Neuropsychiatric Symptoms in Parkinson’s Disease with and without Mild Cognitive Impairment

Objective

Neuropsychiatric symptoms (NPS) are common clinical features of patients with Parkinson’s disease (PD). However, such symptoms in non-demented PD patients have scarcely been investigated. To address this issue, we describe the neuropsychiatric profile in PD patients with and without Mild Cognitive Impairment (MCI).

Participants and Method

Eighty non-demented PD patients were included. The patients were divided into two groups depending on the presence or absence of MCI (PD-MCI and PD-nMCI, respectively). MCI diagnosis was made according to the Movement Disorder Society Task Force Level I criteria. NPS were evaluated using the Neuropsychiatric Inventory (NPI). For each domain, the presence and magnitude of symptoms (frequency x severity) was calculated. The total NPI score was also computed, in which higher scores suggest greater behavioral disturbance.

Results

PD-nMCI (n = 59, 74%) and PD-MCI (n = 21, 26%) groups were similar in the disease stage and years since diagnosis. In contrast with the PD-nMCI group, participants in the PD-MCI group were older. Fourteen PD-MCI (66%) and 45 PD-nMCI (76%) patients reported at least one neuropsychiatric symptom in the previous month. In both groups, the most frequent NPS were sleep disorders, depression, anxiety, apathy, irritability, and disinhibition. Additionally, the proportion of these symptoms between groups did not differ significantly (p > 0.05). There was only a tendency of greater score in the disinhibition subscale in PD-MCI group (p < 0.02). In both groups, NPS were not associated with clinical variables (years since diagnosis, Unified Parkinson's Disease Rating Scale -III) after adjusting for age.

Conclusions

Preliminary findings suggest that NPS are frequent in PD patients independent of the degree of cognitive impairment, and they may encompass non-motor features of the clinical spectrum of the disease. Further longitudinal investigations are needed to determine whether such symptoms may predict the cognitive decline in these patients.

Seasonal variations of changes in lipid and glucidic variables after bariatric surgery

Seasonality is a phenomenon that is characterized by changes over the year in sleep, mood, behaviour, appetite and body weight. In humans, seasonal variations have been found in certain variables, such as lipid variables and body mass index. We hypothesize that this rhythm could influence the expected variation of the levels of biochemical variables in cases of body weight loss. Thus, the goal of this study was to observe whether the time of year in which bariatric surgery (BS) took place modulated the changes in several variables related to glucidic and lipid metabolism. Blood samples were obtained from 24 women and 10 men before BS and 1 and 3 months after BS. We calculated the percentage of variation that occurred for each individual and for each variable as a function of the time of the year. Data were adjusted to a 12-month period sinusoidal curve, with significance being set at p < 0.05. The results showed that almost all of the studied variables changed due to the BS according to a seasonal rhythm. Most of the variables showed a decrease that was most prominent in winter. In the cases of body mass index (BMI), adrenocorticotropin hormone (ACTH), and cortisol, the highest variation occurred in winter. Insulin and cholesterol in high-density lipoproteins (cHLD) variations were higher in springtime. Glucose variation showed a decrease after surgery with acrophase in summer-fall and plasminogen activator inhibitor-1 (PAI-1) and homeostatic model assessment-insulin resistance (HOMA-IR) in spring-summer. Ghrelin levels showed increases with a rhythm of variation with an acrophase in summer-fall. The seasonal rhythm found in this study fits nearly with the inverse of the endogenous circannual rhythm of the variables studied. The time of the year when the highest variation takes place is related to the circannual rhythm of the variable. The results agree with the manifestation of seasonal rhythm in human biochemical variables, which are reflected in the responses to weight loss after BS.

Dexmedetomidine metabolic clearance is not affected by fat mass in obese patients

BACKGROUND

Obesity has been associated with reduced dexmedetomidine clearance, suggesting impaired hepatic function or reduced hepatic blood flow. The aim of this study was to clarify the effect of obesity in dexmedetomidine metabolic clearance.

METHODS

Forty patients, ASA I-III, 18-60 yr old, weighing 47-126 kg, scheduled for abdominal laparoscopic surgery, were enrolled. Anaesthetic agents (propofol, remifentanil, and dexmedetomidine) were dosed based on lean body weight measured by dual X-ray absorptiometry. Serial venous samples were drawn during and after dexmedetomidine infusion. A pharmacokinetic analysis was undertaken using non-linear mixed-effect models. In the modelling approach, the total body weight, lean body weight, and adjusted body weight were first tested as size descriptors for volumes and clearances. Hepatic blood flow, liver histopathology, liver enzymes, and gene expression of metabolic enzymes (UGT2B10 and UGT1A4) were tested as covariates of dexmedetomidine metabolic clearance. A decrease in NONMEM objective function value (ΔOFV) of 3.84 points, for an added parameter, was considered significant at the 0.05 level.

RESULTS

A total of 637 dexmedetomidine serum samples were obtained. A two-compartmental model scaled to measured lean weight adequately described the dexmedetomidine pharmacokinetics. Liver blood flow was a covariate for dexmedetomidine clearance (ΔOFV=-5.878). Other factors, including fat mass, histopathological damage, and differential expression of enzymes, did not affect the dexmedetomidine clearance in the population studied (ΔOFV<3.84).

CONCLUSIONS

We did not find a negative influence of obesity in dexmedetomidine clearance when doses were adjusted to lean body weight. Liver blood flow showed a significant effect on dexmedetomidine clearance.

CLINICAL TRIAL REGISTRATION

NCT02557867.

Current practice in regional anaesthesia in South America: An online survey

OBJECTIVE

A survey was conducted in order to obtain a profile of the practice of regional anesthesia in South America, and determine the limitations of its use.

METHODS

After institutional ethics committee approval, a link to an online questionnaire was sent by e-mail to anaesthesiologists in Argentina, Bolivia, Chile, Colombia, Panamá, Paraguay, Perú, and Uruguay. The questionnaire was processed anonymously.

RESULTS

A total of 1,260 completed questionnaires were received. The results showed that 97.6% of the anaesthesiologists that responded used regional anaesthesia in clinical practice, 66.9% performed peripheral nerve block (PNB) regularly, 21.6% used continuous PNB techniques, and 4.6% used stimulating catheters. The primary source of training was residency programs. As regards PNB, the most common performed were interscalene (52.3%), axillary (45.1%), femoral (43.2%), and ankle block (43%). As regards the localisation technique employed, 16% used paraesthesia, 44.2% used a peripheral nerve stimulator, and 18.1% ultrasound guidance.

CONCLUSIONS

Regional anaesthesia and PNB are commonly used among South American anaesthesiologists. Considering that each country has its own profile for use, this profile should guide training in clinical practice, especially in residency programs.

Sustitución de melaza por mucílago de café (Coffea arabica L.) En bloques nutricionales para rumiantes

El objetivo de este trabajo fue evaluar la incorporación del mucílago, subproducto del café, en la fabricación de bloques nutricionales sobre sus variables de fabricación, composición química y preferencia animal. Se utilizaron bloques nutricionales elaborados con distintos porcentajes de inclusión de mucilago de café (0, 25, 50, 75 y 100 %) en sustitución de la melaza, además de los ingredientes base como, maíz, cemento, urea, minerales y azufre. Se evaluaron las variables: días de fraguado, consistencia, facilidad de mezclado y dureza; la composición química se conoció a través del análisis de proteína cruda, insoluble y soluble, fibra detergente neutra, materia orgánica y cenizas. Para la prueba de preferencia animal se utilizó una prueba de cafetería, en la cual, a través de la observación continua, se realizaron las mediciones siguientes: número de visitas, número de lamidas o mordidas, tiempo efectivo de mordidas o lamidas y el consumo de cada bloque por cada animal. Con estas mediciones, se calcularon las siguientes variables: velocidad de lamida/mordida, velocidad de consumo, tamaño de lamida/mordida, tasa de consumo e índice de preferencia. Los datos de calidad y preferencia fueron sometidos a un análisis de varianza mediante el procedimiento GLM del paquete estadístico SAS (SAS, 1991). Para las variables de calidad se utilizó un diseño experimental completamente al azar con cuatro tratamientos y diez repeticiones por tratamiento. Para la prueba de preferencia, el experimento tuvo un período de colecta de datos de cuatro días con dos periodos de evaluación. Se utilizó un diseño experimental cuadrado latino 4x4. En ambos casos, las medias fueron evaluadas utilizando la prueba de Tukey (p

Stability in air of silver and silver oxide nanoparticle shells deposited over silica spheres without using coupling agents

The deposition of silver nanoparticles on the surface of silica was carried out using our simple, robust and rapid chemical method without surface modification of silica or added coupling agents. The process was carried out at room temperature using water/methanol mixtures, tetraethyl orthosilicate as Si source and silver nanoparticles (NPs) in a single-pot reaction. Using EDS, XRD, HRTEM and High Angle Annular Dark Field (HAADF) STEM characterization techniques, we have found the coexistence of silver NPs and silver oxides NPs anchored to the surface of sub-micron silica spheres, with Ag NPs predominating sizes around 2-3 nm approximately, and Ag2O NPs sizes over 10 nm.

A phase II study of intravenous (IV) wild-type reovirus (Reolysin) in the treatment of patients with bone and soft tissue sarcomas metastatic to the lung

10524

Background: Reolysin is a Dearing strain, naturally occurring, ubiquitous human reovirus. The PKR (double stranded RNA-activated protein kinase) is inhibited and therefore the virus replicates specifically in transformed cells possessing an activated Ras pathway producing lysis. In vitro and in vivo studies with Reolysin in sarcoma cell lines revealed significant antitumor activity. Methods: This phase II open-label, single agent study was designed to characterize the efficacy and safety of Reolysin given IV every 28 days in patients (pts) with bone or soft tissue sarcoma with lung metastasis using a Simon two-stage design. 38 pts were accrued to the first stage. If 1 or more pts experience clinical benefit (prolonged SD > 6 months, partial or complete response) up to 52 pts could be accrued. The agent will be considered active if 3 or more responses or prolonged SD are observed. Results: Since July 2007, 43 pts age 19–76 (median 49) were enrolled (20 female) and received a total of 141 cycles (range 1–18). All pts had performance status 1 (29 pts) or 0 (14 pts). 38 pts received prior chemotherapy, radiotherapy, biological agents or combinations for their metastatic disease, 15 pts received more than 3 chemotherapy regimens. The sarcoma subtypes included: synovial sarcoma (13 pts), osteosarcoma (7 pts), leiomyosarcoma (7 pts), MFH (5 pts), Ewing/PNET (1 pt), chordoma (1 pt), others (9 pts). Side effects were mild to moderate (grade 1–2) and included constitutional symptoms fever, chills, fatigue. Two pts experienced respiratory side effects (cough and dyspnea) and 2 pts had diarrhea. Hematological side effects included grade 2–3 neutropenia (6 pts) and grade 2 thrombocytopenia (2 pts). One patient experienced grade 2 AST elevation. 33 pts are evaluable for response to date: 14 pts (42%) had SD for 2+ months including 5 pts having SD for more than 6 months. Conclusions: Utilization of single agent reovirus for treatment of sarcoma is a novel and unique therapeutic approach to date. Reolysin is well tolerated and shows promise for the treatment of metastatic sarcoma. Primary efficacy goals have been met. Accrual is ongoing to a total of 52 pts.

[Table: see text]

Unique origin and low penetrance of the 946delGAG mutation in Valencian DYT1 families

Mutations in the DYT1 gene cause idiopathic torsion dystonia (ITD) transmitted in families as an autosomal dominant trait with incomplete penetrance. The most common mutation, 946delGAG, has been observed in populations with different ethnic and geographic origins. We have investigated 40 individuals from 22 unrelated families with ITD originating from the Land of Valencia, Spain, for the presence of this mutation and we found 5 patients and 6 unaffected subjects from 4 families who were carriers of the mutation. This finding indicates that 18% of families may be diagnosed as DYT1 and that penetrance is reduced. We detected two different geographic and linguistic origins of the Valencian families. However, by haplotype analysis using D9S1260, D9S1261, D9S63 and D9S1262 as flanking markers, we demonstrated that all affected and unaffected carriers shared a common chromosome confirming identical origin of the mutation in the four families. We postulate a unique origin for the 946delGAG mutation in the Land of Valencia and, based on linguistic criterion, we propose that the mutation might have occurred at the beginning of the second millennium. Genetic analysis of another family from Castilla-La Mancha showed a different haplotype segregating with the disease, suggesting that at least two distinct mutational events for the 946delGAG mutation have occurred in Spain.

Plasmodium falciparum: diversity studies of isolates from two Colombian regions with different endemicity

The population structure of Plasmodium falciparum has been widely studied in diverse epidemiological contexts, but emphasis has been made in regions with high and stable transmission. In order to establish the genetic structure of P. falciparum in areas of Colombia with different degree of endemicity, we studied 100 samples from malaria patients of two different municipalities. The frequency of multiclonal infection in these areas and the correlation with the endemicity were carried out by comparison of the amplified products from polymorphic segments of MSP-1, MSP-2, and GLURP genes. We found low size polymorphism of the studied genes: 1 MSP-1 allele, 3 MSP-2 alleles, and 4 GLURP alleles. We conclude that the P. falciparum population in the regions studied is genetically homogeneous.

Evaluation of the mutagenicity of antimalarial products isolated from Solanum nudum (Solanaceae)

Diosgenone is a major component of the hexane extract from the plant Solanum nudum (Solanaceae). The products from degraded and acetylated diosgenone that showed in vitro antimalarial activity against the FCB-2 strain of Plasmodium falciparum and methanol, dichloromethane and ethereal extracts of Solanum nudum were tested for their mutagenic activity using the Ames test with the TA-97a, TA-98, TA-100 and TA-102 strains of Salmonella typhimurium. These compounds were not mutagenic at the tested concentrations.

Effect of Solanum nudum extracts on the liver of mice infected with Plasmodium berghei

The plant Solanum nudum has been used by the community of Tumaco (Nariño, Colombia) as a cure for malaria. Our group has confirmed the in vitro antimalarial activity against the strain of Plasmodium falciparum FCB-2. During our in vivo studies on the therapeutic effect of Solanum nudum extracts on mice infected with Plasmodium berghei, we observed yellowish tint in the palms of mice treated with the aqueous extract via i.p. at a concentration of 2.4% w/vol. This finding suggested the need to carry out a histology study of the liver. Plasmodium berghei infection produces liver changes such as the deposit of pigment in sinusoids, leucocytes infiltration, esteatosis and necrosis of hepatocytes. These changes were also observed when the mice were treated with methane and hexane extracts from Solanum nudum; however necrosis of hepatocytes in mice infected with malaria decreased 47-65% when they were administered either with aqueous extract, or tumacoside A and degraded diosgenone, compounds from methane and hexane extracts of Solanum nudum respectively.

[Health-related quality of life of elderly patients in primary care]

OBJECTIVES

To study the quality of life of the consultant elderly people and the associated factors to them.

DESIGN

A transversal and observational study.

SETTING

Primary care. An urban health center.

PARTICIPANTS

Patients over 64 years without any physical or psiquical limitation that disturb the communication between patient and doctor, that ask for a consultation. Election of a necessary sample trough consecutive sampling, to precision of 0,05 points and 95% CI.

OPERATIONS

The patients filled out the valid version to Spanish of the Nottinghan Health Profile. The social demographics and the morbility variables were taken through clinical histories or in other case, through the patients interviews.

MEASUREMENTS AND MAIN RESULTS

The questionnaire was answered for 386 patients with a global mid punctuation of 9166 points (25,5% of deterioration; 95% CI, 23,8-27,1%), being the deterioration in each one of following sizes: <<energy>> (22%; 95% CI, 25,3-18,7%); <<pain>> (22,5%; 95% CI, 24,9-20,1%); <<sleep>> (31,7%; 95% CI, 34,8-28,6%), <<social isolation>> (16,5%; 95% CI, 18,9-14%); <<emotional state>> (27,9%; 95% CI, 30,5-25,8%) and <<mobility>> (28,3%; 95% CI, 30,7-25,9%). It was presented with a high level of deterioration and with differences statistically significant, women (28,7% versus 19,0%; p < 0,001), except in <<energy>> sphere, patients with elevated age (23,1%, 21,1%, 24,4%, 30,5% y 35,9% in 65-69, 70-74, 75-79, 80-84 and > 84 years old respectively; p < 0,001), except in <<pain>> and <<sleep>> sphere), those who lived alone or without partner, those who were included in the house attention program 42,8% frente a 23,3%; p < 0,001), those who had a major number of chronic disease and those who took a great number of drugs.

CONCLUSION

There are an important deterioration in the quality of life of our elderly people, associated to different social demography factors and morbidity. The assessment of the quality of life should be an habitual tool in our clinical practice.

[Is ambulatory blood pressure monitoring reliable in hypertensive patients with atrial fibrillation?]

Atrial fibrillation (AF) is commonly seen in patients (pts) with systemic hypertension. They are usually excluded from ambulatory blood pressure monitoring (ABPM) because its accuracy is unknown. The aim of our study was to determine if ABPM can be used to assess 24 hour BP in pts with AF. We included hypertensive pts with chronic (> 6 months) AF, controlled heart rate (60-100 c.p.m), under therapy and also hypertensive pts in sinus rhythm (control group--CG). They were submitted to 24 hour ABPM (Spacelabs 90207). Manual BP with a standard mercury sphygmomanometer was taken during 3 visits (office BP) and on the day of ambulatory monitoring. Simultaneous measurements with a T-Tube were also performed. Thirty pts with chronic AF (63% males), mean age 73 +/- 8 years (52-85) and 18 pts in sinus rhythm (CG) were studied. The age, gender, office BP, ambulatory BP and proportion of successful measurements was similar in the 2 groups. In CG systolic and diastolic office BP did not differ from day ambulatory BP (148 +/- 14/84 +/- 7 vs 138 +/- 18/76 +/- 11 mmHg) and the same was seen in pts in AF (table). In this group, only the systolic BP taken immediately before the ambulatory device was put on, was significantly different from day ambulatory BP (148 +/- 21 vs 137 +/- 19 mmHg, p = 0.04). The proportion of successful measurements in AF group was 94 +/- 8 (65-98) with 93% > 80%. In 64 simultaneous measurements the differences were 6 +/- 5 and 5 +/- 5 mmHg for systolic and diastolic BP. Casual and ambulatory heart rate was also similar in the two groups (76 +/- 7/76 +/- 12--AF group; 78 +/- 10/78 +/- 8--control group). In conclusion, this study demonstrates that ABPM can be used to assess BP in patients with atrial fibrillation. There was a high percentage of successful recordings (93%). As in patients in sinus rhythm, there was no significantly difference in mean office blood pressure and daytime ambulatory blood pressure.

Evaluation of mutagenic activity of several antimalarial extracts from Eupatorium inulaefolium

Eupatorium inulaefolium is used as an antimalarial agent by traditional healers of the Tumaco region (Nariño-Colombia). Several extracts of this plant have been tested by our laboratory and in vitro antimalarial activity against the FCB-2 strain of Plasmodium falciparum has been confirmed. For this reason, the mutagenic effect of the methanol, dichloromethane, and hexane extracts of Eupatorium inulaefolium (number 83377 university of Antioquia herbarium) were evaluated using the Ames test. None of the extracts evaluated had mutagenic effects on TA-98 or TA-100 strains of Salmonella typhimurium.

Long-term (four years) follow-up of patients with treated nocturnal hypertension assessed by ambulatory blood pressure monitoring

STUDY OBJECTIVE

Nocturnal Hypertension (NH) is an independent risk factor for cardiovascular morbidity and mortality (M-M). However, an inappropriate decrease in diastolic BP during the night significantly increases morbidity. There are no prospective studies on the long-term consequences on M-M in treated NH. We accordingly studied M-M in 107 consecutive patients with treated NH, assessed by ambulatory blood pressure monitoring (ABPM), during a four-year follow-up.

PATIENTS AND METHODS

From the initial 107 patients six died (5 from brain or cardiovascular causes). In 65 patients it was possible to repeat the ABPM during the follow-up period. They were hypertensive patients class I-II (JNC IV) 62 +/- 10 years old, 56 were male and were observed before and after starting treatment on a four-year follow-up period. We considered age, sex, body mass index, previous cerebral and cardiovascular accidents, type and number of drugs administered, smoking habits, plasma cholesterol, glycemia, and causal and ambulatory blood pressure monitoring (ABPM) (24 hr, 6 am-10 am, 10 pm-6 am and pulse pressure) before and after follow-up, dipper status and the period of follow-up.

RESULTS

The patients whom died were older and had a significantly higher systolic blood pressure compared to the survivors. We considered two groups: with (A - n = 18) or without (B - n = 47) cerebral and cardiac morbidity. The A group had more previous cerebral and cardiovascular accidents (p = 0.05), a more intensive treatment (p = 0.02), and a greater fall in diastolic blood pressure (DBP) during the night in both absolute and percentage numbers, after treatment, than the B group. However, after regression analysis, the only independent risk marker differentiating between the two groups was the percentage fall in the DBP after treatment (dipper phenomenon) (p = 0.01).

CONCLUSIONS

In 65 treated hypertensive (NH) patients assessed by ABPM before and after treatment (four-year follow-up) we identified a group with cerebral and cardiovascular morbidity. These patients, in contrast with another group with no morbidity, had more previous cerebral and cardiovascular accidents, they were more intensively treated, and they had a greater fall in diastolic blood pressure after therapy (absolute and percentage values). However, after regression analysis the diastolic nocturnal blood pressure dipper phenomenon after treatment was the only risk marker associated with morbidity. In such cases it is possible that treatment guided by ABPM can decrease morbidity.

[Arterial hypertension difficult to control in the elderly patient. The significance of the "white coat effect"]

OBJECTIVE

Previous studies have revealed a high prevalence of white coat effect among treated hypertensive patients. The difference between clinic and ambulatory blood pressure seems to be more pronounced in older patients. This abnormal rise in blood pressure BP in treated hypertensive patients can lead to a misdiagnosis of refractory hypertension. Clinicians may increase the dosage of antihypertensive drugs or add further medication, increasing costs and producing harmful secondary effects. Our aim was to evaluate the discrepancy between clinic and ambulatory blood pressure in hypertensive patients on adequate antihypertensive treatment and to analyse the magnitude of the white coat effect and its relationship with age, gender, clinic blood pressure and cardiovascular or cerebrovascular events.

POPULATION AND METHODS

We included 50 consecutive moderate/severe hypertensive patients, 58% female, mean age 68 +/- 10 years (48-88), clinic blood pressure (3 visits) > 160/90 mm Hg, on antihypertensive adequate treatment > 2 months with good compliance and without pseudohypertension. The patients were submitted to clinical evaluation (risk score), clinic blood pressure and heart rate, electrocardiogram and ambulatory blood pressure monitoring (Spacelabs 90,207). Systolic and diastolic 24 hour, daytime, night-time blood pressure and heart rate were recorded. We considered elderly patients above 60 years of age (80%). We defined white coat effect as the difference between systolic clinic blood pressure and daytime systolic blood pressure BP > 20 mm Hg or the difference between diastolic clinic blood pressure and daytime diastolic blood pressure > 10 mm Hg and severe white coat effect as systolic clinic blood pressure--daytime systolic blood pressure > 40 mm Hg or diastolic clinic blood pressure--daytime diastolic blood pressure > 20 mm Hg. The patients were asked to take blood pressure measurements out of hospital (at home or by a nurse). The majority of them performed an echocardiogram examination.

RESULTS

Clinic blood pressure was significantly different from daytime ambulatory blood pressure (189 +/- 19/96 +/- 13 vs 139 +/- 18/78 +/- 10 mm Hg, p < 0.005). The magnitude of white coat effect was 50 +/- 17 (8-84) mm Hg for systolic blood pressure and 18 +/- 11 (-9 +/- 41) mm Hg for diastolic blood pressure. A marked white coat effect (> 40 mm Hg) was observed in 78% of our hypertensive patients. In elderly people (> 60 years), this difference was greater (50 +/- 15 vs 45 +/- 21 mm Hg) though not significantly. We did not find significant differences between sexes (males 54 +/- 16 mm Hg vs 48 +/- 17 mm Hg). In 66% of these patients, ambulatory blood pressure monitoring showed daytime blood pressure values < 140/90 mm Hg, therefore refractory hypertension was excluded. In 8 patients (18%) there was a previous history of ischemic cardiovascular or cerebrovascular disease and all of them had a marked difference between systolic clinic and daytime blood pressure (> 40 mm Hg). Blood pressure measurements performed out of hospital did not help clinicians to identify this phenomena as only 16% were similar (+/- 5 mm Hg) to ambulatory daytime values.

CONCLUSIONS

Some hypertensive patients, on adequate antihypertensive treatment, have a significant difference between clinic blood pressure and ambulatory blood pressure measurements. This difference (White Coat Effect) is greater in elderly patients and in men (NS). Although clinic blood pressure values were significantly increased, the majority of these patients have controlled blood pressure on ambulatory monitoring. In this population, ambulatory blood pressure monitoring was of great value to identify a misdiagnosis of refractory hypertension, which could lead to improper decisions in the therapeutic management of elderly patients (increasing treatment) and compromise cerebrovascular or coronary circulation.

The "Rabassa Morta" in Catalan viticulture: the rise and decline of a long-term sharecropping contract, 1670s-1920s

For long periods, and in line with recent theoretical literature, therabassa mortasharecropping contract successfully reduced problems of moral hazard and opportunistic behavior, and provided incentives for sharecroppers to respond to market opportunities. However, from the late nineteenth century, technical change, rising wages, and weak wine prices all increased the incentives for postcontractual opportunistic behavior on the part of the sharecropper, leading to conflicts and loss of trust between the principal and agent.

["White-coat hypertension": variation of normality or of hypertension?]

INTRODUCTION

Previous studies have demonstrated a high prevalence of "white coat" hypertension (20%), but it is still controversial if it implies an increase in cardiovascular risk.

PATIENTS

Between 1992 and 95 we prospectively studied 175 untreated hypertensive patients aged over 18 years (V Joint National Committee's stage I-II), and 91 controls.

DESIGN AND METHODS

The subjects were submitted to clinical evaluation, ambulatory blood pressure monitoring, 24-hour Holter monitoring, signal-averaged ECG, echocardiography/Doppler and ergometry. "White coat" hypertension was defined as mean daytime (6.00-22.00 H) ambulatory blood pressure < 136/87 mm Hg (males) and < 131/86 mm Hg (females).

RESULTS

"White coat" hypertension was present in 29 patients (18%). "White coat" hypertension patients had an identical prevalence of smoking, family history of cardiovascular disease, abnormal ECG and retinopathy (> Keith-Wagener II) as patients with daytime hypertension. Ambulatory blood pressure values (24 hour, 6.00-22.00 h, 22.00-6.00 h, sleep, blood pressure load, heart rate) were all significantly different from controls (p < 0.03 to 0.0007). In patients with daytime hypertension, only 24 hour and daytime diastolic ambulatory blood pressure (p < 0.005) were different from "white coat" hypertension patients. Exercise testing blood pressure values (6 min exercise, maximal, 3 min recovery) were significantly different between "white coat" hypertension patients and the control group (n = 70) (p varying from 0.05 to 0.005) but not between "white coat" hypertension and daytime hypertension (n = 33) patients. Diastolic function was studied only in 39 daytime hypertension patients, 10 individuals with "white coat" hypertension and 34 controls (for technical reasons and because we only analyzed individuals younger than 55 years). E velocity and E/A ratio were similar in "white coat" hypertension and daytime hypertension, but only in daytime hypertension patients they reached a significant difference from controls (p = 0.04; p = 0.01), probably due to the small number of patients.

CONCLUSIONS

These data (clinical, ambulatory blood pressure, ergometric, diastolic function) suggest that "white coat" hypertension might not be a benign entity.

[Paroxysmal atrial fibrillation and flutter and "occult" arterial hypertension. The importance of the ambulatory monitoring of the blood pressure. Apropos 2 cases]

The authors describe two hypertensive patients with paroxysmal auricular flutter or fibrillation. The arterial hypertension was suspected because of a hypertensive response in a treadmill stress test, confirmed by a 24-hour blood pressure ambulatory monitoring and there was no damage in target organs. They focus that auricular flutter/fibrillation may be related to "occult hypertension".

[Civil aviation and cardiology. Admission rules and follow-up of the technical flying personnel of TAP-Air Portugal]

The authors, based in European and American rules, consensus positions of Clinical Aerospace Congresses and their own experience, marked admission and follow-up rules of conduct for TAP Air Portugal aircrew. They stressed the importance of modern technology in arterial pressure ambulatory diagnosis and pointed the necessity of arterial pressure treatment in the other cardiovascular risk factors context. They relief ischemic myocardial disease because it is incompatible with flying safety, even in those submitted to coronary angioplasty or bypass graft surgery. For those with arrhythmias, valvular heart disease, myocarditis, cardiomyopathy and adult life congenital heart disease, we emphasize admission and follow-up rules.

[Anomalous origin of the left coronary from the pulmonary artery in adults: diagnosis with bidimensional, pulsed and color Doppler echocardiography]

Anomalous origin of the left coronary artery (LCA) from the pulmonary trunk (PT) is an uncommon but frequently lethal congenital lesion of infancy. Clinically it may be difficult to distinguish from congestive cardiomyopathy, and the diagnosis is usually made by angiography. We describe the case of a 38 years old woman, in whom identification of this anomaly was achieved by 2D-Echo, pulsed Doppler and color flow mapping. She complained of fatigue, effort dyspnea and atypical chest pain. A II/VI systolic murmur at left sternal border was heard. There was cardiac enlargement on chest X-ray and ECG was suggestive of an old anterolateral myocardial infarction. The 2D-Echo study showed a dilated, poorly contracting left ventricle. A prominent right coronary ostium was recorded, but the LCA ostium could not be visualized. There was retrograde diastolic and systolic flow in proximal PT, where an anomalous vessel was seen in continuity with it by color flow mapping. Cardiac catheterization confirmed the diagnosis. The patient underwent successful reimplantation of the anomalous LCA, from the PT to the aorta. This case demonstrates usefulness of Echocardiography in the assessment of coronary artery anomalies.

[Assessment of the anti-hypertensive effect of diltiazem in delayed-action capsules by ambulatory monitoring of arterial pressure]

The aim of this parallel controlled-placebo study was to assess the antihypertensive effect of diltiazem in a slow release formulation in monotherapy by the ambulatory blood pressure monitoring (ABPM). Twenty patients with moderate essential hypertension entered the trial. Whole day ambulatory blood pressure (BP) monitoring, with a COLIN ABPM 630, was done after a wash-out period, after placebo administration and 60 days of therapy with diltiazem in a 120 or 180 mg once or twice daily administration. We verified by ABPM that placebo administration did not have an antihypertensive effect (146 +/- 10 mmHg/87 +/- 7 mmHg at base line to 145 +/- 8 mmHg/84 +/- 6 mmHg with placebo p = ns). Eithy four percent of the patients showed a significant systolic and diastolic BP decrease after 60 days of therapy (from 146 +/- 10 mmHg/87 +/- 7 mmHg at base line to 132 +/- 7/77 +/- 6 mmHg - p less than 0.025). In 56% of the patients this was achieved with 180 mg/day and this effect was sustained throughout the 24 hours. We did not find a significant decrease on heart rate. The ABPM is a valuable technique to assess the effect of antihypertensive drugs and demonstrated that diltiazem in a slow release formulation was effective in decreasing systolic and diastolic BP, throughout the day even in patients with low doses, once daily.

[Significance of the unexpected hypertensive response to exertion. Correlation with ambulatory blood pressure monitoring and echocardiography]

The aim of this study was to analyse the meaning of unexpected hypertensive response during treadmill stress test in resting normotensive individuals without any evidence of cardiovascular pathology. The study group of 52 persons who fulfil the inclusion criteria was compared with a homogenous control population composed by 200 individuals with a suitable blood pressure response to stress. The adopted criteria for hypertensive response were the presence of blood pressure greater than or equal to 180/100 mmHg after 6 stress, in maximal stress greater than or equal to 210/110 mmHg and after 5' recovering greater than or equal to 150/90 mmHg. 74% of patients with hypertensive response appeared to be hypertensive according to the criteria of ambulatory blood pressure monitoring--day blood pressure greater than or equal to 140/90 mmHg and night blood pressure greater than or equal to 120/80 mmHg. After echocardiographic study to define the index of left ventricular mass, 68% of individuals with hypertensive stress response showed left ventricular hypertrophy with a medium index of 145 + 17 g/m2 (P less than or equal to 0.01) in most cases with a concentrical hypertrophy type. The appearance of tensional response of hypertensive type ascertains the probability of hypertensive disease. The analysis of tensional response to stress is an integrant part of a methodology of approaching patients suspect of high blood pressure.

[The relationships between cholesterol and arterial pressure in the Málaga-86 study. Something more than a casual association?]

The frequent association of this vascular risk factors implies not just a potentiation of the vascular risk, but also the need for a wider therapeutical approach on this patients not only regarding the control of the arterial hypertension but also other risk factors. After a cross-sectional study of the prevalence of various vascular risk factors in the province of Málaga (Spain), we analysed the results as for the cholesterolemia and blood pressure in normotensives and hypertensives. In the hypertensive population we observed a tendency to present a higher levels of cholesterol as well as a higher prevalence of hypercholesterolemia (p less than 0.001); on the other hand, hypercholesterolemic people versus normocholesterolemics showed similar data related to their blood pressure and prevalence of hypertension. Finally we discussed the likely etiopathogenetic interrelationships between both vascular risk factors.