Role of nitric oxide in the cerebral circulation during hypotension after hemorrhage, ganglionic blockade and diazoxide in awake goats

The role of nitric oxide in cerebrovascular response to hypotension was analyzed by evaluating the changes in cerebrovascular resistance after inhibition of nitric oxide synthesis with Nw-nitro-L-arginine methyl ester (L-NAME) during three types of hypotension in conscious goats. Blood flow to one brain hemisphere was electromagnetically measured, hypotension was induced by controlled bleeding, and by i.v. administration of hexametonium (ganglionic blocker) or of diazoxide (vasodilator drug), and L-NAME was injected by i.v. route (35 mg kg-1). Under control conditions (13 goats), L-NAME increased arterial pressure from 98 +/- 3 to 123 +/- 4 mmHg and decreased cerebral blood flow from 65 +/- 3 to 40 +/- 3 ml min-1 (all P < 0.001); cerebrovascular resistance increased from 1.52 +/- 0.04 to 3.09 +/- 0.013 mmHg ml-1 min-1 (P < 0.01) (delta = 1.59 +/- 0.12 mmHg ml-1 min-1). After bleeding (five goats), mean arterial pressure decreased to 60 +/- 4 mmHg and cerebral blood flow decreased to 37 +/- 4 ml min-1 (all P < 0.01); cerebrovascular resistance did not change (1.56 +/- 0.14 vs. 1.54 +/- 0.12 mmHg ml-1 min-1, P > 0.05). During this hypotension, L-NAME increased arterial pressure to reach the normotensive values an did not affect the hypotensive values for cerebral blood flow; cerebrovascular resistance increased from the hypotensive values to 2.91 +/- 0.19 mmHg ml-1 min-1 (P < 0.01) (delta = 1.37 +/- 0.16 mmHg ml-1 min-1), and this increment is comparable to that under control conditions (P > 0.05). Ganglionic blockade (six goats) decreased arterial pressure to 67 +/- 2 mmHg) and did not affect significantly cerebral blood flow; cerebrovascular resistance decreased from 1.71 +/- 0.11 to 1.05 +/- 0.09 mmHg ml-1 min-1 (P < 0.01). During this hypotension, L-NAME increased arterial pressure to 103 +/- 6 mmHg (P < 0.001), and did not affect cerebral blood flow; cerebrovascular resistance increased from the hypotensive values to 1.68 +/- 0.18 mmHg ml-1 min-1 (P < 0.01) (delta = 0.63 +/- 0.10 mmHg ml-1 min-1), and this increment was lower than under control conditions (P < 0.01). Diazoxide (six goats) decreased arterial pressure to 69 +/- 5 mmHg (P < 0.01) without changing cerebral blood flow; cerebrovascular resistance decreased from 1.89 +/- 0.11 to 1.16 +/- 0.14 mmHg ml-1 min-1 (P < 0.01). During this hypotension, L-NAME increased arterial pressure to 87 +/- 6 mmHg (P < 0.05) and did not affect the hypotensive values for cerebral blood flow (P > 0.05); cerebrovascular resistance increased from the hypotensive values to 1.53 +/- 0.13 mmHg ml-1 min-1 (P < 0.05) (delta = 0.36 +/- 0.06 mmHg-1 ml-1 min-1), and this increment was lower than under control conditions (P < 0.01). Therefore, the role of nitric oxide in cerebrovascular response to hypotension may differ in each type of hypotension, as this role during hemorrhagic hypotension may not change and during hypotension by ganglionic blockade or diazoxide may decrease. These differences may be related to changes in nitric oxide release as stimuli on the endothelium (shear stress and sympathetic activity) may vary in each type of hypotension.

[The determination of arterial pressure by the physician or the nurse: its relation to ambulatory pressure and left ventricular mass. The MAPA-Madrid Group. Monitorización Ambulatoria de la Presión Arterial (Ambulatory Monitoring of Arterial Pressure)]

BACKGROUND

In the present study we evaluated the influence of the observer's status--physician or nurse--on blood pressure levels and the relationship among clinic blood pressure measurement with ambulatory blood pressure and left ventricle mass.

PATIENTS AND METHODS

Cross sectional study performed in seven primary care centers. Participating physicians and nurses were trained for blood pressure measurement prior to the study and subsequently retrained at 3 month intervals during the study. Patients included in the study were 122 subjects with mild to moderate hypertension who underwent the following study protocol: a) measurement of clinic blood pressure by physician and nurse, in an independent fashion, on 3 visits; b) clinic-epidemiologic questionnaire; c) conventional hematological and biochemical study; d) electrocardiogram; e) 24-hour ambulatory blood pressure monitoring, f) M-mode and Doppler echocardiography (only in 58 subjects).

RESULTS

Nurse-measured blood pressure levels were higher than those determined by physicians (mean differences: 3.9 [6.7] mmHg in systolic blood pressure and 2.6 [5.4] mmHg in diastolic blood pressure). The blood pressure level differences between the two observers were higher in female patients and subjects with low educational level, independently of the observer's gender. Nurse-measured blood pressure was more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure.

CONCLUSIONS

Nurse-measured blood pressure levels are lower than those determined by physicians and more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. These data support that nurses, instead of doctors, should routinely measure blood pressure in primary care centers.

Role of Haemophilus influenzae in intra-amniotic infection in patients with preterm rupture of membranes

Haemophilus spp. were isolated from the amniotic fluid of eight of 110 consecutive women with preterm premature rupture of membranes (PROM) between 1992 and 1998. Isolates were nontypeable and classified according to biochemical test results as Haemophilus influenzae biotype I (n = 1), biotype II (n = 4), biotype III (n = 1) or biotype IV (n = 2). Primers recognizing specific sequences in the 16S rRNA of the cryptic genospecies of Haemophilus were employed to amplify the DNA of the eight isolates. One isolate classified as Haemophilus influenzae biotype II was confirmed as belonging to the genital cryptic species. Infectious morbidity occurred in five women and two newborns and was associated in most cases with biotype II.

[20210G/A mutation of prothrombin gene in a patient with deep venous thrombosis ad pulmonary embolism without other risk factors of thrombosis]

A new genetic anomaly predisposing to venous thrombosis was described in 1996, namely the transition of guanine (G) to adenine (A) at position 20210 in the 3-untranslated region of the prothrombin gene. This mutation is associated with high levels of plasma prothrombin and increased risk of thrombotic events in the venous system. We report the case of a man who, lacking known risk factors for thrombosis, suffered a massive pulmonary embolism and deep venous thrombosis in both lower legs. Thrombophilic analysis confirmed that the patient and close relatives were carriers of the heterozygotic 20210G/A variant of the prothrombin gene. Two relatives with the genetic defect had also suffered some type of deep venous thrombosis.

Emergence and genetic evolution of HIV-1 variants with mutations conferring resistance to multiple reverse transcriptase and protease inhibitors

The emergence of genotypic resistance in protease and reverse transcriptase (RT) gene regions was longitudinally evaluated in plasma samples from a group of 12 HIV-1-infected patients treated with different combination of antiretroviral therapies and selected on the basis of their clinical failure. Complex mutational patterns in the reverse transcriptase gene were observed. In particular, combinations of AZT (41L, 67N, 70R, 210W, and 219Q/E) and 3TC (184M) were seen in 10 patients. Two patients presented codon 151 multinucleoside analogue resistance (MNR). Additionally, seven patients harbored RT nonnucleoside analogue-related resistance substitutions (98G, 103N, and 181C). Multiple protease-selected mutations were found in each patient with an average of six substitutions per patient, with 10I/F/V, 63P, 71V, 82A/T, 84V, and 90M being the most prevalent substitutions. Overall, these results showed that for most patients virological failure was coupled with detectable genotypic resistance. Furthermore, most patients exhibited genotypic resistance to almost all available anti-HIV-1 drugs. The high viral loads found in most patients at the end of the study suggest that the replication of these multidrug resistant viruses are not severely compromised. Phylogenetic analysis of these pol sequences revealed that a specific HIV-1 genotype prone to develop multidrug resistance was not found.

Basal inhibitory action of endogenous endothelin on the sympathetic contraction in the isolated rat tail artery

In order to test whether endogenous endothelin modulates the sympathetic vasoconstriction, arterial segments, 2 mm long, from rat tail artery were mounted in organ baths for isometric tension recording. Electrical field stimulation (2-8 Hz, 0.2 ms, 70 V during 1 s) produced frequency-dependent arterial contraction (maximal contraction 770+/-49 mg) that was nearly abolished (over 95% reduction) by tetrodotoxin (10(-6) M) or phentolamine (10(-6) M). This contraction was increased by pretreatment with the antagonist of endothelin ET(B) receptors N-(N-(N-(2, 6-dimethyl-1-piperidinyl)carbonyl)-4-methyl-L-leucyl)-1-(methoxycarbo nyl)-D-tryptophyl)D-norleucine (BQ-788, 10(-7)-3x10(-6) M), and was not modified either by the antagonist of endothelin ET(A) receptors cyclo(D-alpha-aspartyl-L-prolyl-D-valyl-L-leucyl-D-tryptophyl) (BQ-123, 10(-7)-3x10(-6) M) or the agonist of endothelin ET(B) receptors endothelin-1 (8-21), N-Suc-(Glu(9), Ala(11,15)) (IRL-1620, 10(-8)-10(-7) M). The potentiating effect of BQ-788 was not modified in arterial segments without endothelium or pretreated with the inhibitor of nitric oxide synthesis N(W)-nitro-L-arginine (L-NA, 10(-4) M) or with the inhibitor of endothelin converting enzyme N-(alpha-rhamnopyranosyloxy-hydroxyphosphinyl)-leu-trp (phosphoramidon, 10(-4) M). Exogenous noradrenaline (10(-9)-10(-4) M) produced concentration-dependent arterial contractions that were not modified by BQ-788 (3x10(-6) M), BQ-123 (3x10(-6) M) or IRL-1620 (10(-7) M). Therefore, an inhibitory action of endogenous endothelin on sympathetic vasoconstriction may be present under basal conditions. This inhibition could be produced by endothelin through activation of prejunctional endothelin ET(B) receptors, which may inhibit noradrenaline release from perivascular sympathetic nerves.

[Safety of meningococcal A and C vaccine. Data from the Spanish drug surveillance system. Meningococcal Vaccine Research Group of the Spanish System of Drug Surveillance]

OBJECTIVE

Data on meningococcal vaccines safety are scanty. In 1997 several vaccination campaign took place in Spain. Thus, this situation was used to improve our knowledge about the safety profile of this vaccine.

METHODS

An inquiry was carried out to the Regional Centers of the Spanish Pharmacovigilance System to know the number of vaccinated people and the type and number of suspected cases of adverse reactions.

RESULTS

There were 133 identified cases of suspected adverse reactions associated with meningococcal A and C vaccine until June 1st, 1998. Most of them affected the skin (25,3%) or nervous system (similar proportion). Those of allergic reactions accounted for 35,2%. Two cases were considered as severe, although they were resolved without secuelae.

CONCLUSIONS

Serious risks were not detected. The Spanish Pharmacosurveillance System as an epidemiological surveillance resource has been useful to know the safety problems associated with antimeningococcal vaccine in the community.

Pharmacokinetic variables and tissue residues of enrofloxacin and ciprofloxacin in healthy pigs

OBJECTIVES

To determine pharmacokinetics of enrofloxacin and its metabolite ciprofloxacin after a single i.v. and i.m. administration of enrofloxacin and tissue residues after serial daily i.m. administration of enrofloxacin in pigs.

ANIMALS

20 healthy male pigs.

PROCEDURE

8 pigs were used in a crossover design to investigate pharmacokinetics of enrofloxacin after a single i.v. and i.m. administration (2.5 mg/kg of body weight). Twelve pigs were used to study tissue residues; they were given daily doses of enrofloxacin (2.5 mg/kg, i.m. for 3 days). Plasma and tissue concentrations of enrofloxacin and ciprofloxacin were determined. Residues of enrofloxacin and ciprofloxacin were measured in fat, kidney, liver, and muscle.

RESULTS

Mean (+/-SD) elimination half-life and mean residence time of enrofloxacin in plasma were 9.64+/-1.49 and 12.77+/-2.15 hours, respectively, after i.v. administration and 12.06+/-0.68 and 17.15+/-1.04 hours, respectively, after i.m. administration. Half-life at alpha phase of enrofloxacin was 0.23+/-0.05 and 1.94+/-0.70 hours for i.v. and i.m. administration, respectively. Maximal plasma concentration was 1.17 +/-0.23 microg/ml, and interval from injection until maximum concentration was 1.81+/-0.23 hours. Renal and hepatic concentrations of enrofloxacin (0.012 to 0.017 microg/g) persisted for 10 days; however, at that time, ciprofloxacin residues were not detected in other tissues.

CONCLUSIONS AND CLINICAL RELEVANCE

Enrofloxacin administered i.m. at a dosage of 2.5 mg/kg for 3 successive days, with a withdrawal time of 10 days, resulted in a sum of concentrations of enrofloxacin and ciprofloxacin that were less than the European Union maximal residue limit of 30 ng/g in edible tissues.

Second-site reversion of a human immunodeficiency virus type 1 reverse transcriptase mutant that restores enzyme function and replication capacity

Nonconservative substitutions for Tyr-115 in the reverse transcriptase (RT) of human immunodeficiency virus type 1 (HIV-1) lead to enzymes displaying lower affinity for deoxynucleoside triphosphates (dNTPs) (A. M. Martín-Hernández, E. Domingo, and L. Menéndez-Arias, EMBO J. 15:4434-4442, 1996). Several mutations at this position (Y115W, Y115L, Y115A, and Y115D) were introduced in an infectious HIV-1 clone, and the replicative capacity of the mutant viruses was monitored. Y115W was the only mutant able to replicate in MT-4 cells, albeit very poorly. Nucleotide sequence analysis of the progeny virus recovered from supernatants of four independent transfection experiments showed that the Y115W mutation was maintained. However, in all cases an additional substitution in the primer grip of the RT (M230I) emerged when the virus increased its replication capacity. Using recombinant HIV-1 RT, we demonstrate that M230I mitigates the polymerase activity defect of the Y115W mutant, by increasing the dNTP binding affinity of the enzyme. The second-site suppressor effects observed were mediated by mutations in the 66-kDa subunit of the RT, as demonstrated with chimeric heterodimers. Examination of available crystal structures of HIV-1 RT suggests a possible mechanism for restoration of enzyme activity by the second-site revertant.

Mutational analysis of Phe160 within the "palm" subdomain of human immunodeficiency virus type 1 reverse transcriptase

The highly conserved Phe160 residue is located in the "palm" subdomain of human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT), and makes contact with Tyr115, a residue which is involved in deoxynucleoside triphosphate (dNTP) binding and fidelity of DNA synthesis. Five mutant RTs having Tyr, Trp, Ile, Ala or Gln instead of Phe160 were obtained by site-directed mutagenesis. F160Y and F160W retained substantial DNA polymerase activity, whereas the catalytic efficiency of nucleotide incorporation of mutants F160I, F160A and F160Q was less than 10 % that of the wild-type RT, using poly(rA).oligo(dT)20 as the template-primer. The low catalytic efficiency of mutants F160I, F160A and F160Q was due to their lower affinity for the dNTP substrate. F160Y displayed similar kinetic parameters as the wild-type RT in nucleotide insertion assays carried out with heteropolymeric DNA/DNA template-primers. However, nucleotide affinity was two- to sixfold reduced in the case of mutant F160W. Fidelity assays revealed similar misinsertion and mispair extension ratios for the three enzymes, although F160W showed a slightly higher accuracy of DNA synthesis, particularly in the presence of high concentrations of dNTP. When introduced in an infectious proviral clone, mutations F160I, F160A and F160Q rendered non-viable virus. The importance of Phe160 for polymerase function and viral replication could be mediated by its interaction with Tyr115, as suggested by the analysis of the available crystal structures of HIV-1 RT.

Efficacy of low-dose subcutaneous interleukin-2 to treat advanced human immunodeficiency virus type 1 in persons with </=250/microL CD4 T cells and undetectable plasma virus load

The immunologic efficacy of low-dose recombinant interleukin-2 (rIL-2) administered subcutaneously (sc) once a day in combination with highly active antiretroviral therapy (HAART) was assessed in a pilot study in patients with advanced human immunodeficiency virus (HIV) disease. Twenty-five persons with </=250 CD4 cells/microL and plasma HIV-1 RNA levels </=500 copies/mL for >24 weeks were randomly assigned to receive sc rIL-2 (3 x 10(6) IU once a day) with their previous antiretroviral regimen (n=13) or to continue with the same treatment (n=12). The level of CD4 T cells was significantly higher in the IL-2 group at week 24 (105+/-65/microL; P<.05) but not in the control group (30+/-78/microL). Memory T cells initially contributed to the CD4 T cell increase at week 4 (P<.05). Naive T cell increases (99+/-58/microL) in the IL-2 group became statistically significant at week 24 compared with the control group (28+/-27/microL; P<.05). Subcutaneous rIL-2 once a day in combination with HAART was well tolerated and improved immunologic surface markers in patients with advanced HIV infection.

Time course and prognostic significance of hemostatic changes in sepsis: relation to tumor necrosis factor-alpha

OBJECTIVES

To describe the time course and prognostic significance of tumor necrosis factor-alpha (TNF-alpha) levels and hemostatic abnormalities in clinical sepsis.

DESIGN

Prospective, observational study with sequential measurements in an inception cohort.

SETTING

An emergency department in a university teaching hospital. Patients were followed up until they either left the hospital or died.

PATIENTS

During a 1-yr period, 43 adult patients were selected from all emergency department patients who met the established criteria for sepsis. Excluded were patients with either organ dysfunction or septic shock at the time of admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Blood samples were collected serially (day of admission and on days 3, 5, and 7) to determine TNF-alpha, platelet count, fibrinogen, factor VII, antithrombin III, tissue-type plasminogen activator activity, plasminogen activator inhibitor activity, plasminogen, and alpha2-antiplasmin. Fibrinopeptide A was measured only on the day of admission. Data were analyzed to determine whether admission values or serially obtained values within 7 days were useful in predicting outcome. Thirteen patients died and 30 survived. On admission, assay values indicated that platelet count and antithrombin III were significantly lower than normal (as observed in 50 healthy adults). Fibrinogen, plasminogen activator inhibitor type 1, tissue-type plasminogen activator, fibrinopeptide A, and TNF-alpha were higher than normal, whereas concentrations of factor VII, plasminogen, and alpha2-antiplasmin were in the normal range. No differences were detected in the admission values between survivors and nonsurvivors, except for antithrombin III. However, subsequent values of some variables demonstrated a difference between survivors and nonsurvivors. Survivors showed increasing platelet count and antithrombin III values compared with nonsurvivors, in whom the values remained low, with no significant changes during the study period. High TNF-alpha levels were found in both groups, but only survivors experienced progressive decrease during the observation period.

CONCLUSIONS

Early clinical sepsis is characterized by high plasma levels of TNF-alpha and by activation of the coagulation and fibrinolysis systems. Longitudinal analysis of some variables (antithrombin III, platelet count, and TNF-ea) showed some differences with time between the survivor and nonsurvivor groups, but we feel that such differences were not large enough to be predictive in individual patients.

Seroprevalence of Chlamydia pneumoniae in Chile

We used microimmunofluorescence to survey the prevalence of antibodies to Chlamydia pneumoniae in 403 serum samples from asymptomatic subjects aged 6 months to 89 y in Santiago, Chile. The results suggest that Chlamydia pneumoniae infection is endemic in Chile, with a seroprevalence of 60% which does not differ by gender.

Quantification of integrated and total HIV-1 DNA after long-term highly active antiretroviral therapy in HIV-1-infected patients

OBJECTIVE

To assess the impact of long-term virus suppression on the peripheral blood CD4 T cells integrated and total HIV-1 DNA loads in patients receiving highly active antiretroviral therapy (HAART).

METHODS

A total of 10 HIV-1-infected patients receiving a triple combination therapy (two nucleoside analogues and one protease inhibitor) were longitudinally studied to compare integrated and total HIV-1 DNA loads. HIV-1 DNA quantification was performed using a quantitative nested polymerase chain reaction (PCR) on genomic peripheral blood mononuclear cell (PBMC) DNA obtained at baseline and at 48 weeks of HAART.

RESULTS

All the study patients showed an early and sustained decrease in plasma HIV-1 RNA to below the limit of detection (200 copies/ml). Concordant with the plasma viral decline, a significant increase in the CD4 T cell count was observed (P = 0.007). A statistically significant fivefold decrease in total HIV-1 DNA was detected after 48 weeks of HAART (P = 0.005). However, no statistically significant change was noted after the therapy when the integrated HIV-1 DNA copy number was compared (P = 0.333). Taken together, these results suggest that in the patients analysed the integrated HIV-1 DNA does not decay rapidly after HAART.

CONCLUSION

Within the study cohort the total amount of PBMC HIV-1 DNA decreased drastically after 48 weeks of HAART. Nevertheless, the integrated HIV-1 DNA did not significantly decay during this period. Although the data presented here are limited by the number of patients analysed, our findings suggest that 48 weeks of HAART does not significantly reduce the integrated HIV-1 proviral DNA load in the latently infected CD4 T cell reservoir.

[Localized Castleman's disease associated with high-grade lymphoma]

Castleman's disease is a rare entity which is characterized by its histologic features: hyperplasia of lymph nodes and capillary proliferation. Two distinct histological patterns has been described: hyaline vascular type and plasma-cell type. Two different clinical course has been identified. While localized type is usually a benign disease in which surgical resection is curative, multicentric type has a poor prognosis regarded to the appearance of severe infection or neoplasm (Kaposi's sarcoma or malignant lymphoma. We present a rare association of localized Castleman's disease that presents synchronously with a diffuse large-cell lymphoma.

Human immunodeficiency virus type 1 genetic evolution in patients with prolonged suppression of plasma viremia

Treatment of human immunodeficiency virus type 1 (HIV-1)-infected patients with combination drug regimens results in a reduction of plasma viral load to levels below the limit of detection. To investigate the genomic fluctuations in HIV-1 populations from long-term responders to antiviral therapies we analyzed the viral sequence evolution of env and pol genes from sequential peripheral blood mononuclear cell (PBMC) DNA samples of three infected patients. Analyses of sequences covering the V3 and flanking env regions obtained from blood samples at the beginning of the therapy and at 14 or 24 months from baseline revealed that HIV-1 quasispecies continue to evolve in the three patients following combination antiretroviral therapy. Minor drug-resistant mutant subpopulations were also searched for and found in one patient. Interestingly, no minor resistant subpopulations were found in the other two patients despite the fact that they showed evidence of ongoing viral replication. Finally, the genetic analysis of the env gene shows a reduction in PBMC env viral population diversity after long-term response to the therapy in all the patients analyzed.

A comparative evaluation of Etest and broth microdilution methods for fluconazole and itraconazole susceptibility testing of Candida spp

The Etest strip is a promising tool of broad application in clinical microbiology. The method provides MIC readings and is easier to perform than broth microdilution. We carried out a study to compare the MICs of fluconazole and itraconazole obtained by the Etest with those obtained by broth microdilution, performed according to the guidelines of the NCCLS document M27-A, with 402 clinical isolates (360 Candida albicans, 17 Candida tropicalis, nine Candida krusei, nine Candida glabrata and seven Candida parapsilosis) and seven control isolates. The agreement between MICs by the two methods (at +/- 2 dilutions) was 74.5% for fluconazole and 61.4% for itraconazole. These results suggest that further development is necessary to standardize the medium and incubation conditions before introduction of the Etest as a routine method in the clinical microbiology laboratory for fluconazole and itraconazole susceptibility testing.

Frequency and determinants of white coat hypertension in mild to moderate hypertension: a primary care-based study. Monitorización Ambulatoria de la Presión Arterial (MAPA)-Area 5 Working Group

Most of the previous studies on white coat hypertension were performed in hypertension clinics or academic settings and included relatively small series of patients. Consequently, the prevalence of white coat hypertension in primary care settings and the clinical and epidemiologic characteristics of this subgroup of patients are not well known. We performed this study to estimate the frequency of white coat hypertension in a population of mildly to moderately hypertensive subjects attended in a primary care setting and to examine possible epidemiologic and clinical factors that may identify these patients. Patients included in the study underwent clinical interview, measurement of clinic blood pressure (BP) on three visits, determination of serum lipids, glucose, uric acid, and urinary albumin excretion, 24-h ambulatory BP monitoring, and M-mode and Doppler echocardiography. Patients were classified as white coat hypertensives if their daytime ambulatory BP were < 135/85 mm Hg. We studied 345 patients, 136 (39%) of whom were diagnosed with white coat hypertension. The frequency of white coat hypertension was inversely proportional to the severity of clinic BP values. The diagnosis of white coat hypertension was independently associated with female gender and low educational level. Left ventricular mass index and urinary albumin excretion were lower in the white-coat hypertensive group compared with the group with sustained hypertension. Our results show that a high proportion of patients with mild to moderate hypertension attended in a primary care setting have white coat hypertension. Some clinical characteristics may be helpful in the identification of this group of subjects. White coat hypertensives show less target-organ damage than sustained hypertensive patients.

[Prognostic features of residual pleural thickening in metapneumonic pleural effusion]

Residual pleural thickening (RPT) develops in some patients after metapneumonic pleural effusion (MPE). Our aim was to identify factors that predict the development of RPT by retrospectively analyzing patients with MPE secondary to bacterial pneumonia in our practice from 1992 through April 1997. Patients were assigned to groups based on the presence or not of RPT (> 10 mm) three months or more after diagnosis of MPE. One hundred twenty-eight patients were included in the analysis. Seventy-nine patients (62%) developed RPT and 49 (38%) did not. Patients with RPT had significantly lower glucose levels and pH and higher LDH levels in pleural fluid. A higher percentage of patients with RPT had loculate pleural effusions and empyema, and they more often required insertion of drains. Logistic regression analysis showed that only glucose < 40 mg/dl (OR: 3.4; CI 95%: 2.3 to 4.5; p < 0.05) and the presence of pus collected from the initial thoracocentesis (OR: 3.6; CI 95%: 2.6 to 4.5; p < 0.01) were significantly associated with increased risk of developing residual pachypleuritis in subjects with MPE.

Adherence of Acinetobacter baumannii to rat bladder tissue

Acinetobacter baumannii, an important nosocomial pathogen, causes severe infections in patients of intensive care units, but its pathogenic attributes are unknown. Previously, the adherence of A. baumannii to cell lines has been negative in the authors' laboratory. In this work, the adherence of strains of A. baumannii of various biotypes to small pieces of rat bladder tissue was investigated. Tissue pieces were submerged into cultures of A. baumannii and sessile cells were counted after removing planktonic bacteria. Fimbriae and sessile cells were examined by transmission and scanning electron microscopy, respectively. In contrast to a uropathogenic strain of Escherichia coli, all cultures exhibited a mannose- and galactose-resistant agglutination of human group O red blood cells as well as mannose- and galactose-resistant adherence to the bladder tissue. Inhibition of exopolysaccharide synthesis did not modify adherence. Indeed, adherence, apparently unrelated to these fimbriae or to the exopolysaccharide, may be a factor contributing to the pathogenicity of A. baumannii in the urinary tract or in other tissues.

[Complex anomalies of the anterior chest wall. Personalized surgical treatment]

Among the congenital anomalies of the anterior chest wall, the group of the asymmetrical deformities, mixed or complex, are the least frequent and the ones that require a difference surgical strategy for each patient according to their anatomical features. In this paper we present our experience and findings with this type of malformation. The fundamental aspects of the surgical indications and procedure are commented. The evolution and the results are very satisfactory. We stress the positive reaction of the patients and their families after the operation.

Absence of hypoalbuminemia despite massive proteinuria in focal segmental glomerulosclerosis secondary to hyperfiltration

We observed that some patients do not develop hypoalbuminemia despite the presence of massive proteinuria. To investigate whether the absence or presence of hypoalbuminemia could be a marker in the distinction between idiopathic focal segmental glomerulosclerosis (FSG) and FSG secondary to hyperfiltration, we reviewed all our patients with biopsy-proven FSG and persistent nephrotic-range proteinuria (>3.5 g/24 h). Patients who met these conditions were then separated into those with hypoalbuminemia (serum albumin level <3 g/dL; group I; n = 19) and those with normoalbuminemia (>3.5 g/24 h; group II; n = 18). All group I patients had nephrotic edema in contrast with the absence of edema in all group II patients. Serum cholesterol and triglyceride levels were significantly greater in group I. All group I patients had been diagnosed with idiopathic FSG. The diagnoses of group II patients were FSG secondary to massive obesity in eight patients (44%), vesicoureteral reflux in five patients (27%), and renal mass reduction in three patients (16%); only two patients (11%) in this group had idiopathic FSG. The case histories of 19 other patients with nephrotic-range proteinuria associated with hyperfiltering disorders (reflux nephropathy, massive obesity, renal mass reduction), but without renal biopsy, were also reviewed; despite massive proteinuria (5.8 +/- 3.1 g/24 h), serum albumin and total protein levels were always within normal values. In conclusion, patients with FSG secondary to hyperfiltration do not develop hypoalbuminemia or the other characteristic complications of nephrotic syndrome, despite the presence of massive proteinuria values.

Genetic evolution of hepatitis G virus in chronically infected individual patients

Comparative sequence analysis of different isolates of hepatitis G virus (HGV) has demonstrated significant intersubject genetic heterogeneity, but few data on intrasubject genetic evolution have been reported. To further investigate the genetic diversification of the HGV genome, 36 plasma samples from eleven patients chronically infected with HGV serially obtained 2-4 years apart were analysed. We determined the viral nucleotide sequence of the 5' non-coding (NC) and the NS3 regions by directly sequencing the RT-PCR amplified products obtained from the viral RNAs. Intrasubject sequence variation was found to be 1.3-2.4 x 10(-3) base substitutions per genome site per year within the 5' NC region and 1.3-9.4 x 10(-3) base substitutions per genome site per year within the NS3 region. Depending on the genomic region analysed (i.e. 5' NC or NS3 region), pairwise comparisons and phylogenetic reconstructions showed that intersubject genetic distances were 17.5- to 20.8-fold greater than intrasubject ones. Overall, the evolution rate of HGV in the regions analysed is not significantly different from that found in hepatitis C virus.

[Basophilic blast crisis in chronic myeloid leukemia]

Acute basophilic leukaemia is usually characterized by a very rapid clinical course, hyperhistaminemia, resistance to antineoplastic therapy and early death due to complications related to disease. This entity is a rare condition, accounting for less than two percent of all haematopoietic malignancies. Most of the case reports are basophilic blast crisis in patients with a previous lympho or myeloproliferative disorder. A 62-year-old woman who was diagnosed as Philadelphia positive chronic myelogenous leukaemia after four years of evolution developed a basophilic blast crisis, whose characteristics are reported. Accompanying this transformation there was also a cytogenetic change. Despite chemotherapy the patient died of disease progression.