Is New‐Onset Diabetes of Clinical Significance in Treated Hypertensive Patients?—Con

There is little doubt that diabetes is more common in hypertensive than normotensive individuals. There are also some data suggesting that the use of certain antihypertensive agents, i.e., diuretics and more specifically some beta blockers will increase the occurrence of new onset diabetes (NOD) when compared to other medications, especially angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The clinical significance of this 1%-3.5% difference, however, has not been established. Different studies report different outcomes. In large outcome trials the occurrence of NOD did not effect mortality or morbidity outcomes. Although one study reported that NOD had the same prognosis as pretreatment diabetes, another did not. At present, data are insufficient to suggest that NOD is of important clinical significance or that present treatment recommendations, especially regarding the use of diuretics, should be changed.     

Results of the ALLHAT Trial: Is the Debate About Initial Antihypertensive Drug Therapy Over?

Results of the ALLHAT study have focused attention on the preferred approaches to the management of hypertension. Some of the conclusions of this trial have already been questioned. In this issue of The JCH, Marvin Moser, MD, and Michael A. Weber, MD, two of the senior editors, present their critiques of the ALLHAT results.     

Are There Pleiotropic Effects of Antihypertensive Medications or Is It All About the Blood Pressure in the Patient With Diabetes and Hypertension?

Many small studies with varied surrogate end points and numerous preclinical data have suggested the likelihood of there being specific benefits that exceed simple blood pressure control with drug classes such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers, which may be particularly relevant to the patient with diabetes and hypertension. Large clinical trials, however, have provided only token support for this idea. Likewise, meta-analyses that have incorporated varied clinical trials, albeit with somewhat heterogeneous data, have not been particularly forthcoming in their support of this concept. In the patient with diabetes and hypertension, tight blood pressure control, more so than using a specific drug class, is the most important aspect of therapy.     

Should Dietary Salt Restriction Be a Basic Component of Antihypertensive Therapy?

The general intake of salt (sodium chloride) is much higher than the recommended allowances, in part because of added salt in food industry processed food. However, population studies have not been able to show an association between salt intake and unfavorable health outcome.Based on population studies and randomized studies, the effect of an extreme salt reduction of 100 mmol on blood pressure in hypertensive persons is about one third of the effect of antihypertensive medications. This effect-size estimate is based on single measurements of blood pressure and is probably overestimated compared with 24-hour blood pressure measurements. Salt reduction has effects on heart rate and serum levels of renin, aldosterone, catecholamines, and lipids that may be unfavorable. Because of insufficient compliance, extreme salt reduction can only be obtained if salt in food industry processed food is eliminated. The full consequences of such elimination are not known. Other nonpharmacological interventions, such as weight reduction and diets including fruits, vegetables, and low-fat dairy foods, are probably easier to implement and more effective to decrease blood pressure than salt reduction. Furthermore, salt reduction does not seem to add to the effect size when combined with other nonpharmacological interventions. Salt sensitivity due to sodium channel mutations has been shown in a minority of blacks but not in Caucasians.In conclusion, at present, dietary salt restriction should not be a basic component of antihypertensive therapy.     

Is sleeve lobectomy safe after induction therapy?—a systematic review and meta-analysis

BackgroundSleeve lobectomy (SL) is a lung-sparing procedure, which is accepted as a valid operation for centrally-located advanced tumors. These tumors often require induction treatment by chemotherapy and/or radiotherapy to downstage the disease and thus facilitate subsequent surgery. However, induction therapy may potentially increase the risk of bronchial anastomotic complications and related morbidity. This meta-analysis aims to determine the impact of induction therapy on the outcomes of pulmonary SL.MethodsWe compared studies of patients undergoing SL or bilobectomy for non-small cell lung cancer (NSCLC) with and without induction therapy. Outcomes of interest were in-hospital mortality, morbidity, anastomosis complication and 5-year survival. Odds ratio (OR) were computed following the Mantel-Haenszel method.ResultsTen studies were included for a total of 1,204 patients. There was no statistical difference for between patients who underwent induction therapy followed by surgery and patients who underwent surgery alone in term of post-operative mortality (OR: 1.80, 95% confidence interval (CI): 0.76–4.25, P value =0.19) and morbidity (OR: 1.17, 95% CI: 0.90–1.52, P value =0.237). Anastomosis related complications rate were 5.2% and appears increased after induction therapy with a statistical difference close to the significance (OR: 1.65, 95% CI: 0.97–2.83, P value =0.06). Patients undergoing surgery alone showed better survival at 5 years (OR: 1.52, 95% CI: 1.15–2.00, P value =0.003).ConclusionsSL following induction therapy can be safely performed with no increase of mortality and morbidity. However, the need for induction therapy before surgery is associated with increased anastomotic complications and poorer survival prognosis at 5 years.     

Secondary Hypertension—Whom and How Do You Study? What Type of Therapy Is Appropriate?

Following a hypertension symposium in Los Angeles, CA on October 20, 2004, a roundtable was convened to discuss secondary or treatable forms of high blood pressure, when and whom should be studied, and treatment methods. Dr. Marvin Moser, Clinical Professor of Medicine at Yale University School of Medicine, New Haven, CT, moderated the panel discussion. Participants included Dr. Ron Victor, from the Southwestern Medical Center, Dallas, TX and Dr. Joel Handler of the Orange County Kaiser Permanente Hypertension Clinic, Anaheim, CA.     

Is the left bundle branch pacing a choice to conquer the right bundle branch block?—A case report

In patients with preserved ejection fraction or right bundle branch block (RBBB) pattern requiring a high percentage of ventricular pacing, His‐bundle pacing (HBP) might be an alternative to biventricular pacing, although the high threshold occasionally occurs. We provided a case of the intrinsic RBBB correction by capturing intra‐Hisian left bundle branch (LBB) or distal His‐bundle with different output settings. LBB pacing had the advantage of a much lower threshold while remained most synchrony as HBP. LBB pacing might be a promisingly safe and effective procedure for patients with high‐grade atrioventricular (AV) block and RBBB pattern.     

Is There a Role for Diet in the Therapy of Rheumatoid Arthritis?

Patients with rheumatoid arthritis (RA) often inquire about dietary interventions to improve RA symptoms. Although the majority of studies of diet and RA were published prior to the start of the twenty-first century, this review discusses the evidence for a relationship between diet, in particular omega-3 fatty acid supplements, vitamin D supplements, alcohol, and the Mediterranean diet and RA disease activity. We review possible mechanisms by which these dietary intakes may affect RA disease activity. Given the complexity of studying the relationship between diet and RA disease activity, we highlight areas deserving further study before specific recommendations can be made to RA patients.     

Expert Panel Discussion The ASCOT Trial—Are β‐Blockers Still Useful as Antihypertensive Medication?

Following a hypertension symposium in New York, NY in March 2006, an expert panel was convened to discuss the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) and the future of β-blocker therapy. Dr Marvin Moser of the Yale University School of Medicine, New Haven, CT chaired the panel, which included Dr Thomas D. Giles, President of the American Society of Hypertension and Professor of Medicine at Louisiana State University School of Medicine, New Orleans, LA; Dr Thomas G. Pickering, Director of Behavioral Cardiovascular Health at Columbia University College of Physicians and Surgeons, New York, NY; and Dr Ronald G. Victor, Professor of Internal Medicine and Division Chief of Hypertension at the University of Texas Southwestern Medical Center, Dallas, TX.     

“Is There a Gun in the Home?” Assessing the Risks of Gun Ownership in Older Adults

An important ethical and safety concern that geriatricians, primary care providers, and home health professionals need to address is gun ownership by elderly adults. Those aged 65 and older now have the highest rate of gun ownership in America, and they also have a high prevalence of depression and suicide. Dementia can add additional layers of risk. Even older gun owners who are otherwise intellectually intact may benefit from information about gun safety with the increasing numbers of children being cared for by grandparents. Health professionals should ask patients, “Is there a gun in the home?” in the clinic and during home visits. Healthcare professionals must have knowledge and skills to address safe gun ownership in elderly adults. The 5 L's (Locked, Loaded, Little children, feeling Low, Learned owner) will assist professionals in addressing all aspects of safe ownership.