Poor blood pressure control in general practice: In search of explanations

SummaryBackgroundArterial hypertension is managed mainly by general practitioners. The blood pressure level of most patients treated in a general practice setting is greater than or equal to 140/90mmHg.AimsTo understand why a blood pressure level greater than or equal to 140/90mmHg does not lead to a change of treatment.MethodsOver a 2-week period, 479 hypertensive patients were included in a cross-sectional study by 27 general practitioners. Consultation data were collected, as were reasons why patients with a blood pressure level greater than or equal to 140/90mmHg did not have their treatment changed.ResultsBlood pressure level was greater than or equal to 140/90mmHg in 58% of patients; treatment was changed in 15% of these individuals. The lack of change in treatment was justified by the physicians as follows: the blood pressure measurements were not considered to be representative (about 30% of cases); the therapeutic result was considered to be satisfactory in the circumstances (about 30% of cases); change was not appropriate given the patient's specific context (the remaining third of cases). The proportion of uncontrolled hypertensive patients whose treatment remained the same was significantly higher among patients with a disease that affected their lifestyle or threatened their life expectancy.ConclusionThe disappointing therapeutic results observed in the management of arterial hypertension do not arise only from poor application of guidelines by general practitioners. Reluctance to rely on blood pressure measurements, a perception that guidelines are revised frequently and are not always clear, and consideration of the general practitioner's activity in the patient's specific context are the main factors involved

I021 Impact du polymorphisme génétique C(-260)T du CD14 sur la pression pulsée en fonction d’autres facteurs de risque cardiovasculaires : etude populationnelle transversale à partir du registre monica

Objectif de l’étudeLe CD14 est à l’intersection entre l’inflammation, les maladies infectieuses et le syndrome métabolique. Une corrélation positive entre la concentration plasmatique du CD14 soluble (sCD14) et la rigidité aortique a été décrite dans une étude transversale. Mais différents résultats ont été retrouvés sur l’incidence des évènements cardiovasculaires en fonction du polymorphisme C(-260)T du gène du CD14.L’objectif de cette étude est d’étudier l’influence du polymorphisme C(-260)T du CD14 sur la pression pulsée et indirectement sur le risque cardiovasculaire à partir de l’étude populationnelle transversale MONICA.Déroulement de l’étude1 155 sujets âgés entre 35 et 64 ans, en prévention primaire, ont été recrutés à partir des listes électorales de la Haute Garonne entre 1995 et 1997.MéthodesLa pression pulsée brachiale était mesurée au repos à 2 reprises puis moyennée. La concentration plasmatique du sCD14 a été mesurée par méthode immunoenzymatique. La randomisation est de type mendélienne. Les sujets ont été répartis en fonction du polymorphisme C(-260)T du CD14 après génotypage : homozygotes CC, homozygotes TT ou hétérozygotes CT.RésultatsLes sujets homozygotes TT ont une pression pulsée (PP) significativement plus basse et une concentration en sCD14 significativement plus élevée. Après ajustement avec les principaux facteurs confondants (âge, sexe, facteurs de risque cardiovasculaires traités), seul le génotype du CD14 reste corrélé à la PP. Cette corrélation n’intervient qu’en présence de facteurs de risque traités. Les diabétiques traités homozygotes TT sont ceux qui bénéficient de la plus importante baisse de PP par rapport aux homozygotes diabétiques CC (− 19,4mmHg, p=0,006).ConclusionCette étude suggère que les facteurs de risque ont un impact différent sur la pression pulsée en fonction du polymorphisme C(-260)T du CD14. Cette observation pourrait contribuer à affiner le risque cardiovasculaire absolu individuel, les sujets homozygotes TT ayant un risque cardiovasculaire moindre

4′-Formyl­biphenyl-4-yl acetate

In the title compound, C15H12O3, the dihedral angle between the six-membered rings is 30.39 (1)°. The crystal packing is stabilized by inter­molecular C—H⋯O hydrogen bonds

The interaction between the measles virus nucleoprotein and the Interferon Regulator Factor 3 relies on a specific cellular environment

<p>Abstract</p> <p>Background</p> <p>The genome of measles virus consists of a non-segmented single-stranded RNA molecule of negative polarity, which is encapsidated by the viral nucleoprotein (N) within a helical nucleocapsid. The N protein possesses an intrinsically disordered C-terminal domain (aa 401–525, N_TAIL) that is exposed at the surface of the viral nucleopcapsid. Thanks to its flexible nature, N_TAILinteracts with several viral and cellular partners. Among these latter, the Interferon Regulator Factor 3 (IRF-3) has been reported to interact with N, with the interaction having been mapped to the regulatory domain of IRF-3 and to N_TAIL. This interaction was described to lead to the phosphorylation-dependent activation of IRF-3, and to the ensuing activation of the pro-immune cytokine RANTES gene.</p> <p>Results</p> <p>After confirming the reciprocal ability of IRF-3 and N to be co-immunoprecipitated in 293T cells, we thoroughly investigated the N_TAIL-IRF-3 interaction using a recombinant, monomeric form of the regulatory domain of IRF-3. Using a large panel of spectroscopic approaches, including circular dichroism, fluorescence spectroscopy, nuclear magnetic resonance and electron paramagnetic resonance spectroscopy, we failed to detect any direct interaction between IRF-3 and either full-length N or N_TAILunder conditions where these latter interact with the C-terminal X domain of the viral phosphoprotein. Furthermore, such interaction was neither detected in <it>E. coli </it>nor in a yeast two hybrid assay.</p> <p>Conclusion</p> <p>Altogether, these data support the requirement for a specific cellular environment, such as that provided by 293T human cells, for the N_TAIL-IRF-3 interaction to occur. This dependence from a specific cellular context likely reflects the requirement for a human or mammalian cellular co-factor.</p

Twenty-four-hour ambulatory blood pressure monitoring efficacy of perindopril/indapamide first-line combination in hypertensive patients: the REASON study

Background: Circadian blood pressure (BP) measurements provide more information on hypertensive complications than office BP measurements. The purpose of this study was to analyze the efficacy of the first-line combination of perindopril 2 mg plus indapamide 0.625 mg versus atenolol 50 mg on BP parameters and variability over 24 h in patients with hypertension. Methods: A double-blind, randomized, controlled, 12-month study comparing perindopril/indapamide and atenolol was performed in 201 patients (age 55.0 years) with uncomplicated sustained essential hypertension. Ambulatory BP measurements (ABPM) were done every 15 min over 24 h. Results: After 1 year of treatment, the decrease in systolic BP was significantly greater for perindopril/indapamide than for atenolol during the entire 24-h period (-13.8 ν −9.2 mm Hg), the daytime and the nighttime periods (P < .01). Diastolic blood pressure (DBP) variations were comparable for the two groups (−7.2 ν −8.3 mm Hg, NS). Pulse pressure (PP) reduction was also significantly greater for perindopril/indapamide than for atenolol (for the whole 24 h, −6.6 ν −0.9 mm Hg, P < .001). The through to peak (T/P) BP ratio and the smoothness index were comparable in the two groups for DBP. For systolic blood pressure (SBP), higher values of the T/P ratio (0.80 ν 0.59) and the smoothness index (1.45 ν 0.98; P < .02) were achieved for the perindopril/indapamide combination than for atenolol. Conclusions: The perindopril/indapamide first-line combination decreased SBP and PP more effectively than atenolol. Moreover, the BP control effect was smooth and consistent throughout the 24-h dosing interval and BP reduction variability was lower than the one induced by atenolo

Increased mean aliphatic lipid chain length in left ventricular hypertrophy secondary to arterial hypertension: A cross-sectional study

About 77.9 million (1 in 4) American adults have high blood pressure. High blood pressure is the primary cause of left ventricular hypertrophy (LVH), which represents a strong predictor of future heart failure and cardiovascular mortality. Previous studies have shown an altered metabolic profile in hypertensive patients with LVH. The goal of this study was to identify blood metabolomic LVH biomarkers by H NMR to provide novel diagnostic tools for rapid LVH detection in populations of hypertensive individuals. This cross-sectional study included 48 hypertensive patients with LVH matched with 48 hypertensive patients with normal LV size, and 24 healthy controls. Two-dimensional targeted M-mode echocardiography was performed to measure left ventricular mass index. Partial least squares discriminant analysis was used for the multivariate analysis of the H NMR spectral data. From the H NMR-based metabolomic profiling, signals coming from methylene (-CH2-) and methyl (-CH3) moieties of aliphatic chains from plasma lipids were identified as discriminant variables. The -CH2-/-CH3 ratio, an indicator of the mean length of the aliphatic lipid chains, was significantly higher (P < 0.001) in the LVH group than in the hypertensive group without LVH and controls. Receiver operating characteristic curve showed that a cutoff of 2.34 provided a 52.08% sensitivity and 85.42% specificity for discriminating LVH (AUC = 0.703, P-value < 0.001). We propose the -CH2-/-CH3 ratio from plasma aliphatic lipid chains as a biomarker for the diagnosis of left ventricular remodeling in hypertension

MoMuLV and HIV-1 nucleocapsid proteins have a common role in genomic RNA packaging but different in late reverse transcription

Retroviral nucleocapsid proteins harbor nucleic acid chaperoning activities that mostly rely on the N-terminal basic residues and the CCHC zinc finger motif. Such chaperoning is essential for virus replication, notably for genomic RNA selection and packaging in virions, and for reverse transcription of genomic RNA into DNA. Recent data revealed that HIV-1 nucleocapsid restricts reverse transcription during virus assembly--a process called late reverse transcription--suggesting a regulation between RNA packaging and late reverse transcription. Indeed, mutating the HIV-1 nucleocapsid basic residues or the two zinc fingers caused a reduction in RNA incorporated and an increase in newly made viral DNA in the mutant virions. MoMuLV nucleocapsid has an N-terminal basic region similar to HIV-1 nucleocapsid but a unique zinc finger. This prompted us to investigate whether the N-terminal basic residues and the zinc finger of MoMuLV and HIV-1 nucleocapsids play a similar role in genomic RNA packaging and late reverse transcription. To this end, we analyzed the genomic RNA and viral DNA contents of virions produced by cells transfected with MoMuLV molecular clones where the zinc finger was mutated or completely deleted or with a deletion of the N-terminal basic residues of nucleocapsid. All mutant virions showed a strong defect in genomic RNA content indicating that the basic residues and zinc finger are important for genomic RNA packaging. In contrast to HIV-1 nucleocapsid-mutants, the level of viral DNA in mutant MoMuLV virions was only slightly increased. These results confirm that the N-terminal basic residues and zinc finger of MoMuLV nucleocapsid are critical for genomic RNA packaging but, in contrast to HIV-1 nucleocapsid, they most probably do not play a role in the control of late reverse transcription. In addition, these results suggest that virus formation and late reverse transcription proceed according to distinct mechanisms for MuLV and HIV-1

Performance Scores in General Practice: A Comparison between the Clinical versus Medication-Based Approach to Identify Target Populations

CONTEXT: From one country to another, the pay-for-performance mechanisms differ on one significant point: the identification of target populations, that is, populations which serve as a basis for calculating the indicators. The aim of this study was to compare clinical versus medication-based identification of populations of patients with diabetes and hypertension over the age of 50 (for men) or 60 (for women), and any consequences this may have on the calculation of P4P indicators. METHODS: A comparative, retrospective, observational study was carried out with clinical and prescription data from a panel of general practitioners (GPs), the Observatory of General Medicine (OMG) for the year 2007. Two indicators regarding the prescription for statins and aspirin in these populations were calculated. RESULTS: We analyzed data from 21.690 patients collected by 61 GPs via electronic medical files. Following the clinical-based approach, 2.278 patients were diabetic, 8,271 had hypertension and 1.539 had both against respectively 1.730, 8.511 and 1.304 following the medication-based approach (% agreement = 96%, kappa = 0.69). The main reasons for these differences were: forgetting to code the morbidities in the clinical approach, not taking into account the population of patients who were given life style and diet rules only or taking into account patients for whom morbidities other than hypertension could justify the use of antihypertensive drugs in the medication-based approach. The mean (confidence interval) per doctor was 33.7% (31.5-35.9) for statin indicator and 38.4% (35.4-41.4) for aspirin indicator when the target populations were identified on the basis of clinical criteria whereas they were 37.9% (36.3-39.4) and 43.8% (41.4-46.3) on the basis of treatment criteria. CONCLUSION: The two approaches yield very "similar" scores but these scores cover different realities and offer food for thought on the possible usage of these indicators in the framework of P4P programmes

The availability of snack food displays that may trigger impulse purchases in Melbourne supermarkets

<p>Abstract</p> <p>Background</p> <p>Supermarkets play a major role in influencing the food purchasing behaviours of most households. Snack food exposures within these stores may contribute to higher levels of consumption and ultimately to increasing levels of obesity, particularly within socioeconomically disadvantaged neighbourhoods. We aimed to examine the availability of snack food displays at checkouts, end-of-aisle displays and island displays in major supermarket chains in the least and most socioeconomically disadvantaged neighbourhoods of Melbourne.</p> <p>Methods</p> <p>Within-store audits of 35 Melbourne supermarkets. Supermarkets were sampled from the least and most socioeconomically disadvantaged suburbs within 30 km of the Melbourne CBD. We measured the availability of crisps, chocolate, confectionery, and soft drinks (diet and regular) at the checkouts, in end-of-aisle displays, and in island bin displays.</p> <p>Results</p> <p>Snack food displays were most prominent at checkouts with only five stores not having snack foods at 100% of their checkouts. Snack foods were also present at a number of end-of-aisle displays (at both the front (median 38%) and back (median 33%) of store), and in island bin displays (median number of island displays: 7; median total circumference of island displays: 19.4 metres). Chocolate items were the most common snack food item on display. There was no difference in the availability of these snack food displays by neighbourhood disadvantage.</p> <p>Conclusions</p> <p>As a result of the high availability of snack food displays, exposure to snack foods is almost unavoidable in Melbourne supermarkets, regardless of levels of neighbourhood socioeconomic disadvantage. Results of this study could promote awareness of the prominence of unhealthy food items in chain-brand supermarkets outlets.</p

Determinants of persistence in hypertensive patients treated with irbesartan: results of a postmarketing survey

BACKGROUND: Persistence is a key factor for long-term blood pressure control, which is of high prognostic importance for patients at increased cardiovascular risk. Here we present the results of a post-marketing survey including 4769 hypertensive patients treated with irbesartan in 886 general practices in Switzerland. The goal of this survey was to evaluate the tolerance and the blood pressure lowering effect of irbesartan as well as the factors affecting persistence in a large unselected population. METHODS: Prospective observational survey conducted in general practices in all regions of Switzerland. Previously untreated and uncontrolled pre-treated patients were started with a daily dose of 150 mg irbesartan and followed up to 6 months. RESULTS: After an observation time slightly exceeding 4 months, the average reduction in systolic and diastolic blood pressure was 20 (95% confidence interval (CI) -19.6 to -20.7 mmHg) and 12 mmHg (95% CI -11.4 to -12.1 mmHg), respectively. At this time, 26% of patients had a blood pressure < 140/90 mmHg and 60% had a diastolic blood pressure < 90 mmHg. The drug was well tolerated with an incidence of adverse events (dizziness, headaches,...) of 8.0%. In this survey more than 80% of patients were still on irbesartan at 4 month. The most important factors predictive of persistence were the tolerability profile and the ability to achieve a blood pressure target ≤ 140/90 mmHg before visit 2. Patients who switched from a fixed combination treatment tended to discontinue irbesartan more often whereas those who abandoned the previous treatment because of cough (a class side effect of ACE-Inhibitors) were more persistent with irbesartan. CONCLUSION: The results of this survey confirm that irbesartan is effective, well tolerated and well accepted by patients, as indicated by the good persistence. This post-marketing survey also emphasizes the importance of the tolerability profile and of achieving an early control of blood pressure as positive predictors of persistence