Short- and long-term results of total vs subtotal thyroidectomies in the surgical treatment of Graves' disease.

OBJECTIVE: Approximately one out of five patients with Graves' disease (GD) undergoes a thyroidectomy after a mean period of 18 months of medical treatment. This retrospective and non-randomized study from a teaching hospital compares short- and long-term results of total (TT) and subtotal thyroidectomies (ST) for this disease. METHODS: From 1987 to 1997, 94 patients were operated for GD. Thirty-three patients underwent a TT (mostly since 1993) and 61 a ST (keeping 4 to 8 grams of thyroid tissue--mean 6 g). All patients had received propylthiouracil and/or neo-mercazole and were in a euthyroid state at the time of surgery; they also took potassium iodide (lugol) for ten days before surgery. RESULTS: There were no deaths. Transient hypocalcemia (< 3 months) occurred in 32 patients (15 TT and 17 ST) and persistent hypocalcemia in 8 having had TT. Two patients developed transient recurrent laryngeal nerve palsy after ST (< 3 months). After a median follow-up period of seven years (1-15) with five patients lost to follow-up, 41 patients having had a ST are in a hypothyroid state (73%), thirteen are euthyroid (23%), and two suffered recurrent hyperthyroidism, requiring completion of thyroidectomy. All 33 patients having had TT--with follow-ups averaging two years (0.5-8)--are receiving thyroxin substitution. CONCLUSIONS: There were no instances of persistent recurrent laryngeal nerve palsy in either group, but persistent hypoparathyroidism occurred more frequently after TT. Long after ST, hypothyroidism developed in nearly three of four cases, whereas euthyroidy was maintained in only one-fourth; recurrent hyperthyroidy was rare.

[Blood pressure monitoring in aged hypertensive patients treated with sustained-release nicardipine or nifedipine]. / Monitoring tensionnel chez des hypertendus âgés traités par nicardipine ou nifédipine à libération prolongée.

In a double-blind parallel study, 20 elderly hypertensive subjects (mean age 85 years) were treated either by nicardipine or by nifedipine in slow-release form for 7 days. Blood pressure was measured by ambulatory, non-invasive daytime monitoring. Efficacy of both drugs was similar on the seventh day of treatment. However, the hypotensive effect induced by nifedipine was maximal on the first day of treatment, in contrast to the progressive effect induced by nicardipine. In 2 cases, marked hypotension was observed after the first tablet of nifedipine.

[Review: arterial hypertension and advanced age]. / Revue: hypertension artérielle et âge avancé.

In elderly and very old patients, arterial hypertension is a major cardiovascular risk factor. However, its management is still controversial. In this review paper, the effects of old age on cardiovascular homeostasis are discussed. Because of less efficient baroreflexes, increased blood pressure variability, postural hypotension, impaired renal and electrolytes regulation, elderly patients are more prone to side effects of treatment. Special attention should be paid to the blood pressure measurements: in this respect, ambulatory non invasive blood pressure profiles can be particularly helpful for the diagnosis and the control of hypertension. A practical approach acknowledging specific aspects of old age and recent advances in antihypertensive therapy is proposed.

Blood pressure variability in ambulatory hypertensive patients: effect of beta-blocking agents and/or diuretics.

Using a semiautomatic device (Remler), ambulatory blood pressure was recorded in ambulatory hypertensive patients who were either untreated (n = 55) or treated chronically with beta-blocking agents (n = 28), diuretics (n = 42), or a combination of both (n = 75). In all patients, one blood pressure reading was obtained during usual activities every 30 min for 12 h. The selection of untreated patients was based on clinic measurements (two to three repeated blood pressures of greater than 140/89 mm Hg). The mean systolic and diastolic blood pressures averaged from all patients over the whole day did not differ significantly among the groups, ranging from 133.7 to 141 mm Hg for the systolic and from 83.8 to 88.4 mm Hg for the diastolic. The variability of blood pressure, reflected by the difference between the average of the three highest and the three lowest values of the day, was not different among the four groups and ranged from 41.4 to 50.6 mm Hg for the systolic and from 30.1 to 34.4 mm Hg for the diastolic. Similarly, variability expressed as the standard deviation of the mean of all blood pressures measured during the day did not differ among the groups. In all groups, blood pressure was highest in the morning and lowest in early afternoon, and tended to rise again in the late afternoon. Thus, blood pressure variability of hypertensive patients is not changed by antihypertensive therapy with beta-blocking agents and/or diuretics.

Ambulatory blood pressure recording to identify hypertensive patients who truly need therapy.

Ambulatory blood pressure profiles were obtained with the Remler system, a portable semi-automatic blood pressure recorder, in 245 untreated patients considered by their physician to be hypertensive. The average blood pressures recorded during the usual daily activities of the patients were greater than 140 mmHg for the systolic and greater than 89 mmHg for the diastolic in only 96 (39%) and 107 (44%) of them respectively. Blood pressure monitoring in ambulatory patients appears to be useful for the practitioner to detect those patients who require antihypertensive therapy. Possibly, unnecessary therapy of only seemingly hypertensive patients may be avoided by this technique.

[Usefulness of the Remler device in avoiding overtreatment of the so-called hypertensive population]. / Utilité du Remler pour éviter de surtraiter la population dite hypertendue.

To assess the reliability of the Remler system, a semi-automatic pressure recording device, several blood pressures were measured simultaneously by the conventional auscultatory method and by the Remler in 12 normotensive volunteers. In all situations tested both the Remler and auscultatory blood pressures were very close, thus demonstrating the reliability of this new technique. Ambulatory blood pressure recordings were then obtained with the Remler in 245 untreated patients referred for hypertension by their private physicians. Surprisingly, in close to 60% of them the average of all blood pressures recorded during usual activities was within the normal range. Since cardiovascular complications seem to correlate better with ambulatory than with office blood pressure levels, the Remler system appears particularly useful in recognizing those patients who, although hypertensive in the physician's office, remain normotensive during the day and therefore may not require antihypertensive treatment.

CGS 13945: a new orally active angiotensin-converting enzyme inhibitor in normal volunteers.

The new converting enzyme inhibitor CGS 13945 was evaluated in 14 male volunteers. The study consisted of two parts. First, the capacity of a single oral dose (10, 20, 50, 100, 250, or 500 mg) to inhibit the pressor response to exogenous angiotensin I was tested, with blood pressure and heart rate monitored continuously through an intra-arterial catheter. The 250-mg and particularly the 500-mg dose markedly reduced the pressor response to angiotensin I within 1/2 h and for a period exceeding 4 h. There was a close correlation between the pressor response to angiotensin I and plasma converting enzyme activity. In a second part, plasma renin and converting enzyme activity, angiotensin I and II, and plasma aldosterone were measured serially before and up to 48 h after oral administration of either 250 or 500 mg of CGS 13945 to six volunteers each. As expected, plasma renin activity and angiotensin I levels rose, while plasma converting enzyme activity and angiotensin II and aldosterone levels fell within 1/2 h. Twenty-four hours following administration of 500 mg CGS 13945, plasma converting enzyme had not quite returned to base line. No side effects were observed. CGS 13945 seems less potent than previously studied converting enzyme inhibitors, but equally effective and relatively long acting.

[Profiles and variations of ambulatory arterial pressure in treated and untreated hypertensive patients]. / Profils et variations de la pression artérielle ambulatoire chez des patients hypertendus traités et non traités.

It is now possible to record numerous ambulatory blood pressures by a noninvasive method using the Remler, a portable semi-automatic device. The blood pressure profiles obtained with this recorder in hypertensive patients during customary daily activities have revealed the existence of a circadian blood pressure variation. Thus, blood pressure is highest in the morning, lowest early in the afternoon and tends to increase again late in the afternoon. This circadian variation is not modified by treatment with diuretics and/or betablockers. These blood pressure recordings also made it possible to establish that antihypertensive therapy with these agents does not modify blood pressure variability over the day.

Enalapril maleate and a lysine analogue (MK-521) in normal volunteers; relationship between plasma drug levels and the renin angiotensin system.

1 Two single doses of 10 mg each of the converting enzyme inhibitor enalapril maleate or MK-421 and of its lysine analogue (MK-521) were administered p.o. to twelve male volunteers. 2 The active diacid metabolite of MK-421 and the lysine analogue were determined by radioimmunoassay and MK-421 by the active metabolite method following in vitro hydrolysis. 3 Peak serum levels of MK-421, active metabolite and lysine analogue were reached within 1, 3 to 4, and 6 h respectively. Practically all MK-421 had disappeared from serum within 4 h. 4 A close correlation between percent inhibition of plasma converting enzyme activity and the serum concentration of active metabolite was observed ( r = 0.98, n = 171, P less than 0.001). Similarly, converting enzyme blockade as expressed by the ratio plasma angiotensin II/angiotensin I was closely correlated with serum active metabolite levels (r = 0.93, n = 15, P less than 0.001).