The association between orthostatic hypertension and all-cause mortality in hospitalized elderly persons

BackgroundLittle 在长期的死亡上对 orthostatic 高血压(OHT ) 和它的效果的流行被知道在老。我们评估了 OHT 的流行，它在 1852 个病人的就医的老 patients.MethodsOut 的死亡上的效果在 31/12/1999 和 31/12/2000 之间承认了到一个尖锐衰老老人病房，有一个平均数的 474 个病人(48% 男性) 81.5 ± 变老；6.8 年在这研究被注册。血压(BP ) 在一个仰卧、站的位置在日子期间被测量三次。有在站之上的收缩或心脏舒张的 BP 层次的至少一增加的病人与 OHT 被诊断。病历，物理考试和实验室参数从医药记录被检索。死亡数据直到 18 th 2014 年 6 月从 Interior.ResultsFour 的部的计算机化的系统被检索 107 个病人(86%) 与 OHT 被诊断。没有 OHT，那些有一个更低的身体团索引并且是更可能的男性，吸烟者，与 OHT 与那些相比有 Parkinsons 疾病和更少的充血的心失败的更高的率。有 OHT 的病人让更好的幸存没有 OHT，比那些评价(P = 0.024 ) 。为有 OHT 的在那些的死亡的危险比率(HR ) 适应了年龄，多重风险因素是：0.67 [95% 信心间隔(CI ) ：0.51 −； 0.87 ] 并且 0.73 (95% CI：0.55 −； 0.97 ) 分别地；一个类似的趋势被有 OHT 的老病人有的 gender.ConclusionHospitalized 在敏感分析注意更好的幸存率比那些没有 OHT。

Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension: How can patients be better selected?

Chronic thromboembolic pulmonary hypertension (CTEPH) comprises organizing thrombotic obstructions in the pulmonary arteries by nonresolving thromboemboli, formation of fibrosis and remodeling of pulmonary blood vessels. Surgical pulmonary endarterectomy (PEA) is the therapy of choice for patients with surgically accessible CTEPH, which leads to a profound improvement in hemodynamics, functional class and survival. Select- ing the candidates that will benefit from surgery is still a challenging task. Criteria for surgical suitability have been described but the decision-making for or against surgical intervention remains still subjective. The optimal characterization of the reciprocal contribution of large vessel and small vessel disease in the elevation of pulmonary vascular resistance is crucial for the indication and outcome of PEA. Recently, Toshner et al intended to validate the partition resistance into small and large vessels compartments (upstream resistance:Rup) by the occlusion technique in the preoperative assessment of PEA. We discuss the advantages and disadvantages of Rup and compare it with other hemodynamic predictor to evaluate operative risk in CTEPH patients.

Pre-treatment considerations in childhood hypertension due to chronic kidney disease

Hypertension(HTN) develops very early in childhood chronic kidney disease(CKD). It is linked with rapid progression of kidney disease, increased morbidity and mortality hence the imperative to start antihypertensive medication when blood pressure(BP)is persistently > 90 th percentile for age, gender, and height in non-dialyzing hypertensive children with CKD. HTN pathomechanism in CKD is multifactorial and complexly interwoven. The patient with CKD-associated HTN needs to be carefully evaluated for co-morbidities that frequently alter the course of the disease as successful treatment of HTN in CKD goes beyond life style modification and anti-hypertensive therapy alone. Chronic anaemia, volume overload, endothelial dysfunction, arterial media calcification, and metabolic derangements like secondary hyperparathyroidism, hyperphosphataemia, and calcitriol deficiency are a few co-morbidities that may cause or worsen HTN in CKD. It is important to know if the HTN is caused or made worse by the toxic effects of medications like erythropoietin, cyclosporine, tacrolimus, corticosteroids and non-steroidal anti-inflammatory drugs. Poor treatment response may be due to any of these co-morbidities and medications. A satisfactory hypertensive CKD outcome, therefore, depends very much on identifying and managing these co-morbid conditions and HTN promoting medications promptly and appropriately. This review attempts to point attention to factors that may affect successful treatment of the hypertensive CKD child and how to attain the desired therapeutic BP target.

Pulmonary arterial hypertension related to human immunodeficiency virus infection:A case series

AIM: To present 18 new cases of human immunodeficiency virus(HIV)-related pulmonary arterial hypertension(PAH) with presenting features,treatment options and follow-up data.METHODS: This is a single-centre,retrospective,observational study that used prospectively collected data,conducted during a 14-year period on HIV-related PAH patients who were referred to a pulmonary hy-pertension unit. All patients infected with HIV were consecutively admitted for an initial evaluation of PAH during the study period and included in our study. Right heart catheterisation was used for the diagnosis of PAH. Specific PAH treatment was started according to the physician's judgment and the recommendations for idiopathic PAH. The data collected included demographic characteristics,parameters related to both HIV infection and PAH and disease follow-up.RESULTS: Eighteen patients were included. Intravenous drug use was the major risk factor for HIV infection. Risk factors for PAH,other than HIV infection,were present in 55.5% patients. The elapsed time between HIV infection and PAH diagnoses was 12.2 ± 6.9 years. At PAH diagnosis,94.1% patients had a CD4 cell count > 200 cells/μL. Highly active antiretroviral therapy(present in 47.1% patients) was associated with an accelerated onset of PAH. Survival rates were 93.8%,92.9% and 85.7% at one,two and three years,respectively. Concerning specific therapy,33.3% of the patients were started on a prostacyclin analogue,and the rest were on oral drugs,mainly phosphodiesterase-5 inhibitors. During the follow-up period,specific therapy was de-escalated to oral drugs in all of the living patients.CONCLUSION: The survival rates of HIV-related PAH patients were higher,most likely due to new aggressive specific therapy. The majority of patients were on oral specific therapy and clinically stable. Moreover,sildenafil appears to be a safe therapy for less severe HIVrelated PAH.

Prehypertension, Hypertension and Associated Cardiovascular Risk Factors among Adult Congolese Urban Dwellers: Results of the Vitaraa Study

Objective: To assess the prevalence of prehypertension and hypertension, their determinants and associated cardiovascular risk factors in Congolese urban dwellers. Methods: From July 2007 to March 2008, we collected information on lifestyle habits, medical history and anthropometric data in 1292 household members of Adoula Quarter, Kinshasa, aged 20 years or more, 731 women (56.6%). We obtained measurements of BP, blood glucose, serum lipids and qualitative proteinuria. We defined blood pressure categories according to JNC7 classification and used logistic regression analyses to assess their independent determinants. We obtained age adjustment of continuous and categorical variables using GLM and Genmod procedures, respectively. Results: Prehypertension was observed in 30.3% of subjects, 34.9% of men and 26.7% of women (P = 0.0045). The prevalence of hypertension amounted to 30.9% with no difference between genders. Participants with prehypertension had average age, BMI and waist circumference intermediate between those with normal BP and hypertensive subjects. Their glucose and lipids levels were similar to those of normotensives. The prevalence of prehypertension amounted to 33% at age 20 - 29 years and decreased to 16.7% at ≥60 years whereas the prevalence of hypertension increased from 11.2% to 71.4%. The rates of diabetes mellitus were similar accross blood pressure catogo- ries whilst prevalences of overweight/obesity, abdominal adiposity, dyslipidemia and metabolic syndrome significatively increased (P = 0.05 or less). Among participants with prehypertension, 73% had two or more additional cardiovascular risk factors. In the logistic model the probability of prehypertension was higher in men (OR: 1.429;95% CI: 1.099 - 1.857) and participants with overweight/obesity (OR: 1.666;1.146 - 2.422), lower in participants aged ≥ 55 years (0.427;0.267 - 0.683) and those with high fruit intake (0.691;0.488 - 0.977). The probability of hypertension was higher in participants aged ≥ 55 years (OR: 6.988;4.561 - 10.706), overweight/obesity (2.263;1.704 - 3.004), those with high vegetables consumption (1.152;1.003 - 1.324) and faster pulse rate (1.013;1.002 - 1.025). Conclusion: Our results suggest that fruit consumption and control of over-weight are important issues for prevention of cardiovascular disease in sub-Saharan Africa where high blood pressure is the main driver of the current epidemic.

Determining the Bulk of the Iceberg of Proteinuric Chronic Kidney Disease in School Children, in South West Nigeria

Introduction: Chronic kidney disease [CKD], as defined by the National Kidney Foundation/Kidney Disease and Outcome Quality Initiative (KDOQI) Group, refers to bilateral kidney injury and/or impaired kidney function of at least 3 months duration. Persistent proteinuria has been recognized as one of the early markers of chronic kidney disease and has been associated with persistent and progressive damage in both children and adult. This study was conducted with the aim of determining the prevalence and severity of persistent proteinuria over three months in primary school children in Ile-Ife. It was a cross-sectional study done over a period of six months. The subjects were 1335 primary school pupils, aged 6 to 14 years selected by multi stage random sampling method from twelve primary schools from a total of 96,301 pupils in the two Local Government Areas (LGA) of Ile-Ife, after meeting the recruitment criteria. The biodata, physical examination, blood pressure measurements and urine testing by dipstick were carried out on all the recruited pupils according to standard protocols while serial monitoring of proteinuria and estimated glomerular filtration rate was done for those with persistent proteinuria over 6 months. Results: Initially 34 (2.6%) of the subjects recruited had significant proteinuria with a M:F ratio of 1:1.6 following first screening and it was persistent in six (0.4%) of them subsequently over three months with a M:F ratio of 1:1.5. The severity of the persistent proteinuria was in the range of 30 mg/dL to 100 mg/dL. Three of them (50%) had worsened level of proteinuria from 30 mg/dL to 100 mg/dl on follow up. Conclusion: Children with undetected persistent proteinuria stand the risk of further glomerular damage over time.

Reliability in endoscopic diagnosis of portal hypertensive gastropathy

AIM: To analyze reliability among endoscopists in diagnosing portal hypertensive gastropathy (PHG) and to determine which criteria from the most utilized classifications are the most suitable. METHODS: From January to July 2009, in an academic quaternary referral center at Santa Casa of S o Paulo Endoscopy Service, Brazil, we performed this singlecenter prospective study. In this period, we included 100 patients, including 50 sequential patients who had portal hypertension of various etiologies; who were previously diagnosed based on clinical, laboratory and imaging exams; and who presented with esophageal varices. In addition, our study included 50 sequentialpatients who had dyspeptic symptoms and were referred for upper digestive endoscopy without portal hypertension. All subjects underwent upper digestive endoscopy, and the images of the exam were digitally recorded. Five endoscopists with more than 15 years of experience answered an electronic questionnaire, which included endoscopic criteria from the 3 most commonly used Portal Hypertensive Gastropathy classifications (McCormack, NIEC and Baveno) and the presence of elevated or flat antral erosive gastritis. All five endosco- pists were blinded to the patients' clinical information, and all images of varices were deliberately excluded for the analysis. RESULTS: The three most common etiologies of portal hypertension were schistosomiasis (36%), alcoholic cirrhosis (20%) and viral cirrhosis (14%). Of the 50 patients with portal hypertension, 84% were Child A, 12% were Child B, 4% were Child C, 64% exhibited previous variceal bleeding and 66% were previously endoscopic treated. The endoscopic parameters, presence or absence of mosaic-like pattern, red point lesions and cherry-red spots were associated with high inter-observer reliability and high specificity for diagnosing Portal Hypertensive Gastropathy. Sensitivity, specificity and reliability for the diagnosis of PHG (%) were as follows: mosaic-like pattern (100; 92.21; High); fine pink speckling (56; 76.62; Unsatisfactory); superficial reddening (69.57; 66.23; Unsatisfactory); red-point lesions (47.83; 90.91; High); cherry-red spots (39.13; 96.10; High); isolated red marks (43.48; 88.31; High); and confluent red marks (21.74; 100; Unsatisfactory). Antral elevated erosive gastritis exhibited high reliability and high specificity with respect to the presence of portal hypertension (92%) and the diagnosis of portal hypertensive gastropathy (88.31%). CONCLUSION: The most suitable endoscopic criteria for the diagnosis of PHG were mosaic-like pattern, redpoint lesions and cherry-red spots with no subdivisions,which were associated with a high rate of inter-observer reliability.

Epidemiology, pathophysiology, clinical characteristics and management of childhood cardiorenal syndrome

Cardiorenal syndrome(CRS) is a new term recently introduced to describe the acute or chronic comorbid state of the heart and kidney that has been long known and frequently managed in very sick individuals. The tight and delicate coordination of physiological functions among organ systems in the human body makes dysfunction in one to lead to malfunction of one or more other organ systems. CRS is a universal very common morbidity in the critically ill, with a high mortality rate that has received very little research attention in children. Simultaneous management of heart and renal failures in CRS is quite challenging; the therapeutic choice made for one organ must not jeopardize the other. This paper reviews the epidemiology, pathophysiology, clinical characteristics and management of acute and chronic CRS in children.

Kidney in primary aldosteronism: A key determinant of treatment outcome

Recently, it has been suggested that primary aldosteronism(PA) is associated with a variety of cardiac,vascular, metabolic, and renal sequelae that reflect the capability of elevated aldosterone to induce organ damage beyond that induced by hypertension itself. The evidence supporting of these views has been obtained from experiments conducted in rodents and clinica studies conducted in patients with this endocrine disorder. It has been suggested that untoward effects of high-salt intake are dependent on activation of mineralocorticoid receptors that might result from increased oxidative stress and changes in the intracellular redox potential. Unilateral adrenalectomy or treatment with mineralocorticoid receptor antagonists are the current options for treating an aldosterone-producing adrena adenoma or idiopathic adrenal hyperplasia. Treatments are largely effective in correcting hypertension and hypokalemia, and currently available information on their capability to prevent deterioration of renal function indicates that surgery and medical treatment are equallybeneficial in the long term. This editorial review will focus on the renal aspects of PA and highlights the role of the kidney as a key determinant of both adaptation to aldosterone-induced volume retention and response of blood pressure to treatment.

夜尿症作为1920—1921年出生人群冠心病死亡危险因素的效用

心血管事件多发生于早晨觉醒和起床时血压升高和心率增加后。夜间觉醒和起床后亦会出现相似的血流动力学改变。

Diabetes, diabetic complications, and blood pressure targets

Association of diabetes with hypertension is frequent and it well known that high blood pressure potentiates the probability of diabetic patients to develop macrovascularand microvascular complications. Strong evidence obtained in a number of large scale prospective studies indicates that adequate blood pressure control in diabetic patients is highly beneficial for prevention of cardiovascular events. Nonetheless, only a limited proportion of hypertensive-diabetic individuals included in studies on anti-hypertensive treatment has met the predefined blood pressure goal. The optimal blood pressure goal to be pursued in diabetic patients with hypertension to guarantee effective protection from cardiovascular outcomes is still under intense debate and recommendations of current guidelines on hypertension treatment are still inconsistent. We comment here on the most important studies and conclude that current evidence does not conclusively support the need to reach a blood pressure target in hypertensive patients with diabetes different from nondiabetic hypertensive individuals.

Effects of Exercise Training on Endothelial Function,Arterial Structure,and Physical Conditioning in Patients with Systemic Autoimmune Myopathies:A Case Series Study

Introduction. Exercise training has been effective in improving endothelial function and decreasing arterial stiffness in several systemic autoimmune diseases. However, to date, no studies have assessed patients with systemic autoimmune myopathies (SAM). Methods. Five female patients with definite SAM (3 dermatomyositis and 2 polymyositis) who underwent a 12-week, twice-a-week, exercise training program were assessed prospectively. The following parameters were assessed: endothelial function measured by flow-mediated dilatation (FMD), carotid femoral by pulse wave velocity (PWV), disease status by International Myositis Assessment & Clinical Studies Group (IMACS) set score, the ventilatory anaerobic threefold (VAT), respiratory compensation point (RCP), maximum effort (ME), maximal oxygen uptake (VO2max) measured by ergospyrometer, and strength and muscle function. Results. Mean age of the patients and duration of disease were 43.9 and 10.5 years, respectively. The median FMD and PWV were 10.2% and 7.1 m/s. After exercise training, important FMD reduction was observed in 4 out of 5 patients, whereas the PWV parameters decreased in only 2 out of 5 patients. The exercise training was safe, without clinical intercurrences or disease relapses. Moreover, an increase in strength and functionality was observed. Concerning aerobic capacity, there was a decrease in the VAT and an increase in ME, without al-terations in the maximum oxygen consumption. Conclusions. In general, exercise training does not alter endothelial function and PWV values, but improves muscle strength and function and also, does not lead to disease reactivation (Clinical Trials (NCT03092167)).

Functional and Structural Arterial Vessel Features of Female Patients with Stable Dermatomyositis and Antisynthetase Syndrome

Introduction: Dermatomyositis (DM) and antisynthetase syndrome (ASS) show a high frequency of metabolic syndrome, which can be preceded by endothelial dysfunction and arterial stiffness. To date, only one study has evaluated these vessel parameters in DM, and no study of ASS exists. Therefore, the aim of the study was to assess the structural and functional arterial of arterial vessels in DM and ASS. Methods: This cross-sectional study enrolled 21 adult female patients (14 DM and 7 ASS) who were age-, gender- and ethnicity-matched to 12 healthy individuals. Patients using lipid lowering agents or prednisone at doses ≥ 0.25 mg/kg/day, and patients with uncontrolled systemic arterial hypertension, diabetes mellitus, cardiac insufficiency, and disease activity were excluded. Arterial stiffness was evaluated using carotid-femoral pulse wave velocity (PWV), and endothelial function was evaluated using dependent flow-mediated dilatation (FMD) of the brachial artery. Results: The mean age of patients with DM or ASS were 45.4 ± 8.6 and 44.0 ± 6.1 years, respectively (P = 1.000), and patients were predominantly of white ethnicity. Six DM patients and three ASS patients had systemic arterial hypertension, whereas 9 DM patients and six ASS patients had dyslipidemia. Endothelial baseline diameter, hyperemia diameter and FMD values were similar among the three groups (P > 0.05). Moreover, the median FMD values were also similar between the patients with DM and patients with ASS [8.3% (4.5% - 10.9%) vs. 6.0% (−1.8% - 8.2%);P = 0.585]. The PWV values were comparable among the three groups (P = 0.253). In addition, no difference was observed between patients with DM and patients with ASS (7.4 ± 0.8 m/s vs. 7.4 ± 0.9 m/s;P = 1.000). Conclusions: Despite the high prevalence of dyslipidemia and systemic arterial hypertension, our female patients with stable DM and ASS had FMD and PWV values comparable to those of the control group.

Safety Food in Celiac Disease Patients: A Systematic Review

The prevalence of Celiac Disease (CD), an autoimmune enteropathy, characterized by chronic inflammation of the intestinal mucosa, atrophy of intestinal villi and several clinical manifestations has increased in recent years. Epidemiological studies have shown that CD is very common and affects about one in 250 people. The mechanism of the intestinal immune-mediated response is not completely clear, but involves an HLA-DQ2 or HLA-DQ8 restricted T-cell immune reaction in the lamina propria as well as an immune reaction in the intestinal epithelium. Subjects affected by CD cannot tolerate gluten protein, a mixture of storage proteins contained in several cereals (wheat, rye, barley and derivatives). Gluten free-diet remains the cornerstone treatment for celiac patients. Therefore the absence of gluten in natural and processed foods represents a key aspect of food safety of the gluten-free diet. In this review, we evaluate the main studies about the safety food in CD patients.

Severe Ectopic Cushing’s Syndrome Due to ACTH-Secreting Pheochromocytoma

We report a new case of ectopic Cushing’s syndrome caused by an ACTH-producing pheochromocytoma. A 55-year-old woman presented with a history of severe proximal muscle weakness, polyuria, progressive virilization, anxiety, dyspnea on exercise, difficult to treat hypertension, and type 2 diabetes mellitus since 4 months. The laboratory data demonstrated ACTH-dependent hypercortisolism. The abdominal computed tomography scan showed a 30 mm well-defined mass in the left adrenal gland suggestive for pheochromocytoma. The adrenal veins were sampled, with intraprocedural cortisol measurement, to dosing selective ACTH and cathecolamines. The results established clearly the left adrenal gland as the source of ACTH overproduction. A left sided adrenalectomy was performed with subsequent resolution of Cushing’s syndrome. The patient was discharged in good clinical condition.

Isolated Soy Protein-Based Diet Ameliorates Glycemia and Antioxidants Enzyme Activities in Streptozotocin-Induced Diabetes

The objective of this study was to evaluate the changes induced by isolated soy protein (ISP)-based diet on glycemia and oxidative stress biomarkers in diabetic rats. Fifteen male Wistar rats (35 ± 4 g, aged 21 days) were assigned to three groups: Casein (C group), which received casein-based diet during experimental protocol;Diabetic treated with Casein (D + C group) that received casein-based diet before and after diabetes induction;Diabetic treated with ISP (D + S group) that received casein-based diet before diabetes induction and after received ISP-based diet for the experimental protocol. Diabetes was induced by a single dose of streptozotocin (50 mg/kg body weight i.v.). After three weeks of dietary treatment, total nitrates, lipid peroxidation, antioxidant enzyme activities of superoxide dismutase (SOD), catalase (CAT), glutathione-S-transferase (GST) were measured in heart homogenates. ISP-based diet promoted an improvement in the glycemic levels of diabetic rats compared with casein-based diet (362 ± 25 vs 461 ± 30 mg/dL). CAT activity demonstrated a significant decrease in D + C and D + S groups. D + S group presented a significant increase in SOD and GST activities. Lipid peroxidation was not different among experimental groups. The overall results suggested the potential benefits of ISP-based diet consumption to improve the life quality of diabetic patients.

Association between physical activity and cardiovascular risk factors:Dose and sex matter

Dear Editor,ETadegn TagedPFailure to meet World Health Organization(WHO)-determined minimum physical activity(PA)levels is an established risk factor for cardiovascular disease(CVD),^(1)but evidence is still scarce on its effects on other CVD risk factors.Furthermore,whether or not there are sex-specific effects on the association between PA and CVD risk is a matter of controversy,with some authors observing a protective effect of PA in men but not in women,^(2)and others finding the opposite trend.^(3)

Twelve-month efficacy and safety of the conversion to everolimus in maintenance heart transplant recipients

AIM: To determine the clinical reasons for conversion to everolimus(EVL) and long-term outcomes in heart transplant(HT) recipients.METHODS: A retrospective 12-mo study has been carried out in 14 Spanish centres to assess the efficacy and safety of conversion to EVL in maintenance HT recipients.RESULTS: Two hundred and twenty-two patients were included(mean age: 53 ± 10.5 years; mean time from HT: 8.1 ± 4.5 years). The most common reasons for conversion were nephrotoxicity(30%), chronic allograft vasculopathy(20%) and neoplasms(17%). The doses and mean levels of EVL at baseline(conversion to EVL) and after one year were 1.3 ± 0.3 and 1.2 ± 0.6 mg/d and 6.4 ± 3.4 and 5.6 ± 2.5 ng/mL, respectively. The percentage of patients receiving calcineurin inhibitors(CNIs) at baseline and on the final visit was 95% and 65%, respectively. The doses and mean levels of CNIs decreased between baseline and month 12 from 142.2 ± 51.6 to 98.0 ± 39.4 mg/d(P < 0.001) and from 126.1 ± 50.9 to 89.2 ± 47.7 ng/mL(P < 0.001), respectively, for cyclosporine, and from 2.9 ± 1.8 to 2.6 ± 1.9 mg/d and from 8.3 ± 4.0 to 6.5 ± 2.7 ng/mL(P = 0.011) for tacrolimus. In the subgroup of patients converted because of nephrotoxicity, creatinine clearance increased from 34.9 ± 10.1 to 40.4 ± 14.4 mL/min(P < 0.001). There were 37 episodes of acute rejection in 24 patients(11%). The most frequent adverse events were oedemas(12%), infections(9%) and gastrointestinal problems(6%). EVL was suspended in 44 patients(20%). Since the database was closed at the end of the study, no further followup data is available.CONCLUSION: Conversion to EVL in maintenance HT recipients allowed minimisation or suspension of the CNIs, with improved kidney function in the patients with nephrotoxicity, after 12 mo.