Blood Pressure and Global Risk Assessment in a Swedish Population

This study investigated the association between SCORE and the 2007 ESH-ESC blood pressure categories and explored achievements of blood pressure goals considering global risk. In 2001–2005, a random sample of inhabitants aged 30–74 years in southwestern Sweden was invited to a survey of cardiovascular risk factors. The study enrolled 2816 participants (participation rate 76%). Blood pressure was categorized according to the 2007 ESH-ESC guidelines. Global risk of 10-year CVD death was estimated using the Swedish SCORE chart also accounting for additional risk from diabetes (SCORE-DM). SCORE-DM increased in both sexes from optimal blood pressure to manifest hypertension but did not differ between the normal blood pressure categories. However, SCORE-DM became significantly higher among those with temporarily high blood pressure (men 3.3 SD (1.7), women 1.1 (1.8)) and hypertension (3.6 (2.0), 2.0 (2.0)), compared to optimal blood pressure (1.6 (2.9), 0.6 (1.9)). In the presence of both hypertension and diabetes, high-risk subjects dominated (men 76%, women 61%), and correspondingly a major proportion of patients with known hypertension were at high risk at a blood pressure ≥160/100 mm Hg. These findings have strong implications on blood pressure evaluation in clinical practice and support the use of SCORE to evaluate global risk

High Blood Pressure - Determinants and Risks

Aim: The overall aim of this thesis was to study determinants and risks associated with increasing blood pressure categories based on a combination of systolic and diastolic blood pressure ranging from optimal blood pressure to manifest hypertension. Emphasis was placed on the importance of focusing on modifiable lifestyle factors and assessment of global risk. The ultimate aim was to identify targets for treatment and prevention. We set out to: 1) study the prevalence and control of hypertension in a representative Swedish population; 2) investigate the association between global risk (SCORE) and ESH/ESC blood pressure categories; 3) study the extent to which physiological factors and lifestyle factors such as physical activity, smoking and alcohol consumption contribute to higher blood pressure levels; 4) investigate the risk of cardiovascular disease associated with different blood pressure categories. Methods: A random sample of residents aged 30-74 years in the municipalities of Vara and Skövde, southwestern Sweden, was surveyed for cardiovascular risk factors in 2002-2005, and 2816 individuals were enrolled (76%). Participants provided detailed information about their medical history and current medication, and completed a questionnaire about lifestyle. Blood pressure was categorized according to the 2007 ESH/ESC recommendations based on a combination of systolic and diastolic blood pressure ranging from optimal blood pressure to manifest hypertension. Information about fatal and non-fatal cardiovascular events was collected from national registers from baseline until end of 2011, and global risk was estimated using the Swedish SCORE chart. Results: In paper I, the prevalence of hypertension in the age group 30-75 years was 20%. A “rule of thirds” emerged, as 1/3 of the participants were not previously known, 1/3 were treated but not controlled, and only 1/3 were treated and controlled. The largest proportion of high global risk was seen in subjects with both hypertension and diabetes (men 76%, women 61%), and a major proportion of patients with known hypertension with a blood pressure ≥160/100mmHg were also at a high global risk (paper II). However, a large proportion of patients with mild hypertension had a low risk according to SCORE (paper II). In paper III, age, insulin resistance, BMI, and CRP showed strong age- adjusted associations with increasing blood pressure categories in both men and women (p values <0.001). In women, lipids (p<0.001), education (p=0.009), physical activity (p=0.038), and alcohol consumption (p=0.002, inverse association) were also associated with blood pressure levels, whereas the same was not seen in men. In multivariate analyses, age, insulin resistance, BMI (both sexes), and alcohol consumption (females) remained significantly associated with blood pressure. In paper IV, distinct associations between blood pressure and risk of cardiovascular disease in both sexes were revealed already at levels from 120/80 mm Hg. Compared to those with optimal blood pressure, participants belonging to all other blood pressure categories had an increased cardiovascular risk, and the risks remained statistically significant even after adjustments for both lifestyle and physiological factors, except in the unstable category. Conclusions: The results of this thesis emphasize that blood pressure is associated with a continuously increased risk of cardiovascular morbidity in men and women, which can be seen already at levels from 120/80 mm Hg. Patients with blood pressure above these levels should thus be identified and advised on lifestyle changes to prevent progression to manifest hypertension as well as future cardiovascular disease. Screening to increase awareness, assessment of global risk, and improvements in the implementation of expert guidelines in clinical practice, including pharmacological treatment when indicated, are important steps to achieve this. It is also vital to emphasize population-based prevention, e.g. within the educational system, to also target normotensive individuals

Influence of social characteristics on use of paediatric emergency care in Sweden - A questionnaire based study

Background: Parental social characteristics influence the use of emergency departments (ED) in the USA, but less is known about paediatric ED care-seeking in countries with national health insurance. This prospective study was designed to evaluate associations between parental care-seeking and social characteristics, with emphasis on impact of non-native origin, at a paediatric ED in Sweden, a European country providing paediatric healthcare free of charge. Methods: Parents attending a paediatric ED at a large urban university hospital filled out a questionnaire on social characteristics and reasons for care-seeking. Information on patient characteristics and initial management was obtained from ED registers and patient records. Paediatric ED physicians assessed the medical appropriateness of each patient visit triaged for ED care. Results: In total, 962 patient visits were included. Telephone healthline service before the paediatric ED visit was less often used by non-native parents (63/345 vs. 249/544, p < 0.001). Low-aquity visits, triaged away from the ED, were more common among non-native parents (80/368 vs. 67/555, OR = 1.66; p = 0.018), and among those reporting lower abilities in the Swedish language (23/82 vs. 120/837, OR = 2.66; p = 0.003). Children of non-native parents were more often assessed by physicians not to require ED care (122/335 vs. 261/512, OR = 0.70; p = 0.028). Conclusions: This study confirms more direct and less urgent use of paediatric ED care by parents of non-native origin or with limited abilities in the Swedish language, proposing that parental social characteristics influence paediatric ED care-seeking, also in a country with healthcare free of charge, and that specific needs of these groups should be better met by prehospital medical services

Adjacent Primary Care May Reduce Less Urgent Pediatric Emergency Department Visits

Aims: Pediatric emergency department (ED) overcrowding is a challenge. This study was designed to evaluate if a hospital-integrated primary care unit (HPCU) reduces less urgent visits at a pediatric ED. Methods: This retrospective cross-sectional study was carried out at a university hospital in Sweden, where the HPCU, open outside office hours, had been integrated next to the ED. Children seeking ED care during 4-week high- and low-load study periods before (2012) and after (2015) implementation of the HPCU were included. Information on patient characteristics, ED management, and length of ED stay was obtained from hospital data registers. Results: In total, 3216 and 3074 ED patient visits were recorded in 2012 and 2015, respectively. During opening hours of the HPCU, the proportions of pediatric ED visits (28% lower; P <.001), visits in the lowest triage group (36% lower; P <.001), patients presenting with fever (P =.001) or ear pain (P <.001), and nonadmitted ED patients (P =.033), were significantly lower in 2015 than in 2012, whereas the proportion of infants ≤3 months was higher in 2015 (P <.001). Conclusions: By enabling adjacent management of less urgent pediatric patients at adequate lower levels of medical care, implementation of a HPCU outside office hours may contribute to fewer and more appropriate pediatric ED visits

Prevalence, awareness, treatment, and control of hypertension: Rule of thirds in the Skaraborg project

Objective. To describe the prevalence, awareness, and control of hypertension in a Swedish population during the early 2000s to address implications for care and prevention. Design. A cross-sectional population survey. Setting. Primary health care in Skaraborg, a rural part of western Sweden. Subjects. Participants (n = 2816) in a population survey of a random sample of men and women between 30 and 75 years of age in the municipalities of Vara (81% participation rate) and Skovde (70%), in western Sweden during 2001-2005. Main outcome measures. Anthropometric measures, blood pressure, leisure-time physical activity, current smoking, fasting glucose, and cholesterol. Hypertension was defined as ongoing treatment for hypertension, or three consecutive blood pressure readings >= 140 systolic and/or >= 90 mmHg diastolic. Hypertension was considered controlled when the blood pressure was < 140/90 mm Hg (both). Results. The prevalence of hypertension was 20% in both men and women with a steep increase by age. Among hypertensive subjects, 33% were unaware, 36% aware but uncontrolled, and 31% aware and controlled, with no statistically significant differences between men and women. Patients with diabetes had a higher awareness (87% vs. 64%, p < 0.001), but the same control rate (56% vs. 44%, p = 0.133), when compared with those without diabetes. Conclusion. A large proportion of subjects with hypertension are still unaware of their condition, or aware but not controlled. It is important to emphasize population-based prevention to reduce the prevalence of hypertension, to perform screening to increase awareness, and to improve implementation of expert guidelines in clinical practice to improve control

The 10-year incidence of hypertension across blood pressure categories in a population-based cohort in southwestern Sweden

Background: To explore the determinants of incident hypertension, and especially the impact of baseline blood pressure categories, in a representative Swedish population. Methods: A 10-year longitudinal study of residents aged 30–74. Blood pressures were measured and categorized according to ESH guidelines with optimal blood pressure < 120/80 mmHg, normal 120–129/80–84 mmHg, and high normal 130–139/85–89 mmHg. Incident hypertension was defined as ongoing treatment or three consecutive blood pressure readings ≥ 140/ ≥ 90 mmHg (one or both) at follow-up, while those with ≥ 140 and/or ≥ 90 mmHg at only one or two visits were labelled as unstable. After excluding subjects with hypertension, ongoing blood pressure lowering medication or a previous CVD event at baseline, 1099 remained for further analyses. Results: Sixteen (2.6%) subjects with optimal baseline blood pressure had hypertension at follow up. Corresponding numbers for subjects with normal, high normal and unstable blood pressure were 55 (19.4%), 50 (39.1%) and 46 (74.2%), respectively. Compared with subjects in optimal group those in normal, high normal and unstable blood pressure categories had significantly higher risk to develop manifest hypertension with odds ratios OR and (95% CI) of 7.04 (3.89–12.7), 17.1 (8.88–33.0) and 84.2 (37.4–190), respectively, with adjustment for age, BMI and family history for hypertension. The progression to hypertension was also independently predicted by BMI (p < 0.001), however, not by age. Conclusions: Subjects with high normal or unstable blood pressure should be identified in clinical practice, evaluated for global hypertension risk and offered personalized advice on lifestyle modification for early prevention of manifest hypertension and cardiovascular disease

Influenza virus NS1 protein interacts with the cellular 30 kDa subunit of CPSF and inhibits 3'end formation of cellular pre-mRNAs

Inhibition of the nuclear export of poly(A)-containing mRNAs caused by the influenza A virus NS1 protein requires its effector domain. Here, we demonstrate that the NS1 effector domain functionally interacts with the cellular 30 kDa subunit of CPSF, an essential component of the 3' end processing machinery of cellular pre-mRNAs. In influenza virus-infected cells, the NS1 protein is physically associated with CPSF 30 kDa. Binding of the NS1 protein to the 30 kDa protein in vitro prevents CPSF binding to the RNA substrate and inhibits 3' end cleavage and polyadenylation of host pre-mRNAs. The NS1 protein also inhibits 3' end processing in vivo, and the uncleaved pre-mRNA remains in the nucleus. Via this novel regulation of pre-mRNA 3' end processing, the NS1 protein selectively inhibits the nuclear export of cellular, and not viral, mRNAs