Non-pharmacological aspects of blood pressure management: what are the data?

Hypertension affects 29% of US adults and is a significant risk factor for cardiovascular morbidity and mortality. Epidemiological data support contribution of several dietary and other lifestyle-related factors to the development of high blood pressure (BP). Several clinical trials investigated the efficacy of non-pharmacological interventions and lifestyle modifications to reduce BP. Best evidence from randomized controlled trials supports BP-lowering effects of weight loss, the Dietary Approaches to Stop Hypertension (DASH) diet, and dietary sodium (Na(+)) reduction in those with prehypertension, with more pronounced effects in those with hypertension. In hypertensive participants, the effects on BP of DASH combined with low Na(+) alone or with the addition of weight loss were greater than or equal to those of single-drug therapy. Trials where food was provided to participants were more successful in showing a BP-lowering effect. However, clinical studies with long-term follow-up revealed that lifestyle modifications were difficult to maintain. Findings from controlled trials of increased potassium, calcium, or magnesium intake, or reduction in alcohol intake revealed modest BP-lowering effects and are less conclusive. The reported effects of exercise independent of weight loss on BP are inconsistent.     

Multiplying linear dimension techniques may predict the cross-sectional area of multifidus muscle at all levels of lumbar spine

Objective: This study was designed to find out the relationship between the multiplied linear dimensions (MLD) measurement and the cross-sectional area (CSA) measurement of the lumbar multifidus muscle. Methods: Sixty healthy female subjects participated in this study. The CSA of the lumbar multifidus muscle from L2 to L5 was bilaterally measured by tracing around the muscle margins with an on- screen cursor. The linear dimensions including lateral dimension (LD), anteroposterior dimension (APD) and MLD of the muscles were also calculated at the same levels of lumbar vertebrae. Results: The linear regression between CSA and MLD for each vertebral level was significant (r=0.89 to 0.97, p<0.0001). In addition, there was significant correlation between CSA and APD (r=0.69 to 0.87, p<0.05).Conclusions: MLD method can be used to predict the CSA of the lumbar multifidus muscle. The method described for assessing the multifidus muscle is a potentially valuable, quick and easy way to evaluate muscle size at different levels of the lumbar vertebrae in clinical practice.     

Patient predictors and utilization of health services within a medical home for homeless persons

Background: The Veterans Health Administration (VHA) established a patient-centered medical home model of care for veterans experiencing homelessness called a Homeless Patient Aligned Care Team (HPACT) to improve engagement with primary care and reduce utilization of hospital-based services. To evaluate the impact of the HPACT model, this study compares the number and type of health care visits in the 12 months before and after enrollment in HPACT at one VHA facility, and explores patient characteristics associated with increases and decreases in visits. Methods: Chart reviews of VHA medical records were conducted for all patients enrolled in an HPACT in Pittsburgh, Pennsylvania, between May 2012 and December 2013 (N = 179). Multivariable mixed-effect logistic regressions estimated differences in having any visit in the 0–6 months and 7–12 months before and after HPACT enrollment, and multinomial logistic regressions predicted increases or decreases versus no change in number of visits over 12 months. Results: Compared with 0–6 months prior to HPACT, patients were more likely to visit primary care in the 0–6 months (adjusted odds ratio [aOR] = 4.91, 95% confidence interval [CI] = 2.94–8.20) and 7–12 months (aOR = 2.30, 95% CI = 1.42–3.72) following HPACT. Patients were less likely to visit the emergency department (ED) or to be hospitalized in the 0–6 months (aOR = 0.57, 95% CI = 0.34–0.94; and aOR = 0.55, 95% CI = 0.25–0.76) and 7–12 months (aOR = 0.43, 95% CI = 0.33–0.91; and aOR = 0.45, 95% CI = 0.26–0.80) following HPACT. Patients were less likely to visit mental health (aOR = 0.35, 95% CI = 0.20–0.60) and addiction specialists (aOR = 0.39, 95% CI = 0.18–0.84) in the 7–12 months following HPACT. Overall, 59% of patients had increases in primary care visits following HPACT. Female patients and those with self-housing were less likely to have increases versus no change in primary care visits (adjusted relative risk ratio [aRRR] = 0.15, 95% CI = 0.03–0.74; and aRRR = 0.35, 95% CI = 0.14–0.90). Conclusions: An integrated HPACT model was successful in engaging homeless veterans in primary care for 1 year, potentially contributing to reductions in ED use. More tailored approaches may be needed for vulnerable populations experiencing homelessness, including homeless women.     

Environmental study of azole‐resistant Aspergillus fumigatus with TR34/L98H mutations in the cyp51A gene in Iran

Azole resistance in Aspergillus is emerging in European and Asian countries. As azoles are mainstay of therapy in the management of aspergillosis, azole resistance has serious implications in patient management. We report the emergence of resistance to triazoles in environmental Aspergillus fumigatus isolates in Iran. The TR₃₄/L98H mutation was the only resistance mechanism. Overall 3.3% of the A. fumigatus isolates from hospital surroundings in Sari and Tehran had the same TR₃₄/L98H STRAf genotype and were related to some resistant clinical and environmental TR₃₄/L98H isolates from the Netherlands and India. It is emphasised that routine resistance surveillance studies focusing on environmental and clinical samples are warranted to yield the true prevalence of azole resistance in A. fumigatus in Iran.