Effect of Antihypertensive Agents on Quality of Life in the Elderly

An evaluation of written materials for supporting hypertensive patient education and counselling when performing a new medicine service in Poland

BACKGROUND

The New Medicine Service (NMS) was developed in England more than ten years ago, as a three-stage consultation led by community pharmacists to support patients taking new medication for a chronic disease. In Poland, the scheme was officially introduced in January 2023. However, its implementation into common practice has been presented with various obstacles, including the need to develop relationships with general practitioners, resolve the payment structure, and provide training with adequate supporting materials. Hence, written materials have been designed for use as an optional tool for counselling patients receiving an NMS in community pharmacies.

METHODS

The present study evaluates the ability of these materials to inform patients about the need to adhere to anti-hypertensive medication. A group of 401 randomly-selected adult visitors to pharmacies and/or healthcare centres were surveyed; one third had hypertension in their history.

RESULTS

The structure, grammar and readability of the text achieved the required threshold of 40% according to the Plain Language Index. The designed materials effectively informed the patients about anti-hypertensive medication, reflected in an increased score in a knowledge test, and were rated positively regarding information level, comprehensibility and presentation.

CONCLUSION

The proposed material may serve as an additional, "patient-friendly" educational tool for use as part of an NMS.

Pathogenesis of Chronic Kidney Disease Is Closely Bound up with Alzheimer's Disease, Especially via the Renin-Angiotensin System

Chronic kidney disease (CKD) is a clinical syndrome secondary to the definitive change in function and structure of the kidney, which is characterized by its irreversibility and slow and progressive evolution. Alzheimer's disease (AD) is characterized by the extracellular accumulation of misfolded β-amyloid (Aβ) proteins into senile plaques and the formation of neurofibrillary tangles (NFTs) containing hyperphosphorylated tau. In the aging population, CKD and AD are growing problems. CKD patients are prone to cognitive decline and AD. However, the connection between CKD and AD is still unclear. In this review, we take the lead in showing that the development of the pathophysiology of CKD may also cause or exacerbate AD, especially the renin-angiotensin system (RAS). In vivo studies had already shown that the increased expression of angiotensin-converting enzyme (ACE) produces a positive effect in aggravating AD, but ACE inhibitors (ACEIs) have protective effects against AD. Among the possible association of risk factors in CKD and AD, we mainly discuss the RAS in the systemic circulation and the brain.

Chronic liver diseases and erectile dysfunction

Chronic liver diseases (CLDs) are characterized by progressive necrosis of hepatocytes, which leads to liver fibrosis and cirrhosis, and ultimately liver dysfunction. The statistics of 2020 shows that the number of patients with CLDs, including chronic hepatitis, fatty liver, and cirrhosis, may exceed 447 million in China. The liver is a crucial organ for the metabolism of various substances, including sex hormones and lipids. CLDs frequently result in abnormalities in the metabolism of sex hormones, glucose, and lipids, as well as mental and psychological illnesses, all of which are significant risk factors for erectile dysfunction (ED). It has been reported that the prevalence of ED in male patients with CLDs ranges from 24.6 to 85.0%. According to a survey of Caucasians, liver transplantation may improve the erectile function of CLDs patients with ED. This finding supports the link between CLDs and ED. In addition, ED is often a precursor to a variety of chronic diseases. Given this correlation and the significant prevalence of CLDs, it is important to evaluate the epidemiology, risk factors, etiology, and treatment outcomes of ED in male patients with CLDs, expecting to attract widespread attention.

Intensive vs. conventional blood pressure goals in older patients with type 2 diabetes: a systematic review and meta-analysis

PURPOSE

Assess the effect of intensive vs conventional blood pressure goals on patient-important outcomes in older adults with type 2 diabetes.

METHODS

A comprehensive search was performed using electronic databases. Randomized controlled trials comparing intensive vs conventional blood pressure goals in adults over 60 years of age with type 2 diabetes were included. Events were evaluated using a modified Mantel-Haenszel meta-analysis with Peto's method. Study selection and data extraction were performed independently and in duplicate.

RESULTS

Seven trials were included. A 19% risk reduction (OR 0.81; 95% CI 0.69-0.95; I² = 8%; p = 0.35) in the occurrence of major adverse cardiovascular events (MACE) and 37% risk reduction (OR 0.63; 95% CI 0.51-0.79; I² = 0%; p = 0.56) in the occurrence of fatal or non-fatal stroke was documented in the intensive treatment group. There were no differences in the occurrence of all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and peripheral vascular disease. Data regarding treatment adverse effects and microvascular outcomes was scarce.

CONCLUSIONS

Intensive blood pressure goals in older patients with diabetes were associated with a lower risk of stroke and MACE, but not with all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and peripheral vascular disease.

Propranolol versus Other Selected Drugs in the Treatment of Various Types of Anxiety or Stress, with Particular Reference to Stage Fright and Post-Traumatic Stress Disorder

Propranolol, a non-cardioselective β1,2 blocker, is most commonly recognised for its application in the therapy of various cardiovascular conditions, such as hypertension, coronary artery disease, and tachyarrhythmias. However, due to its ability to cross the blood-brain barrier and affinity towards multiple macromolecules, not only adrenoreceptors, it has also found application in other fields. For example, it is one of the very few medications successfully applied in the treatment of stage fright. This review focuses on the application of propranolol in the treatment of various types of anxiety and stress, with particular reference to stage fright and post-traumatic stress disorder (PTSD). Both mechanisms of action as well as comparison with other therapies are presented. As those indications for propranolol are, in most countries, considered off-label, this review aims to gather information that can be useful while making a decision about the choice of propranolol as a drug in the treatment of those mental conditions.

Sexual dysfunctions and their treatment in liver diseases

Sexual dysfunction (SD) is a prevalent but very commonly ignored aspect in the treatment of liver diseases and cirrhosis. The etiology of SD is multifactorial and therefore treatment strategies are complex, especially in females. Phosphodiesterase inhibitors are useful and effective in erectile dysfunction in males but in females, no single drug is available for SD, therefore multimodal treatment is required depending upon the cause. The foremost and fundamental requirement in both genders is to be stress-free and have adequate control of liver diseases. Improved quality of life is helpful in improving SD and vice versa is also true. Therefore, patients suffering from liver diseases should come forward and ask for treatment for SD, and physicians should actively enquire about SD while history taking and evaluating these patients. SD results in deterioration of quality of life, and both are modifiable and treatable aspects of liver diseases, which are never addressed actively, due to social taboos and fears of SD treatment in the presence of liver diseases. The diagnosis of SD does not require costly investigations, as the diagnosis can be established based on validated questionnaires available for both genders, therefore detailed targeted history taking using questionnaires is essential. Data are emerging in this area but is still at an early stage. More studies should be dedicated to SD in liver diseases.

Assessment of quality of life and activities of daily living among elderly patients with hypertension and impaired physical mobility in home health care by antihypertensive drugs plus acupuncture: A CONSORT-compliant, randomized controlled trial

BACKGROUND

To evaluate the efficacy of acupuncture in improving quality of life (QOL) and activities of daily living among elderly patients with hypertension and impaired physical mobility in home health care.

METHODS

Seventy participants were allocated randomly to receive either acupuncture together with antihypertensive drugs (n = 35) or antihypertensive drugs only (n = 35). Acupuncture was conducted twice a week for 12 consecutive weeks, each lasting 30 minutes. Acupuncture points San Yin Jiao, Xue Hai, Taichong, Zusanli, and Hegu acupuncture points were used bilaterally. The primary outcome was change in QOL score, evaluating by Short-Form 36 Item Health Survey (SF-36). Secondary outcomes were changes in Barthel index score and blood pressure. Besides, pain evaluation by Visual analog scale, among acupuncture and control subgroups in participants with diagnosis with disease of the musculoskeletal system and connective tissue (ICD-9: 710-739).

RESULTS

Thirty-one participants in each of the acupuncture group and the control group completed the study. After 12 weeks of treatment, compared with the control group, the combination of antihypertensive treatments and acupuncture helped to improve bodily pain (P = .03), physical component summary (P = .04), mental health (P < .001), mental component summary (P = .008), Barthel index (P = .02), and systolic blood pressure (P = .01). In contrast, the control group showed no significant changes. Change in pain score revealed that there were a significant between-group differences after 6weeks (P = .01) and 12weeks of treatment (P = .001).

CONCLUSION

The results of the study suggested that in home health care elderly patients with hypertension and impaired physical mobility, antihypertensive drugs combined with acupuncture therapy will be more beneficial to improve QOL, activities of daily living, and blood pressure.

Safety and efficacy of losartan for the reduction of brain atrophy in clinically diagnosed Alzheimer's disease (the RADAR trial): a double-blind, randomised, placebo-controlled, phase 2 trial

Background

Drugs modifying angiotensin II signalling could reduce Alzheimer's disease pathology, thus decreasing the rate of disease progression. We investigated whether the angiotensin II receptor antagonist losartan, compared with placebo, could reduce brain volume loss, as a measure of disease progression, in clinically diagnosed mild-to-moderate Alzheimer's disease.

Methods

In this double-blind, multicentre, randomised controlled trial, eligible patients aged 55 years or older, previously untreated with angiotensin II drugs and diagnosed (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association criteria) with mild-to-moderate Alzheimer's disease, and who had capacity to consent, were recruited from 23 UK National Health Service hospital trusts. After undergoing a 4-week, open-label phase of active treatment then washout, participants were randomly assigned (1:1) oral over-encapsulated preparations of either 100 mg losartan (after an initial two-dose titration stage) or matched placebo daily for 12 months. Randomisation, minimised by age and baseline medial temporal lobe atrophy score, was undertaken online or via pin-access service by telephone. Participants, their study companions, and study personnel were masked to group assignment. The primary outcome, analysed by the intention-to-treat principle (ie, participants analysed in the group to which they were randomised, without imputation for missing data), was change in whole brain volume between baseline and 12 months, measured using volumetric MRI and determined by boundary shift interval (BSI) analysis. The trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN93682878) and the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT 2012–003641–15), and is completed.

Findings

Between July 22, 2014, and May 17, 2018, 261 participants entered the open-label phase. 211 were randomly assigned losartan (n=105) or placebo (n=106). Of 197 (93%) participants who completed the study, 171 (81%) had complete primary outcome data. The mean brain volume (BSI) reduction was 19·1 mL (SD 10·3) in the losartan group and 20·0 mL (10·8) in the placebo group. The difference in total volume reduction between groups was –2·29 mL (95% CI –6·46 to 0·89; p=0·14). The number of adverse events was low (22 in the losartan group and 20 in the placebo group) with no differences between treatment groups. There was one treatment-related death per treatment group.

Interpretation

12 months of treatment with losartan was well tolerated but was not effective in reducing the rate of brain atrophy in individuals with clinically diagnosed mild-to-moderate Alzheimer's disease. Further research is needed to assess the potential therapeutic benefit from earlier treatment in patients with milder cognitive impairment or from longer treatment periods.

Funding

Efficacy and Mechanism Evaluation Programme (UK Medical Research Council and National Institute for Health Research).

Angiotensin Receptor Blockers Are Not Just for Hypertension Anymore

Beyond blood pressure control, angiotensin receptor blockers reduce common injury mechanisms, decreasing excessive inflammation and protecting endothelial and mitochondrial function, insulin sensitivity, the coagulation cascade, immune responses, cerebrovascular flow, and cognition, properties useful to treat inflammatory, age-related, neurodegenerative, and metabolic disorders of many organs including brain and lung.

Candesartan Neuroprotection in Rat Primary Neurons Negatively Correlates with Aging and Senescence: a Transcriptomic Analysis

Preclinical experiments and clinical trials demonstrated that angiotensin II AT₁ receptor overactivity associates with aging and cellular senescence and that AT₁ receptor blockers (ARBs) protect from age-related brain disorders. In a primary neuronal culture submitted to glutamate excitotoxicity, gene set enrichment analysis (GSEA) revealed expression of several hundred genes altered by glutamate and normalized by candesartan correlated with changes in expression in Alzheimer's patient's hippocampus. To further establish whether our data correlated with gene expression alterations associated with aging and senescence, we compared our global transcriptional data with additional published datasets, including alterations in gene expression in the neocortex and cerebellum of old mice, human frontal cortex after age of 40, gene alterations in the Werner syndrome, rodent caloric restriction, Ras and oncogene-induced senescence in fibroblasts, and to tissues besides the brain such as the muscle and kidney. The most significant and enriched pathways associated with aging and senescence were positively correlated with alterations in gene expression in glutamate-injured neurons and, conversely, negatively correlated when the injured neurons were treated with candesartan. Our results involve multiple genes and pathways, including CAV1, CCND1, CDKN1A, CHEK1, ICAM1, IL-1B, IL-6, MAPK14, PTGS2, SERPINE1, and TP53, encoding proteins associated with aging and senescence hallmarks, such as inflammation, oxidative stress, cell cycle and mitochondrial function alterations, insulin resistance, genomic instability including telomere shortening and DNA damage, and the senescent-associated secretory phenotype. Our results demonstrate that AT₁ receptor blockade ameliorates central mechanisms of aging and senescence. Using ARBs for prevention and treatment of age-related disorders has important translational value.

Neuropeptides and oligopeptidases in schizophrenia

Schizophrenia (SCZ) is a complex psychiatric disorder with severe impact on patient's livelihood. In the last years, the importance of neuropeptides in SCZ and other CNS disorders has been recognized, mainly due to their ability to modulate the signaling of classical monoaminergic neurotransmitters as dopamine. In addition, a class of enzymes coined as oligopeptidases are able to cleave several of these neuropeptides, and their potential implication in SCZ was also demonstrated. Interestingly, these enzymes are able to play roles as modulators of neuropeptidergic systems, and they were also implicated in neurogenesis, neurite outgrowth, neuron migration, and therefore, in neurodevelopment and brain formation. Altered activity of oligopeptidases in SCZ was described only more recently, suggesting their possible utility as biomarkers for mental disorders diagnosis or treatment response. We provide here an updated and comprehensive review on neuropeptides and oligopeptidases involved in mental disorders, aiming to attract the attention of physicians to the potential of targeting this system for improving the therapy and for understanding the neurobiology underlying mental disorders as SCZ.

Acyclic Isoprenoid Attenuates Lipid Anomalies and Inflammatory Changes in Hypercholesterolemic Rats

The present study was aimed to explore the antihyperlipidemic and anti-inflammatory effect of acyclic isoprenoid on high fat diet fed rats. Hypercholesterolemia was induced by the diet comprising of the normal rat chow 84.3%, lard 5%, yolk powder 10%, cholesterol 0.2% and 0.5% bile salt were fed to the rats for the period of 8 weeks. The results showed that abnormally elevated levels of plasma lipid profiles. Three different doses of acyclic isoprenoid (20, 40 and 80 mg/kg b.w/day) were administered orally to hypercholesterolemia suffering rats for the period of 30 days. Among these three doses of acyclic isoprenoid, the dose 80 mg/kg b.w. was significantly decreased the plasma lipid profiles when compared to other two doses. The effect produced by acyclic isoprenoid (80 mg/kg b.w) was comparable to that of simvastatin. Therefore, 80 mg/kg b.w was fixed as a effective dose and used for further analyses. Acyclic isoprenoid administration reinstated the elevated levels of cardiac and inflammatory markers in both blood and serum of hypercholesterolemic rats. In addition, acyclic isoprenoid administration decreased activity of 3-hydroxy 3-methyl-glutaryl-CoA reductase and increased the activity of lecithin cholesterol acyl transferase. These findings suggest that the administration of acyclic isoprenoid was potentially ameliorated the cardiac marker enzymes and inflammatory markers in addition to its antihypercholesterolemic effect.

An Ancient Chinese Herbal Decoction Containing Angelicae Sinensis Radix, Astragali Radix, Jujuba Fructus, and Zingiberis Rhizoma Recens Stimulates the Browning Conversion of White Adipocyte in Cultured 3T3-L1 Cells

Background

Abnormal storage of white adipocyte tissue (WAT) is the major factor causing obesity. The promising strategies for obesity treatment are building up the brown adipocyte tissue (BAT) and/or expedite fatty acid catabolism. Traditional Chinese Medicine (TCM) sheds light on preventing obesity. Ginger is one of the most effective herbs for antiobesity by accelerating browning WAT. To fortify the antiobesity effect of ginger, an ancient Chinese herbal decoction composed of four herbs, Angelicae Sinensis Radix (ASR), Astragali Radix (AR), Jujuba Fructus (JF), and Zingiberis Rhizoma Recens (ZRR; ginger), was tested here: this herbal formula was written in AD 1155, named as Danggui Buxue Tang (DBT₁₁₅₅). Therefore, the antiobesity function of this ancient herbal decoction was revealed in vitro by cultured 3T3-L1 cells.

Materials and Method

The lipid accumulation was detected by Oil Red O staining. Furthermore, the underlying working mechanisms of antiobesity functions of DBT₁₁₅₅ were confirmed in 3T3-L1 cells by confocal microscopy, western blot, and RT-PCR.

Results

DBT₁₁₅₅ was able to actuate brown fat-specific gene activations, which included (i) expression of PPARγ, UCP1, and PCG1α and (ii) fatty acid oxidation genes, i.e., CPT1A and HSL. The increase of browning WAT, triggered by DBT₁₁₅₅, was possibly mediated by a Ca²⁺-AMPK signaling pathway, because the application of Ca²⁺ chelator, BAMPTA-AM, reversed the effect.

Conclusion

These findings suggested that the herbal mixture DBT₁₁₅₅ could potentiate the antiobesity functions of ginger, which might have potential therapeutic implications.

Lower circulating levels of angiotensin-converting enzyme (ACE) in patients with schizophrenia

This study aimed at evaluating changes in the renin-angiotensin system (RAS) in patients with schizophrenia in comparison with controls. Plasma levels of angiotensin-converting enzyme (ACE), ACE2, angiotensin (Ang)-(1-7) and Ang II were assessed in 25 patients with schizophrenia and 20 controls. Patients with schizophrenia presented decreased levels of ACE compared to controls [median (25th-75th percentiles) = 434.79 (341.15-524.02) vs. 508.49 (396.34-608.72); p < 0.05]. No significant differences were found regarding ACE2, Ang-(1-7) and Ang II levels. There were no associations between the measured molecules and clinical parameters. Our results corroborate the hypothesis that the RAS is involved in the pathophysiology of schizophrenia.

More Prevalent Prescription of Medicine for Hypertension and Metabolic Syndrome in Males from Couples Undergoing Intracytoplasmic Sperm Injection

Register-based studies have indicated that men with impaired fertility are at higher risk for developing various adult-onset diseases than fertile men. The majority of men undergoing ICSI treatment are sub-fertile and since they are in contact with the health care system, these men are well suited as target for preventive measures. Our study included all men (N = 459 766) who had fathered children in Sweden between 2006 and 2016. Swedish registry data was used for obtaining information regarding conception method and defining three groups of fathers – ICSI -treated, IVF – treated and non IVF/ICSI. By sourcing data from the Swedish Prescribed Drug Register, we specifically searched for information regarding prescription and usage of at least one prescription for diabetes mellitus, hypertension (HT) or dyslipidemia to serve as a proxy for metabolic disease among the study groups. If all three types of medicine were prescribed, the patient was considered as having metabolic syndrome. Our results indicate male partners in couples who became parents using ICSI to be at higher risk for being treated for hypertension (HR = 1.15 95% CI: 1.06–1.24, p = 0.001) and metabolic syndrome (HR = 1.28 95% CI: 1.01–1.58, p = 0.042) when compared to non IVF/ICSI men.

Relation of Postexercise Reduction of Arterial Blood Pressure and Erectile Dysfunction in Patients with Coronary Heart Disease

Penile erection is a hemodynamic process consisting of 2 synchronized components in which the first (active) requires proper vascular endothelium functioning, whereas the second one (passive) is based on a veno-occlusive mechanism. Antihypertensive treatment reduces the passive component, often leading to the development of erectile dysfunction (ED), but lifestyle modifications can improve the sexual functioning. The study aimed to evaluate the association between blood pressure (BP) reduction caused by cardiovascular training and the intensity of ED in men with coronary heart disease. A total of 101 men (mean age 59.50 ± 7.93) with ED treated invasively for coronary heart disease and subjected to cardiac rehabilitation were enrolled. Patient characteristics, the International Index of Erectile Function 5 (IIEF-5) questionnaire (IIEF-5), and BP values were collected at baseline and after 6 months of cardiac rehabilitation and were analyzed. Cardiac rehabilitation led to a significant reduction of 5.08 mm Hg in systolic BP (p <0.001) and of 1.60 mm Hg in diastolic BP (p <0.001). The IIEF-5 score (EQ) significantly increased (median 15, interquartile range 11 to 19 vs median 18, interquartile range 12 to 21, p <0.001). Greater improvement in sexual performance was significantly negatively correlated with age, concentration of triglycerides, and high-density lipoprotein, whereas it was positively correlated with the presence of diabetes and baseline IIEF-5 score. After excluding patients with diabetes, a greater decrease in systolic BP was found to be significantly associated with greater improvement in erectile performance. In conclusion, a reduction of arterial BP caused by cardiac training is accompanied by improvement in erectile performance. This effect is the strongest in patients with hypertension and those with dyslipidemia.

Hypertension

Systemic arterial hypertension is the most important modifiable risk factor for all-cause morbidity and mortality worldwide and is associated with an increased risk of cardiovascular disease (CVD). Fewer than half of those with hypertension are aware of their condition, and many others are aware but not treated or inadequately treated, although successful treatment of hypertension reduces the global burden of disease and mortality. The aetiology of hypertension involves the complex interplay of environmental and pathophysiological factors that affect multiple systems, as well as genetic predisposition. The evaluation of patients with hypertension includes accurate standardized blood pressure (BP) measurement, assessment of the patients' predicted risk of atherosclerotic CVD and evidence of target-organ damage, and detection of secondary causes of hypertension and presence of comorbidities (such as CVD and kidney disease). Lifestyle changes, including dietary modifications and increased physical activity, are effective in lowering BP and preventing hypertension and its CVD sequelae. Pharmacological therapy is very effective in lowering BP and in preventing CVD outcomes in most patients; first-line antihypertensive medications include angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, dihydropyridine calcium-channel blockers and thiazide diuretics.

Averrhoa carambola L. peel extract suppresses adipocyte differentiation in 3T3-L1 cells

Obesity is associated with an increased risk of many chronic diseases. Recently, a growing body of evidence has shown that phytochemicals may inhibit adipogenesis and obesity. In this study, we report for the first time, the ability of Averrhoa carambola L. peel extract commonly known as star fruit (SFP) to effectively suppress adipocyte differentiation in 3T3-L1 preadipocytes and therefore, address it as a potential candidate to treat obesity and its related diseases. (-)-Epicatechin was identified as a bioactive compound likely responsible for this suppression. As the genetic expression studies revealed that the adipogenic activity of SFP extract was due to the simultaneous downregulation of the C/EBPα and PPARγ as well as the upregulation of PPARα receptor genes, a detailed computational docking study was also elucidated to reveal the likely binding mode of (-)-epicatechin to the receptor of interest, accounting for the likely mechanism that results in the overall suppression of adipocyte differentiation.

The effects of methylphenidate and propranolol on the interplay between induced-anxiety and working memory

RATIONALE

Research documents a reciprocal impact of anxiety on working memory (WM), although its strength and direction depend on factors like task difficulty. A better understanding of these factors may generate insights into cognitive mechanisms of action involved in anxiety, culminating into treatment implications. By blocking the physiological effects of anxiety, propranolol might also block anxiety interference on WM. Conversely, by improving task-directed attention, methylphenidate might reduce anxiety, or, alternatively, by improving cognitive efficiency and free up processing resources to compute anxiety.

OBJECTIVES

To investigate the interplay between induced anxiety and WM, we pharmacologically manipulated either anxiety or cognition, using single doses of 40 mg propranolol (PRO), 20 mg methylphenidate (MPH), or placebo (PLA). In this double-blind parallel-group design study, 60 healthy volunteers (20/drug group) performed a verbal WM task under three loads, 1-, 2- and 3-back, and in two conditions, threat of shock and safety. Startle electromyography (EMG) was used to measure anxiety.

RESULTS

Findings were twofold: (1) MPH blocked anxiety interference only on the 3-back WM performance, while PRO or PLA had no effects on anxiety-WM interference, and (2) drugs had no effects on anxiety, but, after controlling for baseline anxiety, MPH enhanced anxiety-potentiated startle during the 3-back task.

CONCLUSIONS

These findings support that MPH-related improvement of cognitive efficiency permits anxiety to be processed and expressed. In conclusion, MPH may be a useful tool to investigate the mechanisms of interaction between anxiety and WM, particularly those under catecholaminergic control.

Self-efficacy and depression predicting the health-related quality of life of outpatients with chronic heart failure in Singapore

BACKGROUND

Chronic heart failure (CHF) remains as a debilitating disease that has high mortality among adults worldwide. CHF negatively impacts an individual's health-related quality of life (HRQoL), but only few studies have investigated such an impact in the Asian population.

AIMS

This study aims to investigate the HRQoL of outpatients with CHF and identify its predictors among this group of patients in Singapore.

METHODS

This was a cross-sectional, descriptive correlational study. A convenience sampling of 121 outpatients with CHF was recruited from a public hospital over 5 months. The Minnesota Living with Heart Failure Questionnaire (MLHFQ), Short Form-Cardiac Depression Scale, Cardiac Self-Efficacy Scale, and Medical Outcomes Study Social Support Survey were used to measure the study variables.

RESULTS

There were significant differences in the HRQoL as assessed using the MLHFQ between gender, educational level, and primary caregiver status (p<0.05). Self-efficacy (β=0.637, p<0.001) and depression (β=-0.220, p<0.001) were found to be the predictors of the HRQoL in outpatients with CHF, accounting for 67.9% of variance.

CONCLUSION

The results of the study indicated that lower levels of self-efficacy and depression predicted poor HRQoL. Nursing care should focus on detecting depressive symptoms in patients with CHF. A program facilitating better self-care is important in CHF management.

Angiotensin II type 1 receptor blockade by telmisartan prevents stress-induced impairment of memory via HPA axis deactivation and up-regulation of brain-derived neurotrophic factor gene expression

Physical and psychological aspects of chronic stress continue to be a persistent clinical problem for which new pharmacological treatment strategies are aggressively sought. By the results of our previous work it has been demonstrated that telmisartan (TLM), an angiotensin type 1 receptor (AT1) blocker (ARB) and partial agonist of peroxisome proliferator-activated receptor gamma (PPARγ), alleviates stress-induced cognitive decline. Understanding of mechanistic background of this phenomenon is hampered by both dual binding sites of TLM and limited data on the consequences of central AT1 blockade and PPARγ activation. Therefore, a critical need exists for progress in the characterization of this target for pro-cognitive drug discovery. An unusual ability of novel ARBs to exert various PPARγ binding activities is commonly being viewed as predominant over angiotensin blockade in terms of neuroprotection. Here we aimed to verify this hypothesis using an animal model of chronic psychological stress (Wistar rats restrained 2.5h daily for 21days) with simultaneous oral administration of TLM (1mg/kg), GW9662 - PPARγ receptor antagonist (0.5mg/kg), or both in combination, followed by a battery of behavioral tests (open field, elevated plus maze, inhibitory avoidance - IA, object recognition - OR), quantitative determination of serum corticosterone (CORT) and evaluation of brain-derived neurotrophic factor (BDNF) gene expression in the medial prefrontal cortex (mPFC) and hippocampus (HIP). Stressed animals displayed decreased recall of the IA behavior (p<0.001), decreased OR (p<0.001), substantial CORT increase (p<0.001) and significantly downregulated expression of BDNF in the mPFC (p<0.001), which were attenuated in rats receiving TLM and TLM+GW9662. These data indicate that procognitive effect of ARBs in stressed subjects do not result from PPAR-γ activation, but AT1 blockade and subsequent hypothalamus-pituitary-adrenal axis deactivation associated with changes in primarily cortical gene expression. This study confirms the dual activities of TLM that controls hypertension and cognition through AT1 blockade.

Quality of Life in Treatment-Resistant Hypertension

Treatment-resistant hypertension (TRH) is an increasingly common and clinically challenging hypertension phenotype associated with adverse impact on cardiovascular events and death. Recent evidence, although limited, suggests that TRH may also adversely affect health-related quality of life (HrQoL) and other patient-reported outcomes. However, the precise mechanisms for this link remain unknown. A number of recent studies focusing on both the general hypertensive population and those with TRH suggest that patient awareness of difficult-to-control blood pressure, chronically elevated blood pressure levels, and the use of aggressive medication regimens with attendant cumulative adverse effects may play significant roles. This review summarizes the existing literature on HrQoL in persons with TRH, highlights literature from the general hypertensive population with relevance to TRH, and discusses important remaining questions regarding HrQoL in persons with TRH.

Erectile dysfunction in patients with liver disease related to chronic hepatitis B

Background/Aims

Despite sexual function making an important contribution to the quality of life, data on erectile function are relatively scant in patients with chronic liver disease. We evaluated the prevalence of and risk factors for erectile dysfunction (ED) in patients with liver disease related to hepatitis B, especially among those with chronic hepatitis B (CHB) or early-stage cirrhosis.

Methods

In total, 69 patients (35 with CHB and 34 with hepatitis-B-related liver cirrhosis [HBV-LC]) aged 40-59 years were analyzed. Child-Pugh classes of A and B were present in 30 (88.2%) and 4 (11.8%) of the patients with HBV-LC, respectively. The erectile function of the patients was evaluated using the Korean version of IIEF-5.

Results

The prevalence of any ED was 24.6% for all patients, and 8.6% and 41.2% for those with CHB and HBV-LC, respectively (P=0.002). While there was only one (2.9%) CHB patient for each stage of ED, mild, moderate, and severe ED stages were seen in three (8.8%), one (2.9%), and ten (29.4%) of the HBV-LC patients, respectively. Multiple regression analysis identified the type of liver disease (P=0.010), hypertension (P=0.022), score on the Beck Depression Inventory (P =0.044), and the serum albumin level (P=0.014) as significant independent factors for the presence of ED.

Conclusions

The prevalence of ED was significantly higher in patients with early-stage HBV-LC than in those with CHB. Therefore, screening male patients with early viral cirrhosis for ED and providing appropriate support are needed, especially when the cirrhosis is accompanied by hypertension, depression, or a depressed level of serum albumin.

Erectile dysfunction and its management in patients with diabetes mellitus

Diabetes can be described as a syndrome of multiple closely related conditions induced by a chronic state of hyperglycaemia resulting from defective insulin secretion, insulin action or both. Chronic complications associated with diabetes (including neuropathy, vascular disease, nephropathy and retinopathy) are common, and of these, erectile dysfunction (ED) deserves special attention. ED and its correlation with cardiovascular disease require careful evaluation and appropriate treatment. PDE5 inhibitors (PDE5is) are an important tool for the treatment of ED, with new drugs coming onto the market since the late 90s. This review offers an overview of PDE5is and their use in treating ED in diabetes. We underline the differences between different types of PDE5i, focusing on available doses, duration of action, T ½, side effects and selectivity profiles in relation to patients with diabetes. We also discuss the link between diabetes and ED in presence of various associated cofactors (obesity, hypertension and its pharmacological treatments, atherosclerosis, hyperhomocysteinaemia, neuropathy, nephropathy, hypogonadism and depression). Finally a number of past and ongoing clinical trials on the use of PDE5is in patients with diabetes are presented to offer an overview of the appropriate treatment of ED in this condition.

Investigation of the role of non-selective calcium channel blocker (flunarizine) on cerebral ischemic-reperfusion associated cognitive dysfunction in aged mice

The present study was designed to investigate the role of flunarizine (a non-selective calcium channel blocker) on cerebral ischemic-reperfusion associated cognitive dysfunction in aged mice. Bilateral carotid artery occlusion of 12min followed by reperfusion for 24h was given to induce cerebral injury in male Swiss mice. The assessment of learning & memory was performed by Morris water maze test; motor in-coordination was evaluated by rota rod, lateral push and inclined beam walking tests; cerebral infarct size was quantified by triphenyltetrazolium chloride staining. In addition, reduced glutathione (GSH), total calcium and acetylcholinesterase (AChE) activity were also estimated in aged brain tissue. Donepezil treated group served as a positive control in this study. Ischemia reperfusion (I/R) injury produced significant increase in cerebral infarct size. A significant loss of memory along with impairment of motor performance was also noted. Further, I/R injury also produced significant increase in levels of total calcium, AChE activity and decrease in GSH levels. Pretreatment of flunarizine significantly attenuated I/R induced infarct size, behavioral and biochemical changes. Hence, it may be concluded that, a non-selective calcium channel blocker can be useful in I/R associated cognitive dysfunction due to its anti-oxidant, anti-infarct and modulatory actions of neurotransmitters & calcium channels.

Influence of hospitalisation on the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in elderly hypertensive patients

BACKGROUND AND AIMS

The underutilization of beneficial cardiovascular medications such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in the elderly patients continues to be a matter of concern. The aim of the presented study was to compare the prescription of ACEI and ARB in elderly hypertensive patients at the time of hospital admission and discharge and to identify patient-related factors which determine the prescription of ACEI/ARB.

METHODS

The study sample (n = 1111) was selected from 2,157 patients hospitalised at long-term care departments of three municipal hospitals during the period between January 1, 2008 and December 31, 2009 and included hypertensive patients aged ≥65 years suffering from myocardial infarction, heart failure, atrial fibrillation, diabetes mellitus or nephropathy.

RESULTS

In hypertensive patients with myocardial infarction, diabetes mellitus and nephropathy, a significant increase was found in the use of ACEI/ARB during hospitalisation. However, there was no similar change in the use of such medications during hospitalisation in patients with heart failure and atrial fibrillation. Age ≥85 years (OR = 0.59 and OR = 0.50 at hospital admission and discharge, respectively), depression (OR = 0.63 at hospital discharge) and the systolic blood pressure ≤115 mmHg (OR = 0.45 at hospital discharge) decreased the probability of ACEI/ARB prescription. On the other hand, increasing the number of evaluated co-morbid conditions increased the patient's likelihood of being an "ACEI/ARB user" (OR = 1.20 at hospital discharge).

CONCLUSIONS

Our study has identified a subset of elderly hypertensive patients (with heart failure, atrial fibrillation) in whom the use of ACEI/ARB could be improved.

Hidden potential of tropical fruit waste components as a useful source of remedy for obesity

The array of comorbidities that comes with obesity and the propelling surge of this disease globally today make the urgent need for treatment vital. Although promoting a healthy physical regimen and controlled diet to affected patients are the main bulk of present treatment, prescriptions of weight-loss medications have also been introduced to complement this treatment. However, the use of synthetic medications may produce adverse side effects and consequently affect the patient's quality of life. In view of these problems, the use of natural sources as alternative remedies has recently become very popular. Tropical fruit "waste components", namely, the seed, flower, leaf, peel, and part of the fruit, which are often discarded after consumption, have recently been studied and showed evidence suggesting their potential as promising future alternative sources of remedy. The high amounts of phytochemicals present in these components were believed to be responsible for the antiobesity effect observed experimentally. This review aims to introduce some of the recently discussed tropical fruit waste components that have been discovered to possess antiobesity effects. The major bioactive compounds of the respective fruit components identified and deduced to be responsible for the overall bioactivity will be evaluated. Following this, the subsequent need for the development of an effective processing or recycling technique required to effectively tap the maximum potential of these fruit parts will also be addressed.

A Role for the Brain RAS in Alzheimer's and Parkinson's Diseases

The brain renin-angiotensin system (RAS) has available the necessary functional components to produce the active ligands angiotensins II (AngII), angiotensin III, angiotensins (IV), angiotensin (1-7), and angiotensin (3-7). These ligands interact with several receptor proteins including AT1, AT2, AT4, and Mas distributed within the central and peripheral nervous systems as well as local RASs in several organs. This review first describes the enzymatic pathways in place to synthesize these ligands and the binding characteristics of these angiotensin receptor subtypes. We next discuss current hypotheses to explain the disorders of Alzheimer's disease (AD) and Parkinson's disease (PD), as well as research efforts focused on the use of angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), in their treatment. ACE inhibitors and ARBs are showing promise in the treatment of several neurodegenerative pathologies; however, there is a need for the development of analogs capable of penetrating the blood-brain barrier and acting as agonists or antagonists at these receptor sites. AngII and AngIV have been shown to play opposing roles regarding memory acquisition and consolidation in animal models. We discuss the development of efficacious AngIV analogs in the treatment of animal models of AD and PD. These AngIV analogs act via the AT4 receptor subtype which may coincide with the hepatocyte growth factor/c-Met receptor system. Finally, future research directions are described concerning new approaches to the treatment of these two neurological diseases.

Roles of Brain Angiotensin II in Cognitive Function and Dementia

The brain renin-angiotensin system (RAS) has been highlighted as having a pathological role in stroke, dementia, and neurodegenerative disease. Particularly, in dementia, epidemiological studies indicate a preventive effect of RAS blockade on cognitive impairment in Alzheimer disease (AD). Moreover, basic experiments suggest a role of brain angiotensin II in neural injury, neuroinflammation, and cognitive function and that RAS blockade attenuates cognitive impairment in rodent dementia models of AD. Therefore, RAS regulation is expected to have therapeutic potential for AD. Here, we discuss the role of angiotensin II in cognitive impairment and AD. Angiotensin II binds to the type 2 receptor (AT₂) and works mainly by binding with the type 1 receptor (AT₁). AT₂ receptor signaling plays a role in protection against multiple-organ damage. A direct AT₂ receptor agonist is now available and is expected to reduce inflammation and oxidative stress and enhance cell differentiation. We and other groups reported that AT₂ receptor activation enhances neuronal differentiation and neurite outgrowth in the brain. Here, we also review the effect of the AT₂ receptor on cognitive function. RAS modulation may be a new therapeutic option for dementia including AD in the future.

Antihyperlipidemic effect of methanolic extract from Opuntia joconostle seeds in mice fed a hypercholesterolemic diet

The purpose of this study was to evaluate the hypolipidemic effect of a methanolic extract from Opuntia joconostle seeds fed to mice in a hypercholesterolemic diet. Acute toxicity of the methanolic extract was investigated by an established method. Phenolic composition and antioxidant activity were determined by high-performance liquid chromatography and DPPH, respectively. The total phenolic content of Opuntia joconostle seeds was 47.85 ± 1.29 mg gallic acid equivalents/g dry weight. The main phenolic compounds were identified as quercetin, rutin, and cafeic acid. Percent inhibition of DPPH⁺ was 49.76 ± 0.49 %. The oral LD₅₀ for the methanolic extract from the Opuntia joconostle seeds was >5,000 mg/kg BW. Mice fed a hypercholesterolemic diet for six days exhibited significantly (P ≤ 0.001) higher plasma lipid levels than mice fed a normal diet. Remarkably, supplementation with methanolic extract from Opuntia joconostle at doses of 1, 2, and 5 g/kg body weight significantly (P ≤ 0.001) prevented the increase in total cholesterol, low-density lipoprotein cholesterol, triglycerides level, and atherogenic index. Similar concentrations of the HDL cholesterol were observed in both treated and control groups. A significant dose-dependent reduction in lipid levels was noted for treated groups compared to the hypercholesterolemic group. We attribute this result to the seeds' phenolic composition. This methanolic extract has potential to be included in short-term hypercholesterolemia treatment regimens as it exhibits hypolipidemic activity with no apparent toxic manifestations.

Candesartan, an angiotensin II AT₁-receptor blocker and PPAR-γ agonist, reduces lesion volume and improves motor and memory function after traumatic brain injury in mice

Traumatic brain injury (TBI) results in complex pathological reactions, the initial lesion worsened by secondary inflammation and edema. Angiotensin II (Ang II) is produced in the brain and Ang II receptor type 1 (AT₁R) overstimulation produces vasoconstriction and inflammation. Ang II receptor blockers (ARBs) are neuroprotective in models of stroke but little is known of their effect when administered in TBI models. We therefore performed controlled cortical impact (CCI) injury on mice to investigate whether the ARB candesartan would mitigate any effects of TBI. We administered candesartan or vehicle to mice 5 h before CCI injury. Candesartan treatment reduced the lesion volume after CCI injury by approximately 50%, decreased the number of dying neurons, lessened the number of activated microglial cells, protected cerebral blood flow (CBF), and reduced the expression of the cytokine TGFβ1 while increasing expression of TGFβ3. Candesartan-treated mice also showed better motor skills on the rotarod 3 days after injury, and improved performance in the Morris water maze 4 weeks after injury. These results indicate that candesartan is neuroprotective, reducing neuronal injury, decreasing lesion volume and microglial activation, protecting CBF and improving functional behavior in a mouse model of TBI. Co-treatment with a peroxisome proliferator-activated receptor-gamma (PPARγ) antagonist significantly reduced some of the beneficial effects of candesartan after CCI, suggesting that PPARγ activation may contribute to part or to all of the neuroprotective effect of candesartan. Overall, our data suggest that ARBs with dual AT₁R-blocking and PPARγ activation properties may have therapeutic value in treating TBI.

A cottage model for eldercare

OBJECTIVE

An overview of medical, cognitive, and affective changes experienced by geriatric long-term care residents during a migration from traditional healthcare delivery to a cottage-based model.

BACKGROUND

New architectural models hold great promise for improving health and social outcomes for residents. New studies must explore the resident, family, and staff outcomes across transformations, as well as the business case for change.

METHODS

A longitudinal, quasi-experimental design was employed, with an emphasis on regularly acquired institutional data, including the Minimum Data Set, as well as commonly available survey instruments including the MOSES, the 2005 NSWHN, and Castle's Job Satisfaction Questionnaire. Descriptive statistics, McNemar's Exact Test, repeated measures ANOVA, and t-tests were used as well as narratives from families, staff, and management.

RESULTS

Staff perceived enhanced institutional respect (t(72) = 2.38, p = 0.02) and work environment, and families perceived more staff cooperation and a better bond between staff and residents. No changes were discerned in a resident's prevalence of pain (odds ratio 0.43, p = .34, 95% CI [0.07, 1.88]), mobility (odds ratio 0.50, p =.19, 95% CI [0.17, 1.32]), range of motion(odds ratio 0.57, p = .55, 95% CI [0.12, 2.25]), or depression and anxiety (odds ratio 2.33, p =.11,95% CI [0.84, 7.41]). A modest decline in residents' systolic (t(101) = 3.74, p < .001) and diastolic (t(101) = 2.870, p < .01) blood pressures was demonstrated. The rate at which a resident's Activities of Daily Living score declined was attenuated (t(57) = 3.37, p < .001). Operational costs remained constant across the move.

CONCLUSIONS

Cottage settings were aesthetically appealing to residents, family, and staff. Modest improvements in health outcomes were observed, and operational costs remained stable.

Angiotensin II AT(1) receptor blockers as treatments for inflammatory brain disorders

The effects of brain AngII (angiotensin II) depend on AT(1) receptor (AngII type 1 receptor) stimulation and include regulation of cerebrovascular flow, autonomic and hormonal systems, stress, innate immune response and behaviour. Excessive brain AT(1) receptor activity associates with hypertension and heart failure, brain ischaemia, abnormal stress responses, blood-brain barrier breakdown and inflammation. These are risk factors leading to neuronal injury, the incidence and progression of neurodegerative, mood and traumatic brain disorders, and cognitive decline. In rodents, ARBs (AT(1) receptor blockers) ameliorate stress-induced disorders, anxiety and depression, protect cerebral blood flow during stroke, decrease brain inflammation and amyloid-β neurotoxicity and reduce traumatic brain injury. Direct anti-inflammatory protective effects, demonstrated in cultured microglia, cerebrovascular endothelial cells, neurons and human circulating monocytes, may result not only in AT(1) receptor blockade, but also from PPARγ (peroxisome-proliferator-activated receptor γ) stimulation. Controlled clinical studies indicate that ARBs protect cognition after stroke and during aging, and cohort analyses reveal that these compounds significantly reduce the incidence and progression of Alzheimer's disease. ARBs are commonly used for the therapy of hypertension, diabetes and stroke, but have not been studied in the context of neurodegenerative, mood or traumatic brain disorders, conditions lacking effective therapy. These compounds are well-tolerated pleiotropic neuroprotective agents with additional beneficial cardiovascular and metabolic profiles, and their use in central nervous system disorders offers a novel therapeutic approach of immediate translational value. ARBs should be tested for the prevention and therapy of neurodegenerative disorders, in particular Alzheimer's disease, affective disorders, such as co-morbid cardiovascular disease and depression, and traumatic brain injury.

Efficacy and tolerability of nebivolol: does age matter? A retrospective analysis of three randomized, placebo-controlled trials in stage I-II hypertension

OBJECTIVES

This retrospective analysis examined the efficacy and tolerability of nebivolol, a ß(1)-selective, vasodilatory β-blocker, in four different age groups of patients with hypertension.

METHODS

Data were pooled from three 12-week, randomized, placebo-controlled trials (placebo, n = 205; nebivolol [1.25-30/40 mg/day], n = 1811) and stratified into age quartiles (Group 1: 22-46 years; Group 2: 47-53 years; Group 3: 54-62 years; Group 4: 63-84 years). Only patients treated with placebo and the three commonly used nebivolol dosages (5, 10, and 20 mg/day) are presented. Baseline-to-endpoint changes in trough sitting diastolic blood pressure (DBP), systolic blood pressure (SBP), and heart rate (HR) were analyzed for each age quartile using an analysis of covariance (ANCOVA) model. Tolerability was assessed by means of adverse event (AE) rates.

RESULTS

The analysis comprised 205 placebo-treated patients and 1380 patients treated with nebivolol dosages of 5, 10, or 20 mg/day. Older age was associated with higher SBP values at baseline. In all age groups, each of the three most frequently used nebivolol dosages significantly reduced DBP, compared with placebo (-9.1 to -11.8 mmHg versus -3.4 to -5.9 mmHg; p ≤ 0.008 overall). For SBP, a statistically significant effect versus placebo was observed for all dosages and age groups except for 5 and 10 mg/day in Group 4. Within each group, treatment with nebivolol (all three dosages) and placebo resulted in similar AE rates (nebivolol: 26.1-36.6%; placebo: 36.2-42.6%) and AE-related discontinuation rates (1.8-3.8% versus 0-4.3%). In each age group, there were no significant nebivolol-placebo differences in the rates of patients who experienced clinically significant changes or abnormal endpoint levels of metabolic parameters.

CONCLUSIONS

This retrospective analysis suggests that nebivolol monotherapy is efficacious and well tolerated across various age groups, with the efficacy in reducing SBP somewhat diminishing in patients over 62 years of age.

Erectile dysfunction and hypertension: impact on cardiovascular risk and treatment

Erectile dysfunction (ED) is a common complaint in hypertensive men and can represent a systemic vascular disease, an adverse effect of antihypertensive medication or a frequent concern that may impair drug compliance. ED has been considered an early marker of cardiovascular disease. The connection between both conditions seems to be located in the endothelium, which may become unable to generate the necessary dilatation in penile vascular bed in response to sexual excitement, producing persistent impairment in erection. On the other hand, the real influence of antihypertensive drugs in erectile function still deserves discussion. Therefore, regardless of ED mechanism in hypertension, early diagnosis and correct approach of sexual life represent an important step of cardiovascular evaluation which certainly contributes for a better choice of hypertension treatment, preventing some complications and restoring the quality of life.

Hypolipidemic effect of avocado (Persea americana Mill) seed in a hypercholesterolemic mouse model

Avocado seed contains elevated levels of phenolic compounds and exhibits antioxidant properties. We investigated the effect of Avocado Seed Flour (ASF) on the lipid levels in mice on a hyperlipidemic diet. The concentration of phenols was determined by high-performance liquid chromatography, antioxidant activity was evaluated using the Trolox equivalent antioxidant capacity method, and dietary fiber was measured using the Association of Official Analytical Chemists (AOAC) method. The LD50 of ASF was determined using Lorke's method and hypolipidemic activity was evaluated in a hypercholesterolemic model in mice. Protocatechuic acid was the main phenolic compound found in ASF, followed by kaempferide and vanillic acid. The total phenolic content in the methanolic extract of ASF was 292.00 ± 9.81 mg gallic acid equivalents/g seed dry weight and the antioxidant activity resulted in 173.3 μmol Trolox equivalents/g DW. In addition, a high content of dietary fiber was found (34.8%). The oral LD50 for ASF was 1767 mg/kg body weight, and treatment with ASF significantly reduced the levels of total cholesterol, LDL-C, and prediction of the atherogenic index. Therefore, the antioxidant activity of phenolic compounds and dietary fiber in ASF may be responsible for the hypocholesterolemic activity of ASF in a hyperlipidemic model of mice.

Functional outcomes of multi-condition collaborative care and successful ageing: results of randomised trial

OBJECTIVE

To evaluate the effectiveness of integrated care for chronic physical diseases and depression in reducing disability and improving quality of life.

DESIGN

A randomised controlled trial of multi-condition collaborative care for depression and poorly controlled diabetes and/or risk factors for coronary heart disease compared with usual care among middle aged and elderly people

SETTING

Fourteen primary care clinics in Seattle, Washington.

PARTICIPANTS

Patients with diabetes or coronary heart disease, or both, and blood pressure above 140/90 mm Hg, low density lipoprotein concentration >3.37 mmol/L, or glycated haemoglobin 8.5% or higher, and PHQ-9 depression scores of ≥ 10.

INTERVENTION

A 12 month intervention to improve depression, glycaemic control, blood pressure, and lipid control by integrating a "treat to target" programme for diabetes and risk factors for coronary heart disease with collaborative care for depression. The intervention combined self management support, monitoring of disease control, and pharmacotherapy to control depression, hyperglycaemia, hypertension, and hyperlipidaemia.

MAIN OUTCOME MEASURES

Social role disability (Sheehan disability scale), global quality of life rating, and World Health Organization disability assessment schedule (WHODAS-2) scales to measure disabilities in activities of daily living (mobility, self care, household maintenance).

RESULTS

Of 214 patients enrolled (106 intervention and 108 usual care), disability and quality of life measures were obtained for 97 intervention patients at six months (92%) and 92 at 12 months (87%), and for 96 usual care patients at six months (89%) and 92 at 12 months (85%). Improvements from baseline on the Sheehan disability scale (-0.9, 95% confidence interval -1.5 to -0.2; P = 0.006) and global quality of life rating (0.7, 0.2 to 1.2; P = 0.005) were significantly greater at six and 12 months in patients in the intervention group. There was a trend toward greater improvement in disabilities in activities of daily living (-1.5, -3.3 to 0.4; P = 0.10).

CONCLUSIONS

Integrated care that covers chronic physical disease and comorbid depression can reduce social role disability and enhance global quality of life. Trial registration Clinical Trials NCT00468676.

Angiotensin II AT(1) receptor blockers ameliorate inflammatory stress: a beneficial effect for the treatment of brain disorders

Excessive allostatic load as a consequence of deregulated brain inflammation participates in the development and progression of multiple brain diseases, including but not limited to mood and neurodegenerative disorders. Inhibition of the peripheral and brain Renin-Angiotensin System by systemic administration of Angiotensin II AT(1) receptor blockers (ARBs) ameliorates inflammatory stress associated with hypertension, cold-restraint, and bacterial endotoxin administration. The mechanisms involved include: (a) decreased inflammatory factor production in peripheral organs and their release to the circulation; (b) reduced progression of peripherally induced inflammatory cascades in the cerebral vasculature and brain parenchyma; and (c) direct anti-inflammatory effects in cerebrovascular endothelial cells, microglia, and neurons. In addition, ARBs reduce bacterial endotoxin-induced anxiety and depression. Further pre-clinical experiments reveal that ARBs reduce brain inflammation, protect cognition in rodent models of Alzheimer's disease, and diminish brain inflammation associated with genetic hypertension, ischemia, and stroke. The anti-inflammatory effects of ARBs have also been reported in circulating human monocytes. Clinical studies demonstrate that ARBs improve mood, significantly reduce cognitive decline after stroke, and ameliorate the progression of Alzheimer's disease. ARBs are well-tolerated and extensively used to treat cardiovascular and metabolic disorders such as hypertension and diabetes, where inflammation is an integral pathogenic mechanism. We propose that including ARBs in a novel integrated approach for the treatment of brain disorders such as depression and Alzheimer's disease may be of immediate translational relevance.

Brain angiotensin AT1 receptors as specific regulators of cardiovascular reactivity to acute psychoemotional stress

1. Cardiovascular reactivity, an abrupt rise in blood pressure (BP) and heart rate in response to psychoemotional stress, is a risk factor for heart disease. Pharmacological and molecular genetic studies suggest that brain angiotensin (Ang) II and AT(1) receptors are required for the normal expression of sympathetic cardiovascular responses to various psychological stressors. Moreover, overactivity of the brain AngII system may contribute to enhanced cardiovascular reactivity in hypertension. 2. Conversely, brain AT(1) receptors appear to be less important for the regulation of sympathetic cardiovascular responses to a range of stressors involving an immediate physiological threat (physical stressors) in animal models. 3. Apart from threatening events, appetitive stimuli can induce a distinct, central nervous system-mediated rise in BP. However, evidence indicates that brain AT(1) receptors are not essential for the regulation of cardiovascular arousal associated with positively motivated behaviour, such as anticipation and the consumption of palatable food. The role of central AT(1) receptors in regulating cardiovascular activation elicited by other types of appetitive stimuli remains to be determined. 4. Emerging evidence also indicates that brain AT(1) receptors play a limited role in the regulation of cardiovascular responses to non-emotional natural daily activities, sleep and exercise. 5. Collectively, these findings suggest that, with respect to cardiovascular arousal, central AT(1) receptors may be involved primarily in the regulation of the defence response. Therefore, these receptors could be a potential therapeutic target for selective attenuation of BP hyperreactivity to aversive stressors, without altering physiologically important cardiovascular adjustments to normal daily activities, sleep and exercise.