Management of resistant hypertension: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology.

To improve the management of resistant hypertension, the French Society of Hypertension, an affiliate of the French Society of Cardiology, has published a set of eleven recommendations. The primary objective is to provide the most up-to-date information based on the strongest scientific rationale and that is easily applicable to daily clinical practice. Resistant hypertension is defined as uncontrolled blood pressure on office measurements and confirmed by out-of-office measurements despite a therapeutic strategy comprising appropriate lifestyle and dietary measures and the concurrent use of three antihypertensive agents including a thiazide diuretic, a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, for at least 4 weeks, at optimal doses. Treatment compliance must be closely monitored, as must factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression, drug interactions and vasopressor drugs). If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for potential target organ damage and secondary causes of hypertension. The recommended treatment regimen is a combination therapy comprising four treatment classes, including spironolactone (12.5-25 mg per day). In the event of a contraindication or a non-response to spironolactone, or if adverse effects occur, a ß-blocker, an α-blocker, or a centrally acting antihypertensive drug should be prescribed. Because renal denervation is still undergoing assessment for the treatment of hypertension, this technique should only be prescribed by a specialist hypertension clinic.

Comparison of circadian blood pressure variations in hypertensive patients with renal artery stenosis and essential hypertension.

Ambulatory blood pressure measurements in 20 hypertensive patients with uni- or bilateral renal artery stenosis were compared with those in 20 essential hypertensive patients. Analysis of the 24 hour blood pressure curve of the renal artery stenosis group shows a tendency to equalization of blood pressure throughout the day. The nocturnal decrease of systolic or diastolic blood pressure was not significantly different between the two groups (9.2 vs. 15.3 mmHg). The blunted curve seems to be related more to the severity of hypertension than to its aetiology, but further studies are required to elucidate this point.

Spatial reproduction of the root canal system by magnetic resonance microscopy.

This study was intended to achieve an accurate spatial reproduction of the root canal system of extracted teeth by magnetic resonance microscopy (MRM). The measurements were performed in a Bruker spectrometer AMX 300 WB (300 MHz, 7T) with microimaging attachment. The data processing was carried out by a 3D-Fourier analysis and reconstructions were done by the UXNMR (Bruker) software system. The voxel resolution isotropically reached 98 microns, so that insights into the interior of teeth on a microscopic level could be obtained. The spatial configuration of the root canal system could be depicted in all parts from crown pulp to even small lateral canals. Within the pulp, tissue differences in its tissue texture were ascertained. As the necessary strong magnetic fields presently are not allowed to be used in people and as the acquisition of data is costly, the noninvasive MRM technique presently can be applied only in nonclinical situations.

[Computed tomography of lung contusion. An experimental study]. / Computertomographie der Lungenkontusion. Eine experimentelle Studie.

A new experimental model has been developed to determine whether computed tomography has any advantages for the investigation of lung contusions. In 27 dogs, chest wall deformation was produced at speeds varying from 17.3 m/sec to 45.7 m/sec, leading to lung contusion. After the injury, 27 out of 27 (100%) CT examinations demonstrated the contusions, but only nine out of 24 (37.5%) were seen on conventional radiographs. In contrast to conventional radiography, which either failed to show the presence of a contusion, or which under-estimated the extent by more than one cm, in more than half the cases CT agreed with the pathological findings in more than 90%. No lung contusions were found at autopsy which had not been demonstrated by CT.

[Combined bilateral idiopathic necrosis of the humerus and femur heads: bone scintigraphy, x-ray, CT and MRT findings]. / Kombinierte beidseitige idiopathische Nekrose der Humerus- und Femurköpfe: Skelettszintigraphie, Röntgen-, CT- und MRT-Befunde.

Aseptic bone necrosis in adults is usually caused by circulation defects or metabolic diseases but may also occur without any obvious reason. In these "idiopathic" cases, alcoholism seems to play a prominent role. In addition to the frequently affected femoral heads other bones may be involved. Here a remarkable pattern of localizations is reported: the bilateral idiopathic necroses of the heads of both humerus and femur. Untreated aseptic bone necroses close to a joint commonly leads to severe secondary arthrosis and destruction of the joint within a short time. Therefore, only a diagnosis in an early stage of the disease offers the chance of a successful joint-preserving therapy. In cases of clinically suspected aseptic bone necrosis but still negative or doubtful X-ray findings, bone scans or MRI are reliable methods of verifying the diagnosis.

[Total abnormal pulmonary venous return surgically treated in an adult]. / Retour veineux pulmonaire anormal total opéré chez un adulte.

The authors report a case of total anomalous pulmonary venous return (TAPVR) draining into the innominate (brachiocephalic) vein, discovered in a 40-year old male patient and successfully treated by surgery. This type of cardiopathy is usually suspected in the neonatal period, being badly tolerated, and such a prolonged survival is quite exceptional. Survival is conditioned by the site of the TAPVR, by the size of the atrial septal defect and also by the presence or absence of an obstacle to the pulmonary venous return and of pulmonary arterial hypertension. In the absence of pulmonary vascular disease, surgical correction is mandatory and results in regression of the symptoms and of the pulmonary arterial hypertension.

[Reproducibility of the nyctohemeral cycle of blood pressure in patients with severe Parkinson disease]. / Etude de reproductibilité du cycle nycthéméral de la pression artérielle du parkinsonien dans un état grave.

UNLABELLED: Nineteen hospitalised, severe and treated parkinsonians (9 males, 10 females), stage IV and V of Hoehn and Yahr's classification, underwent 2 days running ambulatory blood pressure monitoring (ABPM) by ABPM 630 Nippon-Colin device, during a period of therapeutic stability. Hospitalisation allowed reproducibility of daily activity. Diurnal, nocturnal and 24 hours systolic blood pressure (SBP), as well as nocturnal and 24 hours diastolic blood pressure (DBP) were reproducible with a good correlation for each patient. Diurnal diastolic BP was the lone not reproducible value but had a good day 1-day 2 correlation. [table: see text] CONCLUSION: Parkinsonian ABPM data, except diurnal DBP, are reproducible.

[An often ignored complication of left heart catheterization: embolism of cholesterol crystals. Report of 9 cases]. / Une complication souvent méconnue du cathétérisme gauche: les embolies de cristaux de cholestérol. A propos de 9 observations.

Cholesterol embolism (CE) is caused by the migration of cholesterol crystals from severe atheromatous lesions. Until recently, this was considered to be a classical but rare complication of atheroma. With the upsurge in techniques of left heart catheterization there has been a regain of interest in this subject. Nine cases of cholesterol embolism occurring after left heart catheterisation are reported, 3 after coronary angioplasty, and 3 cases after associated thrombolytic therapy. Three patients developed cutaneous syndromes (livedo reticularis, the "purple toe syndrome") with a favorable outcome in a few weeks. Two patients developed segmental necrosis of the small bowel requiring surgical resection of the affected area. Finally, in 4 cases, the patients died 12 hours to 3 months after catheterization: 2 patients had polyvisceral involvement; one patient developed cardiogenic shock; one patient had intestinal necrosis involving 2/3 of the ileum and the right colon. The cases illustrate the variability of the presentation of CE and its potential gravity. At present, the only effective measures are prophylactic; curative treatment remains particularly disappointing.

[Arterial and venous thromboembolic complications in patients with renal transplants. Apropos of 2 cases]. / Complications thrombo-emboliques veineuses et artérielles chez le transplanté rénal. A propos de deux cas.

The study of two cases of young patients with renal transplants who, successively and a few months after the procedure, presented a thrombophlebitis of the lower extremities (with or without pulmonary embolism), then an acute coronary insufficiency, without any encouraging or triggering factor, raises the hypothesis that this is not a mere coincidence. In fact, in the literature, numerous cardiovascular risk factors) inherent in complicated chronic renal failure, dialysis, steroid therapy and immuno-suppressive treatment (Azathioprime, under these circumstances) were demonstrated. In addition, abnormalities of the platelets aggregation, hemostasis and fibrinolysis, were at the origin of thrombo-embolic accidents. Besides any specific cardiovascular risk factor or any obvious biological anomaly, there is still a predisposition of patients with renal transplants, to arterial as well as venous thrombo-embolic accidents.

[Value of esophageal stimulation for decreasing auricular flutter]. / Intérêt de la stimulation cesophagienne pour la réduction du flutter auriculaire.

The purpose of this study was to evaluate the effectiveness of trans-esophageal atrial stimulation in decreasing atrial flutters. 31 patients, aged between 26 and 86 years, underwent 38 esophageal stimulations between August 1986 and April 1987. Esophageal stimulation was carried out with a device delivering major stimuli (10 to 20 ms) as well as high voltages (10 to 20 volts). A bipolar probe of permanent intracardiac stimulation was placed behind the left atrium, via a trans-esophageal approach under ECG guidance. Stimulations were carried out at a slightly faster rhythm than that of the atrial flutter, for 1 to 30 seconds with a progressive increase of the stimulation frequency (280 to 960 impulses/min) until either a sinus rhythm or an atrial fibrillation was obtained. A sinus rhythm was obtained immediately (21 times out of 38; 55.3%) and at the 24th hour after temporary atrial fibrillation in 8 additional patients (21%). The reduction percentage at 24 hours was therefore 76.3 p. cent. In 6 patients (15.8%), esophageal stimulation failed and in 3 additional patients, after atrial fibrillation, there was either relapse into flutter, or persistence of atrial fibrillation at the 24th hour. Esophageal stimulation was well tolerated in all cases. There were no local or rhythm complications. In conclusion, trans-esophageal atrial stimulation appears to be effective, easy to implement, economical and well tolerated. Its primary use to decrease atrial flutter seems justified, permitting to avoid in 75 p. cent of the time, recourse to intracardiac atrial stimulation or external shock.

[Limitations of scintigraphy using metaiodobenzylguanidine for locating pheochromocytomas. Apropos of 2 cases]. / Limites de la scintigraphie à la MIBG pour localiser les phéochromocytomes. A propos de deux cas.

Two cases of MIBG (metaiodobenzylguanidine) scintigraphy are reported: the first case concerns a female patient hospitalized for high blood pressure (HBP) with symptoms evocative of pheochromocytoma. Urinary titration of catecholamines metabolites, which are usually abnormally high, and tomodensitometry permit the visualization of a left adrenal tumor. On the contrary, the MIBG scintigraphy does not show any abnormal fixation. After resection, the pathological examination confirms the diagnosis of pheochromocytoma. The second case concerns a female patient hospitalized for HBP with, on the chest X-Ray, a left postero-inferior density. Serum and urinary catecholamine levels are normal. Tomodensitometry confirms the tumor of the posterior mediastinum and the MIBG scintigraphy demonstrates a focus of thoracic opposite the tumor. After resection, the pathological examination shows an ectopic supernumerary bronchial bud. These two cases illustrate the limitations of MIBG scintigraphy to locate pheochromocytomas. There are false negative (10%) which may be explained by an insufficient uptake of the tracer by the tumor, by an insufficient image formation or by medication interferences. On the contrary, there may be false positives because of histochemical similarities between the chromaffin tissues and certain glandular or neural tumors. Nevertheless, in spite of serious limitations, which we must be aware of, MIBG scintigraphy remains the best primary examination for the location of pheochromocytomas.

Size discrepancy of apical bases and treatment success in angle Class III malocclusion.

The aim of this retrospective clinical study was to measure the apical bases and determine their size relationship in Class III malocclusion cases before and after orthodontic treatment, in order to evaluate their significance for the treatment success. Maxillary and mandibular apical bases were measured on study models of 104 Class III cases treated by conventional orthodontics, using a specifically constructed conveyance apparatus, and related to each other as an index. Treatment success was quantitatively assessed as the percentage change of PAR scores obtained from the pretreatment and posttreatment study models. Statistically significant relationships were disclosed between the measurements of the apical bases and several other evaluated parameters. The results obtained indicate a high prognostic value of the size relationship of the apical bases for the treatment success of Class III malocclusion.

Efficacy of protection by latex gloves during orthodontic therapy.

The wearing of gloves during orthodontic or dental treatment is generally indicated for reasons of hygiene and protection against infection. This study was aimed at determining the extent and localization of perforations caused by the various orthodontic treatment techniques and interrupting the infection barrier. The impermeability was tested by means of a water retention test according to European standard EN 455, Part 1, performed on 1600 Centramed (Centramed, Koblenz), Tekmedic and SafeEx non-sterile disposable latex gloves (both by Safe Med, Switzerland) and Safe Gan latex gloves with an additional acrylate coating (also by Safe Med). The perforation rate in unused gloves was between 0.5% and 7.5%, rising on average to 11% with increasing use. 36% of the total number of lesions resulted from handling removable appliances, and 57% from handling fixed appliances, especially when replacing arch wires and elastics. Most lesions were in the thumb, index finger and palm region. Only 18% of the defects were noticed by the dentists themselves. The gloves worn by beginners in their first year of postgraduate orthodontic training had about twice as many defects as those worn by qualified orthodontists. When patients with an increased risk of infection are to be treated, additional hand disinfection measures should be taken and 2 pairs of gloves worn in view of the relatively unreliable protection offered by commercially available latex gloves.

Relationship between patient discomfort, appliance acceptance and compliance in orthodontic therapy.

Orthodontic treatment is occasionally a discomfort to patients, due to pain or functional restrictions. In this context, several retrospectively planned studies were performed in the 1980s, but correlations between different aspects of patient discomfort were not investigated. The present study aimed at examining and structuring the psychogenic dimensions of patient discomfort. Furthermore, the impact of the patient's attitude on the intensity of discomfort was to be evaluated in addition to the influences of appliance therapy. The study was performed with 67 patients aged from 9 to 32 years. Prior to insertion of a new appliance, psychogenic scales reflecting their attitude towards orthodontic therapy were submitted to them. They were instructed to keep a discomfort log during the first 7 days after insertion. After 6 months they were given lists for retrospective assessment of discomfort and an appliance-acceptance scale to be filled in. At the same time, the respective orthodontist assessed his patient's compliance on a cooperation scale. The factor analysis revealed 3 levels of patient discomfort: feelings of tension, functional restrictions and aversion to wearing an orthodontic appliance in public. Appliance acceptance after 6 months could be predicted from the attitude towards treatment and the experienced discomfort. Patient compliance also correlated with these factors, so that causal flow diagrams of the investigated variables could be produced. Giving detailed information on any discomfort occurring and explaining how to reduce or eliminate it are vital factors in good treatment cooperation.

Reliability and validity of the Digigraph 100 in orthodontic diagnosis.

Cephalometric analyses of lateral cephalograms allow important statements to be made on diagnosis and treatment planning. Such radiographs should, however, be taken with a considerable reduction in radiation exposure. With the Digigraph 100 (Dolphin Imaging Systems Inc., USA) a cephalometric technique based on distance measurements of emitted sonic signals is now available. This study was aimed at determining the degree to which this procedure can cope with the requirements of reliability and validity in the field of orthodontics. For this purpose 50 volunteers were examined by conventional cephalometry with manual tracing of lateral cephalograms as well as by sonic cephalometry, with Jarabak analysis in both cases. In addition an option was available for reading lateral cephalograms into the Digigraph by means of a radiograph evaluation program. The 31 evaluated parameters were subjected to modified statistical analysis. Good reliability was recorded in the range between 0.96 and 0.99 for eleven sonic cephalometric measurements, whereas 26 values were between 0.69 and 0.95. The validity was significantly lower in comparison to radiocephalometry. In particular, measurements related to landmarks which were difficult to access or could be only indirectly determined, such as the sella point, the articulare point or the apices of the incisors, proved to be weak points of sonic cephalometry. The device is thus indicated rather in the field of communication with the patient or for intermediate examination without radiation exposure. Cephalometry without radiation exposure would represent decisive progress in orthodontic diagnostics. However, some developmental work on the processing software or even the development of a specific sonic cephalometry which deliberately dispenses with parameters that are difficult to record with this procedure is still needed.