Objective: A non-dipping profile has been found in 50–85% of patients with OSA and its frequency increases with OSA severity. Also, lack of nocturnal dipping is related to an increased risk of cardiovascular (CV) events. Our aim was to assess the effect of continuous positive airway pressure (CPAP) therapy in patients with moderate-severe OSA and difficul-to-control arterial hypertension (DtC-HTN). Design and method: We included 101 hypertensive patients with moderate-severe OSA referred to our department for uncontrolled hypertension between 2012 and 2015. For each patient we recorded demographic and anthropometric data, parameters obtained through blood pressure (BP) monitoring (ABPM/24 h using ABPM-05, Meditech device; BP recordings at 15 minutes intervals during daytime and 30 minutes intervals during nighttime) and dipping status. Inclusion criteria were: DtC-HTN in spite of taking at least three antihypertensive drugs at optimal doses, including a diuretic, with mean 24h-BP values >130/80 mmHg and moderate-severe OSA diagnosed through respiratory polygraphy (no electroencephalography recordings) and defined as apnea-hypopnea index (AHI) greater than 15 events per hour. Exclusion criteria were presence of secondary causes of resistant HTN, estimated glomerular filtration rate (eGFR) using CKD-EPI study equation < 30 ml/min/1.73 m2, previous or current use of CPAP therapy, poor adherence to antihypertensive drugs and insomnia. All patients underwent CPAP treatment (manual titration). After 3 months an ABPM/24 h was performed. No changes were made to antihypertensive medication between the two ABPM recordings Results: See table. After 3 months of CPAP therapy, these patients displayed a significant reduction in daytime (−4.04 mmHg) and especially nighttime systolic BP (−7.24 mmHg), with no significant variations in diastolic BP. Thus, there was an increase in the percentage of patients who recovered their dipping profile.Conclusions: In adults with moderate-severe OSA and DtC-HTN under maximal antihypertensive therapy, 3-months treatment with CPAP has improved the mean 24h-BP values. Thus, CPAP treatment may reduce risk of incidence of fatal and non-fatal CV events in OSA patients as compared with untreated OSA patients.

Objective: The role of apolipoprotein E (ApoE) in the onset of metabolic syndrome remains unclear, ApoE being a key surface component of triglyceride-rich lipoproteins, low- and high density lipoproteins (VLDL, HDL) and also found in the hypothalamic area. This study researches the effect of ApoE on hypertension, associating increased combined ApoE at circulatory level to a hypothalamic ApoE deficiency, using a metabolic syndrome model in rats. Design and method: Wistar rats (male, 179–240 g, n = 10), on a high caloric, high fat diet (20 g/day/rat of fodder grain + pork lard as fat supplement 2 ml/day/rat) for 60 days, had measurements of their systolic arterial pressure (SAP), diastolic arterial pressure (DAP) values, weight and plasma lipid levels taken, days 0(T0), 60(T60) and 65(T65). Two groups (n = 20) of male Wistar rats (148g-220 g) on a normal caloric diet (20 g/day/rat ad libidum of combined fodder grain) and on the high caloric, high fat diet, were used as control. After showing raised SAP, DAP and lipid values (cholesterol range 158 – 170 mg/dl, triglycerides 201- 558 mg/dl, SAP 148–206 mmHg, DAP 98–150 mmHg)(T60) the rats were injected with 8 μl liquid ApoE (Millipore apolipoprotein E, Merck) in the hypothalamic area, 2.2 mm posterior to bregma and 7.4 mm ventral to dura. The procedure was performed under anesthesia (ketamine 10% + Xilazine 2%). Arterial pressure was measured using the tail-cuff method. Results: Mean value of SAP decreased from 183,62 (s = 27,22) (p < 0,007) before injection of ApoE to 181,87 (s = 23,44) (p < 0,38), while the control group injected with intracerebroventricular saline showed no decrease. Mean value of DAP decreased from 130,37 (s = 16,22) (p < 0,0004) to 121,37(s = 18,57)(p < 0,14).Conclusions: Preliminary data show the ApoE hypothalamic effects, that influence metabolic disorders and hypertension. Further study is highly necessary, yet we can conclude that deficient ApoE in the hypothalamic area can lead to raised SAP and DAP values.

Objective: Blood pressure variability (BPV) has been proven to correlate with an increased risk of cardiovascular (CV) events even in controlled hypertension. Different BPV indicators have been tested to correlate with increased CV risk, however none, except for dipping profile, have become a standard of measure well enough to enter the guidelines. Average real variability (ARV) of daytime SBP and not high SD has been proven to associate with increased risk of CV events and has been recently proposed as a more reliable representation of BPV than SD as it is less sensitive to the low sampling frequency of ABPM. Incidence of CV events is higher in patients with a lesser drop in nocturnal BP, however data on a possible increased CV risk in extreme dippers are inconsistent thus far. Our aim was to compare novel BPV indicators between the two extremes of the dipping profile and thus prove their importance in the evaluation of the high risk hypertensive patient.Design and method: We included hypertensive patients referred to our department for uncontrolled hypertension between 2012–2014, with a minimum of 40 successful daytime and 8 successful night-time readings on ABPM monitoring (Meditech-05 ABPM, recordings at 15 min intervals during day-time and 30 min intervals during night-time). Exclusion criteria were presence of secondary HTN, eGFR (glomerular filtration rate) < 30 ml/min/1.73m2. Extreme dippers – patients with a nocturnal dip > 20%; risers – patients with an nocturnal dip < 0%. Other BPV indicators calculated: standard deviation (SD) of mean 24 h BP, BP load, average weighted SD and average real variability. Results: In our study average SBP, daytime and night-time SBP SD and ARV did not differ significantly between the two extreme groups, as opposed to classical indicators such as SBP load and weighted SD. Conclusions: At least in the clinical setting of an emergency hospital, hypertensive patients may show distinctive CV risk profiles, with normal average BP values but high BPV. In these patients, the guideline definition of controlled hypertension becomes an understatement and, thus, drug therapy in their case should respect the patients’ chronobiology.

Objective: Hypertension guidelines offer no recommendations on documenting and targeting blood pressure variability (BPV), even though evermore research has documented its role in residual cardiovascular (CV) risk in patients with controlled and uncontrolled hypertension (HTN). Our aim is to underline the significance of novel BPV indicators beyond the dipping pattern on the 24 h ambulatory blood pressure monitoring (ABPM) evaluation as part of the thorough risk profile assessment of the uncontrolled hypertensive patient referred to an emergency hospital.Design and method: We included hypertensive patients referred to our department for uncontrolled hypertension between 2012–2014, with a minimum of 40 successful daytime and 8 successful night-time readings on ABPM monitorings (Meditech-05 ABPM). Exclusion criteria were presence of secondary HTN, eGFR (glomerular filtration rate) < 30 ml/min/1.73m2. BPV was expressed as dipping pattern, standard deviation (SD) of mean 24 h (BP recordings at 15 min intervals during day-time and 30 min intervals during night-time), BP load and average weighted SD. Results: All patients were known hypertensives, however their average BP values on 24hABPM were below 135/85mmHg. Analyzing beyond dipping profiles, we found significant differences between BPV indicators in the dippers vs non-dippers groups (see table). Conclusions: In the emergency hospital setting hypertensive patients may show distinctive CV risk profiles, with normal BP values but a very high variability even beyond dipping profiles. In these cases, the guideline definition of controlled hypertension may become an understatement and thus, one should rather revise the patient's drug therapy and adjust it to his/hers chronobiology.

Objective: Blood pressure variability (BPV) has been proven to correlate with an increased risk of cardiovascular (CV) events even in controlled hypertension. Different BPV indicators have been tested to correlate with increased CV risk, however none, except for dipping profile, have become a standard of measure well enough to enter the guidelines. Average real variability (ARV) of daytime SBP and not high SD has been proven to associate with increased risk of CV events and has been recently proposed as a more reliable representation of BPV than SD as it is less sensitive to the low sampling frequency of ABPM. Incidence of CV events is higher in patients with a lesser drop in nocturnal BP, however data on a possible increased CV risk in extreme dippers are inconsistent thus far. Our aim was to compare novel BPV indicators between the two extremes of the dipping profile and thus prove their importance in the evaluation of the high risk hypertensive patient.Design and method: We included hypertensive patients referred to our department for uncontrolled hypertension between 2012–2014, with a minimum of 40 successful daytime and 8 successful night-time readings on ABPM monitoring (Meditech-05 ABPM, recordings at 15 min intervals during day-time and 30 min intervals during night-time). Exclusion criteria were presence of secondary HTN, eGFR (glomerular filtration rate) < 30 ml/min/1.73m2. Extreme dippers – patients with a nocturnal dip > 20%; risers – patients with an nocturnal dip < 0%. Other BPV indicators calculated: standard deviation (SD) of mean 24 h BP, BP load, average weighted SD and average real variability. Results: In our study average SBP, daytime and night-time SBP SD and ARV did not differ significantly between the two extreme groups, as opposed to classical indicators such as SBP load and weighted SD. Conclusions: At least in the clinical setting of an emergency hospital, hypertensive patients may show distinctive CV risk profiles, with normal average BP values but high BPV. In these patients, the guideline definition of controlled hypertension becomes an understatement and, thus, drug therapy in their case should respect the patients’ chronobiology.

Objective: Hypertension guidelines offer no recommendations on documenting and targeting blood pressure variability (BPV), even though evermore research has documented its role in residual cardiovascular (CV) risk in patients with controlled and uncontrolled hypertension (HTN). Our aim is to underline the significance of novel BPV indicators beyond the dipping pattern on the 24 h ambulatory blood pressure monitoring (ABPM) evaluation as part of the thorough risk profile assessment of the uncontrolled hypertensive patient referred to an emergency hospital.Design and method: We included hypertensive patients referred to our department for uncontrolled hypertension between 2012–2014, with a minimum of 40 successful daytime and 8 successful night-time readings on ABPM monitorings (Meditech-05 ABPM). Exclusion criteria were presence of secondary HTN, eGFR (glomerular filtration rate) < 30 ml/min/1.73m2. BPV was expressed as dipping pattern, standard deviation (SD) of mean 24 h (BP recordings at 15 min intervals during day-time and 30 min intervals during night-time), BP load and average weighted SD. Results: All patients were known hypertensives, however their average BP values on 24hABPM were below 135/85mmHg. Analyzing beyond dipping profiles, we found significant differences between BPV indicators in the dippers vs non-dippers groups (see table). Conclusions: In the emergency hospital setting hypertensive patients may show distinctive CV risk profiles, with normal BP values but a very high variability even beyond dipping profiles. In these cases, the guideline definition of controlled hypertension may become an understatement and thus, one should rather revise the patient's drug therapy and adjust it to his/hers chronobiology.

Background: A benign tumor invading the surrounding structures just like a malignant one — the craniopharyngioma, situated near the sellar area, a rare clinical entity, usually accompanied by both neurological and endocrine dysfunctions, challenges the young clinician faced with vague, unspecific systemic symptoms. Clinical case: A 76 year old woman previously diagnosed with coronary heart disease, type 2 diabetes mellitus and hyperthyroidism presents at the emergency department with a 6 month history of physical asthenia, difficulty maintaining balance and recurrent urinary incontinence with polachiuria. She describes the symptoms as mild at debut but with a progressive evolution which urged her to seek medical advice. On physical examination the patient appears conscientious yet somnolent, with difficulties in maintaining walking balance. She is afebrile, with a regular heart rate of 75 bpm and a blood pressure of 120/60 mm Hg. The general physical examination reveals no abnormalities in the head, neck, chest, abdomen, or extremities. A thorough neurologic examination is performed, which reveals abolished tendon reflexes. Other neurologic examinations, including sensory and motor examinations and cerebellar tests are all within normal range. Her blood test results reveal an elevated ESR (30 mm/h), hyperglycemia (173 mg/dL), increased serum triglycerides (240 mg/dL), mildly increased blood urea nitrogen (51.70 mg/dL), low serum TSH (0.007 μUl/mL) with low fT3 and T4 values. Urine exam and cultures were negative for infection. Heart and carotid artery ultrasound exams found no significant abnormalities (LVEF 55%, impaired diastolic relaxation patterns and carotid atheromatosis, without significant stenosis). The obstetric examination excluded a perineal rupture as possible cause of the patient's urinary incontinence. Finally, the CT exam reveals a sellar and subsellar tumor with multiple calcifications, near the third ventricle. The mass causes hydrocephalus with periventricular edema. The native brain MRI exam describes the tumor with a craniocaudal diameter of 4 cm and axial 2.4/1.6 cm, with mixed solid and cystic structure and an aspect of a craniopharyngioma, with frontal lobe compression, coming in close contact to the optic chiasm. Thus, the common base between neurological symptoms and endocrine dysfunctions was revealed in the clinical entity described as a brain tumor associated with pituitary deficiency. Conclusion: We are presenting a rare and unspecific symptomatology for a craniopharyngioma, the patient showing none of the common signs of nausea, vomiting and headaches. The patient had previously been misdiagnosed and treated for hyperthyroidism while actually suffering from pituitary deficiency. After diagnosing the neoplasm, she was referred for further treatment by surgical resection and radiotherapy.