Effect of candesartan cilexetil on diabetic and non-diabetic hypertensive patients: meta-analysis of five randomized double-blind clinical trials

Objective

To study the effect of candesartan cilexetil (CC) in the management of blood pressure (BP) in diabetic and non-diabetic hypertensive patients.

Methods

A selection of five randomized double-blind clinical trials in which patients were treated for hypertension with CC was analyzed. All of these were similar in design: i) a 4-week placebo run-in period, ii) a 4-to 6-week period (V1) with CC 8 mg once daily (od), after which the dosage was doubled if BP was not normalized (BP >140/90 or BP >130/80 mmHg in diabetes), and iii) a 4- to 6-week period (V2) with CC 8 or 16 mg od. Efficacy was measured at V1 and V2.

Results

702 patients were screened. The population consisted of 397 males (56.6%) with a mean age of 60 ± 11 years, with 153 diabetic (21.8%) and 549 non-diabetic (78.2%) patients. At baseline, mean BP values were 160/94/65 mmHg for SPB, DBP, and pulse pressure (PP) respectively, with differences between diabetic and non-diabetic patients. SBP, DBP, and PP values showed a significant reduction at V1 (p < 0.001) and V2 (p < 0.001) compared with baseline for all hypertensive patients. Mean changes at V2 in SBP and PP values were higher in diabetic than non-diabetic patients (p < 0.001), and to a lesser degree on DBP values (p = 0.034).

Conclusions

CC was effective in lowering BP in diabetic and non-diabetic hypertensive patients. CC is a promising therapy to manage hypertensive diabetic patients, as demonstrated by the significant BP reduction.

Short abstract

The effect of candesartan cilexetil (CC) on controlling blood pressure (BP) in hypertensive diabetic and non-diabetic patients was analyzed. Five randomized double-blind trials were pooled treating hypertension by CC (n = 702), including 153 diabetic (21.8%) and 549 non-diabetic (78.2%) patients. After treatment with CC (8–16 mg), significant reductions in SBP, DBP, and pulse pressure (PP) values were observed after 4–6 weeks (p < 0.001) and after 8–12 weeks (p < 0.001) compared with baseline for all hypertensive patients. Mean BP reductions after 8–12 weeks were higher in diabetic patients than non-diabetic (p < 0.001). CC is a promising therapy to treat hypertensive patients, both diabetic and non-diabetic.     

Ambulatory blood pressure in hypertensive patients with left ventricular hypertrophy: efficacy of first-line combination perindopril/indapamide therapy

Background

Ambulatory blood pressure (BP) is more sensitive than office BP and is highly correlated with the left ventricular mass (LVM) of hypertensive patients with left ventricular hypertrophy (LVH).

Methods

In this prospectively designed ancillary study of the PICXEL trial, the effects of first-line combination perindopril/indapamide on ambulatory BP were compared with those of monotherapy with enalapril in 127 patients. Hypertensive patients with LVH received once daily either perindopril 2 mg/indapamide 0.625 mg (n = 65) or enalapril 10 mg (n = 62) for 52 weeks. Dose adjustments were allowed for uncontrolled BP. Twenty-four-hour ambulatory BP and echocardiographic parameters were measured at baseline, week 24, and week 52.

Results

At study end, both treatments significantly improved ambulatory BP compared with baseline (p ≤ 0.01). Perindopril/indapamide treatment reduced 24-hour and daytime systolic BP (SBP) and pulse pressure (PP) significantly more than enalapril treatment (p < 0.01). No significant between-group differences were noted for diastolic BP (DBP) or for night-time measurements. Trough/peak ratios were higher with perindopril/indapamide than with enalapril (88.5 vs 65.8 for SBP and 86.7 vs 63.9 for DBP, respectively). The global smoothness index was higher with perindopril/indapamide than with enalapril (6.6 vs 5.2 for SBP and 5.6 vs 4.9 for DBP, respectively). With perindopril/indapamide treatment, LVM index was significantly reduced (−9.1 g/m² from baseline; p vs baseline <0.001). More patients required dose increases with enalapril (87%) than with perindopril/indapamide (71%). No unusual safety elements were noted.

Conclusions

First-line perindopril/indapamide combination decreased ambulatory SBP and PP, and LVM more effectively than enalapril.     

Effect of sodium restriction on blood pressure of unstable or uncontrolled hypertensive patients in primary care

BACKGROUND/OBJECTIVES

The aims of the present study are: 1) to quantify sodium consumption of patients with unstable or uncontrolled hypertension, 2) to investigate if reduced sodium intake can lower BP in these patients, and 3), to assess the acceptability and feasibility of this approach.

SUBJECTS/METHODS

This study included 25 adults (age: 50+ years) with frequently elevated BP or patients with uncontrolled, uncomplicated hypertension despite drug treatment in a general practice setting. BP and salt intake (24h urinary excretion and food records) were measured at baseline and after a sodium reduced diet.

RESULTS

Mean (± SD) systolic (SBP) over diastolic (DBP) blood pressure (mmHg) at baseline was 150.7 (± 9.5)/84.149 (± 5.6). Mean urinary sodium excretion was 146 mmol/24h. A reduction of 28 mmol sodium excretion decreased SBP/DBP to 135.5 (± 13.0)/82.5 (± 12.8) (P < 0.001). After one month of no dietary advice, only in 48%, SBP was still ≤140 mmHg.

CONCLUSION

Assessment of sodium intake using food records, 24h urine collections and probing questions to identify use of sodium containing supplements or drugs are essential for tailored advice targeted at sodium intake reduction. The results of the present study indicate that reduced sodium intake can lower BP after 4 weeks in unstable or uncontrolled hypertensive patients.     

Validation of four automatic devices for self-measurement of blood pressure according to the International Protocol of the European Society of Hypertension

Background

Four electronic devices for self-measurement of brachial blood pressure (BP): the Omron M1 Plus, the Omron M6 Comfort, the Spengler KP7500 D, and the Microlife BP A100 Plus, were evaluated in four separate studies according to the International Protocol of the European Society of Hypertension (ESH).

Design

The International Validation Protocol is divided into 2 phases: the first phase is performed on 15 selected subjects (45 pairs of BP measurements); if the device passes this phase, 18 supplementary subjects are included (54 pairs of BP measurements) making a total number of 33 subjects (99 pairs of BP measurements) on which the final validation is performed.

Methods

The same methodology recommended by the ESH protocol was applied for the 4 studies. In each study and for each subject, 4 BP measurements were performed simultaneously by 2 trained observers using mercury sphygmomanometers alternately with 3 measurements by the tested device. The difference between the BP value given by the device and that obtained by the two observers (mean of the two observers) was calculated for each measure. The 99 pairs of BP differences were classified into 3 categories (≤5, ≤10, ≤15 mmHg). The number of differences in each category was compared with the number required by the International Protocol. An individual analysis was then done to determine for each subject the number of comparisons ≤5 mmHg. At least 22 of the 33 subjects should have 2 of their 3 comparisons ≤5 mmHg.

Results

All 4 tested devices passed the first and the second phase of the validation process. The average differences between the device and mercury sphygmomanometer readings were −1.4 ± 5.5 and −0.4 ± 4.8 mmHg for SBP and DBP respectively for the Omron M1 Plus device, −2.1 ± 7.4 and 0.1 ± 4.9 mmHg for SBP and DBP respectively for the Omron M6 Comfort device, −1.4 ± 8.6 and −0.1 ± 3.5 mmHg for SBP and DBP respectively for the Spengler KP7500 D device, and 1.6 ± 4.2 mmHg and 0.54 ± 2.8 mmHg for SBP and DBP respectively for the Microlife BP A100 Plus device. For all devices, readings differing by less than 5, 10, and 15 mmHg for SBP and DBP values fulfill the recommendation criteria of the International Protocol as well as the individual analysis.

Conclusions

Omron M1 Plus (HEM-4011C-E), Omron M6 Comfort (HEM 7000-E), Spengler KP7500 D, and Microlife BP A100 Plus devices fulfilled the validation recommendations of the International Protocol.     

Blood and Urine Cadmium,Blood Pressure,and Hypertension: A Systematic Review and Meta-analysis

Background

Cadmium exposure has been inconsistently related to blood pressure.

Objectives

We updated and reevaluated the evidence regarding the relationships of blood cadmium (BCd) and urine cadmium (UCd) with blood pressure (BP) and hypertension (HTN) in nonoccupationally exposed populations.

Data sources and extraction

We searched PubMed and Web of Science for articles on BCd or UCd and BP or HTN in nonoccupationally exposed populations and extracted information from studies that provided sufficient data on population, smoking status, exposure, outcomes, and design.

Data synthesis

Twelve articles met inclusion criteria: eight provided data adequate for comparison, and five reported enough data for meta-analysis. Individual studies reported significant positive associations between BCd and systolic BP (SBP) among nonsmoking women [β = 3.14 mmHg per 1 μg/L untransformed BCd; 95% confidence interval (CI), 0.14–6.14] and among premenopausal women (β = 4.83 mmHg per 1 nmol/L log-transformed BCd; 95% CI, 0.17–9.49), and between BCd and diastolic BP (DBP) among women (β = 1.78 mmHg comparing BCd in the 90th and 10th percentiles; 95% CI, 0.64–2.92) and among premenopausal women (β = 3.84 mmHg per 1 nmol/L log-transformed BCd; 95% CI, 0.86–6.82). Three meta-analyses, each of three studies, showed positive associations between BCd and SBP (p = 0.006) and DBP (p < 0.001) among women, with minimal heterogeneity (I² = 3%), and a significant inverse association between UCd and HTN among men and women, with substantial heterogeneity (I² = 80%).

Conclusion

Our results suggest a positive association between BCd and BP among women; the results, however, are inconclusive because of the limited number of representative population-based studies of never-smokers. Associations between UCd and HTN suggest inverse relationships, but inconsistent outcome definitions limit interpretation. We believe a longitudinal study is merited.     

Renal function, bisphenol A, and alkylphenols: results from the National Health and Nutrition Examination Survey (NHANES 2003-2006)

Background

Urinary excretion of bisphenol A (BPA) and alkylphenols (APs) was used as a biomarker in most previous studies, but no study has investigated whether urinary excretion of these environmental phenols differed by renal function.

Objective

We estimated the association between renal function and urinary excretion of BPA and APs.

Methods

Analyses were conducted using data from the National Health and Nutrition Examination Survey (NHANES) 2003–2006. Renal function was measured as estimated glomerular filtration rate (eGFR) calculated by the Modification of Diet in Renal Disease (MDRD) Study equation and by the newly developed Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Regression models were used to calculate geometric means of urinary BPA and APs excretion by eGFR category (≥ 90, 60–90, < 60 mL/min/m²) after adjusting for potential confounding factors.

Results

When we used the MDRD Study equation, participants without known renal disease (n = 2,573), 58.2% (n = 1,499) had mildly decreased renal function or undiagnosed chronic kidney disease. The adjusted geometric means for urinary BPA excretion decreased with decreasing levels of eGFR (p for trend = 0.04). The associations appeared primarily in females (p for trend = 0.03). Urinary triclosan excretion decreased with decreasing levels of eGFR (p for trend < 0.01) for both males and females, and the association primarily appeared in participants < 65 years of age. The association between BPA and eGFR was nonsignificant when we used the CKD-EPI equation.

Conclusions

Urinary excretion of triclosan, and possibly BPA, decreased with decreasing renal function. The associations might differ by age or sex. Further studies are necessary to replicate our results and understand the mechanism.     

Low Systolic Blood Pressure and Mortality From All Causes and Vascular Diseases Among Older Middle-aged Men: Korean Veterans Health Study

Objectives:

Recently, low systolic blood pressure (SBP) was found to be associated with an increased risk of death from vascular diseases in a rural elderly population in Korea. However, evidence on the association between low SBP and vascular diseases is scarce. The aim of this study was to prospectively examine the association between low SBP and mortality from all causes and vascular diseases in older middle-aged Korean men.

Methods:

From 2004 to 2010, 94 085 Korean Vietnam War veterans were followed-up for deaths. The adjusted hazard ratios (aHR) were calculated using the Cox proportional hazard model. A stratified analysis was conducted by age at enrollment. SBP was self-reported by a postal survey in 2004.

Results:

Among the participants aged 60 and older, the lowest SBP (<90 mmHg) category had an elevated aHR for mortality from all causes (aHR, 1.9; 95% confidence interval [CI], 1.2 to 3.1) and vascular diseases (International Classification of Disease, 10th revision, I00-I99; aHR, 3.2; 95% CI, 1.2 to 8.4) compared to those with an SBP of 100 to 119 mmHg. Those with an SBP below 80 mmHg (aHR, 4.5; 95% CI, 1.1 to 18.8) and those with an SBP of 80 to 89 mmHg (aHR, 3.1; 95% CI, 0.9 to 10.2) also had an increased risk of vascular mortality, compared to those with an SBP of 90 to 119 mmHg. This association was sustained when excluding the first two years of follow-up or preexisting vascular diseases. In men younger than 60 years, the association of low SBP was weaker than that in those aged 60 years or older.

Conclusions:

Our findings suggest that low SBP (<90 mmHg) may increase vascular mortality in Korean men aged 60 years or older.     

Leveraging Electronic Health Records to Develop Measurements for Processes of Care

Objectives

To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes.

Data Sources/Study Setting

EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties.

Study Design/Methods

Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension.

Principal Findings

Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbach''s alpha = 0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR = 1.13, p < .05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR = 1.02, p < .01) and LDL control (OR = 1.01, p < .01) among patients with diabetes, and better BP control (OR = 1.04, p < .01) among patients with hypertension.

Conclusions

The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.     

Randomized controlled trial of high concentration oxygen in suspected community-acquired pneumonia

Objective

To determine whether high concentration oxygen increases the PaCO₂ in the treatment of community-acquired pneumonia.

Design

Randomized controlled clinical trial in which patients received high concentration oxygen (8 L/min via medium concentration mask) or titrated oxygen (to achieve oxygen saturations between 93 and 95%) for 60 minutes. Transcutaneous CO₂ (PtCO₂) was measured at 0, 20, 40 and 60 minutes.

Setting

The Emergency Departments at Wellington, Hutt and Kenepuru Hospitals.

Participants

150 patients with suspected community-acquired pneumonia presenting to the Emergency Department. Patients with chronic obstructive pulmonary disease (COPD) or disorders associated with hypercapnic respiratory failure were excluded.

Main outcome variables

The primary outcome variable was the proportion of patients with a rise in PtCO₂ ≥4 mmHg at 60 minutes. Secondary outcome variables included the proportion of patients with a rise in PtCO₂ ≥8 mmHg at 60 minutes.

Results

The proportion of patients with a rise in PtCO₂ ≥4 mmHg at 60 minutes was greater in the high concentration oxygen group, 36/72 (50.0%) vs 11/75 (14.7%), relative risk (RR) 3.4 (95% CI 1.9 to 6.2), P < 0.001. The high concentration group had a greater proportion of patients with a rise in PtCO₂ ≥8 mmHg, 11/72 (15.3%) vs 2/75 (2.7%), RR 5.7 (95% CI 1.3 to 25.0), P = 0.007. Amongst the 74 patients with radiological confirmation of pneumonia, the high concentration group had a greater proportion with a rise in PtCO₂ ≥4 mmHg, 20/35 (57.1%) vs 5/39 (12.8%), RR 4.5 (95% CI 1.9 to 10.6) P < 0.001.

Conclusions

We conclude that high concentration oxygen therapy increases the PtCO₂ in patients presenting with suspected community-acquired pneumonia. This suggests that the potential increase in PaCO₂ with high concentration oxygen therapy is not limited to COPD, but may also occur in other respiratory disorders with abnormal gas exchange.     

Estrogen-induced improvement in coronary flow responses during atrial pacing in relation to endothelin-1 levels in postmenopausal women without coronary disease

Background

The cardioprotective role of hormonal replacement therapy remains in doubt, but interest is increasing in the vascular effects of estrogens especially in coronary circulation.

Methods

Coronary blood flow (CBF) was measured in 24 postmenopausal women (age 55 ± 3 years), whose coronary arteries appeared angiographically normal, during incremental atrial pacing (AP) before and 20 minutes after intracoronary administration of either 75 ng/mL 17-β estradiol (treated group, n = 18) or 0.9% saline (controls, n = 6).

Results

Before estrogen, no differences in the coronary vasomotor responses at AP between the two groups (p = NS) could be detected. After estrogen, in the treated group, at the peak of the second AP, the coronary artery diameter decreased by 0.17 mm (p < 0.005) while the CBF increased by 61 mL/min (p < 0.05). These changes differed significantly from those observed at the peak of first AP (p < 0.001 for both cases). In contrast, in the control group no such changes were observed. The endothelin-1 (ET-1) levels in the coronary sinus were significantly reduced after estrogen infusion, which was negatively correlated with the degree of coronary artery constriction (r = −0.40, p = 0.03) and positively correlated with the increase in CBF (r = 0.54, p = 0.01).

Conclusions

In postmenopausal women without coronary artery disease, the intracoronary estrogen infusion mediates a greater increase in CBF and is positively correlated with the reduction of the coronary sinus ET-1 levels at the peak of AP.     

Changes in body weight,blood pressure and selected metabolic biomarkers with an energy-restricted diet including twice daily sweet snacks and once daily sugar-free beverage

BACKGROUND/OBJECTIVES

The type of sweet snack incorporated into an energy-restricted diet (ERD) may produce differential effects on metabolic improvements associated with body weight (BW) loss. This study compared effects of incorporating either twice daily energy-controlled dark chocolate snacks plus once daily sugar-free cocoa beverage (DC) to non-chocolate snacks plus sugar-free non-cocoa beverage (NC) into an ERD on BW loss and metabolic outcomes.

MATERIALS/METHODS

In an 18-week randomized comparative trial, 60 overweight/obese premenopausal women were assigned to DC (n = 30) or NC group (n = 30). Dietary intake was measured at baseline and week 18, and BW, anthropometrics, blood pressure (BP) and serum glucose, insulin and lipid concentrations were measured at baseline, and weeks 6, 12 and 18. Data were analyzed using repeated measures ANOVA.

RESULTS

Using intention-to-treat analysis, women in DC and NC groups reduced energy intake (both P < 0.001) and lost 4.4 ± 0.6 kg and 5.0 ± 0.9 kg (both P < 0.001), respectively. Both groups lowered systolic and diastolic BP [DC = 2.7 (P < 0.05), 2.7 (P < 0.01); NC = 3.4 (P < 0.01), 4.2 (P < 0.01) mmHg, respectively]. Glucose and insulin concentrations decreased by 0.72 mmol/L (P < 0.001) and 13.20 pmol/L (P < 0.01) in DC group and by 0.83 mmol/L (P < 0.001) and 13.20 pmol/L (P < 0.01), respectively, in NC group. Total cholesterol increased in NC group (P < 0.05), with no significant lipid changes in DC group. There were no significant differences in biomarker outcomes between groups.

CONCLUSIONS

Overweight/obese premenopausal women following an 18-week ERD that included either DC or NC sweet snack and sugar-free beverage lost equivalent amounts of BW and improved BP measurements and glucose and insulin concentrations.     

Blood Pressure,Left Ventricular Geometry,and Systolic Function in Children Exposed to Inorganic Arsenic

Background:

Inorganic arsenic (iAs) is a ubiquitous element present in the groundwater worldwide. Cardiovascular effects related to iAs exposure have been studied extensively in adult populations. Few epidemiological studies have been focused on iAs exposure–related cardiovascular disease in children.

Objective:

In this study we investigated the association between iAs exposure, blood pressure (BP), and functional and anatomical echocardiographic parameters in children.

Methods:

A cross-sectional study of 161 children between 3 and 8 years was conducted in Central Mexico. The total concentration of arsenic (As) species in urine (U-tAs) was determined by hydride generation–cryotrapping–atomic absorption spectrometry and lifetime iAs exposure was estimated by multiplying As concentrations measured in drinking water by the duration of water consumption in years (LAsE). BP was measured by standard protocols, and M-mode echocardiographic parameters were determined by ultrasonography.

Results:

U-tAs concentration and LAsE were significantly associated with diastolic (DBP) and systolic blood pressure (SBP) in multivariable linear regression models: DBP and SBP were 0.013 (95% CI: 0.002, 0.024) and 0.021 (95% CI: 0.004, 0.037) mmHg higher in association with each 1-ng/mL increase in U-tAs (p < 0.025), respectively. Left ventricular mass (LVM) was significantly associated with LAsE [5.5 g higher (95% CI: 0.65, 10.26) in children with LAsE > 620 compared with < 382 μg/L-year; p = 0.03] in an adjusted multivariable model. The systolic function parameters left ventricular ejection fraction (EF) and shortening fraction were 3.67% (95% CI: –7.14, –0.20) and 3.41% (95% CI: –6.44, –0.37) lower, respectively, in children with U-tAs > 70 ng/mL compared with < 35 ng/mL.

Conclusion:

Early-life exposure to iAs was significantly associated with higher BP and LVM and with lower EF in our study population of Mexican children.

Citation:

Osorio-Yáñez C, Ayllon-Vergara JC, Arreola-Mendoza L, Aguilar-Madrid G, Hernández-Castellanos E, Sánchez-Peña LC, Del Razo LM. 2015. Blood pressure, left ventricular geometry, and systolic function in children exposed to inorganic arsenic. Environ Health Perspect 123:629–635; http://dx.doi.org/10.1289/ehp.1307327     

Garlic powder intake and cardiovascular risk factors: a meta-analysis of randomized controlled clinical trials

BACKGROUND/OBJECTIVES

Although preclinical studies suggest that garlic has potential preventive effects on cardiovascular disease (CVD) risk factors, clinical trials and reports from systematic reviews or meta-analyses present inconsistent results. The contradiction might be attributed to variations in the manufacturing process that can markedly influence the composition of garlic products. To investigate this issue further, we performed a meta-analysis of the effects of garlic powder on CVD risk factors.

MATERIALS/METHODS

We searched PubMed, Cochrane, Science Direct and EMBASE through May 2014. A random-effects meta-analysis was performed on 22 trials reporting total cholesterol (TC), 17 trials reporting LDL cholesterol (LDL-C), 18 trials reporting HDL cholesterol (HDL-C), 4 trials reporting fasting blood glucose (FBG), 9 trials reporting systolic blood pressure (SBP) and 10 trials reporting diastolic blood pressure (DBP).

RESULTS

The overall garlic powder intake significantly reduced blood TC and LDL-C by -0.41 mmol/L (95% confidence interval [CI], -0.69, -0.12) (-15.83 mg/dL [95% CI, -26.64, -4.63]) and -0.21 mmol/L (95% CI, -0.40, -0.03) (-8.11 mg/dL [95% CI, -15.44, -1.16]), respectively. The mean difference in the reduction of FBG levels was -0.96 mmol/L (95% CI, -1.91, -0.01) (-17.30 mg/dL [95% CI, -34.41, -0.18]). Evidence for SBP and DBP reduction in the garlic supplementation group was also demonstrated by decreases of -4.34 mmHg (95% CI, -8.38, -0.29) and -2.36 mmHg (95% CI, -4.56, -0.15), respectively.

CONCLUSIONS

This meta-analysis provides consistent evidence that garlic powder intake reduces the CVD risk factors of TC, LDL-C, FBG and BP.     

Ethnic differences in appointment-keeping and implications for the patient-centered medical home--findings from the Diabetes Study of Northern California (DISTANCE)

Objective

To examine ethnic differences in appointment-keeping in a managed care setting.

Data Sources/Study Setting

Kaiser Permanente Diabetes Study of Northern California (DISTANCE), 2005–2007, n = 12,957.

Study Design

Cohort study. Poor appointment-keeping (PAK) was defined as missing >1/3 of planned, primary care appointments. Poisson regression models were used to estimate ethnic-specific relative risks of PAK (adjusting for demographic, socio-economic, health status, and facility effects).

Data Collection/Extraction Methods

Administrative/electronic health records and survey responses.

Principal Findings

Poor appointment-keeping rates differed >2-fold across ethnicities: Latinos (12 percent), African Americans (10 percent), Filipinos (7 percent), Caucasians (6 percent), and Asians (5 percent), but also varied by medical center. Receiving >50 percent of outpatient care via same-day appointments was associated with a 4-fold greater PAK rate. PAK was associated with 20, 30, and 40 percent increased risk of elevated HbA1c (>7 percent), low-density lipoprotein (>100 mm/dl), and systolic blood pressure (>130 mmHg), respectively.

Conclusions

Latinos and African Americans were at highest risk of missing planned primary care appointments. PAK was associated with a greater reliance on same-day visits and substantively poorer clinical outcomes. These results have important implications for public health and health plan policy, as primary care rapidly expands toward open access to care supported by the patient-centered medical home model.     

Declines in physical performance by sex and age among nondisabled community-dwelling older Japanese during a 6-year period

Background

Few studies have examined whether declines over time in hand-grip strength (HGS) and fast walking speed (FWS) differ by sex and age among non-Western community-dwelling older adults. This study aimed to quantify changes in HGS and FWS over the 6-year period from 1994 to 2000 and examine whether these changes differed by sex and baseline age among older individuals in a Japanese community.

Methods

We conducted a community-based prospective cohort study. The participants were 513 nondisabled men and women aged 67 to 91 years at the 1994 survey. Independent variables regarding time since baseline, in addition to various time-dependent and time-independent covariates, were obtained in 1994, 1996, 1998, and 2000. The outcome variables were HGS and FWS assessed at each survey. All data on independent and dependent variables that were collected at each survey were simultaneously analyzed using a linear mixed-effects model.

Results

The linear mixed-effects model revealed significant declines in both HGS (−0.70 kg/year, P < 0.001) and FWS (−0.027 m/sec/year, P < 0.001) among nondisabled older participants who had analyzable data in any survey during the 6-year period. Sex was significantly associated with the rate of decline in HGS (P < 0.001), but not FWS (P = 0.211).

Conclusions

In this analysis of nondisabled older Japanese, a mixed-effects model confirmed a significant effect of aging on declines in HGS and FWS and showed that men had a significantly steeper decline in HGS than did women during a 6-year period.Key words: aged, aging, hand-grip strength, walking speed, longitudinal study     

Low-level lead exposure and elevations in blood pressure during pregnancy

Background

Lead exposure is associated with elevated blood pressure during pregnancy; however, the magnitude of this relationship at low exposure levels is unclear.

Objectives

Our goal was to determine the association between low-level lead exposure and blood pressure during late pregnancy.

Methods

We collected admission and maximum (based on systolic) blood pressures during labor and delivery among 285 women in Baltimore, Maryland. We measured umbilical cord blood lead using inductively coupled plasma mass spectrometry. Multivariable models were adjusted for age, race, median household income, parity, smoking during pregnancy, prepregnancy body mass index, and anemia. These models were used to calculate benchmark dose values.

Results

Geometric mean cord blood lead was 0.66 μg/dL (95% confidence interval, 0.61–0.70). Comparing blood pressure measurements between those in the highest and those in the lowest quartile of lead exposure, we observed a 6.87-mmHg (1.51–12.21 mmHg) increase in admission systolic blood pressure and a 4.40-mmHg (0.21–8.59 mmHg) increase in admission diastolic blood pressure after adjustment for confounders. Corresponding values for maximum blood pressure increase were 7.72 (1.83–13.60) and 8.33 (1.14–15.53) mmHg. Benchmark dose lower limit values for a 1-SD increase in blood pressure were < 2 μg/dL blood lead for all blood pressure end points.

Conclusions

A significant association between low-level lead exposures and elevations in maternal blood pressure during labor and delivery can be observed at umbilical blood lead levels < 2 μg/dL.     

Inverse association of des-acyl ghrelin with worksite blood pressure in overweight/obese male workers

Background

Job strain, defined as a combination of high job demands and low job control, has been reported to elevate blood pressure (BP) during work. Meanwhile, a recent experimental study showed that ghrelin blunted the BP response to such mental stress. In the present study, we examined the hypothesis that des-acyl ghrelin may have some beneficial effects on worksite BP through modulating the BP response to work-related mental stress, i.e., job strain.

Methods

Subjects were 34 overweight/obese male day-shift workers (mean age 41.7 ± 6.7 years). No subjects had received any anti-hypertensive medication. A 24-h ambulatory BP monitoring was recorded every 30 min on a regular working day. The average BP was calculated for Work BP, Morning BP, and Home BP. Job strain was assessed using the short version of the Japanese Job Content Questionnaire.

Results

Des-acyl ghrelin showed significant inverse correlations with almost all BPs except Morning SBP, Morning DBP, and Home DBP. In multiple regression analysis, des-acyl ghrelin inversely correlated with Work SBP after adjusting for confounding factors. Des-acyl ghrelin was also negatively associated with BP changes from Sleep to Morning, Sleep to Work, and Sleep to Home.

Conclusions

Des-acyl ghrelin was inversely associated with Worksite BP, suggesting a unique beneficial effect of des-acyl ghrelin on Worksite BP in overweight/obese male day-shift workers.     

Impact of a cash-for-work programme on food consumption and nutrition among women and children facing food insecurity in rural Bangladesh

Objective

To determine whether a cash-for-work programme during the annual food insecurity period in Bangladesh improved nutritional status in poor rural women and children.

Methods

The panel study involved a random sample of 895 households from over 50 000 enrolled in a cash-for-work programme between September and December 2007 and 921 similar control households. The height, weight and mid-upper arm circumference of one woman and child aged less than 5 years from each household were measured at baseline and at the end of the study (mean time: 10 weeks). Women reported 7-day household food expenditure and consumption on both occasions. Changes in parameters were compared between the two groups.

Findings

At baseline, no significant difference existed between the groups. By the study end, the difference in mean mid-upper arm circumference between women in the intervention and control groups had widened by 2.29 mm and the difference in mean weight, by 0.88 kg. Among children, the difference in means between the two groups had also widened in favour of the intervention group for: height (0.08 cm; P < 0.05), weight (0.22 kg; P < 0.001), mid-upper arm circumference (1.41 mm; P < 0.001) and z-scores for height-for-age (0.02; P < 0.001), weight-for-age (0.17; P < 0.001), weight-for-height (0.23; P < 0.001) and mid-upper arm circumference (0.12; P < 0.001). Intervention households spent more on food and consumed more protein-rich food at the end of the study.

Conclusion

The cash-for-work programme led to greater household food expenditure and consumption and women’s and children’s nutritional status improved.     

Compliance, clinical outcome, and quality of life of patients with stable angina pectoris receiving once-daily betaxolol versus twice daily metoprolol: a randomized controlled trial

Background

A randomized, controlled trial was conducted in an outpatient setting to examine the effect of beta-blocker dosing frequency on patient compliance, clinical outcome, and health-related quality of life in patients with stable angina pectoris.

Methods

One hundred and twelve beta-blockers-naive outpatients with stable angina pectoris were randomized to receive betaxolol, 20 mg once daily or metoprolol tartrate, 50 mg twice daily for 8 weeks. The principal outcome measure was overall compliance measured electronically, whereas secondary outcome measures were drug effectiveness and health-related quality of life.

Results

The overall compliance was 86.5 ± 21.3% in the betaxolol group versus 76.1 ± 26.3% in the metoprolol group (p < 0.01), and the correct number of doses was taken on 84.4 ± 21.6% and 64.0 ± 31.7% of treatment days, respectively (p < 0.0001). The percentage of missed doses was 14.5 ± 21.5% in the once-daily group and 24.8 ± 26.4% in the twice-daily group (p < 0.01). The percentage of doses taken in the correct time window (58.6% vs 42.0%, p = 0.01), correct interdose intervals (77.4% v 53.1%, p < 0.0001), and therapeutic coverage (85.6% vs 73.7%, p < 0.001) were significantly higher in the once-daily group. Both studied drugs had similar antianginal effectiveness. Health-related quality of life improved in both groups, but this increase was more pronounced in the betaxolol arm in some dimensions.

Conclusions

The study demonstrates that patient compliance with once-daily betaxolol is significantly better than with twice daily metoprolol. Similarly, this treatment provides better quality of life. These results demonstrate possible therapeutic advantages of once-daily over twice-daily beta-blockers in the treatment of stable angina pectoris.