[Performing self-measurement of blood pressure: a patient survey]

In the present study the knowledge of 200 patients of our hypertension clinic about the technique of blood-pressure self-measurement was investigated using a questionnaire of 22 questions. 44-66% of the patients in different age groups measured their own blood-pressure, showing that self-measurement is commonly used, regardless of the age. 73% of the patients had bought a device on their own, but only 17% on the physician's advice. Possible causes for erroneous measurements were rarely known and underestimated by the patients. Due to lacking or insufficient instruction a relatively high percentage of the patients did not perform correct measurements. 45% did not measure the blood-pressure at the same time of day, 45% did not read systolic and diastolic pressures to the nearest 2 mmHg mark of the manometer scale, 59% did not count the pulse rate and 52% did not document the blood-pressure values. About half of the patients adjusted their medication on the ground of self-measured blood-pressure determinations. 45% of the elderly patients felt that their compliance had improved by self-measurement in contrast to 17% in the younger group. Given the increasing use of blood-pressure self-measurement we conclude that education of patients and physicians on possibilities and limitations of self-measurement as well as optimal training in the correct technique seem advisable.

[Bronchial asthma and kitchen salt]

Epidemiological studies show considerable geographic differences in asthma prevalence and mortality. The regions with high prevalence and mortality are countries with Western-type culture and a high degree of technological progress. They differ from less technically developed countries in a number of ways, including their higher salt intake. Air pollution is often given as the cause of the high prevalence of asthma in the industrialized countries. Against this, it must be pointed out that in the urban agglomerations of the developing countries and in rural areas where heating is by means of open fireplaces (indoor pollution), there is also considerable air pollution. Migration studies from New Zealand and South Africa, where asthma prevalence increases parallel to salt intake, provide evidence that other factors arising from westernization and urbanization play a role. In the industrialized countries England and USA there is also a clear connection between salt intake and asthma: the greater the salt consumption, the higher the asthma prevalence and mortality. On the basis of these observations, the following questions were investigated: (1.) Does salt loading worsen the clinical and functional findings in asthmatics? (2.) Is the sodium or the chloride in salt the more important? To answer these questions, the effect of salt loading (+6.1 +/- 2.8 g NaCl/d = 105 +/- 48 mmol Na), salt restriction, and loading with sodium citrate in equimolar concentrations (+140 +/- 40 ml Shohl's solution = 120 +/- 34 mmol Na) was investigated in 14 asthmatics in a controlled crossover study. Statistical analysis showed that salt intake worsened symptoms (p = 0.06) and increased the use of inhaled steroids (p less than or equal to 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[How reliable is conventional blood pressure registration? Comparison with a semi-automatic device]

The aim of the present study was to determine observer error in measuring blood pressure by the conventional auscultatory method. Casual blood pressure was measured in two age-matched groups of normo- and hypertensive patients with a conventional mercury sphygmomanometer (n = 181) or a semiautomatic device (n = 176) by ten doctors of the university hospital. Although there were no significant differences in mean systolic or diastolic blood pressure values between the groups, the conventionally determined values showed a distinctively different pattern of distribution in comparison to the semiautomatically taken readings. With conventional readings a highly significant preference for terminal digit "0" (44%) and fewer systolic and diastolic values in the lower blood pressure range were observed. Furthermore there was a higher frequency of conventional readings ending in "8" than in "2". Terminal digit preference in the whole group was mainly due to the doctors, who did not measure blood pressure to the nearest 2 mmHg mark. Our results thus stress the importance of better and regular training in the correct technique of measuring blood pressure in order to reduce sources of observer bias.

Generation of intracellular signals by low density lipoprotein is independent of the classical LDL receptor

Low density lipoprotein cholesterol (LDL) and apolipoprotein B-100 (1 to 15 micrograms/mL) had no significant influence on the inositol-1,4,5-trisphosphate (InsP3) formation in vascular smooth muscle cells and fibroblasts. Low density lipoprotein cholesterol (15 micrograms/mL) induced an elevation of intracellular Ca2+ from 85 to approximately 210 nmol/L in vascular smooth muscle cells from rat aorta in the absence or in the presence of 15 micrograms/mL monoclonal antibodies against the classical low density lipoprotein receptor or in the presence of apolipoprotein B-100. Moreover, in both human cultured fibroblasts from normocholesterolemic individuals and from patients with familial hypercholesterolemia homozygote class 1, LDL induced a dose-dependent rise of free intracellular calcium and a biphasic change of intracellular pH. Since homozygote class 1 fibroblasts are classical LDL receptor negative, and as antibodies against this receptor, as well as apolipoprotein B-100, did not attenuate the LDL-induced elevation of cytosolic calcium, we conclude that LDL might modify vascular activity via the observed intracellular changes without involving the classical low density lipoprotein receptor.

A comparative review of the adverse effects of treatments for hyperlipidaemia

Various lipid-lowering drugs have been shown to reduce serum cholesterol and serum triglycerides effectively. In view of trials indicating that lipid-lowering drugs may reduce cardiac morbidity and mortality but not the overall mortality in the study group, increased attention must be focused on potential harmful side effects during treatment with these agents. The adverse effects of many of the principal drugs in this category are discussed. Gastrointestinal symptoms, usually self-limited and reversible, are the most common side effects. Potential harmful adverse effects include drug interactions (cholestyramine), myopathy and hepatic injury (HMG-CoA reductase inhibitors), and increased gallstone formation and ventricular arrhythmias (clofibrate). Not all lipid-lowering drugs have been studied adequately on a long term basis, so that medications given for an indefinite period must be reevaluated frequently. However, there are several agents that lower serum lipid levels effectively and that have been used for more than 20 years without serious side effects.

The lipase inhibitor tetrahydrolipstatin binds covalently to the putative active site serine of pancreatic lipase

Tetrahydrolipstatin (THL) is a selective inhibitor of fat absorption. In animal models, it has anti-obesity and anti-hypercholesterolemic activity and is presently in clinical trials for these indications. THL binds covalently to pancreatic lipase. Complete inhibition of lipolytic activity is obtained concomitant with the incorporation of 1 mol of THL/mol of enzyme. Pancreatic lipase is the best studied lipase, but published results concerning its catalytic mechanism are still controversial. In order to learn more about the inhibitory mechanism of THL, a selective lipase inhibitor interacting at or near the catalytic site, and therefore, to obtain more information on the catalytic mechanism of lipase, we have determined the amino acid residue to which THL is bound. After proteolytic degradation of porcine pancreatic lipase inhibited with radioactively labeled THL, the labeled peptides were isolated and analyzed by quantitative amino acid analysis, N-terminal sequencing, and by mass spectrometry with fast atom bombardment ionization. The data clearly show that THL is bound as an ester to the serine 152 of the lipase.

Effects of slow ascent to 4559 M on fluid homeostasis

Since acute mountain sickness (AMS) is associated with rapid ascent and with fluid retention, we assessed clinical status and fluid homeostasis in men slowly ascending on foot over 3 d to 4559 m and remaining at this altitude 5 d. We studied 15 male mountaineers, 6 of whom had previously had repeated, severe AMS or high altitude pulmonary edema (HAPE), at 1170 m, 3611 m, and 4559 m. We found that four of the six subjects with previous AMS or HAPE compared with none of nine with no such history, developed these conditions. Those who remained well had a diuresis that could not be overcome by increasing fluid intake and no change in renin activity, plasma aldosterone, or atrial natriuretic peptide (ANP). Those who became ill showed considerable weight gain independent of fluid intake, and a great increase in ANP which correlated with measurements of right atrial cross section. We conclude that mountaineers who have previously experienced repeated AMS or HAPE get fluid retention despite slow ascent and that this is associated with widening of the atrium and an increase in ANP.

[Vomiting, fatigue, dizziness, cold hypersensitivity and hyperpigmentation]

Vomiting, fatigue, hyperpigmentation and cold intolerance were the clinical symptoms of a autoimmune polyendocrinopathy type II, confirmed by laboratory results. One year after starting a therapy with L-thyroxine and cortisone the patient feels well.

[Angina pectoris--drug therapy and costs in a medical outpatient clinic in Switzerland]

Prescriptions and costs of pharmacotherapy for exertional angina pectoris were studied in males treated in 1975, 1980 or 1985 at the outpatient clinic of the university of Zürich. Monotherapy was increasingly replaced by two drug regimens (1975 43%, 1980 59%, 1985 35%) or by triple therapy (1975 2%, 1980 10%, 1985 28%) respectively. In 1985 beta-blocking agents and calcium antagonists were more frequently used instead of nitrates in monotherapy. In combined treatment modalities, nitrates associated with calcium antagonists or calcium antagonists combined with beta blockers were used increasingly in 1985. The most used substances in 1985 were isosorbide dinitrate, atenolol and nifedipine. In 1985 nonselective beta blockers (propranolol, pindolol) were administered almost exclusively. The number of tablets administered per day decreased slightly over the years, while the doses of most commonly prescribed drugs increased. The cost per patient doubled during the observation period. Pharmacotherapy of stable angina calculated on the basis of 1985 pharmacy prices rose from 577 SFr. in 1975 to 1180 SFr. in 1985.

Ambulatory twenty-four-hour blood pressure measurements in pharmacological studies

Until a few years ago, only casual blood pressure measurements were used in the diagnosis and treatment of arterial hypertension in clinical practice and in pharmacological studies. The development of portable lightweight devices for 24-h ambulatory blood pressure measurement has proved a substantial step towards reducing the potential pitfalls of casual blood pressure measurements. Ambulatory monitoring of blood pressure can improve pharmacological trials by excluding patients in whom blood pressure is elevated only in the clinic environment, and by increasing the accuracy and reproducibility of blood pressure values. Twenty-four-hour blood pressure measurement has great advantages for trials investigating the time-course of a particular drug, since the 24-h blood pressure rhythm is fully monitored. However, internationally accepted normal values for 24-h blood pressure measurements are required, and the interpretation of results obtained with this method needs to be standardized before the technique can be routinely used in antihypertensive drug trials.

The platelet-derived growth factor isomers, PDGF-AA, PDGF-AB and PDGF-BB, induce contraction of vascular smooth muscle cells by different intracellular mechanisms

The effect of human recombinant platelet-derived growth factor (PDGF) isoforms, (r)PDGF-AA, PDGF-AB and PDGF-BB, on contractility of rat aortic rings as well as on intracellular free Ca2+ ([Ca2+]i), intracellular pHi (pHi) and thromboxane A2 (TXA2) formation in cultured vascular smooth muscle cells (VSMC) was examined. PDGF-BB behaved similar to PDGF-AB and both have features characteristic of conventional vasoconstrictor-agonists that directly increase [Ca2+]i, activate the Na+/H+ exchanger, stimulate the TXA2 formation, and induced contraction in VSMC whereas PDGF-AA induced contraction without increasing of [Ca2+]i, pHi, and TXA2 formation.

[Pain in the side]

In a 54-year-old patient who entered the hospital because of flank pain of the left side, a prevesicular urethral calculus was found. On further investigation hypercalcaemia and hypophosphataemia were detected, possibly indicating hyperparathyroidism. When an ultrasound of the abdomen was made to exclude hydronephrosis, a tumor in the pancreas was found. The result of the fine needle biopsy of this tumor showed a neuroendocrine tumor. The examination of neuroendocrine parameters was without any reference to an active secreting process. On suspicion of a multiple endocrine neoplasia, a MRI of the hypophysis was made which showed no adenomatous alterations. The examination of the neuroendocrine parameters were without any reference to an active secreting process of the hypophysis, too.

[Nutrition and hypertension: what are the goals?]

The dependence of blood pressure on nutritional factors is reviewed in the light of possible therapeutic consequences. Salt restriction, increased administration of potassium, restriction of alcohol intake, weight loss and prescription of fish-oil are discussed by review of own and published data. All these measures may contribute to a reduction of hypertension although to a variable extent. They should be envisaged as therapeutic alternatives to drugs in mild hypertension.

Self-measured blood pressures at home and during consulting hours: are there any differences?

Home blood pressures are lower than casual blood pressures and this difference is probably due to physician-patient interaction in a clinical stress situation. In order to prove this assumption we compared the casual blood pressures of 127 subjects, measured by a physician and by the subjects themselves in the presence of the physician, with self-measured values obtained at home over a 7-day observation period. The casual pressures were higher than the home pressures (delta = 7.6/3.9 mmHg) regardless of whether they were taken by the physician or by the subjects themselves in the presence of the physician. The subjects' casual readings (132.9 +/- 17.5/87.6 +/- 12 mmHg) were slightly, but significantly, higher than those measured by the physician (131.9 +/- 18.4/86.3 +/- 12.6 mmHg) and both systolic and diastolic self-measured casual values were highly significantly correlated with the physician's readings (r = 0.92 and 0.91, respectively; P less than 0.01).

Individualizing antihypertensive therapy with enalapril versus atenolol: the Zurich experience

With the present increasing concern for compliance and quality or life during antihypertensive treatment, drug therapy tailored optimally for the individual patient is becoming increasingly important. The aim of the present double-blind crossover study was to analyse the individual as well as the group blood pressure response under enalapril and atenolol. Our results show that the group effects of these drugs did not differ significantly. However, individually, two-thirds of the responding patients showed a preference for either enalapril or atenolol. A response to one drug did not predict a comparable response to the other drug. We conclude that double-blind crossover studies are a possible way of individualizing antihypertensive treatment. However, no appropriate methodology or definitions of terms for these studies have yet been established.

Casual versus ambulatory twenty-four-hour blood pressure measurement in a comparative study with bisoprolol or nitrendipine

In a double-blind, placebo-controlled, randomly allocated study, the 24-h efficacy of a single morning dose of 10 mg of the beta-blocker bisoprolol (n = 17) versus 20 mg of the calcium channel antagonist nitrendipine (n = 19) was assessed using two different methods of blood pressure determination: (1) casual blood pressure determinations in the morning before the dose; and (2) ambulatory day-time (6 a.m. to 6 p.m.) and night-time (6 p.m. to 6 a.m.) blood pressure monitoring using a non-invasive automatic device (Spacelabs 90202). After 4 weeks both agents induced significant blood pressure reductions compared to the placebo period as assessed by both casual and ambulatory day-time readings, without significant differences in the blood pressure reductions induced by the two drugs (P less than 0.05). Ambulatory night-time values, however, showed a significant blood pressure reduction only for bisoprolol (from 138 +/- 16/84 +/- 12 to 129 +/- 15/77 +/- 11 mmHg); nitrendipine did not induce any significant systolic or diastolic blood pressure changes during this period (140 +/- 11/87 +/- 10 to 136 +/- 13/86 +/- 10 mmHg). Individual response rates were 47% for nitrendipine and 71% for bisoprolol. The incidence of side effects was comparable under both drugs. Our results indicate that bisoprolol was more effective over 24 h than nitrendipine. We also conclude that the value of casual blood pressure readings for the evaluation of therapeutic agents given once a day seems to be limited in comparison to 24-h ambulatory monitoring.

[Peroneal weakness]

The 22 year old male patient was admitted because of right sided peroneal nerve palsy two months after transient foot drop on the left side. Both pareses developed under a strict dietary regime leading to a weight loss of about 30 kg within 3 months. Slimmers' paralysis of peroneal nerve was diagnosed after exclusion of polyneuropathy or trauma as possible causes. Complete remission followed after a less restrictive diet.

Different effects of platelet-derived growth factor isoforms on rat vascular smooth muscle cells

The response of rat aortic smooth muscle cells to all three isoforms of platelet-derived growth factor (PDGF) was studied. 5,000 binding sites/cell were estimated for rPDGF-AA (Kd 0.22 nM), 45,000 for rPDGF-AB and (Kd 0.4 nM), and 31,000 for rPDGF-BB (Kd 0.29 nM). rPDGF-AB and -BB stimulated effectively [3H]thymidine incorporation, inositol 1,4,5-trisphosphate release, diacylglycerol productions, [Ca2+]i increase, and pHi changes at concentration in the range from 3 to 10 ng/ml. The extent of DNA synthesis stimulated by rPDGF-AA varied considerably, and in all cases higher concentrations than 10 ng/ml were required. rPDGF-AA did not stimulate inositol-1,4,5-trisphosphate release, [Ca2+]i increase or pHi changes but induced the production of diacylglycerol, although with a different kinetic compared with that observed with rPDGF-AB or -BB. Apparently rPDGF-AA acts via a different mechanism, generating diacylglycerol without the release of inositol-1,4,5-trisphosphate.

[Effect of a follow-up action in diet instruction]

Efficacy of diet-counseling was analyzed in 349 adipose patients, (140 men and 209 women.) The patients were guided in a specialized consultation service by diet-assistants. A daily caloric intake of 1200 calories was usually recommended. Mean observation time was 14.6 months in women, 15.4 months in men. After completion all patients were invited for a single check-up. 72.9% of the men and 81.4% of the women participated. Mean weight reduction during counseling amounted to 6.7 kg for men (n = 127) and 4.8 kg for women (n = 191). Blood pressure fell from 145/95 to 130/90 in men and from 140/92 to 135/88 in women. At the time of the follow-up visit a further reduction in body weight and blood pressure was noted in both sexes. Analysis of further factors disclosed a better performance of non-smokers vs. smokers and a higher frequency of consultations demanded by women. Treatment by diet-consulting is thus effective and its success persists after termination of the guidance by the diet assistant. A drop-out rate of 25% has to be accepted.

Novel cellular activities for low density lipoprotein in vascular smooth muscle cells

Hyperlipidemia and hypertension play important roles in the pathogenesis of atherosclerosis. To investigate the underlying intracellular mechanisms, we studied the effect of various concentrations of low density lipoprotein from normolipidemic subjects on concentrations of free intracellular calcium, intracellular pH, DNA synthesis, and vascular tone in vascular smooth muscle cells and rings from rat aortas. Low density lipoprotein in the range of 1-15 micrograms/ml induced a dose-dependent increase of concentration of free intracellular calcium and a biphasic change of the intracellular pH. Similar concentrations of low density lipoprotein led to an enhanced DNA synthesis. Furthermore, cumulative addition of 1-15 micrograms/ml low density lipoprotein produced a dose-dependent increase in contractile tension of thoracic aortic rings from rats. The maximal low density lipoprotein-induced contractile response was approximately 70% of that induced by 40 mM KCl. These findings indicate that low concentrations of low density lipoprotein occurring, for example, in the extravascular fluid might contribute to the pathogenesis of cardiovascular diseases by enhancing cell proliferation and vasoconstriction by changing intracellular calcium and intracellular pH.

[Fat intolerance, pressure in the right upper quadrant, hepatomegaly]

Intolerance of dietary fat, massive hepatomegaly and sensation of right upper Quadrant oppression were clinical symptoms of a bioptically verified rare hepatic amyloidosis. There was no other evidence for amyloid deposition in other organs. Hepatomegaly was slightly progressive over a period of 2 years, accompanied by slight edema of lower legs and ascites detected by sonography.

Attenuation of the low-density-lipoprotein-activated phosphoinositide signalling system by calcium blockers in human lymphocytes

1. The capacity of low-density lipoprotein-cholesterol (40 micrograms/ml) to stimulate both the phosphoinositide cycle and the dislocation of the phospholipid- and calcium-dependent protein kinase C activity from the cytosolic to the membranous compartment in human circulating lymphocytes has been studied. 2. Pretreatment of lymphocytes with pertussis toxin inhibited significantly the low-density-lipoprotein-induced formation of inositol trisphosphate. 3. The calcium-channel blockers verapamil, nifedipine and diltiazem, each in a concentration range from 1 mumol/l to 1 nmol/l, attenuated the low-density lipoprotein-induced formation of inositol trisphosphate in a dose-dependent manner. Similar results were observed when so-called non-specific calcium antagonists, such as flunarizine and molsidomine, were used. 4. The results suggest that low-density lipoprotein activates the phosphoinositide cycle in circulating lymphocytes through mechanisms sensitive to calcium blockers and pertussis toxin.