INERTIA OR INACTION? BLOOD PRESSURE MANAGEMENT AND CARDIOVASCULAR RISK IN DIABETES‡

• 1 Diabetes is a significant risk factor for cardiovascular disease (CVD), but the presence of comorbidities, such as hypertension, markedly increases CVD risk. The aim of the present study was to determine the effectiveness of hypertension management in patients with diabetes.
• 2 The cvTRAC Study was a cross‐sectional study of CVD risk factors in primary care practices across Australia. General medical practitioners enrolled patients they considered to be at increased risk of CVD and reported on cardiovascular disease history, CVD risk factor levels and current therapy.
• 3 In all, 9857 men and 8332 women with diabetes participated in the study, with > ;85% having at least two CVD risk factors in addition to diabetes and 68% having a history of hypertension. Lost therapeutic benefit in diabetes patients with hypertension was seen in those who were failing to meet targets on antihypertensive drug therapy (therapeutic inertia: > ;73% of the hypertensive cohort), with a smaller proportion accounted for by those who met prescribing guidelines but were not being treated pharmacologically (treatment gap: 5.4% of the hypertensive cohort). Lack of compliance with lifestyle guidelines was estimated to account for over 8% of those not meeting blood pressure targets. Age (odds ratio (OR) 0.983, 95% confidence interval (CI) 0.980–0.986; P < 0.001), compliance with physical activity guidelines (OR 1.219, 95% CI 1.088–1.366; P = 0.001) and compliance with dietary guidelines (OR 1.298, 95% CI 1.188–1.420; P < 0.001) were independent predictors of target blood pressure attainment in the diabetic population.
• 4 Deficiencies in pharmacological and lifestyle‐related therapeutic strategies contribute to suboptimal hypertension management in diabetes. Therapeutic inertia is a greater contributor to lost therapeutic benefit than treatment gap in this population.

     

Socio-economic status and the therapeutic effectiveness of antihypertensive treatment – the design of the LEO study

ABSTRACT

Objective: The risk of arterial hypertension and subsequent cardiovascular disease morbidity and mortality increases with low socio-economic status (SES). Even small differences in blood pressure, whether untreated or despite treatment, account for this substantial difference. Most of the increased risk in the low socio-economic group is due to traditional cardiovascular risk factors such as overweight and obesity, alcohol consumption and a sedentary life style. Intense treatment of arterial hypertension has been shown to overcome these prognostic inequalities. Therefore, drugs with high efficacy, optimal treatment adherence and a low potential for drug-related side effects are needed in order to reduce the cardiovascular risk burden of patients with a low SES. The angiotensin receptor blocker (ARB) olmesartan will be used to investigate the effectiveness of this drug in different socio-economic classes.

Research design and methods: The LEO (Long-term Effectiveness of Olmesartan in different Socioeconomic groups) study is a large observational long-term study which has been set up to test the effectiveness of olmesartan within this context. The study has a matched-pairs design (1403 patients in both the low and the high socio-economic classes).

Main outcome measures: The LEO study will test whether this regimen can reduce the SES-related difference in long-term blood pressure control and compliance in the low SES population.

Conclusions: The study may generate valuable information about the antihypertensive effectiveness of olmesartan alone or in combination with hydrochlorothiazide in different socio-economic classes. It will further test whether the drug helps to reduce the inherent inequalities in cardiovascular prognosis between different socio-economic groups.

Current status: The study commenced in July 2007. Results are anticipated in December 2008.     

Know your diabetes risk project: Student pharmacists educating adults about diabetes risk in a community pharmacy setting

ObjectivesTo determine the feasibility of educating adults about their risk of prediabetes/diabetes in a community pharmacy, to determine the common risk factors for prediabetes/diabetes in adults visiting a community pharmacy, and to assess any association between risk factors and age.DesignCross sectional.SettingOklahoma community pharmacies between April 1 and December 31, 2008.Participants1,852 patients aged 18 to 80 years.InterventionStudent pharmacists invited adults to complete a survey to assess their risk for diabetes/prediabetes. Students reviewed participants’ risk and educated them on lifestyle changes to lower diabetes risk.Main outcome measuresPatient risk factors, pharmacy identifier, and pharmacy type (independent, chain, or clinic pharmacy) and location (rural, suburban, or city).ResultsDiabetes risk assessment and education of 1,852 adults was performed by 110 student pharmacists in 52 community pharmacies located in 27 cities across 13 (of 77) Oklahoma counties. Obesity/overweight was the most common risk factor (57%), with positive family history, hypertension, elevated cholesterol, member of high-risk ethnic group, and sedentary lifestyle being reported by at least 20% of participants. The number of risk factors increased with age, with a significant increase occurring in participants older than 40 years of age.ConclusionThis project demonstrated that it is feasible to perform diabetes risk assessment and to provide education on lowering that risk through community pharmacies.     

Cardiovascular risk screening program in Australian community pharmacies

Objective To assess the suitability of Australian community pharmacies as cardiovascular disease risk profile screening centres and evaluate whether community pharmacists can play an important role in detecting, educating and referring screened individuals at high risk of cardiovascular disease. Setting 14 Australian community pharmacies. Method Opportunistic cardiovascular disease risk profiling for members of the public aged greater than 30 years with no existing cardiovascular diseases was performed. All major cardiovascular risk factors were measured. Exercise habits, existing conditions and therapy, and family history were also assessed. The results were used to calculate each subject’s 10-year risk of developing cardiovascular events, based on Framingham Risk Equations (New Zealand tables). Each subject’s knowledge of cardiovascular risk factors was assessed using a multiple-choice questionnaire. Written educational materials and verbal counselling were provided. Referral to a doctor for further assessment was recommended as appropriate. The screened individuals were followed up via mailed out questionnaire. A random sample of individuals at elevated risk was phoned to assess for outcomes of the screening and referral process. Main outcome measures Risk of developing cardiovascular disease and knowledge of cardiovascular risk factors. Results A total of 655 individuals (71.4% female) were screened for cardiovascular disease risk factors. Ages ranged from 30 to 90 years (median: 54 years) and 14.2% were smokers. Of the individuals screened, 28.1% had a 10-year risk of developing cardiovascular disease greater than 15%, including 6.9% who had a 10-year risk above 30%. The median calculated 10-year risk of developing cardiovascular disease was 9.5%. Approximately one-third of the individuals had elevated blood pressure, and almost two-thirds were either overweight or obese. The mean total serum cholesterol was 5.31 mmol/l, with 40% of individuals having a level above 5.5 mmol/l and 20% having a high-density lipoprotein cholesterol level below 1.0 mmol/l. There was a statistically significant improvement in the knowledge of cardiovascular disease risk factors at follow-up. Almost half of the contacted high-risk subjects reported lifestyle changes or started drug therapy following re-testing by their general practitioner. Conclusion A pharmacy-based cardiovascular disease risk profile screening and education program has the potential to identify and refer many undiagnosed individuals at high risk of cardiovascular events, and help contain the burden of heart disease.     

Recruitment of participants through community pharmacies for a pharmacogenetic study of antihypertensive drug treatment

Objective To describe the design, recruitment and baseline characteristics of participants in a community pharmacy based pharmacogenetic study of antihypertensive drug treatment. Setting: Participants enrolled from the population-based Pharmaco-Morbidity Record Linkage System. Method We designed a nested case-control study in which we will assess whether specific genetic polymorphisms modify the effect of antihypertensive drugs on the risk of myocardial infarction. In this study, cases (myocardial infarction) and controls were recruited through community pharmacies that participate in PHARMO. The PHARMO database comprises drug dispensing histories of about 2,000,000 subjects from a representative sample of Dutch community pharmacies linked to the national registrations of hospital discharges. Results In total we selected 31010 patients (2777 cases and 28233 controls) from the PHARMO database, of whom 15973 (1871 cases, 14102 controls) were approached through their community pharmacy. Overall response rate was 36.3% (n = 5791, 794 cases, 4997 controls), whereas 32.1% (n = 5126, 701 cases, 4425 controls) gave informed consent to genotype their DNA. As expected, several cardiovascular risk factors such as smoking, body mass index, hypercholesterolemia, and diabetes mellitus were more common in cases than in controls. Conclusion Furthermore, cases more often used beta-blockers and calcium-antagonists, whereas controls more often used thiazide diuretics, ACE-inhibitors, and angiotensin-II receptor blockers. We have demonstrated that it is feasible to select patients from a coded database for a pharmacogenetic study and to approach them through community pharmacies, achieving reasonable response rates and without violating privacy rules.     

Risk factors of endoleak following endovascular repair of abdominal aortic aneurysm. A multicentric retrospective study

Endoleak (EL) represents the most common complication following endovascular abdominal aortic aneurysm repair (EVAR). Unfortunately, the long-term results of EVAR and its durability have been questioned, and EL are variably associated with a risk of late failure. The aim of this retrospective study was to identify risk factors for this complication of aneurysm-endograft complex in patients who underwent EVAR. A group of 104 consecutive patients (99 men, 5 women; median age, 74 years; range, 50-89 years) were enrolled in the study. Both preoperative and follow-up imaging studies were obtained using helical computed tomography scanning at 1, 6, 12, 24, 36 months after EVAR and blindly reviewed by a surgeon and a radiologist. Twenty-seven (25.9%) patients developed EL during follow-up, of which 10 (37%) were primary (<30 days from EVAR), and 17 (63%) were secondary EL. Age and smoking did not affect the EL onset, while a body mass index >25 and a history or presence of arterial hypertension represented significant (p<0.05) risk factors. Moreover, both greatest diameter and maximum length of the aneurysm were significantly higher (p<0.01) in patients who developed EL. No relationship was found with the anatomical features of the aortic neck (i.e. length and diameter), and between the initial size of the aneurysm and the dimension at the time of EL. In conclusion, in our study, being overweight, arterial hypertension and the initial size of the aneurysm represent risk factors for EL development.     

The effect of irbesartan in reducing cardiovascular risk in hypertensive type 2 diabetic patients: an observational study in 16 600 patients in primary care

SUMMARY

Objectives: As arterial hypertension substantially increases the risk of premature death, cardiovascular disease and renal insufficiency in patients with type 2 diabetes, effective and safe antihypertensive therapy is of importance. Therefore, the effect of irbesartan as monotherapy, or in fixed combination with hydrochlorothiazide, on blood pressure, metabolic parameters and microalbuminuria and the safety and tolerability of the drug were assessed.

Research design and methods: Multicentric, prospective, open phase IV study over 3 months in 16?600 patients with the clinical diagnoses of hypertension and type 2 diabetes. Blood pressure was measured sphygmometrically and albuminuria was assessed with semi-quantitative urine dipsticks.

Main outcome measures: Systolic (SBP) and diastolic (DBP) blood pressure reduction, proportion of patients with microalbuminuria and cardiovascular risk calculated based on the SCORE score, each after a follow-up of 3 months compared to baseline. Number and nature of adverse events (AEs).

Results: The sample consisted of 51.3% men, mean age was 62.2 ± 10.7 years, 53.9% of patients were overweight and 26.4% were obese. Mean SBP/DBP decrease after 3 months was 22.3/11.2?mmHg. The BP lowering effect was similar in the analyses of various subgroups (according to age group, sex, presence of micro- or macrovascular complications). Irbesartan treatment reduced the percentage of patients with microalbuminuria from 45.6% to 30.6% at 3 months (32.9% relative reduction). Metabolic parameters (lipids, blood glucose, HbA1c) and weight were improved significantly or showed trends for improvement, respectively. The mean 10-year cardiovascular risk as calculated with the SCORE score was decreased from a baseline value of 9.8% to 5.7% (–58% relative reduction). Tolerability was excellent: only 0.3% experienced an AE.

Conclusions: Treatment with irbesartan in patients with concomitant hypertension and type 2 diabetes led to large blood pressure reductions. In view of the renoprotective effect documented by the reduced rate of patients with albuminuria, and the improvement of further metabolic parameters, these changes translate into a reduction of cardiovascular risk.     

Impact of a community pharmacists' hypertension-care service on medication adherence. The AFenPA study

BackgroundOne of the main factors associated with the inadequacy of blood pressure control is patients' non-adherence to antihypertensive drug therapy.ObjectivesTo determine the effect of an intervention program on antihypertensive medication adherence in the community pharmacy setting.MethodsTreated hypertensive patients were enrolled in a 6-month controlled study involving thirteen Spanish community pharmacies. A pharmacist intervention program which consisted of specific education on issues related to medication adherence and hypertension was provided. Additionally, patients were provided with a home blood pressure monitoring device and instructed to measure their blood pressure. The control group received usual pharmacy care. Antihypertensive medication adherence was evaluated by pill counts at baseline and at the end of the study.ResultsData from 176 patients were included in and analyzed in the study: 89 in the control group and 87 in the intervention group. The percentage of adherence for intervention group patients increased between baseline and the end of the study (86.0% vs. 96.5%), while it didn't change in the control group (86.5% vs. 85.4%). The proportion of patient adherence at the end of the study was higher in the intervention group compared to the control group (96.5% vs. 85.4%; P = .011). The odds of adherence to antihypertensive drug therapy in the intervention group was 4.07 (95% CI: 1.04–15.95; P = .044) times higher than the control group.ConclusionsIn this sample of treated hypertensive patients, the pharmacist intervention was associated with significant improvement in antihypertensive medications adherence, compared to usual care.     

高血压患者动态血压与BMI的相关性

目的观察高血压患者体质量指数(BMI)对动态血压各指标及其昼夜节律是否有影响。方法对160例高血压患者进行动态血压监测,并测量身高和体质量,计算体质量指数。结果超重/肥胖组的平均收缩压(SBP)、平均动脉压(MBP)、平均脉压(PP)均高于非超重组(差异有统计学意义);超重/肥胖组和非超重组在四种动态血压节律分型中的分布均有显著差异性。结论 BMI值影响高血压患者SBP、MBP和PP,同时影响了高血压患者动态血压的节律。     

药源性高血压的发病机制、致病药物及其防治

药源性高血压为常见药物不良反应之一,其发病机制包括交感神经活动亢进,肾性水钠潴留,肾素-血管紧张素-醛固酮系统激活,以及动脉弹性功能和结构改变。临床表现为血压升高、反跳现象,甚至出现高血压危象。高危因素包括高龄、性别、遗传原因、既往高血压病史、超重、钠敏感、基础疾病。高危人群应避免使用可致血压升高的药物;必须使用时,应从最小剂量开始并应监测血压水平。一旦出现高血压应立即停药或减少剂量,并予对症治疗。     

Improvement of diabetes indices of care by a short pharmaceutical care program

Objective Diabetes mellitus is a serious health problem associated with an increased mortality and morbidity. The association of improved glycemic control with sustained decrease in the rate of complications has been shown in randomized clinical trials. Pharmaceutical care is a relatively new concept in Turkey; yet, there are no recorded routine pharmaceutical care programs. Therefore, we aimed to assess the impact of a short pharmaceutical care program conducted in the community pharmacy setting, on the indices of diabetes care of type 2 diabetic patients, particularly those regarding glycemic control and high blood pressure management. Setting The study was carried out at eight community pharmacies in Pendik district of Istanbul. Method All patients who visited any of the eight pharmacies through the pre-determined 1-week period were questioned for the presence of type 2 diabetes. Patients who reported to be type 2 diabetic (n = 67) were informed about the study and invited to involve. During this prospective longitudinal study, pharmaceutical care was provided to the patients by the same clinical pharmacist. The 3 month pharmaceutical care period consisted of six pharmacy visits. Main outcome measure: The main outcome measures were the improvement in glycemic control and blood pressure control; while, weight control, self-monitoring of blood glucose, compliance and being under physician-control were also assessed. Results The study was conducted on 43 patients who accepted to involve. Fasting blood glucose was lowered by a mean of 23% over 3-months from an initial value of 167.2 mg/dl. Number of patients reaching the desired blood glucose goals increased from 16.3% to 39.5%. Systolic and diastolic blood pressures also significantly fell over 3 months (mean reductions were 10.9 mmHg for the systolic and 9.3 mmHg for the diastolic blood pressure). Number of patients reaching the desired blood pressure goal increased from 30.2% to 51.2%. Conclusion Our short-course pharmaceutical care program yielded measurable improvements in clinical indicators of diabetes and comorbidity management. The results suggest that the pharmacist is a beneficial key component of integrated care for patients with type 2 diabetes. We think that the positive results observed in this first reported pharmaceutical care program on diabetes in Turkey can be motivating and encouraging for all community pharmacists.     

Body mass index,chronic atrophic gastritis and heartburn: a population‐based study among 8936 older adults from Germany

Aliment Pharmacol Ther 2010; 32: 296–302

Summary

Background Obesity and overweight have been positively related to gastro‐oesophageal reflux disease (GERD). It has been suggested that this relationship is as a consequence of an increased gastric acid reflux, which is caused by an enhanced intra‐abdominal pressure. Aim To assess potential interaction of the association between body mass index (BMI) and GERD by chronic atrophic gastritis, which goes along with decreased acid production. Methods In the baseline examination of ESTHER, a study conducted in 9953 older adults in Saarland, information on frequency of heartburn, potential risk factors and medical history was obtained by self‐administered standardized questionnaire. Serological measurements of pepsinogen I and II were taken for definition of chronic atrophic gastritis. Results In total, 2565 (28.7%) of the included subjects experienced heartburn within the previous 4 weeks. A pronounced dose‐response relationship was observed between BMI and heartburn occurrence (P < 0.001) among people without chronic atrophic gastritis, but not among people with chronic atrophic gastritis (P‐value for interaction = 0.018). Obese/overweight people with chronic atrophic gastritis had a much lower risk of heartburn compared with obese/overweight people without chronic atrophic gastritis (OR = 0.31, 95% CI = 0.24–0.40). Conclusion Our results are consistent with the hypothesis that BMI is related positively to GERD symptoms by its impact on acid reflux.     

Considerations for Optimal Blood Pressure Goals in the Elderly Population: A Review of Emergent Evidence

Recent hypertension clinical trials and national guideline updates have created a debate on the most appropriate treatment goals in elderly patients with hypertension. In 2014, recommendations by the Eighth Joint National Committee allowed a more lenient goal for patients 60 years and older compared with previous guidelines. Since then, several large clinical trials and meta‐analyses have added more information regarding strict versus lenient treatment goals. Most recently, the American College of Cardiology and American Heart Association Task Force published their highly anticipated hypertension guideline developed in conjunction with nine additional interdisciplinary organizations. This review discusses the culmination of emerging data to provide more insight into the treatment of hypertension in the elderly. A literature search was conducted using PubMed, the Cumulative Index of Nursing and Allied Health, the Cochrane database, and by hand‐searching references from relevant articles. The following key terms were used: hypertension, blood pressure, systolic, and elderly. Available literature suggests that it is reasonable to target an office systolic blood pressure of less than 130 mm Hg in elderly patients with hypertension. An individualized approach is reasonable for those who are institutionalized, with high comorbidity burden, or have a short life expectancy. A diastolic blood pressure of less than 60 mm Hg should be avoided due to the potential for an increase in cardiovascular risk. The method of blood pressure measurement is extremely important to consider when determining the blood pressure goal, and proper procedures for accurate blood pressure measurement must be followed. Other factors important to consider may include the patient's comorbidities, frailty, as well as the patient's potential for adverse drug reactions.     

Being overweight or obese as a risk factor for acute liver injury secondary to acute acetaminophen overdose

Purpose

Increased incidences of hepatotoxicity have been observed in obese patients with acute acetaminophen overdose. We evaluate whether the status of being overweight or obese is associated with increase in the development of hepatotoxicity and acute liver injury (ALI) in patients with acute acetaminophen overdose.

Methods

This was a retrospective cohort study comparing the risk of hepatotoxicity and ALI between overweight or obese patients (body mass index [BMI] ≥ 25) and normal BMI patients (BMI ≤ 24.9) presenting with acute acetaminophen overdose at Siriraj Hospital during January 2004 to June 2012. All patients were treated with intravenous N‐acetylcysteine. Psi parameters were calculated. High psi was defined as psi of ≥5.0 mM‐hour. Data were analyzed using multinomial logistic regressions, odds ratio (OR), stratified OR, and 95% confidence interval (CI).

Results

There were 197 patients who fulfilled the criteria for analysis, 35 (17.8%) were obese, 24 (12.2%) were overweight, and 138 (70%) were normal BMI cases. Hepatotoxicity and ALI developed in 25 (12.7%) and 40 (20.3%) cases, respectively. Multinomial logistic regression revealed that the overweight‐obesity status and log₁₀(psi value) were significant risk factors of ALI, with OR (95% CI) of 2.68 (1.21‐5.95) and 1.74 (1.27‐2.38), respectively, while only log₁₀(psi) was a significant risk factor of hepatotoxicity with OR (95% CI) 378.51 (39.49‐3627.99). From stratification, overweight‐obesity had significant odds ratios for ALI in strata with low acetaminophen concentration, early initiation of N‐acetylcysteine and low psi.

Conclusion

We conclude that being overweight or obese is an independent risk factor of ALI in acute acetaminophen overdoses.     

Proceedings of the 2nd International Symposia on Lifestyle-related Disease Perspective for Primary Prevention and Treatment in Animal Models and Humans, 21 - 22 October 2006, Nishinomiya, Japan

• 1 Longitudinal studies from the US, Australia and Europe have demonstrated tracking of childhood risk factors for cardiovascular disease from adolescence into adult life. These factors include obesity, blood cholesterol levels, blood pressure and measures of insulin resistance. Worldwide increases in childhood obesity and overweight are already resulting in increases in adolescent diabetes and are likely to translate into earlier onset hypertension and cardiovascular disease in adults.
• 2 Low birth weight has also been associated with increased risk of adult cardiovascular disease, diabetes and high blood pressure, but there is considerable debate as to the relative importance of pre‐ and postnatal influences.
• 3 These issues are discussed in the context of results of a longitudinal cohort study of cardiovascular and metabolic risk factors in Western Australia, the ‘Raine’ childhood cohort, which showed that in a well‐nourished Australian population at age 8 there was a U‐shaped relationship between birth weight and a cluster of factors predisposing to adult cardiovascular disease, with postnatal weight gain being the dominant factor.
• 4 Future public health programmes should focus on both pre‐ and early postnatal factors predisposing to obesity, hypertension and diabetes.

     

Are physicians able to identify high-risk abdominally obese individuals? An analysis from the pan-European Survey of HDL‑cholesterol

ABSTRACT

Objectives: Physician perception of the obesity status may influence the approach to the management of cardiometabolic risk factors. The objective of this study was to explore physicians’ perceptions of the obesity status of their patients in comparison with objective measurements of generalised or abdominal obesity.

Research design and methods: The pan-European Survey of high density lipoprotein (HDL)-cholesterol measured the prevalence of low HDL-cholesterol and other cardiometabolic risk factors in 8545 patients in 11 European countries. The survey also included a question, ‘Is your patient obese?’ with possible answers of ‘Yes’ or ‘No’. Answers to this question were compared with actual obesity status, based on standard cut-off values for body mass index (BMI) and waist circumference.

Main outcome measures: Sensitivity and specificity of physicians’ identification of obesity using receiver operating characteristics analysis.

Results: All patients identified as non-obese were subsequently found to have BMI <?30?kg/m². However, 38% of patients identified as obese by physicians did not have BMI ≥?30?kg/m². It appeared that the presence of abdominal obesity (high waist circumference, present according to US criteria in about half of overweight patients) increased the likelihood of a patient being perceived as obese.

Conclusions: Physicians often overestimate obesity, especially in abdominally overweight patients. In practice, physicians tend to identify as obese a subset of patients at higher cardiovascular risk through high waist circumference.     

The relationship between occupational exposure to lead and manifestation of cardiovascular complications in persons with arterial hypertension

The chronic exposure to lead represents a risk factor of arterial hypertension development. Ambulatory blood pressure monitoring is the most prognostically reliable method of measuring of arterial blood pressure. The study is aimed at evaluating the relationship between occupational exposure to lead and manifestation of cardiovascular complications in patients with arterial hypertension. The studies included 73 men (mean age, 54.26 ± 8.17 years) with arterial hypertension, treated with hypotensive drugs: group I—persons occupationally exposed to lead (n = 35) and group II—individuals not exposed to lead (n = 38). An analysis of results obtained during ambulatory blood pressure monitoring disclosed significantly higher values of mean systolic blood pressure, mean blood pressure, pulse pressure, and variability of systolic blood pressure in the group of hypertensive patients occupationally exposed to lead as compared to patients with arterial hypertension but not exposed to lead. The logistic regression showed that a more advanced age, higher concentration of blood zinc protoporphyrin, and a higher mean value of pulse pressure represented independent risk factors of left ventricular hypertrophy in the group of persons with arterial hypertension and chronically exposed to lead (OR_age = 1.11; OR_ZnPP = 1.32; OR_PP = 1,43; p < 0.05). In view of the above data demonstration that occupational exposure to lead represents an independent risk factor of increased pulse pressure may be of key importance in the process of shaping general social awareness as to harmful effects of lead compounds on human health.     

Factors predicting hospital readmissions related to adverse drug reactions

Objective  To analyse the contribution of adverse drug reactions (ADR) to hospital readmissions. Methods  This was a case–control study in which unscheduled admissions of patients who had been admitted to the hospital during the two previous months were assessed during a 21-month period. The patient was considered a case when the main diagnosis of readmission complied with the World Health Organisation’s definition of an ADR. For each case, two controls were selected from those patients that had been admitted for ADR without readmission (n = 177). Information on drugs and other risk factors was obtained from cases by interview and from controls by clinical record review. Results  There were 26,559 unscheduled admissions of which 81 were readmissions associated with ADR (4.5% of the unscheduled readmissions). There were no statistically significant correlations with sex, age or medical history, with the exception of arterial hypertension. The main drug products causing readmission were acenocoumarol (15, 18.5%), antihypertensive-diuretics (14, 17.3%), anticancer drugs (11, 13.6%) and digoxin (seven, 8.6%). In the multivariate logistic analysis, the variables predicting readmission were acenocoumarol [odds ratio (OR) 12.2, 95% confidence interval (CI) 3.8–38.3, P < 0.0001], a record of diabetes mellitus (OR 2.6, 95% CI 1.3–5.5, P < 0.01), the number of drugs taken at the moment of ADR (OR 1.2, 95% CI 1.1–1.4, P < 0.001) and high blood pressure (OR 0.3, 95% CI 0.2–0.6, P < 0.001) even though the latter was a negative predictor, preventing readmission. Of the 81 readmissions associated with ADR, 28 (34.6%) were preventable. Conclusion  A medical record of diabetes mellitus, polypharmacy and acenocoumarol treatment were risk factors predicting hospital readmission related to ADR.     

遗传因素对青少年血压的影响

目的 分析遗传因素对青少年血压的影响.方法 采用整群抽样方法,对上海市青浦区2所初级中学和2所高级中学的11～ 17岁4175名在校学生采用问卷调查的形式收集父母高血压史,同时测量血压、身高、体质量.调查时发现血压超过正常水平的调查对象,在1个月内复测血压.结果 参加调查的学生共4175名,其中女性2183名(52.3％),男性1992名(47.7％);血压正常者占72.5％(3025名),女性76.3％(1666名),男性68.3％(1361名),男女比较差异有统计学意义(P＜0.05);正常高值血压占18.0％(750名)[女性14.2％(310名),男性22.1％(440名)];1级高血压为8.3％(344名)[女性8.2％(179名),男性8.3％(165名)],2级高血压为1.3％(54名)[女性1.3％(28名),男性1.3％(26名)].女性超重和肥胖的检出率分别为6.7％(147名)和3.0％(66名);男性为13.7％(271名)和6.3％(125名),男女超重比例差异有统计学意义(P＜0.05).父亲和/或母亲有高血压史者占13.0％(541名),男性为12.6％(251名),女性为13.3％(290名).高血压遗传背景的检出率在各级血压分组间差异无统计学意义(P＞0.05).结论 遗传因素对青少年高血压无明显影响,超重和肥胖可能与血压水平增高有关.     

The development of a sleep disorder screening program in Australian community pharmacies

Objective To develop, pilot and determine the feasibility of a sleep-specific screening and awareness program in community pharmacies. Setting The screening was piloted in five Australian community pharmacies. Method The Pharmacy Tool for Assessment of Sleep Health was constructed by drawing on known relationships between sleep disorders, and lifestyle factors, medical conditions and medications. Four validated instruments were used in the screening tool: the Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), Multivariable Apnea Prediction Index (MAPI) and International Restless Legs Syndrome Study Group Screening Criteria (IRLS). These instruments were used to predict the participant’s risk of a sleep disorder and the results were compared with reported lifestyle, medical and medication factors. On-site training of consenting pharmacists was provided, followed by an eight week client recruiting and screening period. Feedback was elicited from participating pharmacists and clients. Main outcome measure The feasibility of, and trends found from, the developed screening tool and protocol. Results Of 167 clients who requested or were invited to participate by pharmacists, 84 (50.3%) were screened. Analysis of collected data indicated that 33.3%, 21.4% and 27.4% of participants were at risk of having or developing insomnia, obstructive sleep apnea (OSA) and restless legs syndrome (RLS) respectively, while 38.1% were not at risk of any of the screened disorders. OSA odds increased 12.8 times (95% CI: 3.2–50.4) with diabetes and 4.9 times (1.2–20.9) with opioid use, while shift workers were 8.4 times (1.6–43.2) more likely to have insomnia. Participants and pharmacists reported the screening protocol and instrument was user friendly and feasible. Conclusion The development and pilot of this screening tool was successful. The prevalence of sleep disorders in the sampled population was high but generally consistent with previous studies on the general population. Furthermore, associations found may form a foundation for a clinical algorithm to identify those at a higher risk of having or developing a sleep disorder. Further work is required to validate this screening tool in the community pharmacy context.