A questionnaire survey of general practitioners in Japan’s Kanagawa Prefecture for the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2014

To evaluate the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2014 (JSH2014) among Japanese general practitioners (GPs), we used a questionnaire survey with 209 GPs from the Kanagawa Physicians Society. Overall, 93.6% of GPs felt that the contents of the JSH2014 were useful. Based on the results showing that 81.8% of GPs instructed the measurement of blood pressure (BP) in the early morning at home to most patients, GP’s acceptance of home BP methods and their penetration among patients with hypertension were considerably high. Regarding the number of home BP measurements, percentages for “one time,” “two times,” “three times,” and “as many times as the patient decides,” were 20.2%, 44.9%, 12.2%, and 22.9%, respectively; as such, no consensus was reached. Overall, 80.6% of GPs instructed most patients on sodium restriction; however, the content and method of restriction varied. Furthermore, 14.7% collected spot urine to assess salt intake. Many GPs respected the JSH2014 and faithfully adopted the guidelines during medical care. However, GPs did not necessarily agree with all guidelines. GPs sometimes selected the appropriate method for the individual patients and careful observations of how the guidelines affect actual clinical practice may lead to better medical care.     

China’s international trade and air pollution in the United States

China is the world’s largest emitter of anthropogenic air pollutants, and measurable amounts of Chinese pollution are transported via the atmosphere to other countries, including the United States. However, a large fraction of Chinese emissions is due to manufacture of goods for foreign consumption. Here, we analyze the impacts of trade-related Chinese air pollutant emissions on the global atmospheric environment, linking an economic-emission analysis and atmospheric chemical transport modeling. We find that in 2006, 36% of anthropogenic sulfur dioxide, 27% of nitrogen oxides, 22% of carbon monoxide, and 17% of black carbon emitted in China were associated with production of goods for export. For each of these pollutants, about 21% of export-related Chinese emissions were attributed to China-to-US export. Atmospheric modeling shows that transport of the export-related Chinese pollution contributed 3–10% of annual mean surface sulfate concentrations and 0.5–1.5% of ozone over the western United States in 2006. This Chinese pollution also resulted in one extra day or more of noncompliance with the US ozone standard in 2006 over the Los Angeles area and many regions in the eastern United States. On a daily basis, the export-related Chinese pollution contributed, at a maximum, 12–24% of sulfate concentrations over the western United States. As the United States outsourced manufacturing to China, sulfate pollution in 2006 increased in the western United States but decreased in the eastern United States, reflecting the competing effect between enhanced transport of Chinese pollution and reduced US emissions. Our findings are relevant to international efforts to reduce transboundary air pollution.A key driver of the rapid economic growth in China over the past decade is the great expansion in the production of goods for export (1). Although growth has slowed since the global financial crisis, between 2000 and 2007 the volume of Chinese exports grew by 390% (2). As the Chinese economy has grown, the economic structure has also changed, transitioning from a net importer to a large net exporter of energy-intensive industrial products (2). The energy needed to support this economic growth and transformation has come from combustion of fossil fuels, primarily coal, which has contributed to a global increase in emissions of carbon dioxide (CO₂) (3, 4). At the same time, increased combustion of fossil fuels, relatively low combustion efficiency, and weak emission control measures have also led to drastic increases in air pollutants such as sulfur dioxide (SO₂), nitrogen oxides (NO_x), carbon monoxide (CO), black carbon (BC), and primary organic carbon (OC) (5–8). Indeed, fossil-fuel–intensive manufacturing, large manufacturing volume, and relatively weak emission controls have meant that China emits far more pollutants per unit of gross domestic product (GDP) than countries with more advanced industrial and emission control technologies (SI Appendix, Table S1). Per unit of GDP in 2006, China emitted 6–33 times as much air pollutants as the United States (Fig. 1 E–H). For these reasons, air quality has recently become a major focus of environmental policy in China (8).Open in a separate windowFig. 1.Air pollutants embodied in Chinese trade between 2000 and 2009. (A–D) Production-based emissions (thin lines), consumption-based emissions (thick lines), and their differences (i.e., Chinese EET associated with its trade with the rest of the world in purple shading, and EET associated with Sino-US trade alone in green shading). All Chinese emissions are calculated here, the US production-based emissions are taken from the National Emissions Inventory, and the US consumption-based emissions are derived based on production-based emissions and Sino-US trade-related emissions. Although China’s production-based emissions are growing rapidly, its EET are equivalent to substantial fractions of the production-based emissions. Similarly, the EET due to Sino-US trade are equivalent to large proportions of the production-based US emissions since 2006. (E–H) Emissions per GDP. Although China’s production-based emissions per unit GDP have been decreasing, its consumption-based emissions per unit GDP have decreased less significantly or have increased since 2008. (I–L) Emissions per capita. Per capita emissions are very different between the United States and China, and this disparity is increased when the consumption-based emissions are considered. For data sources, see SI Appendix, Table S1, footnote.In this study, the terms “export,” “import,” and “trade” all refer to transaction of goods between countries. The pollutants emitted in China due to its production of goods for foreign consumption are regarded as emissions embodied in export (EEE) of China (9, 10). The EEE is unique in that the associated goods are consumed outside of China, raising a question about the extent to which China and its export partners should be accountable for the emissions (10–12). The attribution depends on whether the emission accounting is based on production or on consumption. Production-based accounting considers all emissions physically produced in China to be Chinese emissions, including the EEE. Such accounting is used as default in current emission inventories such as the Emission Database for Global Atmospheric Research (13). By comparison, consumption-based accounting views all emissions associated with production of goods consumed by China to be China’s responsibility, no matter whether the production occurs in China or in other countries (9, 10). Thus, the consumption-based Chinese emissions exclude the EEE but include the emissions embodied in import of China (EEI, i.e., emissions in other countries due to production of goods for Chinese consumption). The numerical difference between production- and consumption-based emissions of China is the EEE less the EEI, the result of which is regarded as the emissions embodied in net trade (EET) of China (10). Similar emission analyses are applicable to other countries.Previous studies have quantified the substantial CO₂ emissions embodied in Chinese trade (10, 11). Thus, far, however, relatively little attention has been paid to trade-related emissions of short-lived air pollutants and especially the resulting impacts on the global atmospheric environment, except for an analysis done for local air quality of the Pearl River Delta (14). This is true despite the direct harm these pollutants do to human health (15–18), agriculture (19), ecosystems (20), and global climate (21, 22). And as scientific evidence of transport of Chinese air pollution across the Pacific Ocean has grown since the late 1990s (23–29), the United States and Canada have a special interest in reducing Chinese air pollution. In the case of CO₂, consumption-based accounting of emissions has been motivated by the argument—often made by developing countries—that consumers who benefit from a process should bear some responsibility for associated environmental damage (30). A similar accounting for emissions of air pollutants and consequent impacts on the global atmospheric environment may therefore be necessary to facilitate discussion of international collaborations on transboundary air pollution control (31).We quantify the emissions of SO₂, NO_x, CO, BC, and OC embodied in Chinese exports and imports between 2000 and 2009 using an economic input–output model constructed from economic and emission data. The model resolves trade between China and four countries/regions [the United States, the European Union (EU), Japan, and an aggregated region of all other countries] and 42 industry sectors, and allocates pollutant emissions to countries and industry sectors according to where goods are consumed. As part of our analysis, we also quantify the uncertainties in emission derivation using a Monte Carlo approach. We then simulate the effects of export-related Chinese emissions on air pollution in China and downwind regions, using the GEOS-Chem global chemical transport model. See SI Appendix for details of our analytic approach, data sources, and model simulations.     

Circumferential and focal radiofrequency ablation for the treatment of Barrett’s esophagus

This invited profile summarizes the technical aspects and clinical trial results related to the use of circumferential and focal radiofrequency ablation in the management algorithm for Barrett’s esophagus. What makes this relatively new endoscopic intervention unique is its promising safety and efficacy profile reported in published clinical trials. This technology appears to have overcome many of the limitations of prior endoscopic ablative modalities, and is thus garnering a role in the management of this disease state.     

Improving Heart Failure Therapeutics Development in the United States: The Heart Failure Collaboratory

The current heart failure clinical trial environment is strained by increasing complexity and cost, regulatory requirements, competing demands on stakeholders, implementation challenges, and decreasing patient and investigator participation. To begin the process of developing potentially effective strategies and tactics, stakeholders including patients; investigators; academic leaders; pharmaceutical and device industry representatives; society representatives; third-party payers; and government representatives from the U.S. Food and Drug Administration, National Institutes of Health, and Centers for Medicare and Medicaid Services convened in March of 2017. This paper summarizes the discussions, outlines current challenges and actionable opportunities, and makes targeted recommendations to achieve the goals of improving efficiency in clinical trials and speeding the development of effective heart failure therapies, including the formation of an organized Heart Failure Collaboratory.     

Specialized Care for Women: the Impact of Women’s Heart Centers

Purpose of the review

Cardiovascular disease (CVD) has been and remains the leading cause of mortality in women in the United States. For decades, more women died every year of CVD compared to men. Heart centers for women (HCW) are developed in response to the need for greater patient and physician awareness of CVD in women and to conduct sex-specific research in women. Today, many HCW provide multispecialty and focused areas of cardiovascular care for women. HCW provide their female patients with expertise over the many stages of a woman’s life. And HCW partner with national organizations to advance research and education through specialized and focused care for women. The purpose of this review is to review the historical development of heart centers for women and discuss the types of care they provide for women.

Recent findings

Mortality rates from cardiovascular disease in women are finally reaching the levels of men after decades of focus on awareness, prevention, and evidence-based guideline-directed care for women.

Summary

Heart centers for women have evolved to provide subspecialty and comprehensive care for women that includes education and research. Heart centers for women are partnering with many other disease-based and patient advocacy organizations to provide care for all women at all stages of life. Alarmingly, there has been increasing CVD mortality in both men and women recently.

     

What is the prevalence of resistant hypertension in the United States?

Purpose of review Resistant hypertension, defined as blood pressure uncontrolled on three, or controlled with at least four, antihypertensive agents (including a diuretic), is associated with higher risk of secondary hypertension, cardiovascular and renal events, and increased healthcare expenditures. Until recently, however, the prevalence of resistant hypertension in the United States (US) was based on clinical trial registries or pharmacy databases. Recent findings Recent analyses of National Health and Nutrition Examination Survey (NHANES) data, drawn from representative samples of the adult, noninstitutionalized, civilian population, have estimated the prevalence of resistant hypertension at 8.9 ± 0.6% of the US hypertensive population in 2003-2008. A time-sequence comparison of NHANES data from 1998 through 2008 suggests that, unlike hypertension, resistant hypertension is becoming more prevalent (e.g., 20.7% in 2005-2008), due to aging and increased obesity in the general population. Resistant hypertension was more frequent in people who were older, obese, male, African American or nonblack Hispanic. Summary In coming years, even if the prevalence of hypertension remains stable, resistant hypertension is likely to increase, especially as the proportion of treated hypertension increases. Because of increased use of healthcare resources, resistant hypertensive patients should be identified early, and greater efforts made to control their blood pressures.