Ambulatory blood pressure monitoring and prognosis in the management of essential hypertension

Over the past decade, several prospective outcome studies have demonstrated that ambulatory blood pressure measurements provide a better prediction of major cardiovascular events compared with clinic blood pressure measurements. This review summarizes the advantages of ambulatory blood pressure over clinic blood pressure to predict outcome in untreated and treated hypertensive subjects. Based on available evidence, an operational flow-chart in order to interpret results of ambulatory blood pressure for a better management of these subjects is suggested.     

Effects of alignment on interface pressure for transtibial amputee during walking

Purpose. To assess the mechanical behaviour at interface for unilateral transtibial amputees during walking when the prosthesis is misaligned, since studies examining interface pressure between residual limb and prosthetic socket have been restricted to unsupported stance and natural gait.

Method. One male subject with transtibial amputation volunteers for the study. Interface pressures over five sites are measured under three sagittal alignment settings. MP (mean peak interface pressure), TP₉₀₊ (time in which pressure exceeded 90% of peak pressure) and TPI₉₀₊ (time-pressure integral at the period of sustained sub-maximal load) are discussed for each alignment setting.

Results. Compared with optimal alignment, the trend of interface pressure, the mean peak pressure do not change much, but the duration of sub-maximal pressure changes remarkably, except that at the patellar tendon, and finally the TPI₉₀₊ changes considerably with different alignment settings.

Conclusions. The results offer the clinician and paramedical staff further insight in residual limb/socket interface mechanics in the transtibial amputation patients and provide potentially useful information for socket design and prosthesis fitting.     

Genital pyoderma gangrenosum: Report of two cases and published work review of Japanese cases

Pyoderma gangrenosum is an ulcerative skin disorder showing characteristic non‐infectious ulcers and affects the lower extremities in approximately 70% of cases. Pyoderma gangrenosum is commonly associated with systemic diseases such as inflammatory bowel disease, rheumatoid arthritis and hematological malignancies. Herein, we report two cases of Japanese patients diagnosed with genital pyoderma gangrenosum. Case 1 was a 74‐year‐old woman without associated systemic complications, whose skin lesion resembled a squamous cell carcinoma and was limited to the vulva. Case 2 is an 89‐year‐old man, who suffered from myelodysplastic syndrome and acute myeloid leukemia, and presented with penile and leg ulcers mimicking pressure sores. Both cases responded well to systemic steroids. We review 13 genital pyoderma gangrenosum cases (76.9% male; aged 30–89 years) from 1996 to 2012 in Japan, including 11 previously reported cases and the present study's two cases. Four of the 13 genital pyoderma gangrenosum cases had associated systemic diseases and their skin lesions spread to the extragenital areas. Eight of the remaining nine genitalia‐localized pyoderma gangrenosum cases had no associated systemic diseases. In conclusion, genital pyoderma gangrenosum is rare and may be misdiagnosed. It should therefore be considered in cases of refractory genital ulcers. In addition, genitalia‐localized pyoderma gangrenosum tends to be without systemic complications.     

Maternal controlling feeding behaviours and child eating in preschool‐aged children

Aim: This paper explored the relationship between maternal controlling feeding behaviours and child eating and weight in preschool‐aged children. Methods: Ninety mothers of 2‐ to 5‐year‐old children (M = 3.48, SD = 0.84, 54.4% males) completed self‐report measures assessing maternal controlling feeding behaviours, child eating patterns and weight. Results: Univariate analyses indicated that child food neophobia was associated with authoritarian feeding (r= 0.29), pressure to eat (r= 0.28) and restriction (r= 0.34). Child food pickiness was associated with authoritarian feeding (r= 0.35). No association was found between maternal feeding strategies and child weight. Multivariate regression analyses indicated that authoritarian feeding, restriction and pressure to eat were significantly associated with the variance in child food neophobia (adjusted R²= 12.6%) and pickiness (adjusted R²= 12.0%). Conclusions: The findings suggest that maternal control in feeding is associated with undesirable eating patterns in preschool‐aged children. Interventions targeting reduction in maternal controlling feeding may promote desirable eating patterns in preschool‐aged children.     

Insulin Resistance and Cardiovascular Drugs

Under certain circumstances the effect of insulin to promote glucose uptake in peripheral tissues is reduced because of a resistance to insulin action. This insulin resistance and the resulting hyperinsulinaemia are now recognised as common background factors that may be responsible for hypertension, hyperlipidaemia, decreased thrombolysis and also impaired glucose tolerance and diabetes. Hyperinsulinaemia has also been identified as an independent risk factor for coronary heart disease and promotes smooth muscle cell growth and plaque formation.

A series of studies have now demonstrated that treatment with selective beta-blockers as well as thiazide diuretics impair insulin sensitivity by 15–30% and causes a compensatory increase in insulin concentrations. Furthermore, lipoprotein concentrations are affected in an unfavourable way. This is in contrast to the drugs belonging to ACE-inhibitors, calcium-channel blockers and α₁-blocker classes that are either neutral or may have the opposite effects in these respects.     

Respiratory Variations in Arterial Blood Pressure and Heart Rate in Normotensive and Renal Hypertensive Dogs

Respiratory sinus arrhythmia (RSA), systolic and diastolic respiratory blood pressure waves (RBPWsyst, RBPWdiast), mean heart rate (HR), mean respiratory frequency (RF) and the heart beat to respiratory cycle ratio (HB/RC) were measured in 23 spontaneously breathing, normotensive or renal hypertensive dogs under light anaesthesia. No significant differences were found between conditions of normal and chronically elevated blood pressure. All these parameters were analyzed statistically by means of linear regression analysis and rank correlation coefficient (rs). A correlation was found to exist between RSA and mean systolic blood pressure (negative), RF (negative), RBPWsyst (positive), RBPWdiast (positive). RF correlated with both HB/RC (negative) and RBPWsyst (negative). A correlation was also seen between PA and both BPsyst (positive) and BPdiast (positive), BPsyst and BPdiast (positive) and between HR and RBPWdiast (negative); however, all the remaining, theoretically possible correlations were not significant. The results may be referred to resonance mechanisms in a common nervous oscillator system.     

Predictors of early vs. late permanent shunt insertion after aneurysmal subarachnoid hemorrhage

Objective: Numerous studies have identified different predictors for secondary hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH), although predictors regarding timing of the shunt operation have never been reported. Predictors for an early shunt, which was defined as a shunt operation performed ≤30 days after SAH onset, and for a late shunt, performed at >40 days, were investigated.

Methods: A total of 735 consecutive SAH patients admitted to our hospital between 2003 and 2014 who underwent surgery for ruptured aneurysms within five days of onset were retrospectively assessed.

Results: Secondary hydrocephalus developed in 225 patients, including 70 with an early shunt and 96 with a late shunt. Multivariate analysis showed that predictors for secondary hydrocephalus were age ≥70 years, World Federation of Neurosurgical Society (WFNS) grade IV-V, Fisher grade 3–4, intraventricular hemorrhage, anterior cerebral artery aneurysms, and external drainage for acute hydrocephalus (p < 0.05). In the early and late shunt groups, multivariate analysis indicated that early shunt was significantly associated with coil embolization, and late shunt was correlated with middle cerebral artery aneurysms and cerebral infarction due to vasospasm (p < 0.05).

Discussion: The difference in the predictors between the early and late shunts implied that the mechanisms of secondary hydrocephalus differed between the early and late shunt groups. Knowledge of the associated risk factors might help to predict the timing of the shunt operation for early rehabilitation planning in the future.     

Home blood pressure for the management of hypertension: will it become the new standard of practice?

Accurate identification of hypertension is crucial for the prevention of cardiovascular disease. Home blood pressure monitoring (HBPM) provides superior prediction of cardiovascular disease, compared with clinic pressures. HBPM can be a valuable resource for the effective treatment of hypertension, when combined with other modalities used to improve patient education, lifestyle enhancement, adherence to medication and reduction of unnecessary clinic visits. In some developed nations, more than half of households with a hypertensive patient have a device for HBPM. The use of HBPM by patients and the acceptance of HBPM measurements by providers is increasing. The long-term effectiveness of HBPM, combined with telemetry for disease prevention, is promising. More research is still needed to establish its full value. It is predicted that HBPM has definite potential for more effective strategies to control hypertension and reduce the need for on-site clinical care.     

Angiotensinogen mRNA and Pressor Reactions to Angiotensin in Brain Stem Areas of Spontaneously Hypertensive Rats

The role of angiotensin (ANG II) at the tissue level, particularly in the brain, remains imperfectly defined. We measured angiotensinogen (A°) mRNA in the brain stems, sensory and sympathetic ganglia, and blood vessels of Wistar-Kyoto (WKY) and stroke-prone spontaneously hypertensive rats (SHR-SP) by quantitative, liquid hybridization. We micro-injected ANG II and glutamate into the brain stems of these rats to gain insight into the functional significance of our findings. A° mRNA was found in the dorsolateral, dorsomedial, and ventrolateral pons, as well as in the dorsolateral, dorsomedial, and ventrolateral medulla of both strains. A° mRNA was 8–10 pg/μg total mRNA higher (p<0.05) in the dorsomedial medulla (nucleus tractus solitarii) in WKY and SHR-SP (28.27 ± 1.26 and 33.50 ± 1.42 pg/μg RNA respectively) than in the other areas. SHR-SP had higher values (27.22±1.77 vs. 21.53±0.57 pg/μg mRNA) than WKY (p<0.05) in the dorsolateral pons (locus coeruleus). A° mRNA was also identified in the optic nerves and chiasm, trigeminal and coeliac ganglia, arteries and veins. Injections of glutamate and ANG II into the dorsomedial, dorsolateral, and ventrolateral.     

Efficacy of a new Antihypertensive Agent (Indenolol) Assessed by Ambulatory Blood Pressure Monitoring

The effects of two-week treatment periods with indenolol (I) and metoprolol (M) were examined by 24-hour mean blood pressure (BP) monitoring in control conditions and during exercise stress test in 7 patients with essential hypertension, using the Oxford method. Both drugs induced a significant reduction in mean BP and heart rate (HR) as compared to pretreatment values (mean BP: from 1173 mmHg to 1064 after I, p < 0.05 and to 1023 after M, p < 0.01; HR: from 782 bpm to 662 after I, p < 0.01 and to 672 after M, p < 0.01). I and M induced a significant reduction in systolic and diastolic BP throughout the day and most of the night. During bicycle ergometer the basal and peak values of systolic and diastolic BP were significantly lower after both treatments as compared to the pretreatment values (both p < 0.01). Our data suggest that I once a day possesses a substantial and consistent antihypertensive action, effective over most of the 24 hours.