Emanuel Bravo - Academia.edu (original) (raw)
Papers by Emanuel Bravo
Clinical Pharmacology and Therapeutics, 1981
Lofexidine, an imidazoline, is a new central alpha adrenergic agonist reported to be an effective... more Lofexidine, an imidazoline, is a new central alpha adrenergic agonist reported to be an effective antihypertensive in animals. l o Limited clinical studies in humans seemed to support these findings,' "* but the hemodynamic characterization of the blood pressure lowering effect is still preliminary. We know of no reports on the effect of lofexidine on cardiac performance in humans.
Clinical Pharmacology and Therapeutics, 1981
The efficacy of dihydroergotamine (DHE-45) in the treatment of orthostatic hypotension due to def... more The efficacy of dihydroergotamine (DHE-45) in the treatment of orthostatic hypotension due to deficient circulatory reflexes was investigated in 10 patients. Over the short term, intramuscular DHE-45 induced an increase (P less than 0.005) in supine blood pressure (137 +/- 8.9 to 158 +/- 8.1 mm Hg 15 min after DHE-45 and 142 +/- 9.9 to 183 +/- 7.5 mm Hg 60 min after DHE-45) associated with an increase in total peripheral resistance (TPR) (37 +/- 1.9 to 41 +/- 2.8 U . m2 and 34 +/- 2.2 to 41 +/- 2.3) and no change in cardiac output (CO), plasma renin activity (PRA), or plasma norepinephrine. Eight patients tolerated head-up tilt to a higher angle--the drop of mean arterial pressure at equivalent angles of tilt (pre- and post-DHE-45) was less. The other two patients did not improve. On the other hand, oral DHE-45 (1-mo therapy) did not induce a change in mean arterial pressure, heart rate, CO, or TPR; the only significant hemodynamic change was an increase in the ratio cardiopulmonary volume/total blood volume (12 +/- 1.9% to 16 +/- 0.7%, P less than 0.025). Changes in PRA, plasma aldosterone, and plasma catecholamines were not significant. Response to head-up tilt was variable after the first week of therapy. Blood level 2 hr after an oral dose was one order of magnitude lower (0.1 to 0.2 ng/ml) than after intramuscular injection (1.2 to 3.2 ng/ml). The discrepancy between the effects of intramuscular and oral DHE-45 for treatment of idiopathic orthostatic hypotension in this group of patients might be related to the nature of the disease (autonomic insufficiency) or to low bioavailability, suggesting that either another formulation of the drug or methods to improve absorption are needed for long-term therapy.
Clinical Pharmacology and Therapeutics, 1984
blockade might have interfered with steroido genesis, thus blunting the effect of increased PRA. ... more blockade might have interfered with steroido genesis, thus blunting the effect of increased PRA. Finally, blood pressure response to nitrendipine in the whole group correlated inversely with pretreatment PRA (r = 0.88), suggesting greater activity of the drug in low-renin hypertension.
Urology, 2002
Remote robotic telemanipulators have been recently used in performing laparoscopic urologic proce... more Remote robotic telemanipulators have been recently used in performing laparoscopic urologic procedures, both in the laboratory and in clinical practice. We present, to our knowledge, the initial 2 cases of robotic-assisted laparoscopic adrenalectomy in humans. Robotic-assisted laparoscopic adrenalectomy (one right, one left) was performed in 2 patients with an adrenal tumor (one nonfunctional, one pheochromocytoma). Patient age was 81 and 47 years, and tumor size was 4.5 and 3 cm, respectively. Both cases were performed transperitoneally using the da Vinci Robotic Surgical System. Robotic-assisted laparoscopic adrenalectomy was successful in both cases without conversion to conventional laparoscopy or open surgery. The operative time was 110 and 165 minutes, the blood loss was 50 and 100 mL, and the hospital stay was 2 and 3 days. No intraoperative or postoperative complications occurred. Robotic-assisted laparoscopic adrenalectomy is technically feasible. With increasing experience and refinement in the technology, the role of robotics in urologic laparoscopy is likely to expand.
Urology, 2000
Objectives. To compare the anesthetic aspects and intraoperative hemodynamic data and immediate p... more Objectives. To compare the anesthetic aspects and intraoperative hemodynamic data and immediate postoperative outcomes in patients whose pheochromocytoma resection was performed either laparoscopically or by traditional open surgery. Methods. Fourteen consecutive patients who underwent laparoscopic procedures (a single surgeon) were compared with 20 patients who underwent open surgery. The patients' records were reviewed for demographic information, preoperative medical history and therapy, intraoperative hemodynamic data, fluid balance, and immediate postoperative course. Results. No differences between the highest intraoperative blood pressures and number of hypertensive episodes between the two groups were found. However, in laparoscopic patients, the intraoperative hypotension was less severe (mean lowest blood pressure 98/57 mm Hg versus 88/50 mm Hg, P ϭ 0.05), and the hypotensive episodes were less frequent (median 0 versus 2, P ϭ 0.005) and required fewer interventions with vasopressors (P ϭ 0.02). Extreme high and extreme low heart rates did not differ between the two groups. The estimated blood loss was lower in the laparoscopic group (P ϭ 0.0001), but the total intraoperative fluid requirement and operative times were similar in the two groups. Patients in the laparoscopic group resumed walking earlier (median 1.5 versus 4 days, P ϭ 0.002) and resumed oral food intake sooner (median 1 versus 3.5 days, P ϭ 0.0001). The median duration of hospitalization in patients who underwent laparoscopic and open adrenalectomy was 3 and 7.5 days, respectively (P ϭ 0.001). Conclusions. Intraoperative hemodynamic values during laparoscopic adrenalectomy for pheochromocytoma were comparable to those of traditional open surgery, but the patients who underwent the laparoscopic procedure had a faster postoperative recovery.
The Journal of Urology, 1999
Journal of Hypertension, 1993
Journal of Endourology, 2000
Page 1. JOURNAL OF ENDOUROLOGY Volume 14, Number 2, March 2000 Mary Ann Liebert, Inc. Laparoscopi... more Page 1. JOURNAL OF ENDOUROLOGY Volume 14, Number 2, March 2000 Mary Ann Liebert, Inc. Laparoscopic Adrenalectomy for Large-Volume (>5 cm) Adrenal Masses MICHAEL G. HOBART, MD, INDERBIR S. GILL, MD ...
Journal of Computer Assisted Tomography, 1979
The Journal of Clinical Endocrinology & Metabolism, 2005
Radiological characterization of an adrenal tumor as adenoma may decrease the need for follow-up ... more Radiological characterization of an adrenal tumor as adenoma may decrease the need for follow-up imaging studies, biopsies, and unnecessary adrenalectomies. We retrospectively reviewed 299 adrenalectomies in 290 patients at Cleveland Clinic Foundation over a recent 5-yr period to assess the value of noncontrast Hounsfield units (HU) in characterizing whether an adrenal mass is adenoma or nonadenoma. The mean (؎ SD) HU value for the adrenocortical adenoma/hyperplasia group was 16.2 ؎ 13.6 and significantly lower (P < 0.0001) than primary adrenocortical cancers (36.9 ؎ 4.1), metastases (39.2 ؎ 15.2), and pheochromocytomas (38.6 ؎ 8.2). The sensitivity and specificity for 10-and 20-HU cutoff values to differentiate adenomas/hyperplasias from nonadenomas were 40.5 and 100% and 58.2 and 96.9%, respectively. The size of the adrenal tumor had less value with only 40.7 and 81.3% sensitivity and 94.7 and 61.4% specificity for 2-and 4-cm cutoff values. A combination of less than or equal to 4-cm adrenal mass size and noncontrast computed tomography HU less than or equal to 20 had 42.1% sensitivity and 100% specificity. Our study, the largest with surgical histopathology as the gold standard for diagnosis, supports a noncontrast computed tomography attenuation value of 10 HU as a safe cutoff value to differentiate adrenal adenomas/hyperplasias from nonadenomas. (
Hypertension, 1984
The antihypertensive, hemodynamic, and humoral effects of the new convertingenzyme inhibitor enal... more The antihypertensive, hemodynamic, and humoral effects of the new convertingenzyme inhibitor enalapril (MK-421) were assessed by sequential studies during 3 months of uninterrupted treatment (20 mg twice daily) in 10 hypertensive patients. Six achieved good blood pressure (mean arterial pressure) control with enalapril alone (from 126 ± 7.0 mm Hg pretreatment to 105 ± 1.6 mm Hg at 3 months, p < 0.05). The other four required the addition of diuretics (hydrochlorothiazide 25 mg orally twice daily) at different stages of follow-up, with resultant blood pressure control (128 ± 9.6 mm Hg pretreatment to 113 ± 1.9 mm Hg at 2 months after the addition of diuretics). Neither the acute nor long-term blood pressure response could be predicted from the pretreatment levels of plasma renin activity. The blood pressure reduction during enalapril therapy was characterized by a decrease in total peripheral resistance (53 ± 2.5 U-M 2 pretreatment to 38 ± 3.0 U-M 2 at 3 months, p < 0.05) with no significant change in cardiac output or heart rate. This lack of reflex tachycardia could not be ascribed to baroceptor dysfunction since the response to head-up tilt (the increase in diastolic blood pressure, in heart rate, and in plasma catecholamines) was normal and not significantly different from pretreatment response. Average blood volume did not change (91% ± 4.3% of normal in the pretreatment period to 93% ± 2.9% after 3 months of therapy, p = NS) despite the significant lowering of arterial pressure with enalapril alone (n = 6). This could have been possibly related to the reduction in plasma aldosterone (12.6 ± 2.3 to 8 ± 0.9 ng/dl, p < 9.95) induced by treatment. In conclusion, the hemodynamic consequences of blood pressure reduction by enalapril were similar to those produced by other converting-enzyme inhibitors and angiotensin II antagonists. These findings suggest that the hemodynamic effects of enalapril were related to interference with the generation of angiotensin II rather than a direct action of the drug.
The American Journal of the Medical Sciences, 1986
The American Journal of Medicine, 1982
The American Journal of Medicine, 1978
Of 20 patients with idiopath,ic orthostatic hypotension who have been investigated up to date, fo... more Of 20 patients with idiopath,ic orthostatic hypotension who have been investigated up to date, four (20 per cent) have repeatedly shown marked spon&ous~fluctuations in their supine blood pressure. They were selected on the basis of at least 20 mm Hg difference in mean arterial pressure re
The American Journal of Medicine, 1972
The American Journal of Cardiology, 1982
The American Journal of Cardiology, 1975
The American Journal of Cardiology, 1978
To assess the pattern of mortality following coronary artery bypass grafting (CABG), death certif... more To assess the pattern of mortality following coronary artery bypass grafting (CABG), death certificates, autopsies, survivor interviews and hospital records were reviewed in 123 (7.2%) mortalities which occurred in 1714 hospital survivors of CABG followed for an average of 465 17 months. Eighty-four (4.9%) patients were lost to follow-up. Four modes of death, based upon the duration of final episodes were determined:
Clinical Pharmacology and Therapeutics, 1981
Lofexidine, an imidazoline, is a new central alpha adrenergic agonist reported to be an effective... more Lofexidine, an imidazoline, is a new central alpha adrenergic agonist reported to be an effective antihypertensive in animals. l o Limited clinical studies in humans seemed to support these findings,' "* but the hemodynamic characterization of the blood pressure lowering effect is still preliminary. We know of no reports on the effect of lofexidine on cardiac performance in humans.
Clinical Pharmacology and Therapeutics, 1981
The efficacy of dihydroergotamine (DHE-45) in the treatment of orthostatic hypotension due to def... more The efficacy of dihydroergotamine (DHE-45) in the treatment of orthostatic hypotension due to deficient circulatory reflexes was investigated in 10 patients. Over the short term, intramuscular DHE-45 induced an increase (P less than 0.005) in supine blood pressure (137 +/- 8.9 to 158 +/- 8.1 mm Hg 15 min after DHE-45 and 142 +/- 9.9 to 183 +/- 7.5 mm Hg 60 min after DHE-45) associated with an increase in total peripheral resistance (TPR) (37 +/- 1.9 to 41 +/- 2.8 U . m2 and 34 +/- 2.2 to 41 +/- 2.3) and no change in cardiac output (CO), plasma renin activity (PRA), or plasma norepinephrine. Eight patients tolerated head-up tilt to a higher angle--the drop of mean arterial pressure at equivalent angles of tilt (pre- and post-DHE-45) was less. The other two patients did not improve. On the other hand, oral DHE-45 (1-mo therapy) did not induce a change in mean arterial pressure, heart rate, CO, or TPR; the only significant hemodynamic change was an increase in the ratio cardiopulmonary volume/total blood volume (12 +/- 1.9% to 16 +/- 0.7%, P less than 0.025). Changes in PRA, plasma aldosterone, and plasma catecholamines were not significant. Response to head-up tilt was variable after the first week of therapy. Blood level 2 hr after an oral dose was one order of magnitude lower (0.1 to 0.2 ng/ml) than after intramuscular injection (1.2 to 3.2 ng/ml). The discrepancy between the effects of intramuscular and oral DHE-45 for treatment of idiopathic orthostatic hypotension in this group of patients might be related to the nature of the disease (autonomic insufficiency) or to low bioavailability, suggesting that either another formulation of the drug or methods to improve absorption are needed for long-term therapy.
Clinical Pharmacology and Therapeutics, 1984
blockade might have interfered with steroido genesis, thus blunting the effect of increased PRA. ... more blockade might have interfered with steroido genesis, thus blunting the effect of increased PRA. Finally, blood pressure response to nitrendipine in the whole group correlated inversely with pretreatment PRA (r = 0.88), suggesting greater activity of the drug in low-renin hypertension.
Urology, 2002
Remote robotic telemanipulators have been recently used in performing laparoscopic urologic proce... more Remote robotic telemanipulators have been recently used in performing laparoscopic urologic procedures, both in the laboratory and in clinical practice. We present, to our knowledge, the initial 2 cases of robotic-assisted laparoscopic adrenalectomy in humans. Robotic-assisted laparoscopic adrenalectomy (one right, one left) was performed in 2 patients with an adrenal tumor (one nonfunctional, one pheochromocytoma). Patient age was 81 and 47 years, and tumor size was 4.5 and 3 cm, respectively. Both cases were performed transperitoneally using the da Vinci Robotic Surgical System. Robotic-assisted laparoscopic adrenalectomy was successful in both cases without conversion to conventional laparoscopy or open surgery. The operative time was 110 and 165 minutes, the blood loss was 50 and 100 mL, and the hospital stay was 2 and 3 days. No intraoperative or postoperative complications occurred. Robotic-assisted laparoscopic adrenalectomy is technically feasible. With increasing experience and refinement in the technology, the role of robotics in urologic laparoscopy is likely to expand.
Urology, 2000
Objectives. To compare the anesthetic aspects and intraoperative hemodynamic data and immediate p... more Objectives. To compare the anesthetic aspects and intraoperative hemodynamic data and immediate postoperative outcomes in patients whose pheochromocytoma resection was performed either laparoscopically or by traditional open surgery. Methods. Fourteen consecutive patients who underwent laparoscopic procedures (a single surgeon) were compared with 20 patients who underwent open surgery. The patients' records were reviewed for demographic information, preoperative medical history and therapy, intraoperative hemodynamic data, fluid balance, and immediate postoperative course. Results. No differences between the highest intraoperative blood pressures and number of hypertensive episodes between the two groups were found. However, in laparoscopic patients, the intraoperative hypotension was less severe (mean lowest blood pressure 98/57 mm Hg versus 88/50 mm Hg, P ϭ 0.05), and the hypotensive episodes were less frequent (median 0 versus 2, P ϭ 0.005) and required fewer interventions with vasopressors (P ϭ 0.02). Extreme high and extreme low heart rates did not differ between the two groups. The estimated blood loss was lower in the laparoscopic group (P ϭ 0.0001), but the total intraoperative fluid requirement and operative times were similar in the two groups. Patients in the laparoscopic group resumed walking earlier (median 1.5 versus 4 days, P ϭ 0.002) and resumed oral food intake sooner (median 1 versus 3.5 days, P ϭ 0.0001). The median duration of hospitalization in patients who underwent laparoscopic and open adrenalectomy was 3 and 7.5 days, respectively (P ϭ 0.001). Conclusions. Intraoperative hemodynamic values during laparoscopic adrenalectomy for pheochromocytoma were comparable to those of traditional open surgery, but the patients who underwent the laparoscopic procedure had a faster postoperative recovery.
The Journal of Urology, 1999
Journal of Hypertension, 1993
Journal of Endourology, 2000
Page 1. JOURNAL OF ENDOUROLOGY Volume 14, Number 2, March 2000 Mary Ann Liebert, Inc. Laparoscopi... more Page 1. JOURNAL OF ENDOUROLOGY Volume 14, Number 2, March 2000 Mary Ann Liebert, Inc. Laparoscopic Adrenalectomy for Large-Volume (&amp;amp;amp;amp;gt;5 cm) Adrenal Masses MICHAEL G. HOBART, MD, INDERBIR S. GILL, MD ...
Journal of Computer Assisted Tomography, 1979
The Journal of Clinical Endocrinology & Metabolism, 2005
Radiological characterization of an adrenal tumor as adenoma may decrease the need for follow-up ... more Radiological characterization of an adrenal tumor as adenoma may decrease the need for follow-up imaging studies, biopsies, and unnecessary adrenalectomies. We retrospectively reviewed 299 adrenalectomies in 290 patients at Cleveland Clinic Foundation over a recent 5-yr period to assess the value of noncontrast Hounsfield units (HU) in characterizing whether an adrenal mass is adenoma or nonadenoma. The mean (؎ SD) HU value for the adrenocortical adenoma/hyperplasia group was 16.2 ؎ 13.6 and significantly lower (P < 0.0001) than primary adrenocortical cancers (36.9 ؎ 4.1), metastases (39.2 ؎ 15.2), and pheochromocytomas (38.6 ؎ 8.2). The sensitivity and specificity for 10-and 20-HU cutoff values to differentiate adenomas/hyperplasias from nonadenomas were 40.5 and 100% and 58.2 and 96.9%, respectively. The size of the adrenal tumor had less value with only 40.7 and 81.3% sensitivity and 94.7 and 61.4% specificity for 2-and 4-cm cutoff values. A combination of less than or equal to 4-cm adrenal mass size and noncontrast computed tomography HU less than or equal to 20 had 42.1% sensitivity and 100% specificity. Our study, the largest with surgical histopathology as the gold standard for diagnosis, supports a noncontrast computed tomography attenuation value of 10 HU as a safe cutoff value to differentiate adrenal adenomas/hyperplasias from nonadenomas. (
Hypertension, 1984
The antihypertensive, hemodynamic, and humoral effects of the new convertingenzyme inhibitor enal... more The antihypertensive, hemodynamic, and humoral effects of the new convertingenzyme inhibitor enalapril (MK-421) were assessed by sequential studies during 3 months of uninterrupted treatment (20 mg twice daily) in 10 hypertensive patients. Six achieved good blood pressure (mean arterial pressure) control with enalapril alone (from 126 ± 7.0 mm Hg pretreatment to 105 ± 1.6 mm Hg at 3 months, p < 0.05). The other four required the addition of diuretics (hydrochlorothiazide 25 mg orally twice daily) at different stages of follow-up, with resultant blood pressure control (128 ± 9.6 mm Hg pretreatment to 113 ± 1.9 mm Hg at 2 months after the addition of diuretics). Neither the acute nor long-term blood pressure response could be predicted from the pretreatment levels of plasma renin activity. The blood pressure reduction during enalapril therapy was characterized by a decrease in total peripheral resistance (53 ± 2.5 U-M 2 pretreatment to 38 ± 3.0 U-M 2 at 3 months, p < 0.05) with no significant change in cardiac output or heart rate. This lack of reflex tachycardia could not be ascribed to baroceptor dysfunction since the response to head-up tilt (the increase in diastolic blood pressure, in heart rate, and in plasma catecholamines) was normal and not significantly different from pretreatment response. Average blood volume did not change (91% ± 4.3% of normal in the pretreatment period to 93% ± 2.9% after 3 months of therapy, p = NS) despite the significant lowering of arterial pressure with enalapril alone (n = 6). This could have been possibly related to the reduction in plasma aldosterone (12.6 ± 2.3 to 8 ± 0.9 ng/dl, p < 9.95) induced by treatment. In conclusion, the hemodynamic consequences of blood pressure reduction by enalapril were similar to those produced by other converting-enzyme inhibitors and angiotensin II antagonists. These findings suggest that the hemodynamic effects of enalapril were related to interference with the generation of angiotensin II rather than a direct action of the drug.
The American Journal of the Medical Sciences, 1986
The American Journal of Medicine, 1982
The American Journal of Medicine, 1978
Of 20 patients with idiopath,ic orthostatic hypotension who have been investigated up to date, fo... more Of 20 patients with idiopath,ic orthostatic hypotension who have been investigated up to date, four (20 per cent) have repeatedly shown marked spon&ous~fluctuations in their supine blood pressure. They were selected on the basis of at least 20 mm Hg difference in mean arterial pressure re
The American Journal of Medicine, 1972
The American Journal of Cardiology, 1982
The American Journal of Cardiology, 1975
The American Journal of Cardiology, 1978
To assess the pattern of mortality following coronary artery bypass grafting (CABG), death certif... more To assess the pattern of mortality following coronary artery bypass grafting (CABG), death certificates, autopsies, survivor interviews and hospital records were reviewed in 123 (7.2%) mortalities which occurred in 1714 hospital survivors of CABG followed for an average of 465 17 months. Eighty-four (4.9%) patients were lost to follow-up. Four modes of death, based upon the duration of final episodes were determined: