[Telmisartan effect's on remodelling bone markers in hypertensive patients]

INTRODUCTION

The telmisartan is an angiotensin II receptor blocker (ARB) with a few own characteristics that it allows us to obtain a few additional benefits. It displays the ability to act as a partial agonist of PPARgamma. On the other hand, PPAR gamma intervenes in the control of bone remodelling though with not concordant results. The objective of this study to value the effect of telmisartan on bone markers in hypertensive patients.

SUBJECTS

A sample of 31 hypertensive patients with hypertension were included. The dose of telmisartan was of 80 mg/24 h and the period of follow-up was 12 weeks. The control group included 32 hypertensive patients treated before with IECA (enalapril-20 mg/24 h - or quinapril - 40 mg/24 hours). The following parameters were determined P1NP, β-CTX, 25OHD and PTH , osteocalcin, insulin and adiponectin.

RESULTS

The patients treated with Telmisartan shown a significantly decrease in systolic blood pressure (156 ± 19 mmHg vs 133 ± 15 mmHg, p = 0.001) and diastolic blood pressure (92 ± 9 mmHg vs 82 ± 6 mmHg, p = 0.01) . Changes were not observed in other parameter, PTHi (48 ± 22 pg/ml vs 45 ± 22 pg/ml, p > 0.05) and 25-vitamin D (21 ± 10 ng/ml vs 25 ± 8 ng/ml, p > 0.05), CTX (0.195 ± 0.12 ng/ml vs 0.221 ± 0.13 ng/ml, p > 0.05), PINP (39 ± 20 ng/ml vs 40 ± 19 ng/ml, p > 0.05), osteocalcin (11 ± 9 ng/ml vs 11 ± 5 ng/ml, p > 0.05), glucose, adiponectin, insulin and HOMA. When the patients divided in two groups depending on the levels of vitamin D (insufficient and not insufficient), with a cut of 20 ng/ml, there was changes on bone markers but a decrease of the glucose was observed in patients with levels of vitamin D over 20 ng/ml (135 ± 53 mg/dl vs 119 ± 39 mg/dl, p = 0.01). The patients treated with IECAS decreases the systolic blood pressure but the diastolic blood pressure values of arterial systolic does not show changes.

CONCLUSIONS

Telmisartan has a neutral effect to level of the bone markers of bone remodelling.

Food anaphylaxis in antiphospholipid syndrome and thrombosis

BACKGROUND

We have observed that some cases of food anaphylaxis were followed by severe thrombosis associated to anticardiolipin antibodies. Food anaphylaxis associated with antiphospholipid syndrome has seldom been published.

OBJECTIVE

The aims were: 1) to test anticardiolipin antibodies in an important number of patients with anaphylaxis due to vegetal foods and their relationship with possible thrombosis; and 2) to study seed and fruit hypersensitivity in patients with previous thrombotic events associated with antiphospholipid antibodies (aCL).

METHODS

We included 30 patients diagnosed of thrombosis associated with aCL, 52 patients who suffered from anaphylaxis due to seeds or fruits, and 120 control patients. Haematological, cardiopulmonary vascular and rheumatologic studies had been performed as needed. In vivo and in vitro allergy tests with a large battery of vegetal allergens were carried out in all the patients. Measurement of IgG aCL antibodies and specific IgE to vegetal food was done by ELISA and CAP-FEIA (Phadia). Immunodetection and inhibitions with lipoproteins belonging to seeds were performed.

RESULTS

Seventy-five percent of the patients diagnosed as having antiphospholipid primary syndrome had specific IgE against different proteins from different vegetable allergens, most of them seeds, and clearly against lipoproteins that were also recognised by the patients with food anaphylaxis but not by the control cases. Among the patients with anaphylaxis, 28% had anticardiolipin antibodies and 17.3% thrombosis.

CONCLUSION

Our study suggests that seed lipoproteins which cause severe food anaphylaxis might have a potential role in the antiphospholipid syndrome and related thrombosis.

ERCP's role in the management of acute biliary-pancreatic pathology in the laparoscopic era

OBJECTIVES

Laparoscopic cholecystectomy (LC) combined with endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in the management of the acute biliopancreatic pathology. Nevertheless, controversy remains about the appropriate timing for retrograde cholangiopancreatography.

METHODS

A retrospective study was undertaken on a consecutive series of 117 patients with acute biliary-pancreatic pathology, who underwent laparoscopic cholecystectomy between April 1995 and April 1999. Criteria for preoperative endoscopic retrograde cholangiopancreatography were defined, and the patients were divided into 3 groups based on the presence or absence of a preoperative retrograde cholangiopancreatography indication: (1) ERCP+LC group: patients with retrograde cholangiopancreatography indicated and performed (n = 30); (2) LC group: patients without retrograde cholangiopancreatography criteria treated only by LC (n = 47); (3) LC-ERCP group: patients with retrograde cholangiopancreatography criteria but not performed (n = 40).

RESULTS

The groups were similar in age, sex, ASA, and clinical diagnosis. No statistical differences occurred in operative times (73.8 min, 68 min, 67 min), major complications (3.3%, 4.25%, 12.5%), and mean postoperative stay (3.7 +/- 4; 4.7 +/- 2; 5.7 +/- 2). Postoperative retrograde cholangiopancreatography had to be used, respectively, in 0%, 10.6%, and 7.5%. The best predictive criteria for common bile duct pathology were choledocholithiasis on an ultrasound scan and the presence of cholangitis. The other criteria tested had a low predictive value.

CONCLUSIONS

Preoperative endoscopic retrograde cholangiopancreatography followed by early laparoscopic cholecystectomy can be performed safely in acute biliary-pancreatic pathology, avoiding 2-stage treatment of these patients and minimizing hospital stay and inconvenience to the patients. Nevertheless, this therapeutic/diagnostic tool must be used selectively.

Appropriateness of antibiotic prescriptions in community-acquired acute pediatric respiratory infections in Spanish emergency rooms

OBJECTIVE

To describe the variability and appropriateness of antibiotic prescriptions in community-acquired acute respiratory infections (ARI) during childhood in Spain.

METHODS

A descriptive, multicenter study of variability in clinical practice was conducted by evaluating a prospective series of pediatric patients attending the emergency rooms of 11 Spanish hospitals and diagnosed with community-acquired ARI. The appropriateness of the antibiotic prescriptions was assessed by comparing our clinical practice with consensus guidelines developed for this study.

RESULTS

We collected data from 6,249 ARI emergencies studied on 30 separate days. Antibiotics were prescribed in 58.7% of the ARI (bronchiolitis, 11.5%; bronchitis, 40.2%; pharyngotonsillitis, 80.9%; nonspecified ARI, 34.8%; pneumonia, 92.4%; otitis, 93.4%; sinusitis, 92.6%). The most commonly used antibiotics were amoxicillin/clavulanate (33.2%), amoxicillin (30.2%), cefuroxime axetil (8.5%) and azithromycin (6%). According to the consensus guidelines developed for this study, therapy was considered to be appropriate in 63.1% of the ARI (first choice, 52.1%; alternative choice, 11.0%) and inappropriate in 36.9%. The percentages of inappropriate prescription according to ARI groups were: bronchiolitis, 11.5%; bronchitis, 31.5%; pharyngotonsillitis, 54.8%; nonspecified ARI, 34.7%; pneumonia, 13.9%; otitis, 25.6%; and sinusitis, 22.2%.

CONCLUSIONS

There is excessive use of antibiotics in acute respiratory infections that are presumably viral in origin. An important number of ARI of potentially bacterial origin are treated with antibiotics that are not sufficiently efficacious or that have a broader spectrum than necessary.

Assessment of antibiotic prescription in acute respiratory infections in adults. The Spanish Study Group on Antibiotic Treatments

OBJECTIVE

This study aims to ascertain the variability in the use of antibiotics for the treatment of acute respiratoryinfections in several hospital emergency services in Spain, as well as the appropriateness of antibiotics prescription through evaluation by a panel of experts using available scientific evidence.

METHOD

A cross-sectional study was carried out in the emergency services of 10 hospitals in different Spanish regions. We chose patients diagnosed as having acute respiratory infection, aged over 14 years. Among the collected variables were: type of respiratory infection, antibiotic prescription, comorbidity, qualification of the prescribing doctor and hospital admission. The consensus conference held by a panel of experts established first choice treatment and the alternative and inappropriate use for each respiratory infection, based on the available scientific evidence. All the observed prescriptions in our study were classified according to this pattern.

RESULTS

A sample of 2899 acute respiratory infections was studied (5.5% of all emergencies). Antibacterial agent treatment was prescribed in 82.6% of these, varying according to the infection between 98.5% of pneumonias and 49% of croup-influenza-common cold. The most commonly used antibiotics were amoxicillin-clavulanate and cefuroxime. The global percentage of inappropriate prescription was 40.5% (95% CI; 35.4-45.5). The prescriptions were inappropriate in 16.9% of cases of pharyngotonsillitis, 17.8% of chronic bronchitis, 26.9% of acute bronchitis, 29.3% of pneumonias, 30.8% of otitis and sinusitis and in 70.8% of croup, flu, common cold and non-specified infections. Significant variability among participating centres was observed, both in choice of antibiotics and in their degree of appropriateness.

CONCLUSIONS

There is excessive use of antimicrobial drugs in acute respiratory infections, and the majority are used for viral infections. There is indiscriminate use of broad spectrum antibiotics, which are valid in some infections but clearly inappropriate in others. Similarly, there are important differences in the choice of antibiotics and their degree of appropriateness among hospitals.

[Multicenter study of the variability and adequacy of antimicrobial therapy for community-acquired pneumonia in adults]

We performed a study to evaluate the variability and adequacy of prescribing antibiotics in community-acquired pneumonia (CAP) in 10 Spanish hospitals. We studied 452 patients with CAP. Initial empirical administration of antibiotics was prescribed in 90.7% of the cases, 82.5% as monotherapy. Macrolides and third and second generation cephalosporins were the most widely used groups of antibiotics. Penicillin and amoxicillin were only prescribed in 1. 7% of the patients. A significant variability between hospitals was observed. Reference patterns for the use of antibiotics in CAP were devised by a panel of experts. According to the recommendations of this panel, 29% of the total prescriptions were not adequate, with this percentage reaching 65% in outpatients older than 65 years or with comorbidity. This was mainly due to the fact that monotherapy with erythromycin, which was considered inadequate, was the most widely prescribed treatment.

[Practice variation and appropriateness study of antimicrobial therapy for acute pharyngotonsillitis in adults]

OBJECTIVE

Infectious pharyngotonsillitis is usually managed with antibiotics by general practitioners and pediatricians both in primary care and the emergency services. In the present work we try to assess the antibiotic variability and appropriateness in the management of acute pharyngotonsillitis among several emergency services in our country related to scientific evidence based in an expert panel criteria.

METHOD

A transversal trial was carried on in ten emergency services of our country. We included patients older than fourteen years an analyzed the following variables: type of respiratory infection, antibiotic prescription, comorbidity, physician's status and hospital admission. The antibiotics were classified in three levels according to the expert panel criteria: first election, alternative use and inappropriate use. We compared the antibiotic treatments to these three levels.

RESULTS

2,869 patients were diagnosed of acute respiratory infection, 356 (12.4%) with pharyngotonsillitis. Commonly the patients were prescribed antibiotics (315; 81%) and the most used were amoxicillin-clavulanate (33%), amoxicillin (16%), penicillin (7%), cefuroxime (6%), erythromicin (4%) and cefixime (3%). Among the 315 prescriptions, 98 (32%) were first election, 147 (50%) alternative use and 50 (17%) inappropriate use.

CONCLUSIONS

Most of the patients suffering of pharyngotonsillitis were empirically prescribed antibiotics probably many of these cases were non-bacterial pharyngotonsillitis. Alternative and inappropriate use of antibiotics was high.

Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh

BACKGROUND

Despite being one of the most exact indications, laparoscopic treatment of eventrations and ventral hernias is barely known among the array of laparoscopic techniques.

METHODS

A total of 60 patients were assigned at random over a 3-year period to two homogeneous groups to be operated on for major ventral hernias with mesh. Half of them were operated upon laparoscopically and the rest with open surgery. Early and longer-term complications were analyzed, as were operative time and postoperative hospital stays.

RESULTS

The two groups were homogeneous in terms of demographic and clinical characteristics. The group that was operated on laparoscopically presented a lower rate of postoperative and longer-term complications; similarly, surgery time was significantly lower (p < 0.05). Hospitalization time was also significantly lower than in the group undergoing conventional open surgery (p < 0.05).

CONCLUSIONS

Laparoscopic treatment of postoperative eventration and primary ventral hernia reduces complications and relapse rates, eliminates reintervention through mesh infection, reduces operative time, and considerably shortens the hospital stay.

Relation of hepatitis C virus genotypes to risk factors and hepatic disease in Spanish patients

OBJECTIVE: To ascertain the prevalence of hepatitis C virus (HCV) genotypes in Spain and their distribution by risk factors. METHODS: The study covered 216 patients with hepatitis C. Of these, 63 were intravenous drug users (IVDU), 44 had received transfusions, and 30 were hemodialyzed, and in 79 the risk factors were unknown. Antibodies against HCV were detected by second-generation enzyme immunoassay (EIA) and confirmed by immunoblot. HCV RNA presence was investigated by reverse transcription---polymerase chain reaction (RT-PCR), and a reverse hybridization test of the amplifications was used for the genotyping. RESULTS: The most frequently encountered genotypes were 1b (48.1%), 1a (21.3%) and 3a (11.1%). HCV genotypes 1a (42.8%) and 3a (20.6%) were the most prevalent genotypes in IVDU patients, while 1b was the most frequent in patients with unknown risk factors (62.0%), transfused patients (68.1%) and hemodialyzed patients (50.0%). Mixed infections were detected in nine cases (4.1%); three appeared in IVDU patients (4.7% of the total IVDUs), two in transfused patients (4.5%) and four (50%) in patients with unknown risk factors. No statistically significant differences were found in average ages of the IVDU patients with different genotypes. Non-IVDU patients having genotype 3a presented the lowest average age of all. No significant statistical differences were observed in alanine aminotransferase levels among patient groups with different genotypes (p>0.05 in all cases). Subtype 1b was present in six of the seven cases of cirrhosis (85.7%) and in nine of the 18 cases of active chronic hepatitis (50.0%).

Multicenter randomized, controlled study of intramuscular administration of interferon-beta for the treatment of chronic hepatitis C

The intramuscular administration of interferon-beta (IFN-beta) at a dosage of 6 million units three times per week for 6 months has been evaluated in 90 patients included in a multicenter, randomized, controlled trial for the treatment of chronic hepatitis C. Transaminase levels were significantly reduced in IFN-beta-treated patients (p = 0.015) and were significantly lower with respect to those of the untreated controls (p = 0.040 at 6 months). Four treated (8%) and one untreated (2.5%) patients had normal transaminase values after 6 months. At study end (12 months), three quarters of the IFN-beta-treated patients had sustained transaminase normalization, whereas the untreated case had relapsed. Hepatitis C viremia was cleared in 6 (12%) treated patients but in none of the untreated controls (p = 0.058). Side effects of IFN-beta were infrequent (a mild flu-like syndrome in < 10%, asthenia in 16%, anorexia in 8%, headaches and weight loss in 8%, and hair loss in 4%). Leukocyte and platelet counts decreased during IFN-beta treatment, but no dose modifications were necessary. Such decreases were not statistically significant when compared with the levels in the untreated controls. Intramuscular IFN-beta at the dosage used has little efficacy in the treatment of chronic hepatitis C. Because of IFN-beta tolerance, higher doses and alternate routes of injection might prove beneficial for the treatment of this disease.

Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis

BACKGROUND & AIMS

Paracentesis associated with plasma expanders is widely used for the treatment of ascites in cirrhosis. This study investigated the clinical importance of paracentesis-induced-circulatory dysfunction and compared the efficacy of albumin, dextran 70, and polygeline in preventing this complication.

METHODS

A total of 289 cirrhotic patients with ascites were randomized to treatment by total paracentesis plus intravenous albumin (97 patients), dextran 70 (93 patients), or polygeline (99 patients). Postparacentesis circulatory dysfunction was defined as an increase in plasma renin activity on the sixth day after paracentesis of more than 50% of the pretreatment value to a level > 4 ng.mL-1.h-1.

RESULTS

Postparacentesis circulatory dysfunction occurred more frequently in patients treated with dextran 70 (34.4%; P = 0.018) or polygeline (37.8%; P = 0.004) than in those receiving albumin (18.5%). The plasma expander used and the volume of ascites removed were independent predictors of this complication. Postparacentesis circulatory dysfunction persisted during follow-up and was associated with a shorter time to first readmission (1.3 +/- 0.5 vs. 3.5 +/- 0.8 months, median +/- SEM; P = 0.03) and shorter survival (9.3 +/- 4.2 vs. 16.9 +/- 4.3 months; P = 0.01). Creatinine and sodium levels in serum, and Child-Pugh score at inclusion, and postparacentesis circulatory dysfunction were independent predictors of survival.

CONCLUSIONS

Postparacentesis circulatory dysfunction is not spontaneously reversible and is associated with a shorter time to first readmission and shorter survival. Albumin is the best plasma expander to prevent this complication.

Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites

BACKGROUND

The aim of the study was to investigate the incidenc, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites.

METHODS

The study is a follow-up investigation in 234 nonazotemic patients with cirrhosis and ascites. Thirty-nine variables obtained at inclusion were analyzed as possible predictors of hepatorenal syndrome occurrence (Kaplan-Meier method, Mantel-Cox test, and step-wise Cox regression procedure).

RESULTS

The probability of hepatorenal syndrome occurrence was 18% at 1 year and 39% at 5 years. Sixteen variables had predictive value for hepatorenal syndrome occurrence in the univariate analysis: history of ascites, hepatomegaly, nutritional status, blood urea nitrogen level, serum creatinine concentration, serum sodium and potassium concentration, serum and urine osmolality, urinary sodium excretion, free water clearance after a water load, glomerular filtration rate, arterial pressure, plasma renin activity, plasma norepinephrine concentration, and esophageal varices. Neither etiology (alcoholic vs. nonalcoholic) nor the Child-Pugh score had predictive value. A multivariate analysis disclosed only three independent predictors of hepatorenal syndrome occurrence: low serum sodium concentration, high plasma renin activity, and absence of hepatomegaly.

CONCLUSIONS

The hepatorenal syndrome is a relatively frequent complication in cirrhotic patients with ascites that is associated with an extremely short survival. Liver size, plasma renin activity, and serum sodium concentration are predictors of hepatorenal syndrome occurrence in these patients.

Large-volume paracentesis and intravenous saline: effects on the renin-angiotensin system

Fourteen cirrhotic patients with tense ascites were treated with total paracentesis and intravenous isotonic saline infusion. Standard liver and kidney function tests, plasma renin activity and aldosterone concentration were measured before, at 48 hrs and at 7 days after total paracentesis. The volume of ascites removed was 7.7 +/- 5.6 l (mean +/- S.E.M.). None of the treated patients had clinical complications or significant alterations in liver or kidney function test results. Paracentesis and intravenous isotonic saline infusion were not associated with significant changes in mean plasma renin activity or plasma aldosterone concentration. These results suggest that this therapeutic procedure could be a safe and cost-effective alternative treatment of tense ascites in patients with cirrhosis.

Recombinant gamma-interferon as adjuvant to hepatitis B vaccine in hemodialysis patients

Patients undergoing long-term hemodialysis are at high risk of acquiring hepatitis B yet tend to have poor rates of response to hepatitis B vaccine. The effect of recombinant human gamma-interferon (2 million units/m2) on the response to a recombinant hepatitis B vaccine was evaluated in a prospective, randomized controlled trial in 81 hemodialysis patients. A similar proportion of both groups of vaccinees ultimately developed antibody to HBsAg including 81% of the 41 recipients of vaccine alone (group I) and 89% of the 40 recipients of vaccine with gamma-interferon (group II). However, the antibody to HBsAg response occurred earlier in recipients of vaccine with gamma-interferon, so that at 4 mo 63% of group I and 88% of group II had antibody to HBsAg (p less than 0.025). Furthermore, titers of antibody to HBsAg tended to be higher in the vaccinees given interferon; the final geometric mean titers were 232 IU/L in group I and 330 IU/L in group II (p = not significant). Retrospective testing for antibody to hepatitis C virus revealed that 21 (26%) hemodialysis patients were seropositive at entry into this trial, but the presence of antibody to hepatitis C virus did not appear to affect the response rate to the hepatitis B vaccine. These results suggest that the effects of gamma-interferon as an adjuvant in increasing the response rate to hepatitis B vaccination deserve further evaluation perhaps most appropriately in persons who have not responded to an initial course of vaccine.