[Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]. / Diabetisches Fußsyndrom ­ Teil 2 : Revaskularisation, Behandlungsalternativen, Versorgungsstrukturen, Rezidivprophylaxe.

Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).

[Diabetic foot syndrome-Part 1 : Definition, pathophysiology, diagnostics and classification]. / Diabetisches Fußsyndrom ­ Teil 1 : Definition, Pathophysiologie, Diagnostik und Klassifikation.

There are ca. 8 million persons with diabetes mellitus living in Germany. A late sequelae of diabetes is the diabetic foot syndrome (DFS), the prevalence of which is greatly increasing. It comprises all alterations of the foot as a result of diabetic polyneuropathy as well as microvascular and macrovascular (peripheral arterial occlusive disease, PAOD) alterations. Many of the ca. 250,000 newly diagnosed diabetic foot ulcers per year become chronic wounds. Despite intensive efforts for prevention, early diagnosis and adequate wound care, ca. 13,000 persons with diabetes undergo major limb amputation in Germany every year. With consistent treatment in interdisciplinary centers and by exhausting all possible methods of wound treatment, pressure relief as well as arterial revascularization, the major amputation rate in patients with diabetic foot problems can be reduced by 80%. With a suitable strategy of prevention, the recurrence rate of foot ulcers would be reduced.

[Concept of plantarization for toe correction in diabetic foot syndrome]. / Konzept der Plantarisierung zur Zehenkorrektur beim diabetischen Fußsyndrom.

OBJECTIVE: Elimination of plantarization of the tip of the toe and torsion of digit 1 (D1) or D5 using percutaneous tenotomy of the flexor hallucis longus (FHL) - or the flexor digitorum longus (FDL) muscle. INDICATIONS: Flexible, in some cases also fixated hyperflexion misalignment and torsion misalignment of the distal phalanx of the toe with plantarization of physiologically non-loaded bearing parts of the toes in patients with diabetic foot syndrome (neuropathy). CONTRAINDICATIONS: Critical limb ischemia. SURGICAL TECHNIQUE: Percutaneous tenotomy of the FHL or FDL tendons using the minimally invasive lancet technique without the use of a tourniquet while the tendon is flexed by causing hyperextension of the distal phalanx and simultaneous extension of the distal interphalangeal (DIP) or interphalangeal (IP) joints. POSTOPERATIVE MANAGEMENT: Immediate full weight-bearing mobilization in sufficiently wide protective footwear with customized cushioning or a diabetes-adapted foot bed, follow-up in initially frequent intervals (2-4 per week) in order to track the development of the transfer lesions. In the case of existing wounds, more frequent visits and relief of the wounds using a post-operative shoe are required. No thrombosis prevention with full weight-bearing is necessary. RESULTS: In 138 patients with diabetic foot syndrome with polyneuropathy, of which 90 were men (65.2 %) and 48 were women (34.8 %) with a median age of 65.1 years, a total of 291 toe operations with tenotomy of the FHL- or FDL-tendon were performed. Patients were either acutely affected by apical toe lesions (92.1 %) or showed an increased risk of ulcer formation (7.9 %). The median time to closing of the wound was 13 days. It was longer with higher Wagner stages. Of the surgically treated toes 3.1 % were affected by nosocomial infections. At the 1­year follow-up 92.4 % of the patients did not show pathological results of the operated toe. Recurrence of the DFS occurred mostly during the first 6 months postoperatively. In the first year postoperatively 68.1 % of the patients remained in remission. Of the toes with Wagner grade 0, 93.7 % were free of local recurrence during the entire monitoring period and 72.2 % of the operated toes with Wagner grade 3. Within the first 1.5-8.5 months 13 % of the patients were affected by transfer lesions.

Trends in amputations in people with hospital admissions for peripheral arterial disease in Germany.

BACKGROUND: Using the information of the federal statistics, a detailed description of the hospitalisation rate for amputation in Germany was possible for the first time, and trends since 2005 can be reported. PATIENTS AND METHODS: Detailed lists of all amputations coded as minor amputations (OPS 5 - 864) and major amputations (OPS 5 - 865) performed in 2005 and 2008, divided into the 4th and 5th number of the OPS-code, were provided by the Federal Statistical Office. RESULTS: Despite an increase in total number of hospitalized patients suffering from peripheral arterial disease and neurovascular disease there is a relevant decrease in age adjusted major amputation rates per 100.000 population in Germany from 27.0 in 2005 to 25.1 in 2008 in males and from 19.7 in 2005 to 17.1 in 2008 in females. Overall minor amputation rates do not show such a decrease but increased in males (from 47.4 in 2005 to 53.7 in 2008) und remained unchanged in females (23.1 in 2005 and 23.1 in 2008). In the 6th and 7th decade of life males have approximately four times higher major and minor amputation rates than females. CONCLUSIONS: Hospitalisation rate for major amputation in Germany decreased in the recent years whereas hospitalisation rate for minor amputation did not.

Novel polyurethanes with interconnected porous structure induce in vivo tissue remodeling and accompanied vascularization.

Tissue engineering and regenerative medicine have furnished a vast range of modalities to treat either damaged tissue or loss of soft tissue or its function. In most approaches, a temporary porous scaffold is required to support tissue regeneration. The scaffold should be designed such that the turnover synchronizes with tissue remodeling and regeneration at the implant site. Segmented polyester urethanes (PUs) used in this study were based on epsilon-caprolactone (CL) and co-monomers D,L-lactide (D,L-L) and gamma-butyrolactone (BL), and 1,4-butanediisocyanate (BDI). In vitro, the PUs were nontoxic and haemocompatible. To test in vivo biocompatibility, the PUs were further processed into porous structures and subcutaneously implanted in rats for a period up to 21 days. Tissue remodeling and scaffold turnover was associated with a mild tissue response. The tissue response was characterized by extensive vascularization through the interconnected pores, with low numbers of macrophages on the edges and stroma formation inside the pores of the implants. The tissue ingrowth appeared to be related to the extent of microphase separation of the PUs and foam morphology. By day 21, all of the PU implants were highly vascularized, confirming the pores were interconnected. Degradation of P(CL/D,L-L)-PU was observed at this time, whereas the other two PU types remained intact. The robust method reported here of manufacturing and processing, good mechanical properties, and in vivo tissue response of the porous P(CL/D,L-L)-PU and PBCL-PU makes them excellent candidates as biomaterials with an application for soft tissue remodeling, for example, for cardiovascular regeneration.

The effect of vacuum mixing and pre-heating the femoral component on the mechanical properties of the cement mantle.

We investigated the effect of pre-heating a femoral component on the porosity and strength of bone cement, with or without vacuum mixing used for total hip replacement. Cement mantles were moulded in a manner simulating clinical practice for cemented hip replacement. During polymerisation, the temperature was monitored. Specimens of cement extracted from the mantles underwent bending or fatigue tests, and were examined for porosity. Pre-heating the stem alone significantly increased the mean temperature values measured within the mantle (+14.2 degrees C) (p < 0.001) and reduced the mean curing time (-1.5 min) (p < 0.001). The addition of vacuum mixing modulated the mean rise in the temperature of polymerisation to 11 degrees C and reduced the mean duration of the process by one minute and 50 seconds (p = 0.01 and p < 0.001, respectively). In all cases, the maximum temperature values measured in the mould simulating the femur were < 50 degrees C. The mixing technique and pre-heating the stem slightly increased the static mechanical strength of bone cement. However, the fatigue life of the cement was improved by both vacuum mixing and pre-heating the stem, but was most marked (+ 280 degrees C) when these methods were combined. Pre-heating the stem appears to be an effective way of improving the quality of the cement mantle, which might enhance the long-term performance of bone cement, especially when combined with vacuum mixing.

Mutational and expression analysis of CDK1, cyclinA2 and cyclinB1 in epilepsy-associated glioneuronal lesions.

Gangliogliomas and focal cortical dysplasias (FCDs) constitute glioneuronal lesions, which are frequently encountered in biopsy specimens of patients with pharmacoresistant focal epilepsy and relate to impaired differentiation and migration of neural precursors. However, their molecular pathogenesis and relationship are still largely enigmatic. Recent data suggest several components of the insulin-pathway, including TSC1 and TSC2 mutated in tuberous sclerosis complex (TSC), to be altered in gangliogliomas and FCD with Taylor type balloon cells (FCD(IIb)). The proteins tuberin (TSC2) and hamartin (TSC1) constitute a tumour suppressor mechanism involved in cell-cycle control. Hamartin and/or tuberin were reported to colocalize and/or interact with CDK1, cyclinB1 and cyclinA2 that are critically involved in cell-size and cell-growth control. Here, we have carried out mutational and expression analyses of CDK1, cyclinB1 and cyclinA2 in gangliogliomas and FCD(IIb). Mutational screening was performed by single-strand conformation polymorphism analysis in gangliogliomas (n = 20), FCD(IIb) (n = 35) and controls. CyclinB1 revealed a polymorphism (G to A, cDNA Position 966, GenBank: NM_031966) in exon 7 with similar frequencies in FCD(IIb), gangliogliomas and control specimens (FCD n = 9/35; gangliogliomas n = 5/20; control n = 20/100). We used real-time reverse transcription polymerase chain reaction to determine expression levels of CDK1, cyclinB1 and cyclinA2 in 10 FCD(IIb) and nine gangliogliomas compared with unaffected adjacent control tissue of the same patients. We observed significantly lower expression of CDK1 and cyclinA2 in FCD(IIb) vs. controls whereas no significant expression differences were present for CDK1, cyclinB1 and cyclinA2 in gangliogliomas. Our data strongly argue against mutational events of CDK1, cyclinB1 and cyclinA2 to play a role in gangliogliomas or FCD(IIb). However, a potential functional significance of lower expression for the cell-size and cell-cycle regulators CDK1 and cyclinA2 in FCD(IIb) composed of large dysplastic neurones and balloon cells needs to be further resolved.

Predictors of response to the 'Coping with Depression' course for older adults. A field study.

This field study explored the prognostic factors of the immediate and long-term effects of the Coping with Depression course for older adults (CWD). With the aim of both indicated as well as secondary prevention, the course is provided by the prevention departments of the community mental health care system in the Netherlands. A total of 317 course participants (age 55-85 years; 69% female) took part in this study; 41% had a major depressive disorder (MDD). A variety of demographic, clinical, psychosocial and treatment factors of possible relevance for indicated and secondary prevention were investigated. Random coefficient regression models and logistic regression models were used to examine their contribution to the immediate and maintenance effect. The course was beneficial for all participants, and the level of depression reached at the end of the course was maintained over the next 14-months. Current MDD, high levels of anxiety, less previous depressive episodes and more education predicted a larger benefit. However, the clinical significance of these predictors was too small to justify further triage. Further treatment should be considered for the participants with a post-treatment score >/=16. Group-membership was not a significant predictor of the variation in effect.

Effectiveness of the Coping With Depression (CWD) course for older adults provided by the community-based mental health care system in the Netherlands: a randomized controlled field trial.

BACKGROUND: The Dutch version of the Coping With Depression (CWD) course for older adults has been implemented in the prevention arm of the community-based mental health care system in the Netherlands. The study group included older adults with subclinical depression as well as those with a major depressive disorder; all were enrolled into the course by mental health care professionals. The effectiveness (immediate and long-term) of the course for this heterogeneous population was studied in an effectiveness trial. METHOD: Participants were self-referred, responding to media announcements. A total of 119 participants aged 55-85 years (69% female), with subclinical depression and major depression, were randomized to either the CWD course (N = 61) or the waiting list (N = 58). RESULTS: Nine participants dropped out of the course. According to a diagnostic interview based on the DSM-IV, 39% had a major depressive disorder (MDD), 69% had had a previous MDD, and 45% had an anxiety disorder. Older adults in the intervention group showed a significant decrease in depression symptoms. Gains were maintained over 14 months. In the intervention condition 83% had a pre-treatment score > or = 16 on the Center for Epidemiologic Studies Depression Scale (CES-D); at post-treatment 62% still scored > or = 16. CONCLUSIONS: The course was beneficial for participants with mild or severe depression, and treatment acceptability was high. It should be fitted into a stepped-care protocol that varies intervention intensity according to clinical needs, using the post-treatment level of functioning as an indication for the next step.

Detection of infectious Cryptosporidium oocysts by cell culture immunofluorescence assay: applicability to environmental samples.

In the past few years many waterborne outbreaks related to Cryptosporidium have been described. Current methods for detection of Cryptosporidium in water for the most part rely on viability assays which are not informative concerning the infectivity of oocysts. However, for estimation of the risk of infection with Cryptosporidium this information is required. For environmental samples the oocyst counts are often low, and the oocysts have been exposed to unfavorable conditions. Therefore, determination of the infectivity of environmental oocysts requires an assay with a high level of sensitivity. We evaluated the applicability of in vitro cell culture immunofluorescence assays with HCT-8 and Caco-2 cells for determination of oocyst infectivity in naturally contaminated water samples. Cell culture assays were compared with other viability and infectivity assays. Experiments with Cryptosporidium oocysts from different sources revealed that there was considerable variability in infectivity, which was illustrated by variable 50% infective doses, which ranged from 40 to 614 oocysts, and the results indicated that not only relatively large numbers of fresh oocysts but also aged oocysts produced infection in cell cultures. Fifteen Dutch surface water samples were tested, and the cell culture immunofluorescence assays were not capable of determining the infectivity for the low numbers of naturally occurring Cryptosporidium oocysts present in the samples. A comparison with other viability assays, such as the vital dye exclusion assay, demonstrated that surrogate methods overestimate the number of infectious oocysts and therefore the risk of infection with Cryptosporidium. For accurate risk assessment, further improvement of the method for detection of Cryptosporidium in water is needed.

Cryptosporidium and Giardia in swimming pools in the Netherlands.

The occurrence of Cryptosporidium and Giardia in indoor swimming pools in the Netherlands was studied at five locations. The backwash water from seven pool filters was analysed for the presence of Cryptosporidium oocysts and Giardia cysts for a period of 1 year. Of the 153 samples of filter backwash water analysed, 18 (11.8%) were found positive for either Cryptosporidium (4.6%), Giardia (5.9%) or both (1.3%). Oocysts and cysts were also detected in the water of one toddler pool and one learner pool. Although most of the (oo)cysts in the filter backwash water were dead, viable and potentially infectious oocysts were detected in the learner pool. On the basis of numbers of potentially infectious (oo)cysts detected in the learner pool, and assuming one visit to an infected pool per year, risk assessment indicated an estimated risk of infection with Cryptosporidium that exceeded the generally accepted risk of one infection per 10,000 persons per year. Guidelines for pool operators on how to manage faecal accidents and public information on the importance of hygiene in swimming pool complexes are recommended tools in controlling the risk of infection.

The criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a sample of self-referred elders with depressive symptomatology.

BACKGROUND: The criterion validity of the Center for Epidemiological Studies Depression scale (CES-D) was assessed in a group of elderly Dutch community-residents who were self-referred to a prevention program for depression. METHODS: Paper-and-pencil administration of the CES-D to 318 elders (55-85 years). Criterion validity was evaluated with the Mini International Neuropsychiatric Interview (MINI), a clinical diagnostic interview based on DSM-IV. Sensitivity and specificity for various cut-off scores of CES-D were compared with the DSM-IV major depressive disorder (MDD) and with clinically relevant depression (CRD), a composite diagnosis of MDD, subthreshold depression or dysthymia. Furthermore the characteristics of true versus false positives were analyzed. RESULTS: For MDD, the optimal cut-off score was 25, (sensitivity 85%, specificity 64%, and positive predicted value of 63%). For CRD, the optimal cut-off was 22 (sensitivity 84%, specificity 60%, and positive predicted value 77%). True positives, MDD and CRD, reported significantly more anxiety symptomatology and more co-morbid anxiety disorders, false positives reported more previous depressive episodes. CONCLUSIONS: The criterion validity of the CES-D for MDD and CRD was satisfactory in this semi-clinical sample of elders. Subjects scoring >/=25 constitute a target group for further diagnostic assessment in order to determine appropriate treatment.

EU Drinking Water Directive reference methods for enumeration of total coliforms and Escherichia coli compared with alternative methods.

AIMS: The reference methods for enumeration of total coliforms and Escherichia coli as stated in the European Drinking Water Directive were compared with alternative methods. METHODS AND RESULTS: Laboratories used the reference method on Lactose TTC agar (LTTC), the Colilert/18 system, Laurysulphate Agar (LSA), Chromocult Coliform Agar and the E. coli Direct Plating (DP) method. They enumerated more total coliforms on LTTC than on LSA. CONCLUSIONS: LTTC is suitable for analysis of very clean water samples only, due to heavy background growth. Colilert/18 is a good alternative but it enumerates a broader group of total coliforms, resulting in higher counts. The DP method appeared to be the best choice for enumeration of E. coli because Colilert/18 produces lower counts and false-negative results. SIGNIFICANCE AND IMPACT OF THE STUDY: This study shows the limitations of the EU reference method on LTTC due to lack of selectivity and suggests alternative methods for the enumeration of total coliforms and E. coli.

The HLA-G genotype is potentially associated with idiopathic recurrent spontaneous abortion.

The causes for recurrent spontaneous abortion (RSA) remain unknown in a large proportion of the cases. Human leukocyte antigen (HLA)-G and HLA-E are expressed on invasive trophoblast cells, and are supposed to confer to materno-fetal tolerance. A total of 14 different nucleotide sequences have been described for HLA-G, including one dysfunctional null allele (HLA-G*0105N), while five different sequences have been described for HLA-E. In this study, 78 RSA couples and 52 fertile controls were typed for HLA-G and HLA-E by direct sequencing or single strand conformational polymorphism (SSCP) respectively. The overall analysis showed no significant difference in allele frequencies for either HLA-G or HLA-E between the two groups. However, HLA-G allele frequencies in women who had suffered from five or more RSA differed significantly from fertile controls (P: = 0.001), and from women who had undergone three or four RSA (P: = 0.027). Detailed analysis demonstrated a significant increase in the proportion of the HLA-G alleles *01013 and *0105N in the whole group of RSA women compared with fertile controls (P: = 0.007). When studying the prognostic value of HLA genotyping for pregnancy outcome (n = 41), 31 patients (76%) gave birth to a living child without performing immunotherapy. Seven out of 10 (70%) couples suffering from a further RSA carried the HLA-G*01013 or *0105N allele, compared with 10 out 31 (32%) couples giving birth (P: = 0.06). This study suggests that the HLA-G genotype may be a contributing factor in RSA.

Evidence for major histocompatibility complex-mediated effects on spermatogenesis in humans.

Studies in fertile and infertile populations suggest an influence of genes of the major histocompatibility complex (MHC) on reproduction, although it remains unresolved if MHC-mediated effects on fertility are based on direct immunological or non-immunological effects of human leukocyte antigen (HLA) genes or rather on defects in MHC-associated non-HLA genes which affect gamete quality and embryonic development. We analysed allele frequencies for HLA class II loci DQA1, DQB1 and DRB1 and HLA class II haplotype frequencies in couples with tubal and andrological infertility who were treated with assisted reproductive techniques. Males with severe andrological infertility had significantly different allele frequencies for all three HLA loci when compared to males with normozoospermia, whereas no difference was found in the females. Differences in allele frequencies were stronger when only males whose partners achieved pregnancies after assisted reproduction treatment were compared. In those subgroups, we could also observe significant differences in three locus HLA class II haplotype frequencies. In summary, patients with male factor infertility differ in their HLA class II allele constitution from males with normozoospermia, which suggests that genes identical to or located in close vicinity to HLA class II genes may influence spermatogenesis and male gamete function.

HLA-G polymorphisms and allele frequencies in Caucasians.

HLA-G, a nonclassical class I MHC molecule, is uniquely expressed on extravillous cytotrophoblasts of the maternal-fetal interface and is suggested to be essential for establishment of maternal-fetal immune tolerance. Although the level of polymorphism in HLA-G has originally been considered low, number, nature and site of polymorphisms seem to vary between different ethnic populations. We investigated HLA-G polymorphisms in a population of German and Croatian origin by SSCP-analysis and direct sequencing as well as RFLP analysis for presence of the 1597delC mutation. HLA-A alleles associated with the different HLA-G alleles were determined by SSP PCR-typing. In Caucasians, HLA-G exhibits a low degree of polymorphism on the amino-acid level and only slightly higher variability on the nucleotide level. In 264 independent chromosomes, 4 HLA-G alleles on the level of amino acid polymorphisms and an additional 6 variations of nucleotide sequences could be identified. The null-allele G*0105N was present at an allele frequency of 2.3%, which is higher than initially suggested for Caucasians but lower than in Hispanics and African-Americans. Furthermore, some HLA-G alleles exhibit strong linkage disequilibrium with HLA-A.

The content of parthenolide and its yield per plant during the growth of Tanacetum parthenium.

During the growth of Tanaceum parthenium (L.) Schultz-Bip. Feverfew, Asteraceae) the percentage of parthenolide was the highest at an early stage (just before the formation of stems). The yield of parthenolide per individual plant gradually increased from about 10 mg at the beginning of the study to about 20 mg when the plant was in full bloom. Parthenolide was present in the leaves and flowerheads, but not in the stems. Drying at ambient temperature and lyophilisation had no negative influence on the yield of parthenolide per individual plant on comparing the results with those of fresh plant material. Based on the results of this study and on data from the literature we propose to distinguish two qualities of feverfew: a: Tanaceti parthenii folium (feverfew leaf), harvested at an early stage before the formation of the stems and b: Tanaceti parthenii herba (feverfew herb), harvested at full bloom, with a minimum parthenolide content of 0.50% and 0.20%, respectively, calculated on a dry weight basis. Both drugs can be easily distinguished by means of microscopic examination.

[Quantitative evaluation of myocardial perfusion with ultrafast magnetic resonance tomography]. / Quantitative Beurteilung der Myokardperfusion mit der ultraschnellen Magnetresonanztomographie.

With the advent of ultrafast Magnetic Resonance Imaging (MRI), it is now possible to produce images with high temporal resolution. This gives the opportunity to record the passage of the paramagnetic contrast material Gadolinium-DTPA through the tissue of the heart muscle, yielding information on regional myocardial perfusion. We assessed the accuracy of MRI to detect and quantify reductions in coronary flow secondary to stenosis in dogs and patients. Regional blood flow was measured in dogs by left atrial injection of microspheres labeled with different radioactive isotopes. Signal intensity (SI) curves were generated in regions of interest over the myocardium and the cavum of the left ventricle. A newly developed two-compartment model based on the indicator-dilution method was used for interpretation of the SI-curves. In an optimization process the free parameters of the model equation were fitted to the measured SI-curves. The following flow parameters were determined: model parameter Q*, time to peak intensity (T), maximum signal intensity (SImax) and mean transit time (MTT) as calculated from a gamma variate fit. Absolute blood flow values were calculated for the parameters MTT and Q* assuming that the intravascular volume represents 10% of the total myocardial tissue volume. Measurements were performed on a 1.5 T Magnetom SP (Siemens AG, Erlangen) using a Turbo Flash sequence (TR = 6.5 ms, TE = 3 ms, TI = 100 ms, Flip Winkel = 9 degrees). Endsystolic images (voxel size = 1.8, 2.7, 15 mm3) were taken with an 18-cm Helmholtz surface coil in the short-axis view. A Gd-DTPA bolus (0.05 mmol/kg) was injected into the left atrium of 3 anesthetized closed-chest dogs. From the myocardial SI-curves the different parameters of myocardial perfusion were compared with flow assessed by microsphere injection over a wide range of myocardial blood flows (from 0.04 ml/min/g to 7.6 ml/min/g). A third-order polynominal fit showed a good correlation for the parameter Q* and MTT, whereas T and SImax were found to have a poor correlation. The linear regression analysis for a limited range of < 2 ml/min/g showed a superior estimation of myocardial perfusion for the parameter Q* than MTT. Blood flow > 2 ml/min/g was significantly underestimated by the MRT-measurements, but the parameter Q* showed the smallest amount of the divergent changes.(ABSTRACT TRUNCATED AT 400 WORDS)

Posterior fossa neurovascular anomalies in essential hypertension.

Intraoperative observations, necropsy, and angiographic studies support the presumption that neurovascular compression of the left ventrolateral medulla may cause neurogenic hypertension. Pulsatile irritation of the ventrolateral medulla at the root-entry zone of cranial nerves IX and X increases blood pressure in animals. To identify and assess the distribution of neurovascular compression at the ventrolateral medulla in human beings, we did a prospective single-blind study in 24 patients with essential hypertension, in 14 patients with renal hypertension, and in 14 normal subjects. To detect neurovascular compression, we used axial and coronal double-echo and magnetic-resonance angiography sequences. Blood pressure control and duration of hypertension were not different in the two groups of patients. 20 patients with essential hypertension had magnetic tomographic evidence of left-sided neurovascular compression at the ventrolateral medulla; 2 patients with renal hypertension and 1 of the normal subjects had a positive finding on the left. On the right side, we found signs of neurovascular compression in 4 patients with essential hypertension, in 4 with renal hypertension, and in 2 of the normal subjects. With magnetic resonance tomography, it is possible to evaluate the neurovascular relations in the posterior fossa and detect neurovascular compression at the ventrolateral medulla. These data in living subjects give further evidence of an association between neurovascular compression at the left ventrolateral medulla and essential hypertension.