From 'essential' hypertension to intensive blood pressure lowering: the pros and cons of lower target values

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Spirometry in chronic obstructive pulmonary disease in Norwegian general practice

Background General practitioners (GPs) in Norway increasingly use spirometry diagnostically as well as in follow up of patients with respiratory complaints, but little is known about their skills and knowledge in this area. The aim of the present study was to investigate how GPs interpret a case history and spirometry recordings of a patient with chronic obstructive pulmonary disease (COPD), and their knowledge about their own spirometer. Methods A web-based survey, consisting of a case history and spirometry recordings of a patient with COPD, was distributed to the 4700 members of the Norwegian GP Association. In addition to background information about themselves and their spirometer, topics included whether they requested, and how they interpreted, a spirometry reversibility-test, identification of the of most likely diagnosis, and recognition of the spirometry parameters used to diagnose COPD and grade airway obstruction. Immediate feedback was provided for educational purposes. Results Six hundred thirty GPs responded. Twenty six percent would not request a reversibility test, but 81% identified COPD as the most likely diagnosis. Less than 50% correctly identified the spirometry parameters used for diagnosis of COPD and grading the airway obstruction. One in five (21%) did not know which spirometer was used in their own practice, and 49 and 61% did not know which reference values were used for adults and children, respectively. Participants evaluated the survey as useful (average 74 points on a 0–100 scale) and would like more case-based surveys concerning use of spirometry in the future (average 91 points). Conclusion In this cohort of self-selected GPs, probably more interested in respiratory medicine than the average GP, we identified several problem areas and gaps in knowledge regarding the use of spirometry.publishedVersio

Blood pressure control and components of the metabolic syndrome: the GOOD survey

<p>Abstract</p> <p>Background</p> <p>The GOOD (Global Cardiometabolic Risk Profile in Patients with Hypertension Disease) survey showed that blood pressure control was significantly worse in hypertensive patients with metabolic syndrome and/or diabetes mellitus than in those with essential hypertension only. This analysis aimed to investigate which components of the metabolic syndrome are primarily associated with poor blood pressure control.</p> <p>Methods</p> <p>The GOOD survey was designed as an observational cross-sectional survey in 12 European countries to assess the cardiometabolic risk profile in patients with essential hypertension. Investigators were randomly selected from a list of general practitioners (70% of investigators) and a list of specialists such as internists, cardiologists and hypertension specialists (30% of investigators). Data from 3,280 outpatients with hypertension, aged at least 30 years who were receiving antihypertensive treatment or had newly diagnosed hypertension according to the European Society of Hypertension and the European Society of Cardiology criteria, were included in the analyses. Blood pressure control, body mass index (BMI), waist circumference, serum triglycerides, total and high density lipoprotein (HDL) cholesterol measurements were compared in patients with diabetes mellitus and metabolic syndrome, with diabetes mellitus only, with metabolic syndrome only, and with neither metabolic syndrome nor diabetes mellitus.</p> <p>Results</p> <p>The highest blood pressure values were found in patients with metabolic syndrome with or without diabetes mellitus. Blood pressure was significantly lower in patients with diabetes mellitus only. The highest BMI, waist circumference and serum triglycerides, and the lowest HDL cholesterol levels among the groups studied occurred in patients with metabolic syndrome, either with or without diabetes mellitus.</p> <p>Conclusion</p> <p>Among the components of the metabolic syndrome, it is not impaired glucose tolerance which is associated with the poor response to antihypertensive treatment. Instead, visceral obesity and dyslipidemia components of the metabolic syndrome, i.e. hypertriglyceridemia and low HDL cholesterol levels, are associated with resistance to antihypertensive treatment.</p

Hypertension and Genetic Variation in Endothelial-Specific Genes

Genome-wide association (GWA) studies usually detect common genetic variants with low-to-medium effect sizes. Many contributing variants are not revealed, since they fail to reach significance after strong correction for multiple comparisons. The WTCCC study for hypertension, for example, failed to identify genome-wide significant associations. We hypothesized that genetic variation in genes expressed specifically in the endothelium may be important for hypertension development. Results from the WTCCC study were combined with previously published gene expression data from mice to specifically investigate SNPs located within endothelial-specific genes, bypassing the requirement for genome-wide significance. Six SNPs from the WTCCC study were selected for independent replication in 5205 hypertensive patients and 5320 population-based controls, and successively in a cohort of 16537 individuals. A common variant (rs10860812) in the DRAM (damage-regulated autophagy modulator) locus showed association with hypertension (P = 0.008) in the replication study. The minor allele (A) had a protective effect (OR = 0.93; 95% CI 0.88-0.98 per A-allele), which replicates the association in the WTCCC GWA study. However, a second follow-up, in the larger cohort, failed to reveal an association with blood pressure. We further tested the endothelial-specific genes for co-localization with a panel of newly discovered SNPs from large meta-GWAS on hypertension or blood pressure. There was no significant overlap between those genes and hypertension or blood pressure loci. The result does not support the hypothesis that genetic variation in genes expressed in endothelium plays an important role for hypertension development. Moreover, the discordant association of rs10860812 with blood pressure in the case control study versus the larger Malmo "Preventive Project-study highlights the importance of rigorous replication in multiple large independent studies

Contrasting Neogene–Quaternary continental margin evolution offshore mid-north Norway: Implications for source-to-sink systems

The Neogene–Quaternary development of the ∼700 km long mid-Norwegian and Lofoten–Vesterålen continental margin is reconstructed using a dense grid of 2D seismic data and exploration wellbores. Overall, widespread ocean current-controlled contourite drifts built up along the whole margin segment from the mid-Miocene onwards (c. 11 Ma, Kai Formation). The onset (c. 8.8 Ma) of a large inner shelf progradation (Molo Formation) was, however, restricted to the southern part of the study area, the inner mid-Norwegian shelf. In the Quaternary (c. 2.7 Ma), grounded ice sheets repeatedly brought large sediment volumes (Naust Formation) to the shelf beyond the Molo Formation. A similar build-out is less pronounced further north, where contourite drift growth instead continued and resulted in build-up of the Lofoten and Vesterålen drifts. In contrast, the drifts of the southern part of the study area occur for the most part stratigraphically below, interbedded with and distal to the progradational Molo and Naust deposits. The study area exemplifies pronounced variability in Neogene–Quaternary continental margin growth. The wide and gently dipping mid-Norwegian margin facilitated coastal and shelf progradation related to fluvial and glacial processes, while the narrow and steep Lofoten–Vesterålen margin received little input from these sources although exposed to the same paleoclimate. Instead, erosion of canyons promoted downslope reworking across the slope and into the deep basins. This low sediment input is interpreted to be controlled by the alpine relief in the north resulting in a small source area and thus low fluvial and glacial sediment input. To the south, hinterland relief allowed for a much larger fluvial and later, glacial source area. Both margin segments were also influenced by contour currents throughout the studied period. We emphasize their importance for understanding the role of erosion and deposition in source-to-sink systems, and thus the need for these processes to be integrated within source-to-sink model

Key Terms and Definitions in Acute Porphyrias: Results of an International Delphi Consensus Led by the European Porphyria Network

Background: Acute porphyrias are a group of rare inherited disorders causing acute neurovisceral attacks. Many terms used frequently in the literature and in clinical practice are ambiguous, which can lead to confusion in the way patients are managed, studied, and reported in clinical studies. Agreed definitions are a necessary first step in developing management guidelines and will facilitate communication of results of future clinical research. Methods: The Delphi method was used to generate consensus on key terms and definitions in acute porphyria. The process started with a brainstorming phase offered to all members of the European Porphyria Network followed by 2 Delphi rounds among international experts in the field of porphyria (the Acute Porphyria Expert Panel). A consensus of 75% or more was defined as the agreement threshold. Results: 63 respondents from 26 countries participated in the brainstorming phase, leading to the choice of 9 terms and definitions. 34 experts were invited to take part in the Delphi rounds. 7 of the initial 9 terms and definitions which entered the first Delphi round achieved the threshold for agreement. Following a second Delphi round, all 9 definitions achieved agreement. Conclusion: Agreement on the definitions for 9 important terms describing acute porphyrias represents a significant step forward for the porphyria community. It will facilitate more accurate comparison of outcomes among porphyria centres and in clinical trials and provide a strong framework for developing evidence based clinical guidelines

APES Beamforming Applied to Medical Ultrasound Imaging

As of today, sonar imaging is the most effective means of documenting the subsea environment. Existing sonar imaging systems generally rely on conventional beamforming methods to form the image. While conventional beamformers are robust and simple, they leave many of the challenges of sonar imaging unresolved. Sonar images are often degraded by noise, and the image resolution as well as the range at which useful images can be obtained is limited. This thesis addresses the use of adaptive beamforming and imaging methods applied to active sonar. The goal of an adaptive beamformer in this context is to improve the quality of the sonar image by allowing the beamformer to adapt to the situation, recognizing sources of noise and interference and suppressing them before they have the chance to contaminate the image. The desired result is an image containing more useful and correct information, less noise, and improved image resolution. Focus has been on investigating how different adaptive methods can be implemented in a practical setting, and analyzing the performance of each method. Key challenges that are addressed include coherent signals, arbitrary array geometries, computational load, and robustness. Two of the most common adaptive beamforming methods, the minimum variance distortionless response (MVDR) and the amplitude and phase estimation (APES) beamformers, are considered, as well as a low complexity variant of the adaptive MVDR beamformer. Adaptive imaging methods based on aperture coherence represent a promising class of adaptive methods, and are also considered. We conclude that in many cases, improved image quality is obtained by using adaptive beamforming methods

How to optimize the use of diuretics in patients with heart failure?

Considering the pathophysiology and clinical presentation of heart failure, using diuretics or drugs with diuretic properties is indispensable for adequate management of heart failure patients. However, in clinical practice, fluid expansion is often undiagnosed, and diuretic therapy is not always adequately titrated. Today, several drug classes with diuretic properties are available in addition to classical thiazides, thiazide-like, and loop diuretics. The purpose of this short review is to discuss different ways to optimize diuretic therapy using currently available drugs. Several approaches are considered, including a combination of diuretics to obtain a sequential nephron blockade, use of a drug combining a blocker of the renin-angiotensin system (RAS) and an inhibitor of the metabolism of natriuretic peptides (ARNI), prescription of potassium binders to maintain and up-titrate RAS blockers and mineralocorticoid antagonists, and finally use of inhibitors of renal reabsorption of glucose through the sodium-glucose cotransporter 2 system. Optimal use of these various drug classes should improve the quality of life and reduce the need for hospital admissions and mortality in heart failure patients

Hemodynamic effects of quinapril, a novel angiotensin‐converting enzyme inhibitor

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109772/1/cptclpt1990116.pd