[Assessment of physicians with a foreign diploma; results of 10 years of testing of physicians with a foreign diploma]. / Toetsing van artsen met een buitenlands diploma.

OBJECTIVE: To determine the result of the assessment procedure, initiated on 1 December 2005, for physicians with a foreign diploma who wish to practice in the Netherlands. DESIGN: Retrospective, descriptive study. METHOD: The Commission for Foreign Healthcare Graduates (CBGV) collected data on physicians with a foreign diploma who followed the procedure for requesting a declaration of professional competence and admission to the Dutch Individual Healthcare Professions (BIG) register between December 2005 - December 2015. The procedure comprises a language and communication test, followed by tests of professional competence. On the grounds of the test results, the CBGV can decide if a physician should follow a specific training course. The number of physicians who ultimately obtained BIG registration was determined. RESULTS: During the study period, 183 of the 206 physicians with a foreign diploma passed the general knowledge and skills tests. A total of 176 of the 183 physicians took the professional competence tests. In 43 (25%) of them no shortcomings in knowledge and skills were seen. They were registered in the BIG register for a period of supervision. In 129 (73%), shortfalls were made up by means of focused training programme. In 4 (2%) of them no training was possible. On the date of assessment, 137 (78%) physicians were registered. This number is expected to rise to 151 (86%). CONCLUSION: The provision of a further course of training that is focused on the elimination of identified shortcomings in physicians with a foreign diploma, increases the percentage of foreign physicians that are successfully admitted to the BIG register.

[Hypertension due to fibromuscular dysplasia: look for additional disease sites]. / Hypertensie door fibromusculaire dysplasie.

Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic vasculopathy that can lead to arterial stenosis, occlusion, aneurysms, and dissection. FMD of the renal arteries can lead to renovascular hypertension. Percutaneous angioplasty of the renal arteries (PTRA) can lead to normalization of blood pressure in 45% of patients with renal artery stenosis caused by FMD, particularly in younger patients and patients with a short history of hypertension. A considerable number of the patients with renovascular FMD also have cervical FMD, which can lead to ischaemic or haemorrhagic stroke. In this article we discuss diagnostic and therapeutic options, illustrated by two cases of patients with renovascular and carotid FMD. Most of the recommendations are based on data from retrospective studies and expert opinion; prospective studies on the optimal diagnostic strategy and treatment are therefore, urgently required.

Reliability and validity of an extended clinical examination.

INTRODUCTION: An extended clinical examination (ECE) was administered to 85 final year medical students at the Radboud University Medical Centre in the Netherlands. The aim of the study was to determine the psychometric quality and the suitability of the ECE as a measurement tool to assess the clinical proficiency of eight separate clinical skills. METHODS: Generalizability studies were conducted to determine the generalizability coefficient and the sources of variance of the ECE. An additional D-study was performed to estimate the generalizability coefficients with altering numbers of stations. RESULTS: The largest sources of variance were found in skill difficulties (36.18%), the general error term (26.76%) and in the rank ordering of skill difficulties across the stations (21.89%). The generalizability coefficient of the entire ECE was above the 0.70 lower bound (G = 0.74). D studies showed that the separate skills could yield sufficient G coefficients in seven out of eight skills, if the ECE was lengthened from 8 to 14 stations. DISCUSSION: The ECE proved to be a reliable clinical assessment that enables examinees to compose a clinical reasoning path through self-obtained data. The ECE can also be used as an assessment tool for separate clinical skills.

The prevalence of renal artery stenosis among patients with diabetes mellitus.

BACKGROUND: Patients with diabetes mellitus (DM) have a high prevalence of atherosclerotic vascular lesions. It is therefore reasonable to assume that also the rate of renal artery stenosis (RAS) is higher. The presence of a RAS can have implications for the treatment of patients with diabetes mellitus and hypertension and renal impairment. Therefore it is important to be informed about the chance that a RAS is present among such patients. METHODS: We prospectively studied the prevalence of atherosclerotic renal artery stenosis (RAS) among patients with diabetes mellitus. Patients were included if they were diagnosed with DM and hypertension with or without impairment of renal function. If causes of renal disease other than DM or hypertension were more probable on the basis of biochemical data, then such patients were excluded. A magnetic resonance angiography (MRA) of the renal arteries was made in 54 included successive patients. PATIENT CHARACTERISTICS: mean age 59 ± 8.5 years (range 35 to 80). Eight patients had DM 1 and 46 DM 2. Mean BMI was 31.4 ± 5.6 kg/m(2). A RAS was present in 18 of the 54 (33%) patients, 3 patients had bilateral stenoses. Factors related to the presence of RAS were diastolic blood pressure, glomerular filtration rate and dyslipidaemia. CONCLUSION: In this group of diabetic patients with hypertension and or renal impairment the prevalence of RAS was 33%.

Clinical significance of low-grade renal artery stenosis.

BACKGROUND: Patients with a renal artery stenosis (RAS) >50% carry an increased risk for future cardiovascular (CV) events. Experimental literature on this topic suggests that this might as well be true for subjects with lower-grade RAS. METHODS: Recruitment in this longitudinal cohort study was conducted from 1982 to 2002 in a Dutch University Hospital. Included in this study were 301 hypertensive patients clinically suspected of having RAS. Study participants were radiologically classified as having no, a low-grade (<50% lumen narrowing) or high-grade (> or =50%) RAS. A predetermined composite CV end-point was defined as one of the following: myocardial infarction or 'objectified' angina pectoris, ischaemic stroke or death from any CV cause. Other end-points were the occurrence of CV complications, all-cause plus CV mortality and decline in renal function. RESULTS: During a median follow-up of 8.2 years, the incidence of the composite end-point totalled 79 events. After full adjustment in Cox models, a significant risk increase in high-grade [hazard ratio (HR) 2.81; P = 0.002] and low-grade RAS (HR 2.32; P = 0.038) was observed. Other end-points did not differ significantly between study groups. CONCLUSION: Hypertensive subjects with RAS of any extent, compared with hypertensives without RAS, carry a substantially increased risk for future CV events. Therefore, even in patients with low-grade RAS, aggressive pharmacological treatment strategies should be adopted as a preventive measure.

The effect of arginine vasopressin on endothelin production in the human forearm vascular bed.

OBJECTIVES: To study whether arginine vasopressin (AVP) can stimulate endothelin production and/or release in vivo, in the human forearm vasculature. DESIGN: The effect of the infusion of AVP into the brachial artery on endothelin production across the human forearm vascular bed was studied in healthy male volunteers, and was compared with intra-arterial infusion of placebo. In another group the effects of AVP on endothelin production were studied after a prior infusion of L-NG-monomethyl-arginine (L-NMMA), a nitric oxide-synthase inhibitor. In a fourth group the effect of L-NMMA alone, without AVP infusion, on endothelin production was studied. METHODS: We measured the effects of AVP, placebo, L-NMMA followed by AVP and L-NMMA followed by placebo on arterial and venous endothelin concentrations in the forearm of four groups, each consisting of five healthy male volunteers. Forearm blood flow was measured by strain gauge plethysmography. The endothelin production was calculated as forearm blood flow times (venous - arterial) endothelin concentration. RESULTS: The group infused with L-NMMA followed by infusion of 8 ng AVP/min per dl forearm volume showed a significant rise in endothelin production from 1.3 (1.8) to 5.0 (2.0) pg/min/dl at 15 minutes (p<0.05, ANOVA). This rise in endothelin production was also significantly different from the endothelin production at 15 minutes in the other three groups (p<0.01, ANOVA). CONCLUSION: In healthy male volunteers intra-arterial infusion of AVP induced a rise in endothelin production in the forearm within 15 minutes, but only after prior infusion of L-NMMA. This observation suggests that the AVP-induced production of nitric oxide offsets AVP-mediated release of endothelin.

The structure of medical competence and results of an OSCE.

BACKGROUND: Medical competence is a central concept in medical education. Educational efforts in medical training are directed at the achievement of a maximal medical competence. The concept of the structure of medical competence (multidimensional or one-dimensional with strongly interrelated competences) therefore affects the educational developments and assessment procedures. PURPOSE: To examine the applicability of a one or more dimensional character of medical competence in student assessments, by analysing the results of 356 students in the history taking station of an objective structured clinical examination (OSCE), in relation to other assessment procedures. METHODS: The performances of 356 students in a history taking station of an OSCE were analysed. Analyses of the checklist scores were aimed at the dimensionality of history taking skills. External criteria were used to test the validity of the scores on the checklist. RESULTS: The analyses of the scores on the history taking checklist indicated at least five dimensions of history taking skills: the frequency of patient-centred skills, the quality of performance of patient-centred skills, complaint-oriented skills, general social skills, and the provision of procedural information. CONCLUSION: Medical competence, as a subject of assessment, can be seen as a multifaceted construct. This study shows that history taking alone might be composed of five different dimensions, suggesting that medical competence in respect of assessment might be viewed as a multifaceted construct which in that sense has implications for the assessment of medical competence.

The benefit of STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery. The STAR-study: rationale and study design.

BACKGROUND: Atherosclerotic renal artery stenosis (ARAS) is associated with progressive loss of renal function and is one of the most important causes of renal failure in the elderly. Current treatment includes restoration of the renal arterial lumen by endovascular stent placement. However, this treatment only affects damage caused by ARAS due to the stenosis and ensuing post-stenotic ischemia. ARAS patients have severe general vascular disease. Atherosclerosis and hypertension can also damage the kidney parenchyma causing renal failure. Medical treatment focuses on the latter. Lipid-lowering drugs (statins) could reduce renal failure progression and could reduce the overall high cardiovascular risk. The additional effect on preserving renal function of stent placement as compared to medical therapy alone is unknown. Therefore, the STAR-study aims to compare the effects of renal artery stent placement together with medication vs. medication alone on renal function in ARAS patients. METHOD: Patients with an ARAS of > or = 50% and renal failure (creatinine (Cr) clearance < 80 mL/min/1.73 m2) are randomly assigned to stent placement with medication or to medication alone. Medication consists of statins, anti-hypertensive drugs and antiplatelet therapy. Patients are followed for 2 yrs with extended follow-up to 5 yrs. The primary outcome of this study is a reduction in Cr clearance > 20% compared to baseline. This trial will include 140 patients.

Resistance to antihypertensive medication as predictor of renal artery stenosis: comparison of two drug regimens.

BACKGROUND: Renal artery stenosis is among the most common curable causes of hypertension. The definitive diagnosis is made by renal angiography, an invasive and costly procedure. The prevalence of renal artery stenosis is less than 1% in non-selected hypertensive patients but is higher when hypertension is resistant to drugs. OBJECTIVE: To study the usefulness of standardised two-drug regimens for identifying drug-resistant hypertension as a predictor of renal artery stenosis. DESIGN AND SETTING: Prospective cohort study carried out in 26 hospitals in The Netherlands. PATIENTS: Patients had been referred for analysis of possible secondary hypertension or because hypertension was difficult to treat. Patients < or =40 years of age were assigned to either amlodipine 10 mg or enalapril 20 mg, and patients >40 years to either amlodipine 10 mg combined with atenolol 50 mg or to enalapril 20 mg combined with hydrochlorothiazide 25 mg. Renal angiography was performed: (1) if hypertension was drug-resistant, ie if diastolic pressure remained > or =95 mm Hg at three visits 1-3 weeks apart or an extra drug was required, and/or (2) if serum creatinine rose by > or =20 micromol/L (> or =0.23 mg/dL) during ACE inhibitor treatment. RESULTS: Of the 1106 patients with complete follow-up, 1022 had been assigned to either the amlodipine- or enalapril-based regimens, 772 by randomisation. Drug-resistant hypertension, as defined above, was identified in 41% of the patients, and 20% of these had renal artery stenosis. Renal function impairment was observed in 8% of the patients on ACE inhibitor, and this was associated with a 46% prevalence of renal artery stenosis. In the randomised patients, the prevalence of renal artery stenosis did not differ between the amlodipine- and enalapril-based regimens. CONCLUSIONS: In the diagnostic work-up for renovascular hypertension the use of standardised medication regimens of maximally two drugs, to identify patients with drug-resistant hypertension, is a rational first step to increase the a priori chance of renal artery stenosis. Amlodipine- or enalapril-based regimens are equally effective for this purpose.

The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group.

BACKGROUND: Patients with hypertension and renal-artery stenosis are often treated with percutaneous transluminal renal angioplasty. However, the long-term effects of this procedure on blood pressure are not well understood. METHODS: We randomly assigned 106 patients with hypertension who had atherosclerotic renal-artery stenosis (defined as a decrease in luminal diameter of 50 percent or more) and a serum creatinine concentration of 2.3 mg per deciliter (200 micromol per liter) or less to undergo percutaneous transluminal renal angioplasty or to receive drug therapy. To be included, patients also had to have a diastolic blood pressure of 95 mm Hg or higher despite treatment with two antihypertensive drugs or an increase of at least 0.2 mg per deciliter (20 micromol per liter) in the serum creatinine concentration during treatment with an angiotensin-converting-enzyme inhibitor. Blood pressure, doses of antihypertensive drugs, and renal function were assessed at 3 and 12 months, and patency of the renal artery was assessed at 12 months. RESULTS: At base line, the mean (+/-SD) systolic and diastolic blood pressures were 179+/-25 and 104+/-10 mm Hg, respectively, in the angioplasty group and 180+/-23 and 103+/-8 mm Hg, respectively, in the drug-therapy group. At three months, the blood pressures were similar in the two groups (169+/-28 and 99+/-12 mm Hg, respectively, in the 56 patients in the angioplasty group and 176+/-31 and 101+/-14 mm Hg, respectively, in the 50 patients in the drug-therapy group; P=0.25 for the comparison of systolic pressure and P=0.36 for the comparison of diastolic pressure between the two groups); at the time, patients in the angioplasty group were taking 2.1+/-1.3 defined daily doses of medication and those in the drug-therapy group were taking 3.2+/-1.5 daily doses (P<0.001). In the drug-therapy group, 22 patients underwent balloon angioplasty after three months because of persistent hypertension despite treatment with three or more drugs or because of a deterioration in renal function. According to intention-to-treat analysis, at 12 months, there were no significant differences between the angioplasty and drug-therapy groups in systolic and diastolic blood pressures, daily drug doses, or renal function. CONCLUSIONS: In the treatment of patients with hypertension and renal-artery stenosis, angioplasty has little advantage over antihypertensive-drug therapy.

Accuracy of normal-dose contrast-enhanced MR angiography in assessing renal artery stenosis and accessory renal arteries.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of breath-hold contrast-enhanced MR angiography in the assessment of renal artery stenosis and accessory renal arteries using a standard dose of gadolinium. SUBJECTS AND METHODS: Thirty-eight patients suspected of having renal artery stenosis underwent MR angiography and intraarterial digital subtraction angiography, which was the method of reference. Three-dimensional gradient-echo MR subtraction angiography (TR/TE, 5.8/1.8 msec) was performed on a 1.5-T imager using a phased array body coil. Before imaging, a separate timing bolus sequence was used, administering 1.0 ml of contrast agent. Gadopentetate dimeglumine (15 ml) was injected using an MR power injector. Two observers, who were unaware of each other's interpretation and of MR findings, assessed digital subtraction angiography. Likewise, two other observers assessed MR angiography. RESULTS: Digital subtraction angiography depicted 75 main and 17 accessory renal arteries (n = 92). All main renal arteries and 13 accessory renal arteries were identified on MR angiography. Compared with digital subtraction angiography, MR imaging correctly classified 57 of 66 arteries without a hemodynamically significant stenosis (0-49%), 22 of 22 arteries as significantly stenotic (50-99%), and four of four occluded arteries; five stenoses were overestimated. There was one false-positive finding of an accessory renal artery on MR angiography that was identified retrospectively on digital subtraction angiography. Interobserver agreement was high. Sensitivity and specificity for grading significant stenosis were 100% and 85%, respectively. CONCLUSION: Contrast-enhanced MR angiography, using +/-0.1 mmol/kg of gadolinium, is an accurate method in the assessment of renal artery stenosis and accessory renal arteries.

[Malignant hypertension in a young man with renal artery occlusion diagnosed with magnetic resonance angiography]. / Maligne hypertensie bij een jongeman met nierarterieafsluiting gediagnosticeerd met magnetische-resonantieangiografie.

A male aged 22 years developed a hypertensive crisis with encephalopathy after his antihypertensive medication had been discontinued with a view to extended diagnostics. Immediate intensive treatment led to rapid and complete recovery. By using gadopentetate acid enhanced magnetic resonance angiography it is possible to obtain a clear image of the morphology of the kidneys and the renal vasculature without the use of iodinated contrast media and arterial catheterisation. This technique revealed an occluded renal artery and a recent infarction that possibly had led to the serious and threatening events.

[Treatment of renal artery stenosis with intra-arterial stents]. / Behandeling van nierarteriestenosen met intra-arteriële stents.

In some patients with hypertension or renal insufficiency, renal artery stenosis can play a causative part. If fibromuscular dysplasia is the pathology of the stenosis, treatment of the stenosis by transluminal percutaneous renal angioplasty (TPRA) results in improvement of the concomitant hypertension in 80-90% of the patients. In case of atherosclerotic lesions 50% of the patients benefit by such treatment. In renal insufficiency TPRA of atherosclerotic lesions results in improvement of renal function in only one third of the patients. As restenosis and elastic recoil are seen as the prime determinants of this lack of success in atherosclerosis, intravascular stents were developed with the aim to accomplish a permanent dilation of the arterial lumen. In recent studies stent placement resulted in cure of high blood pressure in 0-16% of the patients and in improvement in 35-70%. The percentage of improvement must be viewed with caution because of the open design of these studies. Improvement of renal function was reported in 7-36% of the patients and worsening in 8-18%. Based on these outcomes stent placement in stenosed renal arteries should not be regarded as a routine clinical treatment.

Adenosine-induced renal vasodilatation is prolonged in renal artery stenosis.

OBJECTIVE: The objective of this study was to determine whether the response of renal blood flow (RBF) to adenosine infusions differs between hypertensive patients with and without renal artery stenosis (RAS). DESIGN AND METHODS: Twenty-one hypertensive patients who underwent diagnostic angiography of the renal arteries were studied. Nine patients (median age 51 years; 45-61 interquartile ranges) were diagnosed as having essential hypertension (EH). Twelve patients (median age 52 years; 50-58) had hypertension and renal artery stenosis. In all patients three stepwise increasing doses of adenosine (1, 3 and 10 (microg/kg/min) were infused into the renal artery. RBF was measured before and during infusions by means of the 133xenon wash-out method. Arterial and venous plasma samples for renin concentration were obtained from the renal artery and renal vein. Intraarterial blood pressure and heart rate were monitored continuously. RESULTS: Both groups were similar with respect to age, body mass index, mean arterial pressure and baseline RBF (EH: median 428; RAS 343 ml/min/100 g). Both groups showed a similar dose-related increase in RBF during adenosine infusions (normal kidneys: 9, 21 and 34% change vs baseline; stenotic kidneys: 16, 39 and 52% change vs baseline). Ten minutes after discontinuation of the adenosine infusion, RBF returned to baseline in the normal kidney group, but increased further in the stenotic kidney group (71% vs baseline; P = 0.033). Adenosine infusion did not affect the renin secretion in either group. CONCLUSION: Both essential hypertensive patients and patients with renal artery stenosis show a dose-dependent vasodilatation following adenosine infusion. This vasodilatation is sustained after discontinuation of the adenosine infusion in patients with renal artery stenosis, suggesting a potentiated mechanism for vasodilatation induced by adenosine.

Magnetic resonance angiography has a high reliability in the detection of renal artery stenosis.

In this prospective study we examined the value of magnetic resonance angiography (MRA) in the imaging of the proximal renal arteries, with the main aim of detecting renal arterial stenosis, as compared with intraarterial digital subtraction angiography. The study was done among a group of 38 hypertensive patients seen in the outpatient department of the department of medicine of our university hospital. In all patients a magnetic resonance angiography and an intraarterial subtraction angiography of the renal arteries was made, and the outcomes of the investigations were compared. Clinical and biochemical data of the patients also were analyzed in relation to the presence or absence of a stenosis. In one patient, MRA resulted in technical failure because of unsuspected claustrophobia. Of the remaining 37 patients, 14 had renal artery stenosis. Of 12 patients in whom the stenoses were >50% of luminal surface on intraarterial digital subtraction angiography, eight were unilateral and four bilateral. All these stenoses were recognized by magnetic resonance angiography. There was also one false positive result by magnetic resonance. Thus, for the identification of stenoses >50%, magnetic resonance has a sensitivity of 100% and a specificity of 96%. Of the 12 accessory renal arteries seen on digital subtraction angiography, only three were identified by magnetic resonance angiography. We conclude that magnetic resonance angiography has great accuracy in depicting the main renal arteries and detecting clinically significant renal artery stenosis; however, the identification of accessory renal arteries is suboptimal and should be improved.

The place of renal scintigraphy in the diagnosis of renal artery stenosis. Fifteen years of clinical experience.

BACKGROUND: Renal scintigraphy with radiolabeled pentetic acid (diethylenetriamine pentaacetic acid [DTPA]) or, more recently, mertiatide (mercaptoacetyltriglycine [MAG3]), with or without captopril challenge, is widely recommended as a diagnostic test for renal artery stenosis. OBJECTIVES: To address (1) whether the diagnostic accuracy has been improved by the use of captopril and the introduction of mertiatide and (2) whether a renal scan that shows abnormalities is a useful criterion to select patients for renal arteriography. PATIENTS AND METHODS: A standard diagnostic protocol, using both scintigraphy and arteriography, was followed in 505 consecutive high-risk hypertensive patients who were evaluated for renovascular hypertension at the University Hospital Dijkzigt, Rotterdam, the Netherlands, from 1978 to 1992. RESULTS: Renal artery stenosis (> or = 50%) was present in 263 patients. When the single-kidney fractional uptake was used as a diagnostic criterion, a specificity of 0.90 was obtained at a cutoff value of 35% for the worst kidney in scintigraphy using pentetic acid without captopril challenge (n = 225) and at a cutoff value of 37% after captopril challenge (n = 280). This was associated with sensitivity levels of 0.65 and 0.68, respectively. The difference between the uptake of pentetic acid with and without captopril challenge in the 85 patients who were studied under both circumstances was no more accurate as a predictor of renal artery stenosis. In the 93 patients who were studied with mertiatide as well as with pentetic acid, both after captopril challenge, the diagnostic accuracy was no better with mertiatide than with pentetic acid; mertiatide failed to offer any advantage not only when the single-kidney fractional uptake was used as a criterion, but also with the use of other scintigraphic parameters (eg, time to peak, time to pyelum, overall shape of renographic curve, and kidney size). CONCLUSIONS: The diagnostic accuracy of renal scintigraphy has not been improved by the introduction of mertiatide or by the use of captopril. The usefulness of scintigraphy as a diagnostic test for the presence of renal artery stenosis remains questionable. The physician will always confront either a substantial number of arteriograms that do not show abnormalities when renal scintigraphy is omitted as a screening step or a substantial number of missed diagnoses when a renal scan that shows abnormalities is used as a prerequisite for arteriography.

[Measurement of the body temperature of adults by rectal digital thermometer and the infrared tympanic thermometer: equally good results in the department of internal medicine]. / Temperatuurmeting bij volwassenen: met de trommelvliesinfraroodmeter en de rectale digitale meter even goede resultaten op de afdeling Interne Geneeskunde.

OBJECTIVE: To examine whether, in clinical practice, the infrared tympanic thermometer shows temperature readings similar to those obtained with the rectal digital thermometer, so that the former can replace the latter. DESIGN: Prospective comparative study. SETTING: Academic Hospital, Nijmegen, the Netherlands. METHOD: In 104 patients admitted to the department of medicine, body temperature was measured by both methods within approximately ten minutes. This was done on two successive days. The measurements were then analysed by plotting the difference between two measurements against their mean. Then the limits of agreement, which are the mean of the differences between the two measurements plus and minus 2 standard deviations, were determined. With both thermometers also duplicate measurements were made to study the repeatability. RESULTS: The mean difference between the 2 methods in the first measurement was 0.15 degree C (SD: 0.56), in the second measurement it was 0.07 degree C (0.52). The limits of agreement were 1.27 degrees C and -0.97 degree C for the first comparisons and 1.13 degrees C and -0.99 degree C for the second comparisons. In the duplicate measurements, the mean difference between the first and the second measurement was 0.02 degree C (0.19) in the rectal measurement, and 0.09 degree C (0.23) in the tympanic measurement. The patients found the tympanic measurements significantly less painful and unpleasant than the rectal measurement. The mean time needed for the tympanic measurements (8 s) was ten times less than for the rectal measurements (79 s). CONCLUSION: The results of this study show good agreement between the infrared tympanic thermometer and the rectal digital thermometer so that they may be regarded as interchangeable. The patients had a clear preference for the tympanic thermometer, which also took less time.

Endothelin and active renin levels in essential hypertension and hypertension with renal artery stenosis before and after percutaneous transluminal renal angioplasty.

OBJECTIVE: To determine whether active renin and endothelin levels in venous plasma differ between patients with renal artery stenosis and patients with primary hypertension. Among the patients with renal artery stenosis we also compared active renin and endothelin levels between subjects who had been cured or whose blood pressure had improved after treatment of the stenosis and those without a beneficial reaction after such treatment. METHODS: We measured immunoreactive endothelin and active renin levels in peripheral venous plasma before and 1 h after angiotensin converting enzyme inhibition in 25 patients with primary hypertension and in 27 patients with hypertension and renal artery stenosis. Percutaneous transluminal angioplasty was performed in 21 patients of the latter group. For 11 patients of this group, hypertension was cured or there was an improvement, whereas 10 other patients did not respond to this treatment. Baseline active renin and endothelin levels were compared between these groups, as were the clinical characteristics of the patients. RESULTS: Baseline endothelin levels were similar in members of the renal artery stenosis [median 3.6 pg/ml (range 1.4-11.7)] and in members of the no stenosis group [5.0 pg/ml (1.5-8.0)]. Also baseline endothelin levels did not differ between members of the successfully treated [3.6 pg/ml (1.8-8.9)] and unsuccessfully treated groups [3.75 pg/ml (1.4-8.3)]. Angiotensin converting enzyme (ACE) inhibition failed to cause a significant change in endothelin level in members of any of the patient groups. Although baseline renin levels differed significantly between members of the renal artery stenosis and no stenosis groups [40.2 microu/ml (0.9-543) versus 13.4 microu/ml (2.5-931), (P< 0.05)], there was no difference in baseline renin levels between the members of successful and unsuccessful groups [25.7 microu/ml (9.2-475.6) versus 65.3 microu/ml (12.3-542.6)]. ACE inhibition caused a significant increase in renin level in members of all groups except the unsuccessfully treated group. CONCLUSIONS: Circulating endothelin levels did not differ significantly among patients with essential hypertension, hypertension with renal artery stenosis and proven renovascular hypertension and, although the renin-angiotensin system was clearly activated in members of the renovascular hypertension group, ACE inhibition did not affect their endothelin levels. These results suggest that endothelin does not play a direct role in the pathophysiology of renovascular hypertension.