Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current ...hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.
To evaluate the prevalence of synovitis in painful medial tibiofemoral knee osteoarthritis (OA) and to evaluate correlation between synovitis and the structural severity and progression of ...tibiofemoral cartilage damage.
Study: multicenter, longitudinal, 1-year duration.
Patients: primary painful knee OA (ACR criteria) of the medial tibiofemoral compartment, with pain of the signal knee on at least 30 days in the past 2 months, medial joint space width ≥2
mm, at least 10% of one cartilage surface of the medial compartment affected by superficial fibrillation or worse at baseline arthroscopy.
Arthroscopic parameters: knee arthroscopy under local anesthesia was performed and videorecorded at entry and after 1 year. Medial chondropathy was scored by using Société Française d'Arthroscopie (SFA) score (0–100) and reader's overall assessment (VAS score, 100
mm). Progression of medial chondropathy was defined by a change in SFA and VAS scores over 4.5 and 8.0
mm after 1 year, respectively. Medial perimeniscal synovium was scored as normal (few translucent and slender villi, fine vascular network), reactive (proliferation of opaque villi), or inflammatory (hypervascularization and/or proliferation of hypertrophic and hyperemic villi). Medial chondropathy and synovitis were scored by a single reader blind to chronology of paired videotapes.
Four hundred and twenty-two patients were enrolled (mean age: 61 years, females: 59%, body mass index: 31, mean disease duration: 4 years) and completed the 1-year study. Synovial abnormalities were present in 50% of the patients with reactive and inflammatory aspects in 29% and 21% of the patients, respectively. Patients with a reactive or inflammatory medial synovium had a more severe medial chondropathy. The worsening in medial chondropathy after 1 year was statistically more severe in the group of patients with an inflammatory perimeniscal synovial membrane at baseline compared to patients with normal and reactive aspects, with no difference between these two latter groups. The odds ratio for progression in VAS score after 1 year was 3.11 (95% CI 1.07, 5.69) for patients with inflammatory synovium at baseline compared to patients with normal synovium.
This study suggests that abnormalities of the medial perimeniscal synovium are a common feature of painful medial knee OA, associated with more severe medial chondropathy. It also suggests that an inflammatory aspect of the medial perimeniscal synovium could be considered as a predictive factor of subsequent increased degradation of medial chondropathy.
Cardiovascular events occur most frequently in the morning hours. We prospectively studied the association between the morning blood pressure (BP) surge and stroke in elderly hypertensives.
We ...studied stroke prognosis in 519 older hypertensives in whom ambulatory BP monitoring was performed and silent cerebral infarct was assessed by brain MRI and who were followed up prospectively. The morning BP surge (MS) was calculated as follows: mean systolic BP during the 2 hours after awakening minus mean systolic BP during the 1 hour that included the lowest sleep BP. During an average duration of 41 months (range 1 to 68 months), 44 stroke events occurred. When the patients were divided into 2 groups according to MS, those in the top decile (MS group; MS > or =55 mm Hg, n=53) had a higher baseline prevalence of multiple infarcts (57% versus 33%, P=0.001) and a higher stroke incidence (19% versus 7.3%, P=0.004) during the follow-up period than the others (non-MS group; MS <55 mm Hg, n=466). After they were matched for age and 24-hour BP, the relative risk of the MS group versus the non-MS group remained significant (relative risk=2.7, P=0.04). The MS was associated with stroke events independently of 24-hour BP, nocturnal BP dipping status, and baseline prevalence of silent infarct (P=0.008).
In older hypertensives, a higher morning BP surge is associated with stroke risk independently of ambulatory BP, nocturnal BP falls, and silent infarct. Reduction of the MS could thus be a new therapeutic target for preventing target organ damage and subsequent cardiovascular events in hypertensive patients.
Assessment of distal radioulnar joint instability is clinically difficult and subjective. The distal radioulnar joint is postulated to ‘tighten’ in ulnar/radial deviation and pronation/supination. ...Using a rig, we measured mean distal radioulnar joint translation in neutral forearm rotation and neutral wrist radial and ulnar deviation, as well as extremes of wrist radial and ulnar deviation and forearm rotation. We tested the rig on ten cadaver forearms to validate the measurements we made. We tested 50 normal adults and 50 patients with clinical distal radioulnar joint instability. Distal radioulnar joint stability in men and women and on contralateral sides were comparable. Distal radioulnar joint translation decreased significantly with wrist radial and ulnar deviation and forearm pronation and supination, matching clinical practice and further validating the rig. The data in normal patients is comparable with previous computed tomography-based studies. Translation in all positions was statistically increased within the clinical instability group and did not cross-over with the normal ranges. Distal radioulnar joint translation is a physically measurable phenomenon. Our device appears to be a valid test of distal radioulnar joint translation, establishing normal data in vivo.
Level of Evidence: III
Background Depression has been found to predict the incidence of hypertension and other adverse cardiovascular events in prospective studies. Insomnia and short sleep duration, which are typical ...symptoms of depression, have also been shown to increase the risk for hypertension incidence. Insomnia is associated with increased activation of the hypothalamic–pituitary–adrenal axis, and short sleep duration raises average 24-h blood pressure, which over time could lead to structural adaptations that gradually reset the entire cardiovascular system to operate at an elevated pressure equilibrium. No previous published population studies have examined whether insomnia and sleep duration mediate the relationship between depression and hypertension incidence. Methods We conducted multivariate longitudinal (1982–1992) analyses stratified by age of the First National Health and Nutrition Examination Survey (NHANES I) (n = 4,913) using Cox proportional hazards models. Results Middle-aged subjects who suffered from depression at baseline were 44% more likely to be diagnosed with hypertension over the follow-up period after controlling for covariates (hazard ratio (HR) = 1.44, 95% confidence interval (CI) 1.15–1.80). Both short sleep duration and insomnia were also significantly associated with hypertension incidence. Consistent with insomnia and sleep duration acting as mediators of the relationship between depression and hypertension incidence, the inclusion of these variables in the multivariate models appreciably attenuated the association (HR = 1.27, 95%CI 1.00–1.61). Depression, sleep duration, and insomnia were not significantly associated with hypertension incidence in elderly subjects. Conclusions These results suggest the hypothesis that treatment of sleep problems in middle-aged individuals suffering from depression could reduce their risk for developing hypertension, and its vascular and cardiac complications.
BACKGROUND
African Americans have higher rates of nocturnal hypertension and less nocturnal blood pressure (BP) dipping compared with whites. Although nocturnal hypertension is associated with ...increased cardiovascular morbidity and mortality, its clinical significance among those with normal daytime BP is unclear. This paper reports the prevalence and correlates of isolated nocturnal hypertension (INH) in a population-based cohort of African Americans enrolled in the Jackson Heart Study (JHS).
METHODS
The study sample included 425 untreated, normotensive and hypertensive JHS participants who underwent 24-hour ambulatory BP monitoring (ABPM), echocardiography, and 24-hour urine collection. Multiple logistic regression and 1-way analysis of variance models were used to test the hypothesis that those with INH have worse target organ damage reflected by greater left ventricular (LV) mass and proteinuria compared with normotensive participants.
RESULTS
Based on 24-hour ABP profiles, 19.1% of participants had INH. In age and sex-adjusted models, participants with INH had greater LV mass compared with those who were normotensive (P = 0.02), as well as about 3 times the odds of LV hypertrophy and proteinuria (Ps < 0.10). However, multivariable adjustment reduced the magnitude and statistical significance of each of these differences.
CONCLUSIONS
INH was associated with increased LV mass compared with normo tension in a population-based cohort of African Americans enrolled in the JHS. There were trends toward a greater likelihood of LV hyper trophy and proteinuria among participants with INH vs. those who were normotensive. The clinical significance of the noted target organ damage should be explored in this population.
In the past 30 years or so, the introduction of 24-h ambulatory blood pressure monitoring (ABPM) has enabled a more comprehensive estimate of a patient's true blood pressure (BP) and its changes. ...Although this tool has been used in the general population for the diagnosis of white coat hypertension, its role in the clinical management of patients with chronic and end-stage kidney disease is less well defined. In patients with kidney disease, routine clinic and dialysis center BP measurements may be poor indicators of BP control. Loss of the normal nocturnal decline in BP is also common. Moreover, there is increasing evidence that this loss, which ABPM alone can detect, is associated with poor renal and cardiovascular outcomes. To slow the progression of renal disease and lessen cardiovascular morbidity and mortality in patients with kidney disease, tight BP control is needed. However, the traditional methods of measuring BP intermittently in the medical setting may fail to provide an accurate picture of BP load. Ambulatory or some form of home BP monitoring should be more widely adopted in patients with chronic and end-stage renal disease.
Associations between sleep-disordered breathing and cardiovascular disease (CVD) may be mediated by higher cardiovascular risk factor levels in those with sleep-disordered breathing. The authors ...examined these relations in the Sleep Heart Health Study, a multiethnic cohort of 6,440 men and women over age 40 years conducted from October 1995 to February 1998 and characterized by home polysomnography. In 4,991 participants who were free of self-reported CVD at the time of the sleep study, moderate levels of sleep-disordered breathing were common, with a median Respiratory Disturbance Index (RDI) of 4.0 (interquartile range, 1.25-10.7). The level of RDI was associated cross-sectionally with age, body mass index, waist-to-hip ratio, hypertension, diabetes, and lipid levels. These relations were more pronounced in those under age 65 years than in those over age 65. Women under age 65 years with RDI in the higher quartiles were more obese than men with similar RDI. Although the pattern of associations was consistent with greater obesity in those with higher RDI, higher body mass index did not explain all of these associations. If sleep-disordered breathing is shown in future follow-up to increase the risk for incident CVD events, part of the risk is likely to be due to the higher cardiovascular risk factors in those with higher RDI.
Objective: To assess the effectiveness of oral vanadium supplementation for glycaemic control in type 2 diabetes by conducting a systematic review of the literature. Design and Methods: Eligible ...studies were identified by searching 14 databases using standardized terms. Experts, study authors and manufacturers were also contacted. Hand-searching was not undertaken. Selection criteria for inclusion in the review were controlled human trials of vanadium vs. placebo in adults with type 2 diabetes of minimum 2 months duration, and a minimum of 10 subjects per arm. Data extraction, assessment of study quality and outcome analysis were undertaken by two independent reviewers. Results: One hundred and fifty one studies were found but none met the inclusion criteria. We proceeded to summarize the state of existing evidence and plan for a future clinical trial by applying revised, less restrictive criteria to our search, for clinical trials of 30–150 mg daily oral vanadium supplementation in diabetic humans. Only five were identified. These demonstrated significant treatment-effects, but due to poor study quality, must be interpreted with caution. Treatment with vanadium often results in gastrointestinal side-effects. Conclusion: There is no rigorous evidence that oral vanadium supplementation improves glycaemic control in type 2 diabetes. The routine use of vanadium for this purpose cannot be recommended. A large-scale randomized controlled trial is needed to address this clinical question.
The high operating pressures and distances of deep water tiebacks increase the likelihood of hydrate blockage during transient operations such as shut-in and restart. In many cases, complete hydrate ...avoidance through chemical management may become cost prohibitive, particularly later in the field’s life. However, a subclass of crude oils has been observed in which hydrate blockages do not form during restart, rendering active hydrate prevention unnecessary. Over the past 20 years, limited information has been reported about the chemical or physical mechanisms that enable this plug-resistive behavior. This study presents an extensive and systematic method of characterizing whether an oil may naturally resist hydrate plug formation, including (i) chemical and physical property analysis, (ii) water-in-oil emulsion behavior, and (iii) the effect of the oil on hydrate blockage formation mechanics. This last set of experiments utilizes both a high-pressure rheometer and a sapphire autoclave to allow direct observation of hydrate aggregation and deposition, combined with resistance-to-flow measurements. The effect of shut-in and restart on the oil’s plugging tendency is also studied in these experiments. The method was tested with seven petroleum fluids, some of which naturally resisted plugging-type behavior even at hydrate volume fractions up to 50%. Most of the fluids presented in this study did not form stable water-in-oil emulsions but did form stable, nonagglomerating hydrate-in-oil dispersions. The oils suppress hydrate formation rates, and their resistance-to-flow does not increase significantly even when the amount of hydrate present would normally result in a plug.
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