Nephron endowment and blood pressure: What do we really know?

It has been hypothesized that a reduced number of nephrons at birth contributes to the development of essential hypertension. Nephron number in normal human kidneys has been shown to vary up to eightfold. Therefore, a significant proportion of the population appears to be at risk for developing hypertension. Furthermore, nephron deficits might explain why some racial groups have a higher incidence of hypertension and end-stage renal disease than others. Animal studies have demonstrated that maternal limitations in nutrient supply, both gross and nutrient-specific; exposure to elevated levels of hormones or toxins; and genetic factors can lead to permanent deficits in nephron number and, when examined, elevated blood pressure. In this review, maternal and genetic factors influencing nephron endowment and the implications of nephron deficit for hypertension and renal disease in humans are discussed.     

Why do some apheresis donors donate blood just once?

BACKGROUND AND OBJECTIVES: More knowledge about the reasons for non-return of blood donors (BD) would enable blood donation services (BDS) to improve the efficacy of recruitment and retention programmes. We interviewed returning (RBD) and non-returning apheresis BDs (NRBD) of our university hospital-based BDS. MATERIALS AND METHODS: A questionnaire was sent to 1218 individuals who passed the initial health check with no more than one subsequent blood donation. A similar questionnaire was answered by 235 randomly incoming RBDs. We asked for age, sex, profession, education level, motives to donate blood and, if applicable, reasons for non-return. These data were compared between NRBDs and RBDs and were analysed in relationship to the reasons for non-return. RESULTS: We received 267 answered questionnaires (21.9%). As 32 individuals indicated that they had been permanently deferred and 47 BDs had donated blood elsewhere, 188 NRBDs remained for further analysis. We found more women than men among NRBDs. Medical professions were less likely to return than students and trainees. Individuals motivated by personal experience, remuneration or a free health check were more likely to return than others. Whereas logistic reasons were of highest relevance for non-return in general, women indicated anxiety of blood donation as reason for non-return more often than men. CONCLUSION: Reducing women's anxiety of blood donation, reminding medical professions more intensively on blood donation and appealing to personal experience or a free health check may be the most promising approaches to increase BDs' return rates.     

Prevention of exacerbations: how are we doing and can we do better?

Prevention of exacerbations of chronic obstructive pulmonary disease (COPD) can involve removing the cause or reducing the patient's vulnerability to the cause. This article addresses the following issues: What is the problem during an exacerbation, what are the causes of an exacerbation, what can prevent exacerbations, and who are we? The difference between a patient with COPD during an exacerbation and after recovery is small. It is unlikely that patients with early COPD experience less exposure to exacerbation causes than those with severe disease; it is just that the consequences are more severe for those with severe disease. Interventions that produce small absolute benefits can therefore have a disproportionately large effect on exacerbation reduction. Recognized causes include season, cold weather, pollution events, bacterial infection, viral infection, and treatment withdrawal. Countries with warmer climates have much larger mortality in cold weather than those with colder climates. Reducing exacerbations in more temperate climates may be altered as much by changes in clothing and bedroom heating as by changes in treatment. Taking more exercise in cold weather may be the underlying reason for the reduction of exacerbations after pulmonary rehabilitation. Influenza vaccination reduces influenza severity and reduces transmission from health care workers to patients. There are a number of pharmacologic interventions shown to reduce (the effect of) exacerbations, including inhaled corticosteroids, long-acting beta-agonists, long-acting anticholinergics, mucolytics, and perhaps antibiotics that reduce Haemophilus carriage. The effect of the bronchodilators is additive to inhaled corticosteroids; how far the other interventions are complementary is unclear. So far, we have had a very medical response to COPD exacerbations. Altering social and behavioral aspects is likely to be complementary.     

The burden of blood pressure: where are we and where should we go?

Hypertension and related diseases are a global burden of cardiovascular disorders. Ischemic heart disease and cardiovascular disease rank fourth and fifth among the 10 leading causes of mortality worldwide. A generation from now, these diseases will be an epidemic for which we should be ready and against which we should attempt to find the best preventive measures. In Canada, the percentage of cardiovascular deaths increases with age. After the age of 50 years, these deaths actually exceed 50% of total mortality. Cardiovascular diseases also have the highest financial health care costs. The newest guidelines from national and international societies have a unifying goal of controlling cardiovascular burden. Guidelines of the international societies are written for a worldwide audience, including countries with very variable health care systems. However, the supreme goal is universal - to lower blood pressure and other risk factors to reduce the risk of cardiovascular disease with its fatal consequences.     

Statins in children: What do we know and what do we need to do?

Children have been tested and treated for hypercholesterolemia for more than 30 years. Although most treatment regimens have been limited to dietary intervention, statin use is increasing. Statins have been used in children since 1987, but published sources have only reported on small numbers of children with severe hypercholesterolemia. The available data indicates that statins can be useful and well tolerated. New data will be available in the next few years that will lead to the wider use of these drugs. Although statin drugs have proven to be safe in the adult population, physicians will be obliged to follow pediatric patients closely when these agents are widely used in the first few years. The use of highly effective safe drugs such as statins will allow for the assessment of the best time to initiate therapy in younger populations and what benefits may be found over the long term.     

Prevention and treatment of dementia: what should we do today?

Three studies were conducted on elderly patients with dementia. A case of control study on life styles before falling ill revealed that "intake of sweets" was significantly associated with clinically diagnosed dementia of the Alzheimer's type. Evaluation of treatments of outpatients suggests that proper care and some kinds of neuroleptics are useful for alleviation of abnormal behavior such as agitation, wandering, hallucination, insomnia and depression, but not for improvement of cognitive function and memory. A study on caregivers of elderly demented patients was undertaken to determine the relationship between the components of burden and symptoms of patients. Insomnia and abnormal behavior of patients correlated with physical and mental components of the burden of caregivers. Memory disturbance, psychological symptoms and deterioration in ADL correlated with physical burden. These studies indicate that symptoms accompanying dementia such as insomnia, wandering, hallucination and agitation should be the treated intensively for the purpose of improvement of the quality of the lives of patients and caregivers.     

Immunomodulation of asthma: where do we stand?

Conclusions Better treatment options should reduce symptoms, enhance quality of life, improve the course of disease, reverse pathogenetic and physiologic changes, have few side effects, and be cost effective. Because of the heterogeneous nature of asthma, specific agents will probably work best for selected types of patients. However, regardless of the obstacles, ongoing research into the wide range of therapeutic possibilities will provide new insights into the pathogenesis of allergic respiratory diseases.     

Thyroid function inside and outside of pregnancy: what do we know and what don't we know?

A workshop entitled, "The Impact of Maternal Thyroid Diseases on the Developing Fetus: Implications for Diagnosis, Treatment, and Screening," was held in Atlanta, Georgia, January 12-13, 2004. This paper reports on the session that examined the prevalence of thyroid dysfunction in reproductive-age women and the factors associated with abnormal function. For this session the following papers were presented: "Thyroidal Economy in the Pregnant State: An Overview," "The Prevalence of Thyroid Dysfunction in Reproductive-Age Women- United States," and "Risk Factors for Thyroid Disease: Autoimmunity and Other Conditions." These presentations were formally discussed by invited respondents and by others in attendance. Salient points from this session about which there was agreement include the following: physiologic changes associated with pregnancy require an increased availability of thyroid hormones by 40% to 100% in order to meet the needs of mother and fetus during pregnancy. In the first trimester of gestation the fetus is wholly dependent on thyroxine from the mother for normal neurologic development. For the maternal thyroid gland to meet the demands of pregnancy it must be present, disease-free, and capable of responding with adequate stores of iodine. Thyroid autoimmunity is common and may contribute to miscarriages, as well as to hypothyroidism. With sufficient iodine nutrition, autoimmune thyroid disease (AITD) is the most common cause of hypothyroidism. As of 1994, iodine nutrition in the United States appeared to be adequate, but its continued monitoring is essential.     

How do we use ambulatory measurement of blood pressure in the management of hypertension?

We have explored the use and interpretation of ambulatory blood pressure monitoring (ABPM) among clinicians at an Edinburgh Cardiovascular Risk Clinic and among a group of international experts in blood pressure monitoring. Locally, we were able to demonstrate major discrepancies in management advice between doctors and nurses. Although all of the international experts used ABPM regularly, they did not agree on thresholds levels for treatment or target BP. This gives food for thought as we consider how to advise internists and primary care physicians on the use and interpretation of ABPM.     

How do we manage iron deficiency after blood donation?

Summary

Blood donors and the RBCs and other components they willingly provide are essential in the delivery of healthcare in all parts of the world. Nearly 70% of donated blood comes from repeat or committed donors. The amount of iron removed in the 10 min or so it takes to withdraw a unit of blood (500 ml, plus 25 ml for testing) requires over 24 weeks to replace on a “standard” diet, i.e., without added iron in the form of supplements The cumulative effect of repeat blood donations without adequate iron replacement or a longer wait between donations results in iron deficiency (ID) in many donors, low haemoglobin deferral (~8% of donation attempts), and frank anaemia in some. Moreover, ID can be associated with side effects that can impact a blood donor's health, such as fatigue, cognitive changes and other neuromuscular symptoms. In an effort to better identify and prevent ID, blood collection agencies are recommending various strategies, including changes in the donation interval, donation frequency, testing of iron status and iron supplementation. In this review, we present the evidence basis for these strategies and suggest our own approaches to improving iron balance in blood donors.

     

Double hit lymphoma: How do we define it and how do we treat it?

Double/triple hit lymphoma is recognised as a distinct entity within the heterogeneous group of high grade B-cell lymphomas, accounting for between 5 and 10% of cases of diffuse large B-cell lymphoma. Under the WHO 2016 it is now known as high-grade B-cell lymphoma with rearrangements of MYC and BCL2 and/or BCL6. When treated with standard chemotherapy it has a poor outcome. There is currently no standard of care for the management of this condition.Diagnosing double hit lymphoma requires identification of translocations of MYC and BCL2 and/or BCL6. This review will discuss the role of stratification to screen cases based on immunohistochemical profiling as a viable option. Treatment options in the frontline and relapsed setting will be reviewed based on the current literature. Recognition of the risk of CNS involvement and how best to manage this will be discussed. Future considerations and current research will be described.