Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension.

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

The impact of war on the development and progression of arterial hypertension and cardiovascular disease: protocol of a prospective study among Ukrainian female refugees.

Background: Growing evidence supports the impact of psychological factors such as traumatic experiences and Post Traumatic Stress Disorder (PTSD) on the incidence of arterial hypertension (HTN) and cardiovascular diseases (CVD). The war in Ukraine is exposing million inhabitants to traumatic experiences and severe stress. Part of Ukrainians (mostly women and children) left the country to escape war. We report the protocol of a prospective study aiming at the assessment of the impact of war-induced stress on HTN and CVD in women Ukrainian refugees who moved to Poland. Methods and design: The study will be conducted in 3 stages. Stage 1 will assess the prevalence of HTN and PTSD among Ukrainian refugees and will estimate the impact of war-related trauma exposure on these parameters. Data on office blood pressure (BP) will be compared to data already collected in STEPS data 2019 and May Measurement Month 2021 in Ukraine, matched for age and sex. Stage 2 will involve subjects diagnosed with HTN and/or PTSD referred for management and follow-up of these conditions. Psychologic targeted therapies will be offered to subjects with confirmed PTSD, with a periodical reassessment of the severity of PTSD-associated symptoms and of its impact on HTN and cardiovascular health. Clinical history and characteristics will be compared among three groups: subjects with HTN and PTSD, with HTN without PTSD, with PTSD but without HTN. Stage 3 will involve a subgroup among those screened in Stage 1, with the objective of investigating the biological mechanisms underlying the relation between HTN and trauma exposure, identifying early signs of subclinical target organ damage in subjects with HTN with/without PTSD. Discussion: This study will test the hypothesis that trauma exposure and psychological stress contribute to BP elevation and progression of CVD in this population. It will provide new evidence on the effect of an integrated management, including psychological therapy, on BP and cardiovascular risk. Such approach may be further tested and extrapolated to other populations exposed to war and chronic violence, migrants and refugees around the world. Research Study Registration: number 2022/45/P/NZ5/02812.

Long dorsal "Y-shaped" plate for distal diaphyseal humeral fractures.

BACKGROUND: Osteosynthesis of distal diaphyseal humeral fractures is challenging, especially if there is a metaphyseal extension of the fracture line with a butterfly third fragment or if the fracture is bifocal. These fractures put the radial nerve at risk at the time of the fracture and during surgery. We hypothesize that ORIF with a long dorsal Y-plate matching the dorsal aspects of the humeral diaphysis and of the two metaphyseal columns would provide a reliable method of fixation for distal diaphyseal humeral fractures even when there is a metaphyseal extension or bifocal component. METHODS: Between 2015 and 2019, 17 distal diaphyseal humeral fractures in 17 consecutive patients (14 men, 3 women, mean age 38 years) were operated on with a long "Y-shaped" dorsal plate. There were two bifocal fractures and 11 diaphyso-metaphyseal fractures with butterfly fragments. All 17 patients could be retrospectively followed up clinically and radiographically at a mean follow-up of 25 months (min 4, max 40). Clinical charts included VAS pain, elbow range of motion, QuickDASH, MEPS and subjective elbow value. RESULTS: Bone healing was observed in all cases. Five patients (29%) had a pre-operative radial nerve palsy. All pre-operative radial nerve palsies but one recovered spontaneously. One complete radial nerve palsy that was not present before the operation was observed after surgery. It recovered spontaneously in four months. One case of post-operative elbow stiffness required a revision. Only one case (5%) showing a complication directly related to the plate (secondary displacement) required revision. Mean post-operative elbow flexion was 134°. Extension deficit averaged 13°. Subjective elbow value, QuickDASH and MEPS averaged respectively 81%, 19 points and 92 points. DISCUSSION: Currently available plates (long dorsal straight, short dorsal "Y-shaped", long lateral) may have limitations in terms of screw purchase or biomechanical efficiency when ORIF of distal diaphyseal humeral fractures is considered. A long dorsal "Y-shaped" plate is a new alternative which may be successfully used even in the most difficult cases. CONCLUSION: Our study suggests that a long dorsal "Y-shaped" plate is suitable for distal diaphyseal humeral fractures especially when there is a metaphyseal bifocal or third fragment component.

Screening for hypertension at the hairdresser: a feasibility study in France and Morocco.

Purpose: Worldwide, hypertension awareness remains largely insufficient. This is particularly true in some population subgroups with a low socioeconomic status or in young adults who have limited interactions with healthcare systems. Performing Blood Pressure (BP) screening in non-conventional settings, such as in barbershops, has been suggested by a number of American authors. Whether this approach is feasible in Europe or in North Africa has not been evaluated, however. We, therefore, undertook a study to assess the value of BP screening at hairdressers in France and in Morocco.Materials and Methods: This was a prospective multicenter feasibility study. Twenty-three hairdressers in France and six in Morocco participated in the study. After being provided the relevant information, all consenting customers aged over 18 years were included. Three BP measurements were performed by the customers themselves using a validated Omron M7 automatic BP device connected to a printer.Results: In France, 1025 subjects were enrolled, while 300 subjects participated in Morocco. Three hundred and seventy French participants (36%) had an elevated BP. Among the subjects claiming to be normotensive or who did not know their hypertension status, 31.7% had a BP ≥ 135/85 mmHg. Only 42% of the subjects with an elevated BP contacted their physician within 3 months, although hypertension was confirmed in ¾ of them. In Morocco, the participants were older, with only 11.7% of the subjects aged <50 years. They more frequently had unknown elevated BP values (71.9%). The rate of BP monitoring in known hypertensive individuals was 42.7% in France and 17.1% in Morocco. The procedure was very well accepted and considered to be useful in both countries.Conclusion: BP screening at hairdressers is feasible and well-accepted, although it does suffer somewhat from a relatively low efficacy.

Atypical schwannoma of the median nerve. A case report.

Schwannomas of the hand are very rare tumors and represent less than 3% of all soft tissue tumors in the hand. These tumors share clinical, epidemiological and imaging characteristics with the other soft tissue and peripheral nerve tumors; thus, it can be difficult to make a preoperative diagnosis. Here we report the case of a 48-year-old woman who presented with a schwannoma arising from the palmar branch of the median nerve. The tumor measured 54 × 41 x 52 mm and was located in the thenar eminence. The first hypothesis was a vascular tumor. After surgery and histological analysis, the final diagnosis of an atypical schwannoma was established. The presence of shared immunohistochemical characteristics with cellular histiocytoma and myoepithelial tumors forced us to adopt an aggressive follow-up protocol. As of the last follow-up at 9 years, the patient had good clinical outcomes and no recurrence. This case highlights the difficulties encountered in clinical practice to diagnose such tumors.

Shoulder and Elbow Fractures in Athletes.

PURPOSE OF REVIEW: The purposes of this review are to discuss the management of shoulder and elbow fractures in athletes to optimize the return to sport and to highlight treatment impact on the return to play. RECENT FINDINGS: Fractures of the shoulder and elbow can have profound implications in an athlete career. Recent technique of fractures management trended toward to preserve soft tissue which is critical for an early recovery in athletic population. Arthroscopy presents a strong interest for the treatment of intra-articular fracture, and minimally invasive approach as developed in humeral shaft fracture can be considered to avoid soft tissue damage. Non-articular, stable, and minimally displaced fractures are mainly treated conservatively. However, we encourage a more aggressive approach in shoulder and elbow injuries in the athletes including minimally invasive and stable fixation to preserve vascularity and muscle environment.

Patient-accident-fracture (PAF) classification of acute distal radius fractures in adults.

There is not enough evidence in the literature to support the use of any classification system for distal radius fractures (DRF) in adults. However, there is a need for identification of more homogeneous groups of patients with DRF so that the extent of preoperative workup and sophistication of treatment would best match the needs of the patient. The authors propose an innovative method to analyse and stratify acute DRF in adults. A one-page chart includes criteria related to the patient (P), the energy of the accident (A) and the pathology of the fracture (F). Analysis of the pathology includes not only the distal radius itself but also the associated ulnar and carpal lesions. Radiological suspicion of associated carpal of distal radio-ulnar joint ligamentous injuries is included in the analysis. The preliminary results of the use of this chart in 1610 consecutive adult patients (16-102 years) with unilateral acute DRF are presented. A total of six homogeneous groups of patients are described, and the relevance of this classification regarding the therapeutic options is discussed.

Exploring the in situ expression of vascular endothelial growth factor and endoglin in pemphigus foliaceus variants and pemphigus vulgaris.

BACKGROUND: Erythroderma is a severe manifestation of pemphigus foliaceus (PF), a blistering disease mediated by IgG autoantibodies against desmoglein 1. Increasing evidence supports the contribution of angiogenic mediators in the pathogenesis of erythroderma. OBJECTIVE: To evaluate the in situ expression of vascular endothelial growth factor (VEGF) and endoglin in patients with PF with erythroderma. METHODS: Formalin-fixed paraffin-embedded skin samples obtained from patients with erythrodermic PF (n = 19; 12 patients with endemic PF), non-erythrodermic PF (n = 17), pemphigus vulgaris (PV; n = 10), psoriasis (n = 10) and healthy individuals (HI; n = 10) were processed in an automated immunohistochemistry platform utilizing anti-VEGF and anti-endoglin as primary antibodies. Reactivity was evaluated both manually (0 = negative; 1+ = mild; 2+ = intense) and through an automated microvessel analysis algorithm. RESULTS: Vascular endothelial growth factor expression in erythrodermic PF was higher than in non-erythrodermic PF (P = 0.034) and in HI (P = 0.004), and similar to psoriasis (P = 0.667) and PV (P = 0.667). In non-erythrodermic PF, VEGF positivity was similar to HI (P = 0.247), and lower than psoriasis (P = 0.049) and PV (P = 0.049). Both erythrodermic and non-erythrodermic PF presented similar endoglin expression (P = 0.700). In addition, endoglin positivity during erythrodermic PF was similar to psoriasis (P = 0.133) and lower than PV (P = 0.0009). Increased expression of in situVEGF suggests that healing processes are triggered in response to tissue damage led by autoantibodies in PF, especially during erythroderma. Reduced endoglin positivity suggests that an unbalanced angiogenesis may occur during erythrodermic PF. Further studies may help to confirm if the regulation of VEGF and endoglin expression in patients with PF can contribute to control the healing process and enable disease remission. CONCLUSION: Overexpression of VEGF in erythrodermic PF as well as in PV and psoriasis points out a dysregulated repair process in severe forms of these diseases and suggests VEGF and endoglin could act as prognostic markers and future therapeutic targets to enable proper healing in PF.

Treatment of intra-articular fracture of distal radius fractures with fluoroscopic only or combined with arthroscopic control: A prospective tomodensitometric comparative study of 40 patients.

BACKGROUND: Considering articular distal radius fractures treated with volar plate, we hypothesized that articular radio-carpal displacement was better reduced with arthroscopic control than with only fluoroscopic control. METHODS: Forty patients with similar articular radius fracture (type C according to AO classification) and high functional needs were treated with volar plate fixation. They were divided in two comparative groups: 20 patients in Fluoroscopic group and 20 patients in Arthroscopic group. Pre and postoperative radiographs and tomodensitometric images were analysed by an independent observer. We evaluate extra and intra-articular displacements according to "Patient Accident Fracture" classification. RESULTS: We observed a better reduction of the radio-carpal step-off and gap in the arthroscopic group, with a statistically significant difference (p<0.05). The index of postoperative intra-articular reduction was better in the fluoroscopic group (5.5) than in the arthroscopic group (2.2) with a significant difference (p<0.05). CONCLUSIONS: According to these results, arthroscopy is useful to perform a better articular radio-carpal reduction in distal radius fracture. LEVEL OF EVIDENCE: Level 3.

Copeptin and insulin resistance: effect modification by age and 11 ß-HSD2 activity in a population-based study.

PURPOSE: Arginine vasopressin (AVP) may be involved in metabolic syndrome (MetS) by altering liver glycogenolysis, insulin and glucagon secretion, and pituitary ACTH release. Moreover, AVP stimulates the expression of 11ß-hydroxysteroid-dehydrogenase-type 2 (11ß-HSD2) in mineralocorticosteroid cells. We explored whether apparent 11ß-HSD2 activity, estimated using urinary cortisol-to-cortisone ratio, modulates the association between plasma copeptin, as AVP surrogate, and insulin resistance/MetS in the general adult population. METHODS: This was a multicentric, family-based, cross-sectional sample of 1089 subjects, aged 18-90 years, 47% men, 13.4% MetS, in Switzerland. Mixed multivariable linear and logistic regression models were built to investigate the association of insulin resistance (HOMA-IR)/fasting glucose and MetS/Type 2 Diabetes with copeptin, while considering potential confounders or effect modifiers into account. Stratified results by age and 11ß-HSD2 activity were presented as appropriate. RESULTS: Plasma copeptin was higher in men [median 5.2, IQR (3.7-7.8) pmol/L] than in women [median 3.0, IQR (2.2-4.3) pmol/L], P < 0.0001. HOMA-IR was positively associated with copeptin after full adjustment if 11ß-HSD2 activity was high [ß (95% CI) = 0.32 (0.17-0.46), P < 0.001] or if age was high [ß (95% CI) = 0.34 (0.20-0.48), P < 0.001], but not if either 11ß-HSD2 activity or age was low. There was a positive association of type 2 diabetes with copeptin [OR (95% CI) = 2.07 (1.10-3.89), P = 0.024), but not for MetS (OR (95% CI) = 1.12 (0.74-1.69), P = 0.605), after full adjustment. CONCLUSIONS: Our data suggest that age and apparent 11ß-HSD2 activity modulate the association of copeptin with insulin resistance at the population level but not MeTS or diabetes. Further research is needed to corroborate these results and to understand the mechanisms underlying these findings.

Drug adherence in hypertension.

Blood pressure control remains unsatisfactory in all countries of the world with at best 60% of treated hypertensive patients reaching recommended therapeutic goals. Several factors have been identified which may explain why the rate of blood pressure control remains low. Among them, one can cite medical inertia and a poor adherence to drug therapies. In the absence of new drugs to control blood pressure, drug adherence has become a major issue in the management of hypertensive patients. Numerous studies have demonstrated that the major problem is the lack of persistence followed by a poor day to day execution of the prescribed regimens. Although there are multiple ways of assessing drug adherence, only very few of them are accurate and the most accurate ones are either difficult to implement in clinical practice or too expensive and hence not available outside reference centers. Therefore, physicians have no real capacity to establish a correct diagnosis of non persistence or poor adherence even in high risk patients such as those with resistant hypertension. Today a new approach is becoming increasingly used which consists in measuring urinary drug levels. Nevertheless, there is still an important need for simple and cheap techniques or devices helping physicians in their ability to tackle poor adherence to therapy and thereby improve blood pressure control in the population.

Seasonality of sodium and potassium consumption in Switzerland. Data from three cross-sectional, population-based studies.

BACKGROUND AND AIM: Blood pressure displays a seasonal pattern. Whether this pattern is related to high sodium and/or low potassium intakes has not been investigated. We assessed if sodium and potassium consumption present a seasonal pattern. We also simulated the impact of seasonality of sodium consumption on systolic blood pressure levels. METHODS AND RESULTS: Data from three Swiss population-based studies (n = 2845). Sodium and potassium consumption were assessed by urinary excretion using 24 h urine collection. Seasonality was assessed using the cosinor model and was adjusted for study, gender, age, body mass index, antihypertensive drug treatment, urinary creatinine and atmospheric relative humidity. The effect of sodium variation on blood pressure levels was estimated using data from a recent meta-analysis. Both sodium and potassium excretions showed a seasonal pattern. For sodium, the nadir occurred between August and October, and the peak between February and April, with a multivariate-adjusted seasonal variation (difference between peak and nadir) of 9.2 mmol. For potassium, the nadir occurred in October and the peak in April, with a multivariate-adjusted seasonal variation of 4.0 mmol. Excluding participants on antihypertensive drug treatment or stratifying the analysis by gender cancelled the seasonality of sodium consumption. The maximum impact of the seasonal variation in sodium consumption on systolic blood pressure ranged from 0.4 to 1.1 mm Hg, depending on the model considered. CONCLUSION: Sodium and potassium consumptions present specific seasonal variations. These variations do not explain the seasonal variations in blood pressure levels.

Hemi-arthroplasty for distal radius fracture in the independent elderly.

INTRODUCTION: The authors report their experience with hemi-arthroplasty in irreparable fresh distal radius fracture in independent elderly patients as first-line treatment (12 fractures in 11 women; mean age, 74 years) or in second line after clinically disabling primary failure (4 fractures in 4 women; mean age, 78 years). RESULTS: In the 12 primary surgeries, at a mean 32 months' follow-up, there were no complications requiring implant ablation; mean pain score was 1/10, flexion-extension 62°, Lyon Wrist score 75%, and Patient-Related Wrist Evaluation (PRWE) 22 points. In 2 of the 4 secondary surgeries, at a mean 24 months' follow-up, there were no complications requiring implant ablation; mean pain score was 2.5/10, flexion-extension 62°, Lyon Wrist score 58%, and PRWE 50 points: i.e., slightly poorer results than in primary surgery. CONCLUSION: Salvage of complex fracture in independent elderly patients by hemi-arthroplasty, whether primary or secondary to failure, seems to be a considerable progress, to be confirmed in larger series.

Treatment of unstable proximal interphalangeal joint fractures with hemi-hamate osteochondral autografts.

The primary aim of this study was to assess the clinical and radiological results after hemi-hamate resurfacing arthroplasty in patients with acute or chronic unstable fractures of the base of the middle phalanx and to describe technical features that can facilitate the surgical procedure. Hemi-hamate arthroplasties were done in 19 patients (mean age 39 years) with an isolated fracture at the base of the middle phalanx that involved more than 40% of the articular surface. We assessed ten chronic cases (treated >6 weeks after fracture) and nine acute ones (<6 weeks) at a mean of 24 months. Pain scores, QuickDASH scores, grip strengths, range of motion and radiological findings were recorded at follow-up. At follow-up, the mean active flexion at the proximal interphalangeal joint was to 83° with a mean fixed flexion of 17° (active range of motion 66°). The mean active distal interphalangeal motion was 41°. The mean visual analogue scale score was 1.1. The mean QuickDASH score was 11. The mean pinch strength was 82% of the opposite side. Radiographs revealed one partial graft lysis. LEVEL OF EVIDENCE: IV.

Increased serum levels of vascular endothelial growth factor in pemphigus foliaceus patients with erythroderma.

BACKGROUND: Erythroderma is a clinical skin syndrome shared by patients with cutaneous disorders of distinct aetiologies as a result of the combined actions of chemokines, adhesion molecules, and cytokines, such as vascular endothelial growth factor (VEGF). OBJECTIVE: To evaluate the profile of serum levels of VEGF and soluble vascular endothelial growth factor receptor 1 (sVEGFR-1) in pemphigus foliaceus (PF) patients with erythroderma. METHODS: We conducted a retrospective study, which included (i) a chart review of all PF patients from the Autoimmune Blistering Clinic, University of Sao Paulo, Brazil, from January 1991 to December 2014, together with an evaluation of demographic variables, hospitalization duration and complications and (ii) analysis of the circulating VEGF and sVEGFR-1 levels in PF patients with erythroderma by ELISA. The controls included patients with pemphigus vulgaris or psoriasis. RESULTS: We observed higher serum VEGF levels in PF patients during erythroderma than during the non-erythrodermic phase. PF patients showed increased serum levels of sVEGFR-1 during the erythrodermic phase in comparison to controls. Interestingly, the sVEGFR-1 and antidesmoglein-1 levels were positively correlated during the non-erythrodermic period. CONCLUSION: Erythroderma, which represents one clinical form of PF, implies more severe outcomes. The circulating levels of VEGF, a potent endothelial activator, are increased in PF patients with erythroderma; this result suggests the contribution of the blood vessel endothelium to the pathogenesis of this clinical syndrome. Interestingly, our findings showed a positive correlation between the sVEGFR-1 and antidesmoglein-1 antibody levels, indicating a suppressive response to VEGF augmentation during the erythrodermic phase of PF.

[What is the role of primary or secondary hemiarthroplasty for distal radius fractures in independent elderly patients?] / Quelle place pour l'hémiarthroplastie en urgence ou en secondaire pour fracture de l'extrémité distale du radius du sujet âgé autonome ?

The authors report their experience with wrist hemiarthroplasty for acute irreparable distal radius fractures in independent elderly patients (12 women, mean age 76years) and following failed initial treatment in the same population (5 women, mean age 75years). The first 11 cases have a mean follow-up of 30months. No complications requiring implant removal were reported. At follow-up, the mean VAS for pain was 1/10, the mean flexion-extension arc was 60°, the Lyon Wrist score was 73 % and the PRWE (Patient-Related Wrist Evaluation) was 22 points. The five patients who had secondary procedures and were reviewed at mean of 16months' follow-up did not require implant removal but there was one complete forearm rotational ankylosis with ossification. At follow-up, the mean VAS for pain was 3/10, the mean flexion-extension arc was 56°, the Lyon Wrist score was 65 % and the PRWE was 45 points. The authors believe that hemiarthroplasty is a useful salvage procedure for irreparable wrist fractures in the emergency room and after failed initial treatment in active elderly patients.

[Radiological analysis of acute distal radius fractures and clinical outcomes]. / Analyse radiologique des fractures fraîches de l'extrémité distale du radius et évaluation clinique des résultats.

Radiological analysis of acute distal radius fractures (DRF) begins with the initial AP and lateral X-ray views. A CT scan is very often indicated. In addition to the three standard planes, 3D reconstructions are mandatory. We recommend not only AP views of the distal facets of the radius but also a complete 3D view in the surgical position. The distal ulna and carpus should also be analyzed. We describe the radiological sequence and the criteria used. These criteria are recorded in the one-page PAF chart, since they all impact the treatment choice. Clinical outcomes of DRF treatment are rarely addressed in the literature. We review the most commonly used clinical scores and describe the one that we use currently.

[Patient-Accident-Fracture (PAF) classification of distal radius fractures]. / Classification Patient-Accident-Fracture (PAF) des fractures fraîches de l'extrémité distale du radius.

Despite the huge amount of literature devoted to acute distal radius fractures, there is currently no consensus as to treatment recommendations. There is no universally accepted anatomical classification other than the three main categories of the AO classification. The authors believe that the only way to improve this field is to stratify the patients according to their general health and functional needs. They propose a new classification system that they have used since 2009 and demonstrate its therapeutic, epidemiological and teaching values.