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Older hypertensive adults under treatment are especially susceptible to hypotensive episodes, which entail an elevated risk. However, data on this subject are very scarce. The purpose of this study was to determine the prevalence and predictors of office and home hypotension in older (≥ 65 years) treated hypertensive adults. Blood pressure (BP) was measured at the office and at home, using a validated oscillometric device. Office and home hypotension were defined as systolic BP (SBP)

Hypertension is a haemodynamic disorder resulting from a persistent mismatch between cardiac output and peripheral resistance. Hypertension undergoes haemodynamic progression during its natural history. Impedance cardiography is a method of evaluating the cardiovascular system that obtains haemodynamic information from beat to beat through the analysis of variations in the impedance of the thorax on the passage of an electric current. Impedance cardiography unmasks the haemodynamic deterioration underlying the increase in blood pressure as age and systolic blood pressure increases. This method may help to improve blood pressure control through individualized treatment with reduction of peripheral resistance, maintenance of cardiac output or its increase, improvement of arterial compliance and preservation of organ-tissue perfusion. It is useful in the management of patients with resistant hypertension, since a greater percentage of patients controlled with changes in the treatment in relation to the haemodynamic measurements are obtained. Impedance cardiography is important and has prognostic utility in relation to a haemodynamic deterioration pattern and increased cardiovascular events.

BACKGROUND An extremely elevated erythrosedimentation rate (ESR), defined as equal or higher than 100 mm/h, has been linked to serious underlying conditions, such as infections, connective tissue and oncologic disease. AIM To analyze a group of patients in order to determine the underlying diagnosis and the characteristics associated with extremely elevated ESR in our environment. METHODS Cross-sectional study of adult patients, who presented with at least one ESR equal or higher than 100 mm/h at Hospital Italiano, in Buenos Aires (Buenos Aires, Argentina) between January 2002 and August 2014. RESULTS During the previously stated period of time, we analyzed the results of 879 patients. All patients were over 18 years of age. The median for the ESR results was 111 mm/h (interquartile range 105-120). The most prevalent etiology of an elevated ESR was infectious (41.64%), followed by malignancies (21.62%) and autoimmune / inflammatory diseases (12.97%). The most frequent individual diagnosis found was pneumonia (11.49%), followed by undetermined causes (5.92%). CONCLUSION When comparing inpatient versus outpatient populations, the most frequent cause was infectious in the former group, while malignancies were the most frequent diagnosis in the latter.

Crowding in Emergency Departments (ED), results from the imbalance between the simultaneous demand for health care and the ability of the system to respond. The NEDOCS scale (National Emergency Department Crowding Scale) measures the degree of crowding in an ED. Aim: To describe ED Crowding characteristics, using the NEDOCS scale, in an Argentinean hospital. Material and Methods: A retrospective cohort study was conducted with all adult patient consultations between July 2013 and July 2014 at the ED of Hospital Italiano de Buenos Aires. We included all hours in the analysis period (365 days x 24 h = 8,760). The NEDOCS value was calculated for each hour using an automatic algorithm and was quantified in a six points score. Levels 4 (overcrowded), 5 (severely overcrowded) and 6 (dangerously overcrowded) were defined as overcrowding. Contour plots analysis was applied to identify patterns. Results: During the study period, 124,758 visits to the ED were registered. Overcrowding was present in 57.7% (5,055) of the analyzed hours. A predominance of scores between four and five was observed between 10:00 and 24:00 hours. The months with predominance of overcrowding were June, July and August (southern winter). Conclusions: The calculation of the NEDOCS score and the analysis of its temporal distribution are highly relevant to identify opportunities for improvement and to develop mechanisms to prevent the highest categories of overcrowding

OBJECTIVE The objective of this study was to compare the aortic piezoelectric device for noninvasive measurement of central aortic systolic blood pressure (cSBP) with the SphygmoCor. PARTICIPANTS AND METHODS A total of 85 participants from both sexes, aged 18-80 years, were stratified into three age groups ( 60 years), with an equal number of healthy volunteers and hypertensive patients. We performed three cSBP measurements with each device, in an alternate manner, using the Bland-Altman method to determine the level of agreement. The standard of the Association for the Advancement of Medical Instrumentation for brachial blood pressure evaluation was used for the comparison. RESULTS The mean cSBPs were 109.3±12.05 and 109.0±12.2 mmHg with the SphygmoCor and the Aortic device, respectively, showing a strong correlation (r=0.98, P

Objective In this analysis of the telehealth-based Vascular health ASsessment Of The hypertENSive patients Registry, we checked how 24-h central and peripheral hemodynamics compare with hypertension-mediated organ damage (HMOD). Methods In 646 hypertensive patients (mean age 52 ± 16 years, 54% males, 65% treated) we obtained ambulatory brachial and central SBP and pulse pressure (PP), SBP, and PP variability, pulse wave velocity and augmentation index with a validated cuff-based technology. HMOD was defined by an increased left ventricular mass index (cardiac damage, evaluated in 482 patients), an increased intima-media thickness (vascular damage, n = 368), or a decreased estimated glomerular filtration rate or increased urine albumin excretion (renal damage, n = 388). Results Ambulatory SBP and PPs were significantly associated with cardiac damage: the largest odds ratio was observed for 24-h central SBP [1.032 (1.012, 1.051), P = 0.001] and PP [1.042 (1.015, 1.069), P = 0.002], the weakest for brachial estimates. The association was less strong for vascular damage with a trend to the superiority of 24-h central [1.036 (0.997, 1.076), P = 0.070] over brachial PP [1.031 (1.000, 1.062), P = 0.052]. No statistically significant association was observed for renal damage. SBP and PP variabilities, pulse wave velocity and augmentation index were not associated with any form of HMOD. In the multivariate analysis, age was associated with any type of HMOD, whereas central SBP and PP were predictive of an increased risk of cardiac damage. Conclusion In hypertensive patients a variable association exists between peripheral and central hemodynamics and various types of HMOD, with the most predictive power being observed for central SBP and PP for cardiac damage.

Arterial stiffness, assessed through pulse wave velocity (PWV), independently predicts cardiovascular outcomes. In untreated persons, white-coat hypertension (WCH) has been related to arterial stiffness, but data in treated patients with WCH are scarce. The authors aimed to determine a possible association between WCH and arterial stiffness in this population. Adult treated hypertensive patients underwent home blood pressure monitoring and PWV assessment. Variables associated with PWV in univariable analyses were entered into a multivariable linear regression model. The study included 121 patients, 33.9% men, median age 67.9 (interquartile range 18.4) years, 5.8% with diabetes, and 3.3% with a history of cardiovascular or cerebrovascular disease. In multivariable analysis, WCH in treated hypertensive patients remained a determinant of PWV: β=1.1 (95% confidence interval, 0.1-2.1 [P=.037]; adjusted R2 0.49). In conclusion, WCH is independently associated with arterial stiffness in treated hypertensive patients. Whether this high-risk association is offset by antihypertensive treatment should be further investigated.

Introduction Masked uncontrolled hypertension (MUCH) carries an increased risk of cardiovascular (CV) complications and can be identified through combined use of office (O) and ambulatory (A) blood pressure (BP) monitoring (M) in treated patients. However, it is still debated whether the information carried by ABPM should be considered for MUCH management. Aim of the MASked-unconTrolled hypERtension management based on OBP or on ambulatory blood pressure measurement (MASTER) Study is to assess the impact on outcome of MUCH management based on OBPM or ABPM. Methods and analysis MASTER is a 4-year prospective, randomised, open-label, blinded-endpoint investigation. A total of 1240 treated hypertensive patients from about 40 secondary care clinical centres worldwide will be included -upon confirming presence of MUCH (repeated on treatment OBP

Background and purpose: paroxysmal AF is detected during follow-up in approximately 30% of ESUS. We aim to identify patterns of brain lesions suggestive of embolic events and to evaluate the incidence of AF during 4-years of follow-up. Design and method: acute ischemic stroke patients were prospectively included in a multidisciplinary secondary stroke prevention program. Cardioembolic stroke was ruled out with 12-lead ECG, 48-hour cardiac monitoring and transesophageal echocardiography. Large artery disease of intracranial and extracranial vessels was evaluated with MR or CT angiography or cervical duplex plus transcranial doppler ultrasonography. After this thorough evaluation, patients without cardioembolic or large artery disease and non-lacunar lesion on MRI were defined as ESUS. Results: 479 (34%) of 1376 ischemic strokes included from September 2009 to December 2016 were ESUS; median age 78 years (IQR 69-84), 55% female. Pre-stroke VRF profile: 80% HT, 66% dyslipidemia, 14% DM, 51% obesity, 39% smoking, 34% CKD, 3% history of paroxysmal AF, 14% CHD and 10% previous stroke or TIA. Twenty-four patients (5%) died during hospitalization or within the next 30 days. There were 25 % (CI 95% 22-29) of recurrent strokes during 4-years of follow-up after stroke. The AF was detected in 15% of patients in the first year, 28% in the second year, 38% in the third year and 41% in the fourth year. Neuroimaging findings on-admission MRI are shown in the table. Conclusion: ESUS patients with AF during follow-up had higher incidence of hemorrhagic transformation during the acute phase as well as multiple lesions in different territories of the anterior and posterior cerebral circulation. As these findings are often seen in strokes of indubitable embolic origin the presence of these features should raise the suspicion of an underling embolic source.

Background An alerting reaction is a physician-induced phenomenon which produces a transient blood pressure rise in the office. Objective To determine its relationship with target organ damage in treated hypertensives. Method We used three different indexes for calculating alerting reaction depending on the first, second or third office blood pressure measurement. We correlated these indexes with glomerular filtration rate, left ventricular mass index and pulse wave velocity. Thereafter, for multivariate analysis, we selected the index which better correlated with each target organ damage subtype. Results We included 174 adults, mean age 67(±13.7) years. 75% of the patients had some degree of blood pressure fall between measurements 1-3. In multivariate linear regression models, after adjusting for classic risk factors, two out of the three systolic alerting reaction indexes showed an independent association with target organ damage. After further adjusting for office blood pressure and white coat effect (calculated with standardized home blood pressure monitoring), left ventricular mass index maintained a statistically significant association. Conclusion A higher alerting reaction in the office seems to be related to increased target organ damage in treated hypertensives and should not be considered an innocent phenomenon.

To generate outcome-driven thresholds for home blood pressure (BP) in the elderly, we analyzed 375 octogenarians (60.3% women; 83.0 years [mean]) enrolled in the International Database on home BP in relation to cardiovascular outcome. Over 5.5 years (median), 155 participants died, 76 from cardiovascular causes, whereas 104, 55, 36, and 51 experienced a cardiovascular, cardiac, coronary, or cerebrovascular event, respectively. In 202 untreated participants, home diastolic in the lowest fifth of the distribution (≤65.1 mm Hg) compared with the multivariable-adjusted average risk was associated with increased risk of cardiovascular mortality and morbidity (hazard ratios [HRs], ≥1.96; P ≤0.022), whereas the HR for cardiovascular mortality in the top fifth (≥82.0 mm Hg) was 0.37 ( P =0.034). Among 173 participants treated for hypertension, the HR for total mortality in the lowest fifth of systolic home BP (P =0.020). In further analyses of home BP as continuous variable (per 1-SD increment), higher diastolic BP predicted lower cardiovascular mortality and morbidity and cardiac and coronary risk (HR≤0.65; P ≤0.039) in untreated participants. In those treated, cardiovascular morbidity was curvilinearly associated with systolic home BP with nadir at 148.6 mm Hg and with a 1.45 HR ( P =0.046) for a 1-SD decrease below this threshold. In conclusion, in untreated octogenarians, systolic home BP ≥152.4 and diastolic BP ≤65.1 mm Hg entails increased cardiovascular risk, whereas diastolic home BP ≥82 mm Hg minimizes risk. In those treated, systolic home BP

Introducción: El virus herpes simplex (VHS) es la causa reportada más común de encefalitis esporádica con una mortalidad estimada de 50 a 70%. Objetivo: Describir las características de los pacientes con encefalitis herpética (EH) en nuestro medio y sus variables clínicas asociadas. Materiales y Métodos: Estudio anidado de casos y controles sobre una cohorte retrospectiva en el Hospital Italiano de Buenos Aires (2006-2013). Se incluyeron pacientes adultos con sospecha de encefalitis a quienes se les realizó una punción lumbar con posterior reacción de polimerasa en cadena para VHS en líquido cefalorraquídeo. Por cada caso (reacción positiva para VHS) se tomaron cinco controles aleatoriamente seleccionados. Resultados: No se observaron diferencias significativas en las características demográficas y clínicas entre los casos de EH y los controles. La única variable clínica asociada al diagnóstico de EH fue la alteración en la resonancia magnética (RM) de cerebro (OR: 5,37, IC 95% 1,4220,38; p < 0,01). Los patrones más comunes de alteración en la RM fueron las lesiones extra-temporales o lesiones temporales con o sin hemorragia. Discusión: Este hallazgo nos hace jerarquizar el hallazgo de un resultado positivo en la RM durante la valoración inicial de un paciente con clínica compatible de EH.

Introduction: The world population is aging, and this demographic fact is associated with an increased prevalence of sedentary lifestyles, sarcopenia and frailty; all of them with impact on health status. Biologic reserve determination in the elderly with comorbidity poses a challenge for medical activities. Frailty is an increasingly used concept in the geriatric medicine literature, which refers to an impairment in biologic reserve. There is a close and multidirectional relationship between physical activity, the muscular system function, and a fit status; decline in this dimensions is associated with poor outcomes. The aim of this article is to make a narrative review on the relationship between physical activity, sarcopenia and frailty syndrome. Results: The low level of physical activity, sarcopenia and frailty, are important predictorsfor development of disability, poor quality of life, falls, hospitalizations and all causes mortality. For clinical practice we propose a semiological approach based on measurement of muscle performance, mass and also level of physical activity, as a feasible way to determine the biologic reserve. This evidence shows us that the evaluation of muscle mass and performance, provides important prognostic information because the deterioration of these variables is associated with poor clinical outcomes in older adults followed up in multiple cohorts. Conclusions: Low activity is a mechanism and at the same time part of the frailty syndrome. The determination of biologic reserve is important because it allows the prognostic stratification of the patient and constitutes an opportunity for intervention. The clinician should be aware of the clinical tools that evaluate muscular system and level of physical activity, because they place us closer to the knowledge of health status.

Exaggerated orthostatic blood pressure variation (EOV) is a poorly understood phenomenon related to high cardiovascular risk. We aimed to determine whether hypertensive patients with EOV have a distinct hemodynamic pattern, assessed through impedance cardiography. METHODS In treated hypertensive patients, we measured the cardiac index (CI), systemic vascular resistance index (SVRI), blood pressure (BP), and heart rate (HR) in the supine and standing (after 3 minutes) positions, defining three groups according to BP variation: 1) Normal orthostatic BP variation (NOV): standing systolic BP (stSBP)-supine systolic BP (suSBP) between -20 and 20 mmHg and standing diastolic BP (stDBP)-supine diastolic BP (suDBP) between -10 and 10 mmHg; 2) orthostatic hypotension (OHypo): stSBP-suSBP≤-20 or stDBP-suDBP≤-10 mmHg; 3) orthostatic hypertension (OHyper): stSBP-suSBP≥20 or stDBP-suDBP≥10 mmHg. We performed multivariable analyses to determine the association of hemodynamic variables with EOV. RESULTS We included 186 patients. Those with OHyper had lower suDBP and higher orthostatic SVRI variation compared to NOV. In multivariable analyses, orthostatic HR variation (OR = 1.06 (95%CI 1.01-1.13), p = 0.03) and orthostatic SVRI variation (OR = 1.16 (95%CI 1.06-1.28), p = 0.002) were independently related to OHyper. No variables were independently associated with OHypo. CONCLUSION Patients with OHyper have a distinct hemodynamic pattern, with an exaggerated increase in SVRI and HR when standing.

Hypertension is a leading risk factor for disease burden globally. An unresolved question is whether grade 1 hypertension (140-159/90-99. mm. Hg) with low (cardiovascular mortality

Background: Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation Aim: To describe the clinical characteristics, causes and survival associated with HLH. Material and methods: Review of medical records of patients with HLH attended between 2004 and 2016. They were classified according to their probable cause in: associated with immunosuppression, cancer, post-infectious or idiopathic. Kaplan-Meier survival analysis was performed. Results: Twenty seven patients with HLH aged 18 to 87 years (59% men), were detected. Fourteen (52%) were secondary to immunosuppression, six (22%) were post-infectious, five (18%) were associated with cancer and two (7%) were of unknown cause. There were no significant differences in clinical or laboratory features between these etiologies. Within the immunosuppressed group, 12 (86%) were patients with oncologic or hematologic diseases or bone marrow transplantation. Associated cancers were mostly oncohematologic diseases. Thirty-day mortality was 53.4% (95% confidence intervals (CI) 32.7 - 70.3%), despite the treatment. Mortality was significantly associated with the presence of renal failure with a hazard ratio (HR) of 3.4 (95% CI of 1.2 - 9.9, p=0.025). Treatment of the underlying disease proved to be protective against mortality with an HR of 0.3 (95% CI 0.1 to 0.98, p= 0.046). Conclusions: The prognosis of HLH could be related to the treatment of the underlying disease. The study of the pathophysiology of this syndrome will allow a better understanding and treatment.

Background and purpose: In observational studies, patients under statin therapy at the time of stroke onset have lower likelihoods of mortality and poor functional outcome. This neuroprotective effect could be related to anti-inflammatory and antiplatelet actions of statins. Our objective was to evaluate early functional outcome in a cohort of ischemic stroke patients. Design and Method: stroke patients were included in PROTEGE-ACV, a multidisciplinary secondary prevention program aimed to improve adherence to clinical practice guidelines. Vascular risk factor (VRF) profile and control, and statin treatment in the year before stroke were collected, and functionality one-month after discharge was evaluated using modified Rankin scale. Results: 1981 ischemic stroke patients (20% TIA) were included between December 2006 and December 2015; mean age was 76±11 years with 57% females. Patients receiving statins (n 713, 38%) had a significant higher prevalence of hypertension, diabetes, dislipidemia, obesity, metabolic syndrome, coronary heart disease, peripheral artery disease, chronic renal failure and previous stroke. Both groups had similar blood pressure, and patients under statins had lower total cholesterol (182±42 vs 200±40 mg/dL, p 0.00001), LDL-c (106±36 vs 128±47, p 0.00001) with similar levels of HDL-c and triglycerides; these patients also had lower GFR (62±23 vs 67±31 mL/min, 0.0003) and higher fasting glucose levels (103±26 vs 99±21 mg/mL; p 0.0003). Predictors of bad outcome in the multivariate analysis adjusted by age and VRF are shown in the table. Conclusion: Even though patients under statin treatment before stroke had higher prevalence of vascular diseases, they have better functional outcomes one-month after the event. In our cohort, previous statin use seems to have neuroprotective effect, which could be related to modulation of inflammatory response, platelet aggregation, fibrinolysis and nitric oxide production.

Background and purpose: Hypertension is the most prevalent risk factor for acute and chronic cerebrovascular disease. As patients with resistant hypertension are a subgroup with even higher risk, we aimed to evaluate the burden of microangiopatic disease and functional outcome in subjects with stroke and difficult to treat hypertension. Design and method: acute ischemic stroke patients were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records and chronic vascular disease burden was assessed on admission MRI. Functional and cognitive evaluation were performed one-month after stroke. Results: 1327 patients (16% with resistant hypertension) were included from September 2009 and December 2015. Patients with resistant hypertension were older (80±8 vs 77±10, p 0.0004), with higher prevalence of obesity (62% vs 50%, p 0.001), metabolic syndrome (52% vs 38%, p 0.0001) and history of atrial fibrillation (27% vs 16%, p 0.0001). There was a direct relationship between resistant hypertension and the severity of chronic microvascular lesions, and also with functional and cognitive outcomes (table). Conclusion: Hypertension increases vascular events risk, even more in the setting of resistant hypertension. Requirement of a therapeutic strategy involving combination of multiple drugs generally indicates more severe underlying hypertensive disease. It is possible that mechanisms of endothelial dysfunction responsible of the neurovascular unit damage might remain active despite achieving blood pressure target.

Peripheral arterial disease (PAD) is an increasingly recognized disorder that is associated with functional impairment, quality-of-life deterioration, increased risk of cardiovascular ischemic events, and increased risk of total and cardiovascular mortality. Although earlier studies suggested that PAD was more common in men, recent reports based on more sensitive tests have shown that the prevalence of PAD in women is at least the same as in men, if not higher. PAD tends to present itself asymptomatically or with atypical symptoms more frequently in women than in men, and is associated with comorbidities or situations particularly or exclusively found in the female sex, such as osteoporosis, hypothyroidism, the use of oral contraceptives, and a history of complications during pregnancy. Fat-distribution patterns and differential vascular characteristics in women may influence the interpretation of diagnostic methods, whereas sex-related vulnerability to drugs typically used in subjects with PAD, differences in risk-factor distribution among sexes, and distinct responses to revascularization procedures in men and women must be taken into account for proper disease management. All these issues pose important challenges associated with PAD in women. Of note, this group has classically been underrepresented in research studies. As a consequence, several sex-related challenges regarding diagnosis and management issues should be acknowledged, and research gaps should be addressed in order to successfully deal with this major health issue., Video abstract

Background. The morning home blood pressure (BP) rise is a significant asymptomatic target organ damage predictor in hypertensives. Our aim was to evaluate determinants of home-based morning-evening difference (MEdiff) in Argentine patients.Methods. Treated hypertensive patients aged≥18 years participated in a cross-sectional study, after performing home morning and evening BP measurement. MEdiff was morning minus evening home average results. Variables identified as relevant predictors were entered into a multivariable linear regression analysis model.Results. Three hundred sixty-seven medicated hypertensives were included. Mean age was 66.2 (14.5), BMI 28.1 (4.5), total cholesterol 4.89 (1.0) mmol/L, 65.9% women, 11.7% smokers, and 10.6% diabetics. Mean MEdiff was 1.1 (12.5) mmHg systolic and 2.3 (6.1) mmHg diastolic, respectively. Mean self-recorded BP was 131.5 (14.1) mmHg systolic and 73.8 (7.6) mmHg diastolic, respectively. Mean morning and evening home BPs were 133.1 (16.5) versus 132 (15.7) systolic and 75.8 (8.4) versus 73.5 (8.2) diastolic, respectively. Significant beta-coefficient values were found in systolic MEdiff for age and smoking and in diastolic MEdiff for age, smoking, total cholesterol, and calcium-channel blockers.Conclusions. In a cohort of Argentine medicated patients, older age, smoking, total cholesterol, and use of calcium channel blockers were independent determinants of home-based MEdiff.

The absence of an outcome-driven reference frame for self-measured pulse pressure (PP) limits its clinical applicability. In an attempt to derive an operational threshold for self-measured PP, we analyzed 6470 participants (mean age 59.3 years; 56.9% women; 22.5% on antihypertensive treatment) from 5 general population cohorts included in the International Database on HOme blood pressure in relation to Cardiovascular Outcome. During 8.3 years of follow-up (median), 294 cardiovascular deaths, 393 strokes and 336 cardiac events occurred. In 3285 younger subjects (

Age- sex- and ethnicity-specific prediction of cardiovascular outcomes by in-office and out-of-the-office blood pressure : a subject-level meta-analysis of 17,383 adults enrolled in 17 population studies

Diego Giunta,1,2 Agustina Briatore,3 Analía Baum,3 Daniel Luna,3 Gabriel Waisman,2 Fernán Gonzalez Bernaldo de Quiros1–31Internal Medicine Research Unit, 2Internal Medicine Department, 3Health Informatics Department, Hospital Italiano de Buenos Aires, Buenos Aires, ArgentinaIntroduction: Nonattendance at scheduled outpatient appointments for primary care is a major health care problem worldwide. Our aim was to estimate the prevalence of nonattendance at scheduled appointments for outpatients seeking primary care, to identify associated factors and build a model that predicts nonattendance at scheduled appointments.Methods: A cohort study of adult patients, who had a scheduled outpatient appointment for primary care, was conducted between January 2010 and July 2011, at the Italian Hospital of Buenos Aires. We evaluated the history and characteristics of these patients, and their scheduling and attendance at appointments. Patients were divided into two groups: those who attended their scheduled appointments, and those who did not. We estimated the odds ratios (OR) and corresponding 95% confidence intervals (95% CI), and generated a predictive model for nonattendance, with logistic regression, using factors associated with lack of attendance, and those considered clinically relevant. Alternative models were compared using Akaike's Information Criterion. A generation cohort and a validation cohort were assigned randomly.Results: Of 113,716 appointments included in the study, 25,687 were missed (22.7%; 95% CI: 22.34%–22.83%). We found a statistically significant association between nonattendance and age (OR: 0.99; 95% CI: 0.99–0.99), number of issues in the personal health record (OR: 0.98; 95% CI: 0.98–0.99), time between the request for and date of appointment (OR: 1; 95% CI: 1–1), history of nonattendance (OR: 1.07; 95% CI: 1.07–1.07), appointment scheduled later than 4 pm (OR: 1.30; 95% CI: 1.24–1.35), and specific days of the week (OR: 1.00; 95% CI: 1.06–1.1). The predictive model for nonattendance included characteristics of the patient requesting the appointment, the appointment request, and the actual appointment date. The area under the receiver operating characteristic curve of the predictive model in the generation cohort was 0.892 (95% CI: 0.890–0.894).Conclusion: Evidence related to patient characteristics, and the identification of appointments with a higher likelihood of nonattendance, should promote guided strategies to reduce the rate of nonattendance, as well as to future research on this topic. The use of predictive models could further guide management strategies to reduce the rate of nonattendance.Keywords: nonattendance, appointments, schedules

Postprandial hypotension (PPH) is a frequently under-recognized entity associated with increased morbidity and mortality. The prevalence of PPH detected through home blood pressure monitoring (HBPM) is unknown. To determine the prevalence and clinical predictors of PPH in hypertensive patients assessed through HBPM. Hypertensive patients of 18 years or older underwent home blood pressure (BP) measurements (duplicate measurements for 4 days: in the morning, 1 h before and 1 h after their usual lunch, and in the evening; OMRON 705 CP). PPH was defined as a meal-induced systolic BP decrease of ≥20 mm Hg. Variables identified as relevant predictors of PPH were entered into a multivariate logistic regression analysis. In total, 230 patients were included in the analysis, with a median age of 73.6 (interquartile range 16.9) years, and 65.2% were female. The prevalence of PPH (at least one episode) was 27.4%. Four variables were independently associated with PPH: age of 80 years or older (odds ratio (OR) 3.45, 95% confidence interval (CI) 1.35-8.82), body mass index (BMI) (OR 0.88, 95%CI 0.81-0.96), office systolic BP (OR 1.03, 95%CI 1.01-1.05) and a history of cerebrovascular disease (OR 3.29, 95%CI 1.03-10.53). PPH after a typical meal is a frequent phenomenon that can be detected through HBPM. Easily measurable parameters in the office such as older age, higher systolic BP, lower BMI and a history of cerebrovascular disease may help to detect patients at risk of PPH who would benefit from HBPM.

Arterial hypertension and transplantation are closely linked, and its association may promote impaired graft and overall survival. Since the introduction of calcineurin inhibitors, it is observed in 50–80% of transplanted patients. However, many pathophysiological mechanisms are involved in its genesis. In this review, we intend to provide an updated overview of these mechanisms, dealing with the causes common to all kinds of transplantation and emphasizing special cases with distinct features, and to give a perspective on the pharmacological approach, in order to help clinicians in the management of this frequent complication.

Masked hypertension (MH) entails an increased cardiovascular risk. Therefore, it is important to identify those individuals who would benefit the most from out-of-office blood pressure (BP) measurement. We sought to determine the prevalence and identify predictors of MH among adult hypertensive patients under treatment.Treated hypertensive patients aged ≥ 18 years underwent office (duplicate sitting and standing BP in 1 visit) and home BP measurements (duplicate measurements for 4 days in the morning, afternoon, and evening; at least 16 measurements) and completed a questionnaire regarding risk factors and history of cardiovascular disease. MH was defined as normal office BP (140/90mm Hg) with elevated home BP (≥135/85mm Hg, average of all readings discarding first day measurements). Patients with a systolic BP rise upon standing ≥5mm Hg were considered to have orthostatic hypertension (OHT). Variables indentified as relevant predictors of MH were entered into a multivariable logistic regression analysis model.Three hundred and four patients were included (mean age = 66.7 ±13.8; 67.4% women). The prevalence of MH in the whole population was 12.4% and was 20.9% among patients with office-controlled hypertension. Factors independently associated with MH were age (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.03-1.14), high-normal office systolic BP (OR = 5.61, 95% CI = 1.39-22.57), history of peripheral artery disease (PAD) (OR = 8.83, 95% CI = 1.5-51.84), moderate alcohol consumption (OR = 0.08, 95% CI = 0.01-0.73), and OHT (OR = 3.65, 95% CI = 1.27 to 10.51).Easily measurable parameters such as age, office systolic BP, history of PAD, and OHT may help to detect a population at risk of MH that would benefit from home BP monitoring.

Background: A clinical registry encompasses a selective set of rigorously collected and stored clinical data focused on a specific condition. Hip fracture is a common complication of osteoporosis in elderly patients. Hip fracture substantially increases the risk of death and major morbidity in the elderly patients. Limited data regarding hip fracture are available from Latin America and Argentina. The purpose of this project is to create an institutional registry of elderly patients with hip fracture in order to obtain data that reveal the impact of this disease in our environment, allowing us to evaluate different strategies of patient’s care and clinical outcomes. Objective: To describe the implementation of an institutional registry of elderly patients with hip fracture in Argentina. Methods: In this article, we described the creation, implementation, and data management of a prospective registry of elderly patients with hip fracture. The registry contains information on baseline demographics, comorbidities, laboratory, and radiological data. Follow-up at 3 and 12 months postfracture is done by phone interview to assess physical function, readmissions, and morbi-mortality. Clinical Trials registry number NCT02279550. Conclusion: In this project, we have created a hip fracture registry. We hope that this registry will provide valuable data that can lead us to new lines of research, addressed to answer questions raised in clinical practice.

Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation Aim: To describe the clinical characteristics, causes and survival associated with HLH.Review of medical records of patients with HLH attended between 2004 and 2016. They were classified according to their probable cause in: associated with immunosuppression, cancer, post-infectious or idiopathic. Kaplan-Meier survival analysis was performed.Twenty seven patients with HLH aged 18 to 87 years (59% men), were detected. Fourteen (52%) were secondary to immunosuppression, six (22%) were post-infectious, five (18%) were associated with cancer and two (7%) were of unknown cause. There were no significant differences in clinical or laboratory features between these etiologies. Within the immunosuppressed group, 12 (86%) were patients with oncologic or hematologic diseases or bone marrow transplantation. Associated cancers were mostly oncohematologic diseases. Thirty-day mortality was 53.4% (95% confidence intervals (CI) 32.7-70.3%), despite the treatment. Mortality was significantly associated with the presence of renal failure with a hazard ratio (HR) of 3.4 (95% CI of 1.2-9.9, p =0.025). Treatment of the underlying disease proved to be protective against mortality with an HR of 0.3 (95% CI 0.1 to 0.98, p = 0.046).The prognosis of HLH could be related to the treatment of the underlying disease. The study of the pathophysiology of this syndrome will allow a better understanding and treatment.

Introduction Chronic Obstructive Pulmonary Disease (COPD) is the fifth cause of mortality worldwide. Systemic inflammation is a crucial element in its physiopathology. As Renin-Angiotensin System is one of the main components of this inflammatory neurohumoral cascade, Angiotensin Receptor Blockers (ARBs) might have an effect on mortality in COPD patients. Goal To evaluate the association between ARBs treatment and mortality in COPD patients. Methods Retrospective cohort of patients with diagnosis of COPD from 2003 to 2013. COPD cases were detected according to the diagnosis by treating physicians in any field of the electronic clinical health records by controlled vocabulary in patients older than 18 years affiliated to the Hospital Italiano de Buenos Aires (HIBA) Health Plan. Patients were classified in two groups depending on their use of ARBs according to the hospital pharmacy records. The mortality registry of the HIBA was used to obtain the event of death. The 8 year survival experience was described using Kaplan Meier estimator and survival curve comparisons were calculated with the Cox Mantel test. Hazard Ratios (HR) were estimated using a Cox proportional risk model. A propensity score (PS) was developed for the use of ARBs. Results 1140 deaths were detected, 1063 in the no exposure group and 77 in the ARBs exposure group. The 8 year survival was 71% (CI 95% 69–72%). The survival in the non exposed group was 71% (CI 95% 69–73%) and 76% (CI 95% 0,69-0,81) in the ARBs exposed group. The unadjusted HR for mortality was 0.85 (CI 95% 0.67–1.07, p = 0.17) and the adjusted HR by PS was 0.63 (CI 95% 0.50–0.80, p Discussion ARBs use seems to be associated to a lower mortality in patients with COPD. Additional studies are needed to corroborate this finding.

Introduction: intracerebral hemorrhagic transformation (HT) is a multifactorial phenomenon in which ischemic brain tissue converts into a hemorrhagic lesion with blood vessel leakage, and can significantly contribute to additional brain injury after stroke. Understanding mechanisms and identifying predictors of HT may contribute to improve clinical outcomes in stroke patients. Hypothesis: to evaluate clinical predictors of HT in non-lacunar ischemic stroke patients. Methods: patients were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records. Acute SBP, DBP and PP were obtained in the emergency room and HT was evaluated with on-admission and one-week CT or MRI. Predictors of HT were identified by multivariate analysis. Exclusion criteria: TIA, lacunar stroke and patients without one-week CT or MRI. Results: 747 patients with a non-lacunar ischemic stroke (mean age 77±11 years, 61% females) were included. HT was observed in 94 patients (13%); they were older (82±8 vs 77±11; p 0.0001), had higher prevalence of hypertension (94% vs 81%; p 0.003) and AF (45% vs 20%; p 0.0001), and lower e-GFR (56±29 vs 65±27 ml/min/1.73 m2; p 0.04). They also had higher on-admission SBP (168±30 vs 146±23 mmHg; p 0.0001), DBP (88±18 vs 81±13 mmHg; p 0.0001) and PP (78±23 vs 63±21 mmHg; p 0.0001); anticoagulant therapy was more frequent in this group (27% vs 12%; p 0.0001). After adjusting by age and vascular risk factors in the multivariable analysis: the age > 80 years, PP on admission > 60 mm de Hg, e-GFR < 60 ml /min/1,73 m2 and pre-stroke AF were associated with increase of risk of HT. (table) Conclusion: predictors for HT in our cohort were also related with severe vascular disease. Identification of these high risk patients is crucial in clinical decision making regarding thrombolytic treatment and optimal timing for antithrombotic therapy initiation.

Introduction: stroke recurrence in patients with TIA is one of the most frustrating medical situations and it is very important to identify strong predictors of stroke recurrence to enable practitioners to take clinical decisions Hypothesis: to evaluate the relationship between pulse pressure (PP), a marker of vascular disease, and the risk of stroke recurrence in patients with TIA. Methods: TIA patients were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records. Stroke recurrence was analyzed after five years of follow up. For the purpose of the analysis, three groups were defined according to pre-stroke PP: < 60, 60-69 and > 70 mmHg. Results: 357 patients (mean age 75±10 years, 55% females) were included. Vascular risk factors profile: hypertension 83%, dislipidemia 74%, obesity 54%, smoking 41%, diabetes 12%, AF 12%, CKD 28%, CHD 18%. Mean SBP was 130 mmHg and DBP 80 mmHg; 78% was receiving antihypertensives, 47% statins, 43% antiplatelets and 9% anticoagulants before the event. There was a direct relationship between pre-stroke PP and stroke recurrence during follow-up (figure). Conclusion: PP is related to higher burden of vascular disease, mainly an increase in arterial stiffness, which might be a key element in clinical decision making in the setting of stroke recurrence prevention.

Introduction: chronic kidney disease (CKD) coexists with microvascular brain damage. This cerebrorenal connection is considered to involve small vessel disease in both the kidney and brain, based on their hemodynamic similarities. Hypothesis: to evaluate the relationship between microvascular brain damage (white matter hyperintensities -WMH-, microbleeds -MB- and silent brain infarcts -SBI-), and glomerular filtration rate (GFR) in a cohort of ischemic stroke patients. Methods: patients were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records and the burden of microvascular brain damage was evaluated on admission MRI. For the purpose of the analysis three groups were defined according to GFR estimated by Cockroft-Gault formula: >60, 30-60 and Results: 808 patients (mean age 77±11 years, 59% females) were included. GRF was inversely related to age (70±11, 83±6, 85±8 years; p 0.0001), female sex (48%, 69%, 66%; p 0.001), hypertension (76%, 89%, 91%; p 0.0001) and AF (16%, 21%, 34%; p 0.08) prevalence. Chronic microvascular brain damage burden was inversely related to e-GFR (table). Conclusion: decreased GFR indicates small vessel disease not only in the kidney but also in the brain. As small vessel disease is a systemic disorder, information about disease in one organ may suggest damage in the other.

Introduction: pulse pressure (PP), a marker of arterial stiffness, is a useful tool for measuring vascular aging. White matter hyperintensities (WMH), deep and periventricular, are the expression of subclinical ischemic brain damage. Hypotesis: our objective was to evaluate the relationship between pre-stroke blood pressure and the burden of WMH. Method: acute ischemic stroke patients, excluding TIA, were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records and the presence of WMH was evaluated on admission MRI. Periventricular hyperintensities (PVH) and deep white matter hyperintensities (DWMH) were classified according to Fazekas scale (0-3). A correlation analysis between different components of blood pressure and WMH was performed. Results: 808 patients (59% females, mean age 77±11 years) were included between January 2009 and December 2014. Main vascular risk factors were: hypertension (83%), dyslipemia (64%), obesity (52%), smoking (37%), metabolic syndrome (37%), diabetes (14%), AF (19%), CKD (45%), CHD (14%), stroke (10%), peripheral artery disease (12%). There was a positive correlation between PP values and the severity of PVH (R 0.93) and DWMH (R 0.95), but not with SBP (R 0.48 and R 0.50) and DBP (R 0.52 and 0.47). (figure) Conclusion: different blood pressure components may have different deleterious effects on large and small vessels. Pulse pressure, a pulsatile component mainly reflecting large artery stiffness and wave reflections, was the only component of blood pressure with a positive correlation with the burden of WMH in our cohort. As the world is aging, is mandatory to identify predictors of subclinical brain damage, which is related to increased risk of dementia, depression, stroke and gait disorders.

IntroducciónEs innegable el incremento de los costos de los cuidados médicos de las enfermedades crónicas. Existen múltiples razones: envejecimiento poblacional, complicaciones tardías de las patologías asociadas y disponibilidad de tecnologías sanitarias de alto costo. La insuficiencia cardiaca es una de las principales causas mundiales de mortalidad y morbilidad, siendo la consecuencia final de las enfermedades cardíacas y la hipertensión arterial, cumpliendo criterios para convertirse en una patología de gran consumo de recursos. En el presente trabajo estudiaremos los costos de la insuficiencia cardiaca desde la visión de quienes gestionan los recursos sanitarios. Materiales y MétodosEstudio observacional, de cohorte retrospectiva utilizando bases de datos secundarias del Plan de Salud del Hospital Italiano de Buenos Aires. Población adulta con diagnóstico de insuficiencia cardiaca que hayan requerido internación con diagnóstico al egreso de insuficiencia cardiaca entre los años 2007 y 2011.ResultadosEl principal componente de los costos fue atribuible a la estadía hospitalaria, las intervenciones diagnósticas y terapéuticas. La incidencia media de internaciones durante el período fue de 11.4 por cada 10.000 pacientes/año. La mortalidad global en el episodio índice fue del 0,25%, al año 28,8% y global del 60%ConclusiónLa decisión más importante parece ser decidir si el manejo puede hacerse ambulatoriamente o no, poniendo en marcha guías de manejo de la insuficiencia cardiaca para optimizar tiempos de internación, métodos auxiliares de diagnóstico y los medicamentos utilizados.

El objetivo de este trabajo fue describir la prevalencia de síndrome confusional agudo en ancianos hospitalizados, la evolución durante la internación y a los 18 meses. Se evaluó en forma prospectiva a pacientes de 70 años de edad o mayores, internados en el Servicio de Clínica Médica de nuestro hospital, entre septiembre de 2005 y mayo de 2006. Se utilizó una versión validada en español del Confussion Assessment Method para diagnosticar delirium. A los 18 meses se evaluó el estado vital, lugar de residencia, actividades de la vida diaria, dependencia de cuidadores y reinternaciones. Se evaluaron 194 pacientes y 74 fueron excluidos. De los 120 casos incluidos, 52 (43.3%) presentaron delirium. La edad media fue de 82.6 años (DS: 7.4) en el grupo de pacientes con síndrome confusional agudo y de 80.4 años (DS: 5.6) en el grupo de pacientes sin delirium. Al comparar estos dos grupos encontramos diferencias significativas en las características, siendo más frecuentes en el grupo con delirium la residencia previa en un centro de tercer nivel (17.3% vs. 1.5%; p < 0.002), la demencia (40.4% vs. 8.8%; p < 0.001), menor puntaje en la evaluación de las actividades de la vida diaria (5 vs. 6; p < 0.001), más días de internación (7 vs. 5; p = 0.04) y mayor mortalidad intrahospitalaria (21.2% vs. 1.5%; p < 0.001). A los 18 meses de seguimiento después del alta, el desarrollo de delirium durante la internación se asoció a mayor grado de dependencia evidenciado por el peor puntaje en las actividades de la vida diaria (mediana 1/6 vs. 5/6) y a menor sobrevida actuarial 35.3% (CI 95%: 24-49%) a los 569 días y 49% (CI 95%: 32.9-65.4%) a los 644 días (p=0.027).Delirium usually hardens care during hospitalization and increases morbidity during hospital stay and after discharge. The objective of this study was to describe the prevalence of delirium in elderly inpatients in a Buenos Aires hospital, its morbidity and mortality during hospital stay and the next 18 month follow-up. Patients aged 70 or older admitted to internal medicine unit between September 2005 and May 2006 were enrolled. Delirium was assessed with the Spanish version of Confusion Assessment Method. Demographic data, cause of admition and length of stay, destination after discharge and mortality were registered. A new evaluation was made 18 months after discharge. We evaluated 194 patients and 74 were excluded. Of the 120 included, 52 (43.3%) presented delirium. We found significant differences between patients with and without delirium in previous placement in nursing home (17.3% vs. 1.5%; p < 0.002), dementia (40.4% vs. 8.8%; p < 0.001), median activity of daily living (5 vs. 6; p < 0.001), length-of-stay (7 vs. 5; p = 0.04) and mortality rate (21.2% vs. 1.5%; p < 0.001). Evaluation 18 months later showed differences between patients with and without delirium in median of activity of daily living (1/6 vs. 5/6), patients living in nursing homes (27.5% vs. 7.9%), estimated survival 35.3% (CI 95%: 24-49%) at day 569 and 49% (CI 95%: 32.9-65.4%) at day 644. The difference between survival curves was statistically significant (p = 0.027). Delirium increases morbidity and mortality during hospital stay. Elderly with delirium are at risk of worsening disability and of becoming dependent after discharge and it is a risk factor for higher mortality during the following months after discharge.