Juxtaglomerular cell tumor as a rare cause of hypertension in adults

The juxtaglomerular cell tumor is a cause of secondary hypertension in adults. A 35-year-old female patient suffering from hypertension and low serum potassium had a 3 × 3 cm solid mass at the lower pole of left kidney diagnosed by abdominal sonography. Partial nephrectomy was performed and the postoperatory was uneventful. Normalization of blood pressure was observed within the first month.

Análise da prescrição de medicamentos de pacientes hipertensos atendidos pelo SUS da rede municipal de saúde de Rincão - SP

The purpose of this study was to identify the drugs most often prescribed for hypertension at the Municipal Health Care Center of the town of Rincäo, State of São Paulo, Brazil, and the principal interactions arising from their association with other drugs, both anti-hypertensives and those in other classes. The study included 725 hypertensive patients registered at this health care center who were regularly seen by a physician every three months. Data were collected on age, sex, occurrence of diabetes, smoking, sedentary lifestyle and overweight, to obtain a profile of the hypertensive population of the area. Control records of all patients were available at the pharmacy in the health care center, where patients obtained their drugs once a month. Of the 725 patients, 38% were male and 62% female. Most (57%) were between 50 and 70 years of age, 21% used tobacco and 43% led a sedentary lifestyle. Single-drug therapy accounted for 33% of the prescriptions, multidrug therapy for 66%. In addition to anti-hypertensives, 50% of the patients took drugs of other therapeutic classes. Of those receiving multidrug therapy, 34% used three or more anti-hypertensives and 66% used only two of these drugs. Drug interactions were detected in as many as 47% of the prescriptions. Captopril was the drug that showed most interactions with others (54%), followed by hydrochlorothiazide (27%), furosemide (14%), propanolol (4%), and nifedipine (1%). The analysis revealed that drug consumption by the patients investigated is high, with a concomitantly high number of episodes of drug interaction.

Contribuição do uso de medicamentos para a admissão hospitalar

According to the Word Health Organization, adverse drug reactions (ADR) are any harmful and non intentional answer which occurred in doses normally used in human beings. The ADR can be responsible for 2.4% to 11.5% of hospital admissions. Therefore, this study aimed at knowing the admitted patient's demographic profile due to possible ADR, identifying the most frequent drugs and complaints, and evaluating the incidence of hospital admission related to drug use. Patients who were 18 years old or more and were admitted during a period of one month to a medical clinical of a general hospital were interviewed for one month about drug use before being admitted, as well as regarding to the complaint which led them to hospital. These information were analyzed according to official data, like MICROMEDEX® and WHO criteria as well. It was observed that the admission due to drug use occurred in most part of the cases in elderly [47.5% (66/139)] and women [62% (87/139)]. The most frequent drugs used were: omeprazole (16), analgesics (31), antihypertensive (31), simvastatin (7) and formoterol fumarate (6), and the symptoms were normally associated to the digestive (20.5%), circulatory (20.2%), respiratory (18.2%) and central nervous systems (13.9%). It was estimated that 15.5% (139/897) of the hospital admission occurred possibly due to the drug use. The data found by present study suggests some strategies in order to prevent ADR in the context of primary health care services, such as monitoring drug therapy, manly for patients with chronic diseases, elderly and polimedicated people; and pharmaceutical care including dispensation and purchasing of the drugs, a lot of them dispensed over the counter (OTC).

Adverse drug reaction as cause of hospital admission of elderly people: a pilot study

The objective of this study was to estimate the prevalence of adverse drug reactions (ADR) related to hospital admission of elderly people, identifying the use of potentially inappropriate medication (PIM), the ADR and the risk factors associated with the hospitalization. A cross-sectional study was conducted in a private hospital of São Paulo State, Brazil. All patients aged ≥ 60 years, admitted in the general practice ward in May 2006 were interviewed about the drugs used and the symptoms/complaints that resulted in hospitalization. More than a half (54.5 %) of elderly hospitalizations were related with ADR. The therapeutic classes involved with ADR were: cardiovascular (37.7 %), central nervous (34.6 %) and respiratory (5.7 %). The ADR observed were disorders in circulatory (28.4 %), digestive (20.0 %) and respiratory (18.9 %) tracts. 27 elderly had made PIM and in 20 of them this was the cause of hospitalization. Polypharmacy was an ADR risk factor (p = 0.021).These data allows the healthcare professionals upgrade, qualifying them in pharmcovigilance.

Combination Therapy for the Cardiovascular Effects of Perinatal Lead Exposure in Young and Adult Rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Alterations in the water intake caused by central inhibition of angiotensin-converting enzyme in the rat

In the present study we investigated the effects of central (i.c.v.) and subcutaneous (s.c.) injections of a 2 μg dose of lisinopryl, an inhibitor of angiotensin I(ANGI)-converting enzyme (CE), on water intake. I.c.v. but not s.c. injection of lisinopryl abolished drinking in response to s.c. isoprenaline (100 μg/kg) and significantly reduced drinking in response to 24 h water deprivation or s.c. polyethylene glycol (30% w/v, 10 ml/kg). Lisinopryl had no effect on water intake induced by cellular dehydration (s.c. injection of hypertonic saline (2 M NaCl)). These results are consistent with the hypothesis that lisinopryl acts as a CE blocking agent in the brain. The thirst challenge induced by hypotension using isoprenaline acts primarily by generating ANGII systemically and centrally. The other thirst challenges such as cellular dehydration are independent of the ANGII in the brain. This conclusion was made possible by utilizing a new CE blocking agent at a smaller dose than normally used for other ANG I-CE inhibitors. © 1992.

Potential Drug-Drug Interactions in Prescriptions to Patients over 45 Years of Age in Primary Care, Southern Brazil

Background: Few cross-sectional studies involving adults and elderly patients with major DDIs have been conducted in the primary care setting. The study aimed to investigate the prevalence of potential drug-drug interactions (DDIs) in patients treated in primary care. Methodology/Principal Findings: A cross-sectional study involving patients aged 45 years or older was conducted at 25 Basic Health Units in the city of Maringa (southern Brazil) from May to December 2010. The data were collected from prescriptions at the pharmacy of the health unit at the time of the delivery of medication to the patient. After delivery, the researcher checked the electronic medical records of the patient. A total of 827 patients were investigated (mean age: 64.1; mean number of medications: 4.4). DDIs were identified in the Micromedex (R) database. The prevalence of potential DDIs and major DDIs was 63.0% and 12.1%, respectively. In both the univariate and multivariate analyses, the number of drugs prescribed was significantly associated with potential DDIs, with an increasing risk from three to five drugs (OR = 4.74; 95% CI: 2.90-7.73) to six or more drugs (OR = 23.03; 95% CI: 10.42-50.91). Forty drugs accounted for 122 pairs of major DDIs, the most frequent of which involved simvastatin (23.8%), captopril/enalapril (16.4%) and fluoxetine (16.4%). Conclusions/Significance: This is the first large-scale study on primary care carried out in Latin America. Based on the findings, the estimated prevalence of potential DDIs was high, whereas clinically significant DDIs occurred in a smaller proportion. Exposing patients to a greater number of prescription drugs, especially three or more, proved to be a significant predictor of DDIs. Prescribers should be more aware of potential DDIs. Future studies should assess potential DDIs in primary care over a longer period of time.

An economic evaluation of antihypertensive therapies based on clinical trials

OBJECTIVE: Hypertension is a major issue in public health, and the financial costs associated with hypertension continue to increase. Cost-effectiveness studies focusing on antihypertensive drug combinations, however, have been scarce. The cost-effectiveness ratios of the traditional treatment (hydrochlorothiazide and atenolol) and the current treatment (losartan and amlodipine) were evaluated in patients with grade 1 or 2 hypertension (HT1-2). For patients with grade 3 hypertension (HT3), a third drug was added to the treatment combinations: enalapril was added to the traditional treatment, and hydrochlorothiazide was added to the current treatment. METHODS: Hypertension treatment costs were estimated on the basis of the purchase prices of the antihypertensive medications, and effectiveness was measured as the reduction in systolic blood pressure and diastolic blood pressure (in mm Hg) at the end of a 12-month study period. RESULTS: When the purchase price of the brand-name medication was used to calculate the cost, the traditional treatment presented a lower cost-effectiveness ratio [US$/mm Hg] than the current treatment in the HT1-2 group. In the HT3 group, however, there was no difference in cost-effectiveness ratio between the traditional treatment and the current treatment. The cost-effectiveness ratio differences between the treatment regimens maintained the same pattern when the purchase price of the lower-cost medication was used. CONCLUSIONS: We conclude that the traditional treatment is more cost-effective (US$/mm Hg) than the current treatment in the HT1-2 group. There was no difference in cost-effectiveness between the traditional treatment and the current treatment for the HT3 group.

Central autonomic control in spontaneously hypertensive rats: a study on phasic phenomena during rapid-eye-movement sleep

The cardiovascular regulation undergoes wide changes in the different states of sleepwake cycle. In particular, the relationship between spontaneous fluctuations in heart period and arterial pressure clearly shows differences between the two sleep states. In non rapid-eye-movement sleep, heart rhythm is under prevalent baroreflex control, whereas in rapid-eye-movement sleep central autonomic commands prevail (Zoccoli et al., 2001). Moreover, during rapid-eye-movement sleep the cardiovascular variables show wide fluctuations around their mean value. In particular, during rapid-eyemovement sleep, the arterial pressure shows phasic hypertensive events which are superimposed upon the tonic level of arterial pressure. These phasic increases in arterial pressure are accompanied by an increase in heart rate (Sei & Morita, 1996; Silvani et al., 2005). Thus, rapid-eye-movement sleep may represent an “autonomic stress test” for the cardiovascular system, able to unmask pathological patterns of cardiovascular regulation (Verrier et al. 2005), but this hypothesis has never been tested experimentally. The aim of this study was to investigate whether rapid-eye-movement sleep may reveal derangements in central autonomic cardiovascular control in an experimental model of essential hypertension. The study was performed in Spontaneously Hypertensive Rats, which represent the most widely used model of essential hypertension, and allow full control of genetic and environmental confounding factors. In particular, we analyzed the cardiovascular, electroencephalogram, and electromyogram changes associated with phasic hypertensive events during rapid-eyemovement sleep in Spontaneously Hypertensive Rats and in their genetic Wistar Kyoto control strain. Moreover, we studied also a group of Spontaneously Hypertensive Rats made phenotypically normotensive by means of a chronic treatment with an angiotensin converting enzyme inhibitor, the Enalapril maleate, from the age of four weeks to the end of the experiment. All rats were implanted with electrodes for electroencephalographic and electromyographic recordings and with an arterial catheter for arterial pressure measurement. After six days for postoperative recovery, the rats were studied for five days, at an age of ten weeks.The study indicated that the peak of mean arterial pressure increase during the phasic hypertensive events in rapid-eye-movement sleep did not differ significantly between Spontaneously Hypertensive Rats and Wistar Kyoto rats, while on the other hand Spontaneously Hypertensive Rats showed a reduced increase in the frequency of theta rhythm and a reduced tachicardia with respect to Wistar Kyoto rats. The same pattern of changes in mean arterial pressure, heart period, and theta frequency was observed between Spontaneously Hypertensive Rats and Spontaneously Hypertensive Rats treated with Enalapril maleate. Spontaneously Hypertensive Rats do not differ from Wistar Kyoto rats only in terms of arterial hypertension, but also due to multiple unknown genetic differences. Spontaneously Hypertensive Rats were developed by selective breeding of Wistar Kyoto rats based only on the level of arterial pressure. However, in this process, multiple genes possibly unrelated to hypertension may have been selected together with the genetic determinants of hypertension (Carley et al., 2000). This study indicated that Spontaneously Hypertensive Rats differ from Wistar Kyoto rats, but not from Spontaneously Hypertensive Rats treated with Enalapril maleate, in terms of arterial pH and theta frequency. This feature may be due to genetic determinants unrelated to hypertension. In sharp contrast, the persistence of differences in the peak of heart period decrease and the peak of theta frequency increase during phasic hypertensive events between Spontaneously Hypertensive Rats and Spontaneously Hypertensive Rats treated with Enalapril maleate demonstrates that the observed reduction in central autonomic control of the cardiovascular system in Spontaneously Hypertensive Rats is not an irreversible consequence of inherited genetic determinants. Rather, the comparison between Spontaneously Hypertensive Rats and Spontaneously Hypertensive Rats treated with Enalapril maleate indicates that the observed differences in central autonomic control are the result of the hypertension per se. This work supports the view that the study of cardiovascular regulation in sleep provides fundamental insight on the pathophysiology of hypertension, and may thus contribute to the understanding of this disease, which is a major health problem in European countries (Wolf-Maier et al., 2003) with its burden of cardiac, vascular, and renal complications.

Prozessanalytische Technologien "PAT" zur Optimierung von Wirbelschichtgranulationsprozessen

In der Herstellung fester Darreichungsformen umfasst die Granulierung einen komplexen Teilprozess mit hoher Relevanz für die Qualität des pharmazeutischen Produktes. Die Wirbelschichtgranulierung ist ein spezielles Granulierverfahren, welches die Teilprozesse Mischen, Agglomerieren und Trocknen in einem Gerät vereint. Durch die Kombination mehrerer Prozessstufen unterliegt gerade dieses Verfahren besonderen Anforderungen an ein umfassendes Prozessverständnis. Durch die konsequente Verfolgung des PAT- Ansatzes, welcher im Jahre 2004 durch die amerikanische Zulassungsbehörde (FDA) als Guideline veröffentlicht wurde, wurde der Grundstein für eine kontinuierliche Prozessverbesserung durch erhöhtes Prozessverständnis, für Qualitätserhöhung und Kostenreduktion gegeben. Die vorliegende Arbeit befasste sich mit der Optimierung der Wirbelschicht-Granulationsprozesse von zwei prozesssensiblen Arzneistoffformulierungen, unter Verwendung von PAT. rnFür die Enalapril- Formulierung, einer niedrig dosierten und hochaktiven Arzneistoffrezeptur, wurde herausgefunden, dass durch eine feinere Zerstäubung der Granulierflüssigkeit deutlich größere Granulatkörnchen erhalten werden. Eine Erhöhung der MassRatio verringert die Tröpfchengröße, dies führt zu größeren Granulaten. Sollen Enalapril- Granulate mit einem gewünschten D50-Kornverteilung zwischen 100 und 140 um hergestellt werden, dann muss die MassRatio auf hohem Niveau eingestellt werden. Sollen Enalapril- Granulate mit einem D50- Wert zwischen 80 und 120µm erhalten werden, so muss die MassRatio auf niedrigem Niveau eingestellt sein. Anhand der durchgeführten Untersuchungen konnte gezeigt werden, dass die MassRatio ein wichtiger Parameter ist und zur Steuerung der Partikelgröße der Enalapril- Granulate eingesetzt werden kann; unter der Voraussetzung dass alle anderen Prozessparameter konstant gehalten werden.rnDie Betrachtung der Schnittmengenplots gibt die Möglichkeit geeignete Einstellungen der Prozessparameter bzw. Einflussgrößen zu bestimmen, welche dann zu den gewünschten Granulat- und Tabletteneigenschaften führen. Anhand der Lage und der Größe der Schnittmenge können die Grenzen der Prozessparameter zur Herstellung der Enalapril- Granulate bestimmt werden. Werden die Grenzen bzw. der „Design Space“ der Prozessparameter eingehalten, kann eine hochwertige Produktqualität garantiert werden. rnUm qualitativ hochwertige Enalapril Tabletten mit der gewählten Formulierung herzustellen, sollte die Enalapril- Granulation mit folgenden Prozessparametern durchgeführt werden: niedrige Sprührate, hoher MassRatio, einer Zulufttemperatur von mindestens > 50 °C und einer effektiven Zuluftmenge < 180 Nm³/h. Wird hingegen eine Sprührate von 45 g/min und eine mittlere MassRatio von 4.54 eingestellt, so muss die effektive Zuluftmenge mindestens 200 Nm³/h und die Zulufttemperatur mindestens 60 °C betragen, um eine vorhersagbar hohe Tablettenqualität zu erhalten. Qualität wird in das Arzneimittel bereits während der Herstellung implementiert, indem die Prozessparameter bei der Enalapril- Granulierung innerhalb des „Design Space“ gehalten werden.rnFür die Metformin- Formulierung, einer hoch dosierten aber wenig aktiven Arzneistoffrezeptur wurde herausgefunden, dass sich der Wachstumsmechanismus des Feinanteils der Metformin- Granulate von dem Wachstumsmechanismus der D50- und D90- Kornverteilung unterscheidet. Der Wachstumsmechanismus der Granulate ist abhängig von der Partikelbenetzung durch die versprühten Flüssigkeitströpfchen und vom Größenverhältnis von Partikel zu Sprühtröpfchen. Der Einfluss der MassRatio ist für die D10- Kornverteilung der Granulate vernachlässigbar klein. rnMit Hilfe der Störgrößen- Untersuchungen konnte eine Regeleffizienz der Prozessparameter für eine niedrig dosierte (Enalapril)- und eine hoch dosierte (Metformin) Arzneistoffformulierung erarbeitet werden, wodurch eine weitgehende Automatisierung zur Verringerung von Fehlerquellen durch Nachregelung der Störgrößen ermöglicht wird. Es ergibt sich für die gesamte Prozesskette ein in sich geschlossener PAT- Ansatz. Die Prozessparameter Sprührate und Zuluftmenge erwiesen sich als am besten geeignet. Die Nachregelung mit dem Parameter Zulufttemperatur erwies sich als träge. rnFerner wurden in der Arbeit Herstellverfahren für Granulate und Tabletten für zwei prozesssensible Wirkstoffe entwickelt. Die Robustheit der Herstellverfahren gegenüber Störgrößen konnte demonstriert werden, wodurch die Voraussetzungen für eine Echtzeitfreigabe gemäß dem PAT- Gedanken geschaffen sind. Die Kontrolle der Qualität des Produkts findet nicht am Ende der Produktions- Prozesskette statt, sondern die Kontrolle wird bereits während des Prozesses durchgeführt und basiert auf einem besseren Verständnis des Produktes und des Prozesses. Außerdem wurde durch die konsequente Verfolgung des PAT- Ansatzes die Möglichkeit zur kontinuierlichen Prozessverbesserung, zur Qualitätserhöhung und Kostenreduktion gegeben und damit das ganzheitliche Ziel des PAT- Gedankens erreicht und verwirklicht.rn

Taste acceptability of pulverized brand-name and generic drugs containing amlodipine or candesartan.

Trials with pulverized brand-name antihypertensive drugs suggest that, from the perspective of taste acceptability, crushed candesartan, chlortalidon, hydrochlorothiazide, lercanidipine and lisinopril should be preferred to pulverized amlodipine, atenolol, bisoprolol, enalapril, irbesartan, losartan, ramipril, telmisartan and valsartan. Brand-name antihypertensive drugs and the corresponding generic medicines have never been compared with respect to their taste acceptability. We therefore investigated among healthy health care workers the taste acceptability of a pulverized 1 mg-test dose of the brand-name and two generics containing either the dihydropyridine calcium-channel blocker amlodipine (Norvasc(®), Amlodipin-Mepha(®) and Amlodipin Pfizer(®)) or the angiotensin receptor antagonist candesartan (Atacand(®), Cansartan-Mepha(®) and Pemzek(®)). For this purpose, a smiley-face scale depicting four degrees of pleasure was used. Between November and December 2013, the taste test was performed among 19 nurses (15 female and 4 male subjects) and 12 physicians (5 female and 7 male subjects) aged between 25 and 49 years. Pulverized brand-names and generics containing either amlodipine or candesartan did not differ with respect to their taste acceptability.

Avaliação comparativa dos efeitos do anlodipino e da pimobendana na insuficiência valvar crônica de mitral em cães

A insuficiência valvar crônica de mitral (IVCM) é a principal cardiopatia de cães, correspondendo a 75-85% dos casos de cardiopatias. É causada pela degeneração mixomatosa da valva mitral (endocardiose de mitral) sendo, então, uma doença degenerativa adquirida e que pode ocasionar a insuficiência cardíaca congestiva (ICC). Pode acometer qualquer raça de cão, mas é mais frequentemente observada nas raças de pequeno porte, dentre as quais, Poodle miniatura, Spitz Alemão, Dachshund, Yorkshire Terrier, Chihuahua e Cavalier King Charles Spaniel. Na endocardiose de mitral, o volume sanguíneo regurgitado causa sobrecarga do lado esquerdo do coração, devido ao aumento das pressões atrial e ventricular esquerdas, seguida de dilatação e hipertrofia dessas cavidades cardíacas. A elevação da pressão ventricular esquerda pode causar hipertensão pulmonar, congestão e, em estágios avançados, edema pulmonar. A doença pode evoluir assintomática, enquanto que naqueles casos que evoluem para insuficiência cardíaca congestiva (ICC) os sintomas mais usuais são: tosse, intolerância ao exercício, dispneia e síncope. Em 2009 o colégio americano de medicina interna veterinária (American College of Veterinary Internal Medicine -ACVIM) elaborou diretrizes para o tratamento da IVCM, tendo por base a classificação funcional adaptada do American College of Cardiology. Neste trabalho foram utilizados os fármacos anlodipino e pimobendana em associação a outros usualmente indicados no tratamento da ICC em cães, segundo consenso de 2009, indicados no tratamento da ICC em cães. Dois grupos (A e B) de cães, cada um constituído por 10 pacientes com IVCM em estágio C, foram tratados com furosemida e maleato de enalapril, sendo que os animais do grupo A receberão pimobendana e os do grupo B, anlodipino. Os animais foram avaliados em diferentes momentos (T0, T30, T60) observando-se as alterações nos exames ecodopplercardiográfico e eletrocardiográfico, bem como de pressão arterial sistólica

Benefits of ACE inhibitors with tissue-active levels in the cardiac-compromised patient

Angiotensin converting enzyme inhibitors (ACEI) have been proven beneficial to the cardiac-compromised patient, but whether there is an advantage associated with using a tissue-active or systemically-active ACEI is debatable. An investigation into the clinical benefits of tissue ACEI for veterinary patients was undertaken by comparing enalapril with ramipril. Results obtained concluded that although there is much evidence to prove that tissue ACEIs are superior over systemic ACEIs at the cellular level, this does not correlate in the clinical sense. Both enalapril and ramipril provided similar clinical benefits to the cardiac-compromised patient.

Internal mammary artery smooth muscle cells resist migration and possess high antioxidant capacity

Objective- This study investigated whether differences exist in atherogen-induced migratory behaviors and basal antioxidant enzyme capacity of vascular smooth muscle cells (VSMC) from human coronary (CA) and internal mammary (IMA) arteries. Methods- Migration experiments were performed using the Dunn chemotaxis chamber. The prooxidant [NAD(P)H oxidase] and antioxidant [NOS, superoxide dismutase, catalase and glutathione peroxidase] enzyme activities were determined by specific assays. Results- Chemotaxis experiments revealed that while both sets of VSMC migrated towards platelet-derived growth factor-BB (1-50 ng/ml) and angiotensin II (1-50 nM), neither oxidized-LDL (ox-LDL, 25-100 �g/ml) nor native LDL (100 �g/ml) affected chemotaxis in IMA VSMC. However, high dose ox-LDL produced significant chemotaxis in CA VSMC that was inhibited by pravastatin (100 nM), mevastatin (10 nM), losartan (10 nM), enalapril (1 �M), and MnTBAP (a free radical scavenger, 50��M). Microinjection experiments with isoprenoids i.e. geranylgeranylpyrophosphate (GGPP) and farnesylpyrophosphate (FPP) showed distinct involvement of small GTPases in atherogen-induced VSMC migration. Significant increases in antioxidant enzyme activities and nitrite production along with marked decreases in NAD(P)H oxidase activity and O2 .- levels were determined in IMA versus CA VSMC. Conclusions- Enhanced intrinsic antioxidant capacity may confer on IMA VSMC resistance to migration against atherogenic agents. Drugs that regulate ox-LDL or angiotensin II levels also exert antimigratory effects.