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To study patient compliance in hypertensive outpatients amlodipine (5 mg once daily) and slow release nifedipine (20 mg twice daily) were compared in an open, crossover study in general practices.

To assess if dopaminergic control of aldosterone secretion is mediated by the renin-angiotensin system, the effect of chronic angiotensin converting enzyme inhibition by enalapril on the aldosterone response to metoclopramide has been studied in 10 patients with mild to moderate essential hypertension. Enalapril reduced supine blood pressure and increased the heart rate significantly. Plasma renin activity and urinary sodium excretion rose significantly. PRA was not changed by metoclopramide, neither during placebo nor during enalapril treatment. Metoclopramide induced a two-fold increase in plasma aldosterone, the peak response being reached within 15 min. Enalapril treatment did not alter the aldosterone response to metoclopramide. Dopaminergic control of aldosterone secretion appears to be independent of the renin-angiotensin system.

Patient compliance with therapy is often poor and overestimated by the treating physician; it is particularly important in cardiovascular diseases such as hypertension and angina pectoris. Compliance was studied in an open parallel study in out-patients with stable angina pectoris, given either amlodipine (5 mg, once daily) or slow-release nifedipine (20 mg, twice daily) for 12 weeks. Compliance was assessed using pill counting and using an electronic device, the medication event monitoring system, to record the time and date of each opening and closure of the pill container. There was no difference between the two groups in pill count or taking ‘in compliance’ (the percentage of prescribed doses taken as indicated by the monitoring system). Compliance was significantly better (P <0.001) with amlodipine, however, for ‘correct dosing’ (the percentage of days on which the correct dose was taken) and for ‘timing compliance’ (the percentage of doses taken at the prescribed time interval after the last dose). ‘Therapeutic coverage’ (the estimated proportion of treatment time for which the drug was active) was also significantly better for amlodipine (P <0.001). There was no difference in reported side-effects between the two therapies.

A patient is described in whom the diagnosis of pheochromocytoma was suspected on clinical grounds. He had normal urinary and plasma norepinephrine levels, with normal suppression of plasma norepinephrine by Clonidine. However, plasma and urinary epinephrine levels were above normal/and plasma epinephrine was not suppressed but increased by Clonidine. Selective venous sampling showed marked unilateral adrenal epinephrine excess. A large epinephrine secreting pheochromiocytoma was surgically removed. This case suggests that, in pheochromocytomas releasing predominantly epinephrine, normal norepinephrine release from axon terminals of sympathetic postganglionic neurons is maintained and is suppressed by Clonidine administration. It further reaffirms the value of plasma epinephrine estimations in the diagnosis of pheochromocytoma and indicates that normal suppression of plasma norepinephrine by Clonidine does not preclude the presence of a predominantly epinephrine secreting tumor.

Zusammenfassung Die radioimmunologisch gemessenen Plasmaspiegel von Parathormon, die renale Ausscheidung von zyklischem Adenosin 3',5'-Monophosphat (cAMP) und die Stimulierbarkeit der renalen Tubuli nach einer Infusion von Kalzium und von Parathormonextrakt wurden untersucht bei einem Patienten mit nichtfamiliärer hypophosphatämischer Osteomalazie. Die Plasmakonzentration von Parathormon war normal, und die basale renale Ausscheidung von cAMP erhöht. Nach Verabfolgung von Parathormonextrakt war die renale kortikale Adenylzyklase, gemessen als renale Ausscheidung von cAMP, sicher so empfindlich wie bei normalen Personen. Nach einer vorhergehenden Kalziuminfusion war in den Nieren eine größere Parathormon-empfindliche Komponente von Phosphortransport vorhanden als bei zwei Kontrollpersonen. Unsere Ergebnisse zeigen, daß bei nichtfamiliärer hypophosphatämischer Osteomalazie die Stimulierbarkeit der renalen Tubuszellen durch Parathormon erhöht sein könnte.

The tolerability of isradipine was evaluated in an open trial of patients with mild-to-moderate essential hypertension as treated in general practice. The primary objective was to identify all adverse reactions, especially those that were newly occurring (= 6 reports), with a frequency > 1/1,000. Over 1,100 general practitioners and 5,526 patients participated in this trial. After a 2-week washout period, and a 3-week placebo run-in, patients with diastolic blood pressure (DBP) = 95 mm Hg were initially given isradipine at 1.25 mg twice daily. After 4 weeks, doses were doubled if DBP was > 90 mm Hg. If, after a further 4 weeks with doubled dosages, the DBP was still >90 mm Hg, a second (nonspecified free-choice) antihypertensive agent was added to the treatment. Adverse events were recorded by open questioning. The incidence of adverse events was found to be similar to that with placebo; adverse events were generally mild or moderate in intensity and disappeared over time. No newly occurring adverse events were found. In conclusion, isradipine is safe and well tolerated at effective antihypertensive doses in patients with mild-to-moderate hypertension as treated in general practice.

A 37-year-old woman with a multiple endocrine neoplasia type 2a underwent bilateral adrenalectomy and total thyroidectomy with parathyroidectomy in 1977. The left-sided pheochromocytoma was considered to be malignant. Seven yr after the initial operation, an enhanced urinary excretion-ratio of N-methyladrenaline / adrenalin suggested the possible presence of either persistent or metastatic pheochromocytoma lodine-123-labeled metaiodobenzylguanidine scintigraphy (1–123 MIBG) showed a hot spot in the right lung. However, repeated chest-X-rays and computed tomographic scanning of the thorax remained negative. Anatomical localization of the lesion was finally obtained with magnetic resonance imaging. The surgical removal of the small pheochromocytoma was guided by the gamma-ray emission of 1–123 MIBG administered iv before the operation. This case report illustrates the usefulness of new analytical methods and of new imaging techniques in the diagnosis and management of metastatic pheochromocytoma.