Cost of poor blood pressure control in the UK: 62,000 unnecessary deaths per year

Therapeutic RNA-silencing oligonucleotides in metabolic diseases

Recent years have seen unprecedented activity in the development of RNA-silencing oligonucleotide therapeutics for metabolic diseases. Improved oligonucleotide design and optimization of synthetic nucleic acid chemistry, in combination with the development of highly selective and efficient conjugate delivery technology platforms, have established and validated oligonucleotides as a new class of drugs. To date, there are five marketed oligonucleotide therapies, with many more in clinical studies, for both rare and common liver-driven metabolic diseases. Here, we provide an overview of recent developments in the field of oligonucleotide therapeutics in metabolism, review past and current clinical trials, and discuss ongoing challenges and possible future developments.

A randomized, double-blind, placebo-controlled, clinical trial to evaluate the benefits of Nigella sativa seeds oil in reducing cardiovascular risks in hypertensive patients

The efficacy, safety, and utility of Nigella sativa seeds oil as a complementary treatment for hypertension, glucose control, and lipid metabolism were evaluated. Hypertensive patients in the intervention (n = 26) and placebo (n = 29) groups received 2.5 ml of N. sativa seeds oil and sunflower oil twice daily for 8 weeks, respectively. The levels of systolic and diastolic blood pressure (SBP, DBP), blood lipid profile, and fasting blood sugar (FBS), at different stages of the treatment period (0, 3, 6, 8 weeks), and malondialdehyde (MDA) and glutathione reductase (GR), at the baseline and end of the study, were assessed. SBP level in the intervention group was significantly reduced, compared with the baseline values (p < .001) and the placebo group (p < .05). A significant decline was observed in the levels of DBP, total cholesterols, and low density lipoprotein (LDL) (p < .000), MDA, and FBS (p < .001); also, a significant increase was observed in the levels of high density lipoprotein (HDL) and GR (p < .001). The use of N. sativa seeds oil as an adjunct to common medications exhibited additional antihypertensive effects as well as beneficial effects on glucose control and lipid metabolism in hypertensive patients with no renal, hepatic, and patient-reported adverse events.

Association between attendance at outpatient follow-up appointments and blood pressure control among patients with hypertension

Objective

The aim of this study was to assess the impact of regularity in treatment follow-up appointments on treatment outcomes among hypertensive patients attending different healthcare settings in Islamabad, Pakistan. Additionally, factors associated with regularity in treatment follow-up were also identified.

Methods

A cross-sectional study was undertaken in selected primary, secondary and tertiary healthcare settings between September, 2017 and December, 2018 in Islamabad, Pakistan. A structured data collection form was used to gather sociodemographic and clinical data of recruited patients. Binary logistic regression analyses were undertaken to determine association between regularity in treatment follow-up appointments and blood pressure control and to determine covariates significantly associated with regularity in treatment follow-up appointments.

Results

A total of 662 patients with hypertension participated in the study. More than half 346 (52%) of the patients were females. The mean age of participants was 54 ± 12 years. Only 274 (41%) patients regularly attended treatment follow-up appointments. Regression analysis found that regular treatment follow-up was an independent predictor of controlled blood pressure (OR 1.561 [95% CI 1.102–2.211; P = 0.024]). Gender (OR 1.720 [95% CI 1.259–2.350; P = 0.001]), age (OR 1.462 [CI 95%:1.059–2.020; P = 0.021]), higher education (OR 1.7 [95% CI 1.041–2.778; P = 0.034]), entitlement to free medical care (OR 3.166 [95% CI 2.284–4.388; P = 0.0001]), treatment duration (OR 1.788 [95% CI 1.288–2.483; P = 0.001]), number of medications (OR 1.585 [95% CI 1.259–1.996; P = 0.0001]), presence of co-morbidity (OR 3.214 [95% CI 2.248–4.593; P = 0.0001]) and medication adherence (OR 6.231 [95% CI 4.264–9.106; P = 0.0001]) were significantly associated with regularity in treatment follow-up appointments.

Conclusion

Attendance at follow-up visits was alarmingly low among patients with hypertension in Pakistan which may explain poor treatment outcomes in patients. Evidence-based targeted interventions should be developed and implemented, considering local needs, to improve attendance at treatment follow-up appointments.

Randomized Controlled Trials of Tianma Gouteng Decoction Combined with Nifedipine in the Treatment of Primary Hypertension: A Systematic Review and Meta-Analysis

Background

Hypertension is a primary risk factor for cardiovascular disease (CVD). Tianma Gouteng decoction (TGD), originating from Zabingzhengzhixinyi, has been used for thousands of years in China to treat hypertension, giddiness, and migraine. This updated meta-analysis aimed at assessing the efficacy and safety of TGD combined with nifedipine in the treatment of primary hypertension.

Methods

Related research published prior to September 1, 2019, was found in electronic databases without language limitations. Fourteen studies were selected and analyzed for specified criteria, including the quality of the studies. All outcomes were recorded exhaustive. Data management and analysis were performed using RevMan 5.3 software.

Results

A total of 1,537 (769 cases in the experimental group and 768 cases in the control group) patients were enrolled. The total efficacy rate was improved significantly for the combination of nifedipine with TGD compared to nifedipine treatment alone (I ² = 22%, RR = 1.17, and 95% CI: 1.12 to 1.22). Traditional Chinese medicine (TCM) symptoms of patients were obviously improved in the experimental group than in the control group (I ² = 22%, RR = 1.17, and 95% CI: 1.12 to 1.22). Traditional Chinese medicine (TCM) symptoms of patients were obviously improved in the experimental group than in the control group (I ² = 22%, RR = 1.17, and 95% CI: 1.12 to 1.22). Traditional Chinese medicine (TCM) symptoms of patients were obviously improved in the experimental group than in the control group (I ² = 22%, RR = 1.17, and 95% CI: 1.12 to 1.22). Traditional Chinese medicine (TCM) symptoms of patients were obviously improved in the experimental group than in the control group (I ² = 22%, RR = 1.17, and 95% CI: 1.12 to 1.22). Traditional Chinese medicine (TCM) symptoms of patients were obviously improved in the experimental group than in the control group (P < 0.00001) when two studies (shicaihong 2017 and xiaoyugao 2017) were removed. And the results of DBP showed no heterogeneity (I ² = 22%, RR = 1.17, and 95% CI: 1.12 to 1.22). Traditional Chinese medicine (TCM) symptoms of patients were obviously improved in the experimental group than in the control group (P < 0.00001) when two studies (shicaihong 2017 and xiaoyugao 2017) were removed. And the results of DBP showed no heterogeneity (.

Conclusion

The combination of TGD and nifedipine has a better effect in the treatment of hypertension, including blood pressure lowering and patients' TCMs improving. However, our findings must be handled with care because of the small sample size and low quality of clinic trials cited. Other rigorous and large-scale RCTs are in need to confirm these results.

Hypertensive ED patients: Missed opportunities for addressing hypertension and facilitating outpatient follow-up

OBJECTIVES

Hypertension is a leading cause of morbidity and mortality. The emergency department (ED) frequently serves populations with unmet health needs and could have a greater and more systematic role in secondary prevention for hypertension. This study sought to determine, among hypertensive patients discharged from the ED, the frequency that patients 1) received hypertension-specific education, and 2) followed-up with a primary care provider. We secondarily assessed participant beliefs about hypertension.

METHODS

This non-experimental, observational study enrolled a convenience sample of consenting patients with asymptomatic, markedly elevated blood pressure (systolic ≥160 mmHg or diastolic ≥100 mmHg) with medium to low triage acuity discharged from an urban, academic ED. Discharge instructions were assessed through chart review. Patients followed up per their normal routine without intervention. Participants were interviewed by phone two to four weeks after ED discharge to ascertain outpatient follow-up and describe beliefs about hypertension.

RESULTS

From April through June 2014, 200 patients were approached, of whom 90 were enrolled. Of these, 77% of patients reported a previous diagnosis of hypertension, and 60% reported current treatment with antihypertensive medications. Five patients (5.5%) received written instructions at discharge addressing hypertension, although 59 (65.6%) reported that they were informed about their elevated blood pressure during the ED visit. Follow-up with a primary care provider within 2-4 weeks of discharge was completed in 57% of cases. None of the patients who received hypertension-specific discharge instructions completed follow-up.

CONCLUSIONS

Over half of markedly hypertensive patients discharged from the ED followed up with primary care within four weeks. Nonetheless, missed opportunities for improved secondary prevention among ED patients with hypertension are common. There is an urgent need for evidence-based interventions to assist emergency departments in addressing this health threat.

Patients' and Healthcare Personnel's Experiences of Health Coaching with Online Self-Management in the Renewing Health Project

Background

Telehealth applications have shown positive effects for people with chronic conditions and their awareness of health.

Objective

To describe patients' and healthcare personnel's experiences of using health coaching with online self-management in primary health care.

Method

A pragmatic randomised controlled trial was conducted. Patients in the intervention group measured and reported medical parameters such as blood pressure, blood glucose, prothrombin complex (PK) values, and 2-channel ECG. Data were collected through a questionnaire, individual interviews with patients, and focus group discussions with healthcare personnel. The questionnaire was analysed using statistics; texts from interviews and focus groups were analysed using content analysis.

Findings

Patients were satisfied and believed that the intervention had enhanced their care and increased accessibility without causing concerns about privacy. Although being positive, patients commented the lack of support and feedback from healthcare personnel. Healthcare personnel regarded the intervention valuable for the patients' abilities to perform self-management healthcare tasks but preferred that patients did so without them supporting the patients.

Conclusion

Patients expressed satisfaction and acceptance regarding the use of the application. It seems that healthcare personnel are convinced about the benefits for patients and the potential for the intervention but are not convinced about its benefits for healthcare organisations.

Physical health indicators in major mental illness: analysis of QOF data across UK general practice

BACKGROUND

The Quality and Outcomes Framework (QOF) has specific targets for body mass index (BMI) and blood pressure recording in major mental illness (MMI), diabetes, and chronic kidney disease (CKD). Although aspects of MMI (schizophrenia, bipolar disorder, and related psychoses) are incentivised, barriers to care may occur.

AIM

To compare payment, population achievement, and exception rates for blood pressure and BMI recording in MMI relative to diabetes and CKD across the UK.

DESIGN AND SETTING

Analysis of 2012/2013 QOF data from 9731 UK general practices 2 years after the introduction of the mental health, BMI, and blood pressure QOF indicators.

METHOD

Payment, exception, and population achievement rates for the MMI and CKD blood pressure indicators and the MMI and diabetes BMI indicators were calculated and compared.

RESULTS

UK payment and population achievement rates for BMI recording for MMI were significantly lower than for diabetes (payment: 92.7% versus 95.5% and population achievement: 84.0% versus 92.5%, P<0.001) and exception rates were higher (8.1% versus 2.0%, P<0.001). For blood pressure recording, UK payment and population achievement rates were significantly lower for MMI than for CKD (94.1% versus 97.8% and 87.0% versus 97.1%, P<0.001), while exception rate was higher (6.5% versus 0.0%, P<0.001). This was observed for all countries. Compared with England, Northern Ireland had higher population achievement rates for both mental health indicators, whereas Scotland and Wales had lower rates. There were no cross-jurisdiction differences for CKD and diabetes.

CONCLUSION

Differences in payment, exception, and population achievement rates for blood pressure and BMI recording for MMI relative to CKD and diabetes were observed across the UK. These findings suggest potential inequalities in the monitoring of physical health in MMI within the UK primary care system.

Updated national and international hypertension guidelines: a review of current recommendations

Despite the availability of effective pharmacological treatments to aid the control of blood pressure, the global rate of uncontrolled blood pressure remains high. As such, further measures are required to improve blood pressure control. Recently, several national and international guidelines for the management of hypertension have been published. These aim to provide easily accessible information for healthcare professionals and patients to aid the diagnosis and treatment of hypertension. In this review, we have compared new and current guidelines from the American and International Societies of Hypertension; the American Heart Association, American College of Cardiology and the US Center for Disease Control and Prevention; the panel appointed to the Eighth Joint National Committee; the European Societies of Hypertension and Cardiology; the French Society of Hypertension; the Canadian Hypertension Education Program; the National Institute for Health and Clinical Excellence (UK); the Taiwan Society of Cardiology and the Chinese Hypertension League. We have identified consensus opinion regarding best practises for the management of hypertension and have highlighted any discrepancies between the recommendations. In general there is good agreement between the guidelines, however, in some areas, such as target blood pressure ranges for the elderly, further trials are required to provide sufficient high-quality evidence to form the basis of recommendations.

Clinical implications of the 2013 ESH/ESC hypertension guidelines: targets, choice of therapy, and blood pressure monitoring

The European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines for the management of arterial hypertension included simplified blood pressure (BP) targets across patient groups, more balanced discussion on monotherapy vs. combination therapy, as well as reconfirmation of the importance of out-of-office BP measurements. In light of these updates, we wished to review some issues raised and take a fresh look at the role of calcium channel blocker (CCB) therapy; an established antihypertensive class that appears to be a favorable choice in many patients. Relaxed BP targets for high-risk hypertensive patients in the 2013 ESH/ESC guidelines were driven by a lack of commanding evidence for an aggressive approach. However, substantial evidence demonstrates cardiovascular benefits from more intensive BP lowering across patient groups. Individualized treatment of high-risk patients may be prudent until more solid evidence is available. Individual patient profiles and preferences and evidence for preferential therapy benefits should be considered when deciding upon the optimal antihypertensive regimen. CCBs appear to be a positive choice for monotherapy, and in combination with other agent classes, and may provide specific benefits beyond BP lowering. Ambulatory and home BP monitoring have an increasing role in defining the diagnosis and prognosis of hypertension (especially non-sustained); however, their value for comprehensive diagnosis and appropriate treatment selection should be more widely acknowledged. In conclusion, further evidence may be required on BP targets in high-risk patients, and optimal treatment selection based upon individual patient profiles and comprehensive diagnosis using out-of-office BP measurements may improve patient management.

Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control

Hypertension significantly contributes to the increased cardiovascular morbidity and mortality, thus leading to rising healthcare costs. The objective of this study was to quantify the clinical and economic benefits of optimal systolic blood pressure (SBP), in a setting under severe financial constraints, as in the case of Greece. Hence, a Markov model projecting 10-year outcomes and costs was adopted, in order to compare two scenarios. The first one depicted the "current setting", where all hypertensives in Greece presented an average SBP of 164 mmHg, while the second scenario namely "optimal SBP control" represented a hypothesis in which the whole population of hypertensives would achieve optimal SBP (i.e. <140 mmHg). Cardiovascular events' occurrence was estimated for four sub-models (according to gender and smoking status). Costs were calculated from the Greek healthcare system's perspective (discounted at a 3% annual rate). Findings showed that compared to the "current setting", universal "optimal SBP control" could, within a 10-year period, reduce the occurrence of non-fatal events and deaths, by 80 and 61 cases/1000 male smokers; 59 and 37 cases/1000 men non-smokers; whereas the respective figures for women were 69 and 57 cases/1000 women smokers; and accordingly, 52 and 28 cases/1000 women non-smokers. Considering health expenditures, they could be reduced by approximately €83 million per year. Therefore, prevention of cardiovascular events through BP control could result in reduced morbidity, thereby in substantial cost savings. Based on clinical and economic outcomes, interventions that promote BP control should be a health policy priority.

Hypertension awareness, treatment and control in Africa: a systematic review

BACKGROUND

Inadequate diagnosis and suboptimal control of hypertension is a major driver of cardiovascular morbidity and mortality in Africa. Understanding the levels of awareness, treatment and control of hypertension and the associated factors has important implications for hypertension control efforts.

METHODS

The PubMed database was searched for original articles related to awareness, treatment and control of hypertension in Africa published between 1993 and 2013. The key search terms were: Africa, awareness, treatment, control, and hypertension. Exploration of bibliographies cited in the identified articles was done to provide further studies. Full texts of the articles were obtained from various internet sources and individual authors. A data extraction sheet was used to collect this information.

RESULTS

Thirty-eight studies drawn from 23 African countries from all regions of the continent met the inclusion criteria. The levels of awareness, treatment and control varied widely from country to country. Rural populations had lower levels of awareness than urban areas. North African countries had the highest levels of treatment in the continent. There was generally poor control of hypertension across the region even among subjects that were aware of their status and those that were treated. On the whole, the women had a better control status than the men.

CONCLUSION

There are low levels of awareness and treatment of hypertension and even lower levels of control. Tailored research is required to uncover specific reasons behind these low levels of awareness and treatment, and especially control, in order to inform policy formulation for the improvement of outcomes of hypertensive patients in Africa.

Role of Illness Perceptions and Medication Beliefs on Medication Compliance of Elderly Hypertensive Cohorts

Background:

Poor compliance with antihypertensive medications is one possible reason why its success in clinical trials has not been translated into everyday practice. In addition, medication noncompliance in elderly leads to increased hospitalizations, physician visits, and higher health care costs.

Objective:

The study assessed influence of illness perceptions and medications beliefs on medication compliance of elderly hypertensive cohorts.

Method:

A cross-sectional survey research design, utilizing self-administered health surveys, was adapted to address key study objectives. Conceptualized associations among the study variables were explored to assess their individual as well as their collective impact on the medication compliance.

Result:

A total of 78 (66%) study samples were found to be noncompliant with their medications. Analysis revealed that perceptions about illness and beliefs about medication jointly played a significant role in the prediction of medication compliance ( F = 5.966, P < .05; R2 = .212). Significant bivariate correlations were observed between Morisky’s test score versus Brief Illness Perception Questionnaire measure ( r = .332, P = .001), Beliefs of Medication Questionnaire (BMQ) differential score ( r = .301, P = .001), and BMQ components, such as specific necessity ( r = .250, P = .008), specific concern ( r = −.231, P = .001), and general overuse ( r = −.342, P = .001).

Conclusion:

The findings provide practical basis for designing interventions and programs aimed at compliance building in elderly populations having hypertension by incorporating the value and importance of patient perceptions of illness and medications in order to achieve desired patient outcomes.

Prehypertension is not associated with all-cause mortality: a systematic review and meta-analysis of prospective studies

OBJECTIVES

Quantitative associations between prehypertension or its two separate blood pressure (BP) ranges and cardiovascular disease (CVD) or all-cause mortality have not been reliably documented. In this study, we performed a comprehensive systematic review and meta-analysis to assess these relationships from prospective cohort studies.

METHODS

We conducted a comprehensive search of PubMed (1966-June 2012) and the Cochrane Library (1988-June 2012) without language restrictions. This was supplemented by review of the references in the included studies and relevant reviews identified in the search. Prospective studies were included if they reported multivariate-adjusted relative risks (RRs) and corresponding 95% confidence intervals (CIs) of CVD or all-cause mortality with respect to prehypertension or its two BP ranges (low range: 120-129/80-84 mmHg; high range: 130-139/85-89 mmHg) at baseline. Pooled RRs were estimated using a random-effects model or a fixed-effects model depending on the between-study heterogeneity.

RESULTS

Thirteen studies met our inclusion criteria, with 870,678 participants. Prehypertension was not associated with an increased risk of all-cause mortality either in the whole prehypertension group (RR: 1.03; 95% CI: 0.91 to 1.15, P = 0.667) or in its two separate BP ranges (low-range: RR: 0.91; 95% CI: 0.81 to 1.02, P = 0.107; high range: RR: 1.00; 95% CI: 0.95 to 1.06, P = 0.951). Prehypertension was significantly associated with a greater risk of CVD mortality (RR: 1.32; 95% CI: 1.16 to 1.50, P<0.001). When analyzed separately by two BP ranges, only high range prehypertension was related to an increased risk of CVD mortality (low-range: RR: 1.10; 95% CI: 0.92 to 1.30, P = 0.287; high range: RR: 1.26; 95% CI: 1.13 to 1.41, P<0.001).

CONCLUSIONS

From the best available prospective data, prehypertension was not associated with all-cause mortality. More high quality cohort studies stratified by BP range are needed.

Are fixed-dose combination antihypertensives suitable as first-line therapy?

OBJECTIVE

To contemplate how initial antihypertensive therapy with fixed-dose combinations (FDC) might be incorporated into clinical practice, based on a compilation of evidence comparing FDCs with monotherapy and loose-dose combinations in varying patient populations.

METHODS

A non-systematic search of PubMed (from 2007 to 2012) was performed for randomized, controlled trials in order to capture the evidence on FDC versus monotherapy and loose-dose combinations as first-line therapy. The literature search focused on calcium channel blocker (CCB)-renin angiotensin system (RAS) blocker combinations. Additionally, any relevant papers known to the authors were included. International recommendations from published hypertension treatment guidelines were also consulted.

RESULTS

The results of this literature review identified two emergent issues. Firstly, there is a discord between antihypertensive use and actual blood pressure (BP) control achieved - despite an increase in the use of antihypertensives over the last 10 years, BP control rates remain low. Secondly, a greater association between BP and cardiovascular risk in Asians may magnify this discrepancy. A number of international guidelines are recommending early combination therapy, such as CCB-RAS blocker combinations in the majority of patients based on the available evidence, with such combinations showing benefits in terms of compliance, BP lowering and control, and safety. Additionally, recent studies have indicated that improved BP control may be achieved with simplified guidelines and the use of FDCs. Overall, these findings indicate that FDC could be used as first-line.

CONCLUSIONS

The findings from this literature review suggest that physicians may need to readdress their approach to antihypertensive treatment. Earlier use of antihypertensive FDC (including first-line) may help to shrink the current gap between antihypertensive use and BP target control achieved. Most guidelines acknowledge that combination therapy is required in the majority of patients, and FDC are regarded as a suitable alternative, having demonstrated better compliance compared with loose-dose combinations.

Epigenetic manifestation of metabolic syndrome and dietary management

SIGNIFICANCE

Metabolic syndrome constitutes a group of disorders such as insulin resistance, hypertension, and hypertriglyceridemia, predisposing an individual to risk factors such as cardiovascular disease, diabetes, obesity, and dyslipidemia. A majority of these diseases are influenced by the environmental factors, nutrient uptake, and genetic profile of an individual that together dysregulate gene function. These genetic and nongenetic factors are reported to introduce epigenetic cues that modulate the gene function which is inherited by the offspring.

RECENT ADVANCES

Considering the epigenetic modulation of the metabolic disorders, nutrigenomics has been distinctly categorized as a branch that deals with modulatory effect of nutrients on metabolic disorders and disease progression by supplementing the individuals with key nutrient-enriched diets which are derived from plant and animal sources.

CRITICAL ISSUES

Nutritional components of the diet regulate the metabolic health of an individual either by controlling the expression of some key genes related to metabolic pathways or by modulating the epigenetic events on such genes. The present article discusses various metabolic disorders in detail and the effect of nutrients on the specific genes causing those disorders. We also highlight the molecular mechanisms of some metabolic disorders through epigenetic modifications and possible therapeutic interventions.

FUTURE DIRECTIONS

With the advent of high-throughput technologies and epigenetic modulation of the metabolic disorders, an altered epigenetic code that is programmed due to improper nutrients can be reverted back by supplementing the diet with various plant-derived compounds. The implication of small molecular drugs is also of utmost significance for challenging the metabolic disorders.

Liquid chromatography-mass spectrometric determination of losartan and its active metabolite on dried blood spots

A simple and rapid quantitative bioanalytical liquid chromatography-tandem mass spectrometric (LC-MS/MS) method for simultaneous determination of losartan and its active metabolite, losartan carboxylic acid on rat dried blood spots was developed and validated as per regulatory guidelines. Losartan and its metabolite were extracted from dried blood spots using 50% aqueous methanol and separated on Waters XTerra(®) RP18 (250 mm × 4.6 mm, 5 μm) column using mobile phase composed of 40% acetonitrile and 60% aqueous ammonium acetate (10mM). The eluents were monitored using ESI tandem mass spectrometric detection with negative polarity in MRM mode using ion transitions m/z 421.2→179.0, m/z 435.3→157.0 and m/z 427.3→193.0 for losartan, losartan carboxylic acid and Irbesartan (internal standard), respectively. The method was validated over the linear range of 1-200 ng/mL and 5-1000 ng/mL with lower limits of quantification of 1.0 ng/mL and 5.0 ng/mL for losartan and losartan carboxylic acid, respectively. Inter and intra-day precision and accuracy (Bias) were below 5.96% and between -2.8 and 1.5%, respectively. The mean recoveries of the analytes from dried blood spots were between 89% and 97%. No significant carry over and matrix effects were observed. The stability of stock solution, whole blood, dried blood spot and processed samples were tested under different conditions and the results were found to be well within the acceptable limits. Additional validation parameters such as influence of hematocrit and spot volume were also evaluated and found to be well within the acceptable limits.

Maternal undernutrition induces the expression of hypoxia-related genes in the fetal brain

Maternal undernutrition during pregnancy is a risk factor for cerebrovascular and cardiovascular diseases in adulthood. Hypoxia-inducible factor 1 alpha (HIF1α) plays an essential role in cellular hypoxic responses, and its increased expression is associated with cerebrovascular and cardiovascular diseases. However, it is not known whether maternal undernutrition influences HIF1α expression in the fetal brain. We therefore analyzed the expression levels of HIF1α and its downstream genes in the fetal brain (day 17.5 of gestation, 1-2 days before birth). Maternal undernutrition did not noticeably affect the fetal body and brain weights. Both HIF1α mRNA and protein levels were increased in the brain under maternal undernutrition, despite the absence of hypoxia, as judged by the staining profile with hypoxyprobe-1 that identifies hypoxic cells. Importantly, maternal undernutrition caused the accumulation of HIF1α protein in oligodendrocyte precursor cells at the subventricular zone, a site of neurogenesis in the fetal brain. Maternal undernutrition also increased the mRNA level of mammalian target of rapamycin (mTOR), which could increase the level of HIF1α protein under normoxia. Furthermore, microarray analysis revealed that expression levels of mRNAs for 10 HIF1α downstream targets, including enolase 1 and hexokinase 1, were increased in the fetal brain under maternal undernutrition. Thus, the biochemical consequence of maternal undernutrition is similar to that of mild hypoxia. In conclusion, maternal undernutrition induces the expression of HIF1α in oligodendrocyte precursor cells at the subventricular zone, and it also induces the expression of hypoxia-related genes in the fetal brain probably via activation of the mTOR pathway.

Does quality of care for hypertension in primary care vary with postcode area deprivation? An observational study

Background

Hypertension is a common major risk factor for stroke and coronary heart disease. Little is known about how achievement of financially incentivised and non-incentivised indicators of quality of care varies with deprivation, or about the effect of financial incentives on health inequalities in hypertension. General practices in the UK have received financial incentives for high quality care since 2004. This study set out to assess the variations in achievement of incentivised and non-incentivised quality indicators for hypertension by patient area deprivation, before and after the introduction of financial incentives.

Methods

Achievement of 14 quality indicators for hypertension in 304 patient participants in 18 general practices in Norfolk, England was assessed one year before (2003) and one year after (2005) the introduction of financial incentives. Four indicators were incentivised and 10 were non-incentivised. Each participant's postcode was linked to an index of multiple deprivation score.

Results

The range of achievement of incentivised quality indicators was 65-94% in the least deprived third of participants, and 77-94% in the most deprived third in 2003 and 2005 combined. For non-incentivised indicators, the range was 7-85% in the least deprived and 24-93% in the most deprived third.

Achievement of incentivised quality indicators in 2003 and 2005 combined did not vary significantly by area deprivation. Achievement of three of 10 non-incentivised indicators was higher in participants from more deprived postcode areas: providing lifestyle advice (odds ratio 1.34, 95% confidence interval 1.00-1.79), assessment of peripheral vascular disease (1.54, 1.02-2.35) and electrocardiography (1.38, 1.04-1.82).

Conclusions

Participants from more deprived areas received at least the same, and sometimes better, quality of care than those from less deprived areas. Quality of care for hypertension in general practice may not follow the inequitable distribution seen with some other conditions.

Determining the difference in medication compliance between the general patient population and patients receiving antihypertensive therapy: a case study

This study addressed the issue of medication compliance in general, compliance with antihypertensive therapy, and the relationship between these two groups. In addition to determining the reasons for noncompliance with therapy prescription, the aim of this study was to also establish whether it was considered feasible by the patients to comply with their physician's instructions and whether the patients believed that the prescribed therapy was beneficial to their health. Hypertensive patients were compared to the total study population according to age groups. The study was designed as a cross-sectional survey with the use of a 33-item self-administered questionnaire. The study included 635 individuals who were collecting or buying drugs for the treatment of chronic diseases, with special reference to subjects taking antihypertensive agents (n = 361). More than half (n = 361; 56.9%) of the 635 study subjects were on therapy for arterial hypertension and possibly for some other diseases. The great majority of study subjects reported forgetfulness as the main reason for skipping drug doses. Comparison between the total study population and the subjects treated for arterial hypertension according to age groups (compliant, noncompliant and all together) yielded no statistically significant difference. We concluded that there was no difference in medication compliance between the general patient population and patients receiving antihypertensive therapy and there was no correlation between medication compliance and age.

Blood pressure monitoring and control by cardiovascular disease status in UK primary care: 10 year retrospective cohort study 1998-2007

BACKGROUND

Strategies to reduce the burden of cardiovascular disease (CVD) in the UK have emphasized improved management of high-risk individuals rather than population-based approaches.

METHODS

This 10-year retrospective cohort study examined blood pressure (BP) monitoring and control among patients with and without CVD in general practices in Wandsworth, London between 1998 and 2007. Logistic regression was used to assess associations among age, gender, ethnicity, deprivation and BP control.

RESULTS

The percentage of patients with elevated BP (>140/90 mm Hg) decreased at a slower rate in patients without CVD (31.0-25.3%) compared with those with CVD (56.8-36.0%) (P < 0.001). Mean systolic BP decreased from 146.1 to 136.4 mm Hg in patients with CVD and from 133.7 to 130.1 in patients without CVD. Mean diastolic BP decreased from 84.2 to 78.4 mm Hg in patients with CVD and from 80.5 to 79.0 in patients without CVD. Inequalities in BP control decreased among age, ethnic and deprivation groups but increased between men and women without CVD.

CONCLUSIONS

Measurement and control of BP among those with CVD has improved much more rapidly compared with those without CVD. Inequalities in BP control appeared to increase between men and women without CVD, but decreased among age, ethnicity and deprivation groups.

Epigenome mapping in normal and disease States

Epigenomes are comprised, in part, of all genome-wide chromatin modifications, including DNA methylation and histone modifications. Unlike the genome, epigenomes are dynamic during development and differentiation to establish and maintain cell type-specific gene expression states that underlie cellular identity and function. Chromatin modifications are particularly labile, providing a mechanism for organisms to respond and adapt to environmental cues. Results from studies in animal models clearly demonstrate that epigenomic variability leads to phenotypic variability, including susceptibility to disease that is not recognized at the DNA sequence level. Thus, capturing epigenomic information is invaluable for comprehensively understanding development, differentiation, and disease. Herein, we provide a brief overview of epigenetic processes, how they are relevant to human health, and review studies using technologies that enable epigenome mapping. We conclude by describing feasible applications of epigenome mapping, focusing on epigenome-wide association studies (eGWAS), which have the potential to revolutionize current studies of human diseases and will likely promote the discovery of novel diagnostic, preventative, and treatment strategies.

Importance of controlling blood pressure

Cardiovascular disease is the leading cause of death and disability world-wide. Blood pressure, throughout the range seen in developed countries, is the most important risk factor for cardiovascular disease. Lowering blood pressure within the whole population by lifestyle interventions, such as reducing dietary salt intake and increasing the consumption of fruit and vegetables, will be of great benefit. Blood pressure-lowering trials also demonstrate immense benefits in preventing strokes, heart failure and coronary heart disease. There are no differences in outcome between the different methods used to lower blood pressure and the benefit is proportional to the degree of blood pressure-lowering. Thiazide diuretics are effective in lowering blood pressure and have been the most widely prescribed blood pressure-lowering drugs. They work by causing both sodium and water loss, but also cause potassium loss and a fall in plasma potassium levels. The latter may mitigate the beneficial effects from blood pressure-lowering. Some diuretics, such as spironolactone, affect the distal tubule and do not cause a fall in plasma potassium levels. However, spironolactone has endocrine side-effects associated with the fact that it is not specific for the mineralocorticoid receptor. The development of a more selective aldosterone antagonist without endocrine side-effects could be a major advance as it would be able to oppose the effects of aldosterone, both on sodium retention and potassium loss and the other vascular effects.

Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework

OBJECTIVE

To determine levels of blood pressure monitoring and control in primary care and to determine the effect of social deprivation on these levels.

DESIGN

Retrospective longitudinal survey, 2005 to 2007.

SETTING

General practices in England.

PARTICIPANTS

Data obtained from 8515 practices (99.3% of all practices) in year 1, 8264 (98.3%) in year 2, and 8192 (97.8%) in year 3.

MAIN OUTCOME MEASURES

Blood pressure indicators and chronic disease prevalence estimates contained within the UK quality and outcomes framework; social deprivation scores for each practice, ethnicity data obtained from the 2001 national census; general practice characteristics.

RESULTS

In 2005, 82.3% of adults (n=52.8m) had an up to date blood pressure recording; by 2007, this proportion had risen to 88.3% (n=53.2m). Initially, there was a 1.7% gap between mean blood pressure recording levels in practices located in the least deprived fifth of communities compared with the most deprived fifth, but, three years later, this gap had narrowed to 0.2%. Achievement of target blood pressure levels in 2005 for practices located in the least deprived communities ranged from 71.0% (95% CI 70.4% to 71.6%) for diabetes to 85.1% (84.7% to 85.6%) for coronary heart disease; practices in the most deprived communities achieved 68.9% (68.4% to 69.5%) and 81.8 % (81.3% to 82.3%) respectively. Three years later, target achievement in the least deprived practices had risen to 78.6% (78.1% to 79.1%) and 89.4% (89.1% to 89.7%) respectively. Target achievement in the most deprived practices rose similarly, to 79.2% (78.8% to 79.6%) and 88.4% (88.2% to 88.7%) respectively. Similar changes were observed for the achievement of blood pressure targets in hypertension, cerebrovascular disease, and chronic kidney disease.

CONCLUSIONS

Since the reporting of performance indicators for primary care and the incorporation of pay for performance in 2004, blood pressure monitoring and control have improved substantially. Improvements in achievement have been accompanied by the near disappearance of the achievement gap between least and most deprived areas.

Epigenetic modification of the renin-angiotensin system in the fetal programming of hypertension

Hypertension is a major risk factor for cardiovascular and cerebrovascular disease. Lifelong environmental factors (eg, salt intake, obesity, alcohol) and genetic factors clearly contribute to the development of hypertension, but it has also been established that stress in utero may program the later development of the disease. This phenomenon, known as fetal programming can be modeled in a range of experimental animal models. In maternal low protein diet rat models of programming, administration of angiotensin converting enzyme inhibitors or angiotensin receptor antagonists in early life can prevent development of hypertension, thus implicating the renin-angiotensin system in this process. Here we show that in this model, expression of the AT(1b) angiotensin receptor gene in the adrenal gland is upregulated by the first week of life resulting in increased receptor protein expression consistent with the increased adrenal angiotensin responsiveness observed by others. Furthermore, we show that the proximal promoter of the AT(1b) gene in the adrenal is significantly undermethylated, and that in vitro, AT(1b) gene expression is highly dependent on promoter methylation. These data suggest a link between fetal insults to epigenetic modification of genes and the resultant alteration of gene expression in adult life leading ultimately to the development of hypertension. It seems highly probable that similar influences may be involved in the development of human hypertension.

Medicines for hypertension: changes to the UK NICE guidelines

New NICE guidance on the use of medicines for hypertension, published in June 2006, will prompt a major review of treatment for those already receiving medication and also sets out a new treatment pathway for the newly diagnosed. The major change in the guidelines is in the status of beta blockers, which are no longer to be used as a routine treatment for hypertension. The guidelines provide a consensus on treatment, and nurses and their patients now have a clear and straightforward algorithm to follow. It is envisaged that these changes to the way medicines are prescribed for hypertension will have a significant impact on the number of people reaching their target blood pressure, and therefore the number of cardiovascular events occurring each year.

Patient compliance in hypertension: role of illness perceptions and treatment beliefs

Despite many years of study, questions remain about why patients do or do not take medicines and what can be done to change their behaviour. Hypertension is poorly controlled in the UK and poor compliance is one possible reason for this. Recent questionnaires based on the self-regulatory model have been successfully used to assess illness perceptions and beliefs about medicines. This study was designed to describe hypertensive patients' beliefs about their illness and medication using the self-regulatory model and investigate whether these beliefs influence compliance with antihypertensive medication. We recruited 514 patients from our secondary care population. These patients were asked to complete a questionnaire that included the Beliefs about Medicines and Illness Perception Questionnaires. A case note review was also undertaken. Analysis shows that patients who believe in the necessity of medication are more likely to be compliant (odds ratio (OR)) 3.06 (95% CI 1.74-5.38), P<0.001). Other important predictive factors in this population are age (OR 4.82 (2.85-8.15), P<0.001), emotional response to illness (OR 0.65 (0.47-0.90), P=0.01) and belief in personal ability to control illness (OR 0.59 (0.40-0.89), P=0.01). Beliefs about illness and about medicines are interconnected; aspects that are not directly related to compliance influence it indirectly. The self-regulatory model is useful in assessing patients health beliefs. Beliefs about specific medications and about hypertension are predictive of compliance. Information about health beliefs is important in achieving concordance and may be a target for intervention to improve compliance.

Identification of psychosocial factors of noncompliance in hypertensive patients

This cross-sectional study was aimed to identify the predictors of medication noncompliance in hypertensive patients. The study was conducted at the Family Medicine Clinic, Hospital Universiti Sains Malaysia, Kelantan, Malaysia, which is a university-based teaching hospital. All hypertensive patients aged 40 or over-registered from January to June 2004, who had been on treatment for at least 3 months, were screened. Previously validated self-administered questionnaires were used to assess the compliance and psychosocial factors. A total of 240 hypertensive patients were recruited in the study. Of these, 55.8% were noncompliant to medication. Logistic regression showed that age (adjusted odds ratio (OR): 0.96; 95% confidence interval (CI): 0.92-0.997; P: 0.035), patient satisfaction (adjusted OR: 0.97; 95% CI: 0.93-0.998; P: 0.036) and medication barrier (adjusted OR: 0.95; 95% CI: 0.91-0.987; P: 0.009) were significant predictors of medication noncompliance. Therefore, younger age, poor patient satisfaction and medication barrier were identified as independent psychosocial predictors of medication noncompliant in hypertensive patients.

High prevalence of newly detected hypertension in hospitalized patients: the value of inhospital 24-h blood pressure measurement

OBJECTIVE

Screening for hypertension in hospitalized patients could reduce the number of individuals with unrecognized hypertension. We hypothesized that 24-h blood pressure monitoring is an adequate tool to detect unrecognized hypertension among inpatients.

METHODS

Clinically stable inpatients in the Department of Internal Medicine, Department of Visceral Surgery and Department of Orthopaedics were included in the cross-sectional study. Every patient underwent inhospital 24-h blood pressure measurement. Previously unknown hypertension was defined as 24-h blood pressure of at least 125/80 mmHg in the absence of known hypertension. Forty-two patients had an additional 24-h blood pressure measurement after discharge, to compare mean inhospital and outpatient 24-h blood pressure values.

RESULTS

In 314 consecutive inpatients, 24-h blood pressure measurement was performed. Among 139 patients without known hypertension, 53 were hypertensive. The mean routine and 24-h blood pressures in these patients were 135/77 and 137/82 mmHg, respectively. Thirty-seven of these patients had normal routine blood pressure and could be detected only by 24-h blood pressure measurement. Patients with unknown hypertension had a marked cardiovascular risk profile, 26 being at high or very high cardiovascular risk. However, documented cardiovascular disease was present in only seven patients, suggesting that effective treatment could prevent a considerable number of cardiovascular events. The agreement between inhospital and outpatient 24-h blood pressure measurement in 42 patients was good.

CONCLUSIONS

By performing inhospital 24-h blood pressure measurement, a considerable number of patients with previously unknown hypertension can be detected.

Construction of shRNA targeted to the rat angiotensin II type 1 receptors and its RNAi in cytoplasma

The expression vector of shRNA targeted to the rat angiotensin II receptor gene was constructed and the efficacy of siRNAs to modulate the expression of target gene in the in vitro cultured mammalian cells was investigated for antihypertensive therapy in spontaneous hypertensive rat (SHR) at post-transcriptional level. The sense and antisense RNA oligonucleotides strands targeting angiotensin II receptor mRNA were synthesized individually according to the sequence of the rat angiotensin II receptor. For preparation of duplexes, sense- and antisense-stranded oligonucleotides were mixed and annealed, and the annealed duplexes were cloned into the pGenesil-1 vector. . The rat glioma cells were transfected with constructed pGenesil-1-shRNA plasmid and scrambled plasmid. The cultured cells were collected at different phases. RT-PCR and Western blot were performed. The AT1 mRNA and protein levels behaved ultimately same. Compared to control after 48 h, AT1 mRNA levels were decreased to 35.5% +/- 3.0%, and the levels reached their lowest point after 72 h (20.7% +/- 4% of control). At 24 and 48 h, AT1 protein was reduced to 46.9% +/- 4. 2% and 36.98% +/- 3.7% respectively compared to control and a maximum reduction was observed after 72 h of incubation (28.1% +/- 4% compared to controls). Plasmid-based shRNA expression systems targeted against the rat angiotensin II receptor gene were generated successfully. The shRNAs with a 22-nt stem and a short loop were cleaved into small interfering dsRNA (siRNA) by the Dicer. The in vitro transcribed siRNA enables the effective silencing of gene expression to the target mRNA and leads to effective inhibition of translation of proteins and will be lay the foundation of application of gene silencing technology to hypertensive rats.