reversal.

Fryns syndrome phenotype and trisomy 22

Trisomy 22 was detected in a 32-week-old fetus born to an overweight mother with hypertension. Severe intrauterine growth retardation was associated with phenotypic manifestations of Fryns syndrome: diaphragmatic hernia, facial defects, and nail hypoplasia with short distal fifth phalanges. This is the second report of congenital diaphragmatic hernia in trisomy 22. This case demonstrates the importance of karyotyping malformed fetuses or newborns, even if a nonchromosome syndrome seems identifiable on clinical grounds. To date, at least 10 cases of Fryns syndrome have been reported without chromosome analysis.