This document summarizes the available evidence and provides recommendations on the use of home blood pressure monitoring in clinical practice and in research. It updates the previous recommendations on the same topic issued in year 2000. The main topics addressed include the methodology of home blood pressure monitoring, its diagnostic and therapeutic thresholds, its clinical applications in hypertension, with specific reference to special populations, and its applications in research. The final section deals with the problems related to the implementation of these recommendations in clinical practice.

An appropriate cuff according to the individual's arm circumference is recommended with all blood pressure (BP) monitors. An electronic device for home monitoring has been developed (Visomat Comfort 20/40) that estimates the individual's arm circumference by measuring the cuff filing volume and makes an adjustment of measured BP taking into account the estimated arm circumference. Thus the manufacturer recommends the use of a single cuff for arm circumference 23-43 cm. The device accuracy was assessed using the European Society of Hypertension International Protocol. Simultaneous BP measurements were obtained in 33 adults by two observers (connected mercury sphygmomanometers) four times, sequentially with three measurements taken using the tested device. Absolute device-observer BP differences were classified into < or =5, < or =10 and < or =15 mm Hg zones. For each participant the number of measurements with a difference < or =5 mm Hg was calculated. The device produced 60/89/97 measurements within 5/10/15 mm Hg respectively for systolic BP, and 72/97/98 for diastolic. Twenty-three subjects had at least two of their systolic BP differences < or =5 mm Hg and three had no differences < or =5 mm Hg (for diastolic 27 and 1, respectively). Mean device-observer BP difference (systolic/diastolic) was 3.7 +/- 5.6/-1.5 +/- 4.7 mm Hg (4.7 +/- 4.9/ - 1.7 +/- 4.3 in arm circumference 23-29 cm [39 readings] and 3.1 +/- 5.9/-1.4 +/- 5.0 in arm 30-34 cm [60 readings], P=NS). In conclusion, the device fulfils the International Protocol requirements and can be recommended for clinical use. Interestingly, the device was accurate using a single cuff in a wide range of arm circumference (23-34 cm). This study provides no information about the device accuracy in larger arms.

Propagation of odontogenic masticator space abscesses is insufficiently understood. The purpose was to analyse pathways of spread in 30 patients with odontogenic masticator space abscess. The imaging findings in 30 patients (CT in 30, MR in 16 patients) were retrospectively analysed. CT and MR imaging depicted a masticator space abscess within: medial pterygoid muscle in 13 patients (43.3%), lateral masseter and/or pterygoid muscle in 14 (46.7%) and superficial temporal muscle in 3 patients (10%). In the lateral masticator space intra-spatial abscess extension occurred in 7 of 14 patients (50%). The sub-masseteric space provided a pathway in seven (70%). Extra-spatial extension involved the submandibular space only in 3 of 14 patients (21.4%). Medial masticator space abscesses exhibited extra-spatial spread only. Extension affected the parapharyngeal space and/or soft palate in 7 of 13 lesions (53.8%). MR imaging in comparison to CT increased the number of abscess locations from 18 to 23 (27.8%) and regions affected by a cellular infiltrate from 12 to 16 (33.3%). The sub-masseteric space served as a previously underestimated pathway for intra-spatial propagation of lateral masticator abscesses. Medial masticator space abscesses tend to display early extra-spatial parapharyngeal space and/or soft palate extension.

Although self-monitoring of blood pressure by patients at home is being widely used in clinical practice, the evidence on its prognostic value is still limited. Five long-term studies with nearly 60,000 patients/year have provided prognostic information for home blood pressure measurements. Differences exist among these studies regarding the population characteristics, the sample size and follow-up, the methodology and protocol for office and home blood pressure measurement and the adjustment procedure for other risk factors. All these studies, nevertheless, showed systolic home blood pressure to be a significant predictor of cardiovascular risk, and three of them also showed prognostic value of diastolic home blood pressure. Moreover, the prognostic value of home blood pressure appeared to be consistently superior to that of conventional office measurements. The prognostic significance of the white coat and the masked hypertension phenomena detected by home measurements were investigated in two studies, one in treated hypertensive patients and another in a general population sample. These studies showed that patients with white-coat phenomenon have similar cardiovascular risk as those with low office and home blood pressure, whereas the masked hypertension phenomenon is associated with high risk as in patients with uncontrolled hypertension. In conclusion, the available evidence suggests that home blood pressure has strong prognostic value, which appears to be superior to that of the conventional office measurements. More outcome studies on the prognostic value of home blood pressure, however, are needed.

The random variation of BP and the intraindividual variation in the BP response to treatment cause considerable difficulties in the evaluation of the dose-response relationship of antihypertensive drugs. Thus, failures in finding the optimal dose of antihypertensive drugs have not been uncommon. The notion that angiotensin receptor antagonists (angiotensin receptor blockers) have a relatively flat dose-response relationship also appears to be due to limitations of dose-finding studies. The conventional method of office BP measurement that is typically used in dose-finding studies is poorly reproducible and is subject to the white coat effect, placebo effect, and observer bias. These problems can be overcome by using ambulatory or home BP monitoring, which are known to improve the accuracy of studies aiming to detect BP changes. A crossover design study allows all participants to receive all treatments (doses) and paired comparisons are performed. Thus, this design significantly enhances the power to detect differences between doses, compared with the typical parallel-group dose-finding study. A separate analysis of the dose-response relationship exclusively in subjects with a good BP response to the drug (responders) can provide clear insight about the drug effect when it actually works. These measures improve the accuracy of drug trials investigating the dose-response relationship and might prevent misleading information at an early stage of clinical development.

The optimal schedule for home blood pressure monitoring should represent the usual level of home blood pressure, give a reproducible value, and have prognostic ability. Therefore, outcome studies, as well as short-term trials assessing the reproducibility of home blood pressure, its stability over time and its relationship with ambulatory blood pressure should be taken into account. A review of this evidence suggests that the optimal schedule should be based on 12-14 measurements, and even more measurements up to 25 are desirable. Morning and evening measurements should be obtained, with at least duplicate measurements per occasion. Measurements on the initial day should preferably be discarded.

Cardiovascular and renal diseases share many of the same risk factors. In fact, renal failure is usually accompanied by an increased global cardiovascular risk. Thus, preservation of kidney function might simultaneously protect the heart and the brain and, conversely, addressing cardiovascular risk factors might safeguard the kidney. This review considers the evidence supporting this approach, focusing on the protective effect of blood-pressure lowering and the ancillary actions of antihypertensive agents on renal protection. We review recent evidence on renal protection in individuals with and without diabetes, and the importance of offering a high standard of care also to those with the metabolic syndrome or prediabetes in order to prevent initial forms of renal, and as a consequence, cardiovascular damage. Intervention may be appropriate even in individuals with high-normal blood pressure, if they already have early renal and/or cardiovascular risk markers. As a consequence of these insights, thresholds for starting antihypertensive therapy are gradually falling, whereas awareness of the need for an early intervention in patients at high risk of developing renal damage and simultaneously cardiovascular disease is growing.

Unilateral or bilateral dislocation of the TMJ is frequent. Usually it can be treated by the method described by Hippocrates. If conservative treatment (splint therapy, biofeedback, etc.) does not succeed related to recurrent fixed TMJ-dislocation, surgical therapy strategies become necessary. Above all mentally retarded or patients with neuromuscular disorders may necessitate surgical treatment. The two surgical main procedures are: 1. Removal of mechanical obstacles by reduction of the eminentia. 2. Creation of a mechanical obstacle towards the anterior condylar translation. The here presented case shows the treatment of a reccurent, fixed anterior TMJ-dislocation using a miniplate which enables a absolut heightening of the articular tubercle in a 76 years old lady with Morbus Alzheimer and Parkinson. Due to the high incidence of plate fractures, this well discribed therapy, known as miniplate eminoplasty, can not be considered as the treatment of choice for mandibular dislocation. It can be indicated in non-compliant patients or in patients with neuromuscular disorders or in the combination of both as in our case.