Use of a self-rating scale to monitor depression severity in recurrent GP consultations in primary care - does it really make a difference? A randomised controlled study

Background

Little information is available about whether the use of self-assessment instruments in primary care affects depression course and outcome. The purpose was to evaluate whether using a depression self-rating scale in recurrent person-centred GP consultations affected depression severity, quality of life, medication use, and sick leave frequency.

Methods

Patients in the intervention group met their GP regularly at least 4 times during the 3 months intervention. In addition to treatment as usual (TAU), patients completed a self-assessment instrument (Montgomery-Asberg Depression Rating Scale) on each occasion, and then GPs used the completed instrument as the basis for a person-centred discussion of changes in depression symptoms. The control group received TAU. Frequency of visits in the TAU arm was the result of the GPs’ and patients’ joint assessments of care need in each case.

Depression severity was measured with Beck Depression Inventory-II (BDI-II), quality of life with EQ-5D, and psychological well-being with the General Health Questionnaire-12 (GHQ-12). Data on sick leave, antidepressant and sedatives use, and care contacts were collected from electronic patient records. All variables were measured at baseline and 3, 6, and 12 months. Mean intra-individual changes were compared between the intervention and TAU group.

Results

There were no significant differences between the intervention and control group in depression severity reduction or remission rate, change in quality of life, psychological well-being, sedative prescriptions, or sick leave during the whole 12-month follow-up. However, significantly more patients in the intervention group continued antidepressants until the 6 month follow-up (86/125 vs 78/133, p < 0.05).

Conclusions

When GPs used a depression self-rating scale in recurrent consultations, patients more often continued antidepressant medication according to guidelines, compared to TAU patients. However, reduction of depressive symptoms, remission rate, quality of life, psychological well-being, sedative use, sick leave, and health care use 4-12 months was not significantly different from the TAU group. These findings suggest that frequent use of depression rating scales in person-centred primary care consultations has no further additional effect on patients’ depression or well-being, sick leave, or health care use.

Trial registration

ClinicalTrials.gov Identifier: NCT01402206. Registered June 27 2011(retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0578-9) contains supplementary material, which is available to authorized users.

Circulatory effects of noise

Thirteen patients with mild essential hypertension, mean age 44 years (range 21-59), were studied during "stress" before and after postsynaptic alpha-adrenoceptor blockade and combined postsynaptic alpha- and non-selective beta-adrenoceptor blockade. Loud broad band noise (100 dBA for 10 min) was used as the stress stimulus. Exposure to noise caused a significant increase in systolic (7%, p less than 0.05), diastolic (9%, p less than 0.01) and mean arterial pressure (6%, p less than 0.01). The blood pressure elevation was caused by an increase in total peripheral resistance (12%, p less than 0.05). There was no significant change in heart rate, stroke volume or cardiac output. The blood pressure response during noise stimulation was not affected by postsynaptic alpha-adrenoceptor blockade (prazosin, 2 mg orally). The hemodynamic reaction pattern, however, was totally reversed. Thus, the cardiac output increased significantly (9%, p less than 0.05), while the total peripheral resistance tended to decrease. Combined postsynaptic alpha- and non-selective beta-adrenoceptor blockade (labetalol, 200 mg orally) inhibited the increase in systolic blood pressure caused by noise, while the diastolic and mean arterial pressures still increased significantly (5%, p less than 0.01). Labetalol effectively blocked the stress-induced increase in total peripheral resistance and there was no significant increase in cardiac output after combined alpha- and beta-adrenoceptor blockade. Exposure to noise caused a significant increase in circulating noradrenaline (20%, p less than 0.05). Plasma adrenaline and plasma renin activity were not affected by noise stimulation. These results suggest that blood pressure elevation is essential during "stress" but that the hemodynamic pattern causing blood pressure elevation may vary and may be affected by pharmacological blockade of various parts of the sympathetic nervous system.

Hemodynamic effects of loud noise before and after central sympathetic nervous stimulation

The hemodynamic effects of loud noise after central alpha 2-adrenoceptor stimulation were studied in 13 patients with mild (WHO 1) essential hypertension. The patients were randomized (double-blind) to treatment with either placebo or guanfacine 1-2 mg for four weeks and then crossed over and treated for another four weeks. All patients were exposed to a loud broad-band noise (105 dBA for 30 min) and all were studied both on placebo and guanfacine. Guanfacine significantly reduced the resting blood pressure from 141/92 to 134/88 mmHg (p less than 0.01) as well as heart rate at rest from 63 to 58 beats/min (p less than 0.05). Noise stimulation caused a significant increase in blood pressure and resistance in the placebo-treated group, while cardiac output decreased significantly. Pretreatment for one month with the central alpha 2-adrenoceptor stimulating agent guanfacine did not block the noise-induced pressor response nor the increase in peripheral resistance. A significant decrease in stroke volume was observed and cardiac output also tended to decrease in this group. It could be concluded that loud noise is a potent pressor stimulus which causes vasoconstriction and that the blood pressure response during noise could not be blocked by the centrally acting antihypertensive agent guanfacine. Since noise causes vasoconstriction it also induces an increased tone in the small arteries and, if the noise stimulus is sufficiently strong and repeated for a long time, it might cause structural changes in the resistance vessels and permanent arterial hypertension in humans.

Hemodynamic effects of combined beta-adrenoceptor blockade and precapillary vasodilatation in hypertension

Carvedilol (BM14190) is a new compound with combined properties of nonselective beta-adrenoceptor blockade, devoid of ISA, and precapillary vasodilatation. Its acute hemodynamic effects were studied with invasive technique (dye-dilution using Cardio-Green) in 10 patients taking 25 mg orally and noninvasive (fore-arm plethysmography) in 10 patients taking 25 mg and in 10 patients taking 50 mg orally, all with essential hypertension. Significant reductions of systolic and diastolic blood pressures (p less than 0.05 - 0.001) were observed in all groups. TPR did not change acutely whereas resistance in the fore-arm was reduced by 16% (p less than 0.05). When a comparison with propranolol (80 mgx2) was made in a randomized, double-blind placebo controlled trial comprising 30 patients with essential hypertension, carvedilol acutely reduced blood pressure significantly 13/6 mm Hg (25 mg) and 17/10 mm Hg (50 mg) in contrast to propranolol. Resistance in the fore-arm (plethysmography) fell significantly with carvedilol 50 mg whereas propranolol caused a significant rise. After 4 weeks both compounds had reduced blood pressure significantly and to the same extent. Blood flow was still reduced with propranolol in contrast to the findings with carvedilol. We conclude that carvedilol given orally has a useful antihypertensive effect both acutely and during prolonged treatment. It has an attractive hemodynamic profile.

Interaction between a commercially available St. John’s wort product (Movina) and atorvastatin in patients with hypercholesterolemia

OBJECTIVE

The aim of this study was to assess the effect of treatment with a St. John's wort product (Movina) on cholesterol [total cholesterol, low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol] and triglyceride levels in patients with hypercholesterolemia on treatment with a stable dose of atorvastatin in a controlled, randomised, open, crossover interaction study.

METHODS

Sixteen patients with hypercholesterolemia treated with a stable dose of atorvastatin (10-40 mg/daily) for at least 3 months were treated with Movina one tablet (containing 300 mg of hypericum perforatum) twice daily and control (a commercially available multivitamin tablet Vitamineral). After a run-in period of 4 weeks, patients were randomised to treatment with either Movina or control for 4 weeks in a crossover design. The atorvastatin dose was kept unchanged during the study period (12 weeks), and assessments of total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides were performed in the morning with the patients in the fasting condition. The difference between control and active treatment in LDL cholesterol after 4 weeks of treatment was the primary endpoint.

RESULTS

All patients completed the study. The St. John's wort product significantly increased the serum level of LDL cholesterol compared with control (2.66 mmol/l compared with 2.34 mmol/l, p = 0.004). A significant increase in total cholesterol was also observed (5,10 mmol/l compared with 4.78 mmol/l, p = 0.02). No statistically significant change was observed in HDL cholesterol (1.59 mmol/l and 1.56 mmol/l, p = 0.49) or in triglycerides (1.87 mmol/l and 1.94 mmol/l, p = 0.60). No product-related side effects were reported

CONCLUSION

An interaction was observed between the studied St.-John's-wort-containing product and atorvastatin. Physicians and patients should be aware of this interaction and if treatment with a St. John's wort product is considered necessary, then there may be a need for increasing the dose of atorvastatin.

Determination of intrathyroidal iodine by X-ray fluorescence analysis in 60- to 65-year olds living in an iodine-sufficient area

OBJECTIVES

X-ray fluorescence (XRF) is a non-invasive method for determining the iodine content of the thyroid gland in vivo. In spite of the obvious clinical value of such a method in situations of iodine deficiency or iodine overload, the method has not so far been widely used. The objective was to investigate the applicability of the XRF method in a larger number of subjects.

DESIGN AND SUBJECTS

The study comprised 37 individuals, aged 60-65 years, who had spent their entire life with iodine supplementation through iodinated table salt. Individuals with (previous) thyroid disease were excluded. The individual thyroid function had previously been evaluated by measurements of thyroid-related hormones, thyroid volume and 131-Iodine (131I) uptake which indicated a sufficient iodine intake of the population in the area. Iodine in the right thyroid lobe in each subject was examined using XRF.

RESULTS

The mean thyroid iodine concentration was 0.4 mg mL(-1), corresponding to a mean total iodine content of 5.2 mg (range 0.9-20.2). There was a pronounced difference between individuals. No correlation was found between iodine concentration and 131I uptake or thyroid volume. Neither was iodine content and 131I uptake correlated.

CONCLUSIONS

In a population living under iodine-sufficient conditions, a large variation of iodine stored in the thyroid is compatible with euthyroidism. Determination of the iodine pool by XRF investigation is feasible in a clinical setting and the method offers a unique possibility to study the intrathyroidal iodine pool in subjects with thyroid disease. The low radiation dose enables the use of the method in pregnant women and also in young individuals.

Effect of lifelong iodine supplementation on thyroid 131-I uptake: a decrease in uptake in euthyroid but not hyperthyroid individuals compared to observations 50 years ago

BACKGROUND

In Sweden, iodine has been added to table salt (10 mg/kg) since 1936; this amount was increased in 1966 to 50 mg/kg.

OBJECTIVE

To investigate a euthyroid Swedish population (n = 44, 60-65 years) with its entire lifespan with iodine supplementation as for 24-h 131-I uptake (24 h IU) and thyroid nodularity (thyroid scintigraphy). To compare the euthyroid 24 h IU with uptake of thyrotoxic individuals, and with observations from 1955.

METHODS

The 24 h IU was used in euthyroid individuals after oral administration of 0.1 MBq/2.7 microCi radioiodine and imaging of the thyroid gland was carried out using 99mTc-pertechnetate.

RESULTS

In 1999-2000, the mean 24 h IU in the euthyroid individuals was 21% (range 11-33%) and the normal (central 95%) reference interval was 14-30%. Scintigraphy suggested multinodular goitre in three euthyroid individuals. In Graves' patients (n = 53, 50-65 years), the mean 24 h IU was 61% (range 29-89%). In 1955, the 24 h IU in euthyroid individuals was higher (38%, range 10-70%), while hyperthyroid patients had uptake values similar to those recorded in the present investigation (mean 62%, range 40-90%).

CONCLUSIONS

The population sample studied had to be small for ethical reasons. We conclude that the reference interval for 24 h IU is 14-30% in this population that had spent its entire lifespan with iodine supplementation. This is lower than that recorded in a Swedish euthyroid population half a century ago having had low-grade table-salt iodine supplementation for 20 years. Values for hyperthyroid patients, however, do not appear to have been affected likewise.

Urinary iodine and thyroid volume in a Swedish population

OBJECTIVE

To evaluate the present efficacy of an iodine supplementation programme working in Sweden since 1936 by studying the iodine excretion in urine and determining the thyroid volume in a population in a semi-rural community.

DESIGN

A cross-sectional population screening comprising three age groups with randomly selected individuals: group 1 (children): 7-9 years, n = 61 (invited 70); group 2 (teenagers): 15-17 years, n = 61 (invited 63), and group 3 (adults): 60-65 years; n = 57 (invited 73).

MAIN MEASUREMENTS

Urinary iodine was measured spectrophotometrically; thyroid volume by ultrasonography.

RESULTS

The median values for urinary iodine concentration in the three age groups were 194 microg L(-1), 246 microg L(-1) and 190 microg L(-1), respectively, indicating an adequate iodine intake. In the 7-9 year olds, the median value of the thyroid volume was 4.7 mL, which coincides with the recently established upper limit of normal children of that age, 4.0-4.8 mL (ICCIDD, International Council for control iodine deficiency disorders). One eight-year-old boy had a pronounced goiter. Four teenagers and one adult were found to have an enlarged thyroid gland according to earlier established reference volumes (15 years >16 mL; adults > 25 mL).

CONCLUSION

We conclude that the iodine intake in our region is sufficient in age groups ranging from young children to pre-retirement adults.

Screening for thyroid disease of 15-17-year-old schoolchildren in an area with normal iodine intake

OBJECTIVE

The prevalence of thyroid disease in Swedish schoolchildren is today insufficiently known. The aim of the study was therefore to determine the prevalence of abnormal thyroid function and thyroid autoimmunity in teen-age schoolchildren and to compare the findings with a healthy control group of 60-65-year-old inhabitants from the same community.

SETTING

A semirural community of approximately 15,000 inhabitants.

DESIGN

Cross-sectional study.

MAIN OUTCOME MEASURES

Thyroid volume and serum concentrations of serum thyrotropin (TSH), total and free thyroxine (T4), total and free 3,5,3'-triiodothyronine (T3), and antithyroperoxidase antibodies (TPOAb).

RESULTS

Four schoolchildren (7%, 59 screened) had elevated TPOAb concentration, three of the subjects being girls (8%). One girl with a goitre was overtly hypothyroid and one girl showed borderline-high serum TSH concentration suggesting subclinical autoimmune thyroid disease. One euthyroid boy had a goitre and high concentration of TPOAb. The serum free T3 concentration was significantly higher in 15-17-year-old than 60-65-year-old (7.4 vs. 6.4 pmol L(-1), P < 0.001). The concentrations of other thyroid hormones and of TSH in 15-17-year-old did not differ from those of the 60-65-year-old.

CONCLUSIONS

We found three cases of thyroid disease in need of immediate attention or later follow-up. The prevalence of autoimmune thyroid disease was high as indicated from TPOAb measurements. Thyroid tests including TPOAb measurement should be performed on wide indications when teenagers seek medical advice. The reference intervals for teen-age children for commonly used first line tests (TSH and free T4) do not differ from those for adults.

Relations between Helicobacter pylori, thyroid disease and cardiovascular risk factors in a 56-65-year-old population

OBJECTIVE

To estimate the prevalence of and relation between Helicobacter pylori (HP) and thyroid disease in a 56-65-year-old population with cardiovascular risk factors.

DESIGN

Cross-sectional study including every second individual in the age group.

SETTING

The primary health care district of Mölnlycke, with about 14,000 inhabitants.

PATIENTS

170 men and 217 women aged between 56 and 65 years.

MAIN OUTCOME MEASURES

Anthropometric (body mass index (BMI), waist/hip ratio (WHR)) and blood pressure measurements, biochemical analyses, including s-TSH, s-FT4 and HP serology.

RESULTS

There was a high prevalence of metabolic risk factors in this pre-retirement group of individuals. The prevalence of HP was 42% in both men and women. Only a significant correlation between HP and WHR was seen in men.

CONCLUSIONS

No reason could be found for including analysis of HP and thyroid tests in screening programmes for cardiovascular risk factors in men and women.

[Ultrasonic measurement of residual urine is considerate and reliable]

The measurement of residual urine is often an invaluable aid in the examination of patients with prostate enlargement. As a result of the increasing scope of pharmacological treatment options in cases of such urinary problems, more such investigations are now being performed in primary care. Traditionally, residual urine has been measured by catheterisation of the urethra, which is associated with a risk of infection and other complications. As experience of ultrasound measurement of residual urine in 30 patients at a primary health centre suggests it to be a rapid, easily tolerated method unaccompanied by complications, it would seem to be an appropriate procedure even for use in the elderly with any of a variety of chronic diseases. It was also found easy for various categories of staff to learn.

The relations of microalbuminuria to ambulatory blood pressure and myocardial wall thickness in a population

OBJECTIVES

To examine the relationship between microalbuminuria (20-200 microg min(-1)) and 24 h ambulatory blood pressure and heart wall thickness, in a representative population sample of men and women aged 56-65 years.

DESIGN

Every second individual aged 56-65 years (n=488) in the district, was invited for a health examination, which included determination of urinary albumin and creatinine (overnight sample). The highest and lowest decentile of urinary albumin/creatinine ratio were compared.

SETTING

The district of the Primary Health Care and Research Centre of Mölnlycke, Sweden.

SUBJECTS

After excluding 2 individuals with a urinary albumin excretion exceeding 200 microg min(-1). 26 subjects (group 1) could be compared with 27 subjects in the lowest decentile (group 2).

MAIN OUTCOME MEASURES

Comparison between the determinations of the ambulatory blood pressure and echocardiographic variables in the two groups.

RESULTS

Group 1 had significantly higher 24 h ambulatory blood pressure, and heart septum and posterior wall thickness as well as significantly higher fasting blood glucose and serum triglyceride concentrations. The differences in blood pressure (P < 0.05) but not heart wall thickness remained significant (P<0.05) after excluding subjects with hypertension, angina pectoris, treated diabetes mellitus, and/or history of heart or cerebrovascular disease. When excluding individuals with both treated and untreated diabetes mellitus, fasting blood glucose concentration was higher in group 1. The waist-hip ratio, weight and body mass index did not differ between the groups.

CONCLUSIONS

The findings indicate that microalbuminuria is related to signs of cardiovascular and metabolic influence and therefore could be a valuable tool for grading the risk of later cardiovascular morbidity.

[A simple health control for the elderly. Screening for vitamin B12 deficiency and thyroid disease]

Screening for vitamin B12 deficiency and thyroid disease is cheap and enables early diagnosis to be made and treatment to be started while it is still simple and can prevent the development of such serious conditions as dementia, depression, or irreversible tissue damage. In 1995-6, 83% (126/151) of all 75-year-olds in Härryda, a district (population 28,500) to the east of Gothenburg, agreed to undergo a health control designed to detect hypo- or hyper-thyroidism or vitamin B12 deficiency among elderly residents without symptoms (or with atypical symptoms not easily recognised). Of the 126 participants, four (3%) had low plasma cobalamin (vitamin B12) levels (a figure similar to or lower than those reported by others), and were treated with vitamin B12 after further examination; eight (6%) had serum thyroid stimulating hormone (TSH) levels below the lower normal limit, though further examination showed all eight to be euthyroid; and two (1.6%) were diagnosed as being hypothyroid (a lower prevalence than figures reported elsewhere), and were treated with laevothyroxine. The findings suggest that such screening might be useful in primary care. However, the clinical diagnosis of vitamin B12 deficiency, and of hypo- or hyperthyroidism, is often difficult, especially in the elderly; and although a low serum TSH level is also considered to be a reliable marker of hyperthyroidism, like others this study showed that it may occur even in the absence of disease. Thus, serum TSH and plasma B12 levels are useful screening variables, but need to be complemented by other tests before diagnosis is set.

The value of screening for retinopathy and microalbuminuria in patients with type 2 diabetes in primary health care

Patients with type 2 diabetes (NIDDM) attending the Primary Care Centre in Mölnlycke, Sweden, were evaluated regarding their metabolic status, microalbuminuria (UAER), and hypertension. An ophthalmological examination was performed, and two diagnostic methods, slit-lamp biomicroscopy and fundus photography, were compared. Nearly half the patients (42%) had diabetic retinopathy, mainly of the background type. Retinopathy was associated only with the duration of the disease, but the prevalence was as high as 20% within 0-4 years of the diagnosis. Fundus photography was easy to apply, except in the age groups above 80 years, in otherwise healthy and mentally cooperative patients. Fundus photography could not be applied in only 7% of the patients for ophthalmological reasons. The prevalence of microalbuminuria (20-200 micrograms/min) was high--34%--with another 8% above that range. Male sex, mode of antidiabetic treatment, and hypertension were associated with an increased UAER. Screening for retinopathy and microalbuminuria is valuable in primary health care in order to detect treatable diabetic retinopathy and to trace patients with microalbuminuria, a risk factor for clinically overt nephropathy as well as for cardiovascular diseases.

Effect of coffee on ambulatory blood pressure in patients with treated hypertension

Effects of caffeine on ambulatory blood pressure, heart rate, renin-angiotensin system, and ANP were studied in patients treated for mild to moderate hypertension in a randomized, double-blind, placebo-controlled, cross-over trial comparing 2 weeks of caffeine-free diet with 2 weeks of regular coffee use. Twenty-three patients (13 men; aged 28-74 years) with treated, mild to moderate essential hypertension and a regular intake of 3-4 cups of coffee daily completed the study. Mean 24-h, day- or night-time ambulatory blood pressure and heart rate were not different between regimens. Nor were there any effects on the renin-angiotensin system while ANP was significantly increased during caffeine intake. Compliance of the dietary regimen was excellent as assessed by serum caffeine concentration measurements. We conclude that habitual coffee drinking did not influence the 24-h blood pressure profiles or cardiovascular hormones in treated hypertensives.

Screening of an elderly population in primary care for primary hyperparathyroidism

In order to assess the diagnostic outcome of a screening for primary hyperparathyroidism (PHPT) in an elderly population, we determined ionized calcium in serum from 368 individuals participating in a health control at Mölnlycke Primary Care Centre (200 women, 168 men; age range 75-95 years); four-fifths of the individuals living in their homes, the remainder in homes for aged or nursing homes. Intact parathyroid hormone was determined in the samples with oinized calcium concentration greater than mean + 3SD of the truncated population sample, and these individuals were also recalled for another blood sample. Moderate hypercalcaemia, probably due to PHPT, was found in eight individuals (2% of the complete sample, 3% of the women), five having neuropsychiatric or neuromuscular symptoms consistent with PHPT. Surgical intervention is probably indicated in only a small proportion of elderly patients. We conclude that optimal benefits in relation to costs of screening for PHPT in old people will depend on the availability of a safe and simple pharmacological treatment that could determine any causal relationship between hypercalcaemia and symptoms.

Additive effect of isradipine in combination with captopril in hypertensive patients

The effects of combined treatment with the calcium antagonist isradipine and the angiotensin-converting enzyme inhibitor captopril were investigated in a randomized, placebo-controlled parallel-group trial comprising 28 patients with essential hypertension. The average age was 50 years (range, 31 to 65 years). After all patients were given captopril 50 mg twice daily plus placebo for four weeks, they were randomly assigned into groups receiving in addition either placebo or isradipine 1.25 mg twice daily in increasing doses at four-week intervals. During Weeks 20 to 24, the captopril plus placebo group was given hydrochlorothiazide 12.5 mg per day. Blood pressure was measured in the morning, 12 hours after tablet intake. Supine blood pressure was reduced in the captopril plus isradipine group by -8/-6, -14/-9, -16/-8, and -11/-7 mm Hg compared with the placebo group. Changes in diastolic blood pressure were statistically significant at Week 8, whereas changes in systolic blood pressure were statistically significant at Weeks 12, 16, and 20. With the addition of hydrochlorothiazide (Weeks 20 to 24), only supine systolic blood pressure was significantly reduced. One patient was withdrawn from the trial due to a rash. The results indicate that combined treatment with a calcium antagonist and an angiotensin-converting enzyme inhibitor is effective in lowering blood pressure and that the combination is well tolerated during long-term therapy. The combination of captopril and isradipine was more effective than captopril given with a low dose of hydrochlorothiazide.

Screening for thyroid disease in a primary care unit with a thyroid stimulating hormone assay with a low detection limit

In a study at a primary care centre in a predominantly rural area of Sweden the records of all patients with established thyroid disease were scrutinised and 2000 consecutive adult patients screened with an immunoenzymometric thyroid stimulating hormone assay. The aims of the study were fourfold: firstly, to assess the total burden of thyroid disease in primary care centres in Sweden; secondly, to assess the efficacy of clinical diagnosis of the disease in unselected populations of patients; thirdly, to assess the efficacy of clinical evaluation of treatment with thyroxine; and, lastly, to see whether a single analysis of the serum thyroid stimulating hormone concentration by recent methods would be enough to identify an abnormality of thyroid function. Of the roughly 17,400 adults in the study community, 111 women and 10 men were being treated for thyroid disease. Screening detected 68 patients (3.5%) not receiving thyroxine who had a serum thyroid stimulating hormone concentration of 0.20 mU/l or less, all of whom were followed up clinically. Fifty of these patients were also studied biochemically during follow up. Only nine of the 68 patients had thyroid disease (three with thyrotoxicosis requiring treatment), no evidence of the disease being found in the remainder. Sixteen patients had spontaneous hypothyroidism requiring treatment, and neither these nor three patients with thyrotoxicosis had been detected at the preceding clinical examination. Of 35 patients in whom thyroid disease was suspected clinically at screening, none had laboratory evidence of thyroid dysfunction. In this series 1.3% of all women in the study community (2.6% of all 50-59 year olds) and 0.1% of the men were being treated for thyroid disease at the primary care centre, roughly 1.0% of adults subjected to screening were found to have thyroid disease requiring treatment, and most patients with a thyroid stimulating hormone concentration of 0.20 mU/l or less did not have thyroid dysfunction. It is concluded that measuring the basal serum thyroid stimulating hormone concentration by present methods is insufficient for the biochemical assessment of thyroid dysfunction in unselected populations.

Diltiazem in hypertensive patients with type II diabetes mellitus

Twenty-three patients with essential hypertension and diabetes mellitus type II were treated with the calcium antagonist diltiazem (120 to 180 mg twice daily). The mean dose was 307 mg/day. The study was a double-blind, placebo-controlled, crossover design. All measurements were performed 12 to 14 hours after drug intake. Blood pressure, heart rate and forearm blood flow were measured noninvasively. Platelet function was studied by measuring adenosine diphosphate-induced platelet aggregation and the platelet specific proteins, beta thromboglobulin and platelet factor 4. Thromboxane B2 formation in serum and the plasma concentration of diltiazem and its metabolites N-demethyldiltiazem, deacetyldiltiazem and N-demethyldeacetyldiltiazem were measured both during placebo and diltiazem treatment. Diabetic control was evaluated by following HbA1C, fasting blood glucose and urinary glucose. Diltiazem reduced both systolic and diastolic (supine and standing) blood pressure significantly. Forearm blood flow was significantly increased by 32%, p less than 0.05. Supine heart rate decreased significantly, while no such change was seen in the standing position. No significant changes were observed in platelet function during diltiazem treatment. There was no relation between the observed blood pressure reduction and the plasma concentration of diltiazem or its metabolites. A positive correlation between the change in heart rate and the metabolite N-demethyldeacetyldiltiazem was observed (r = 0.647, p = 0.005). Three patients were excluded during diltiazem treatment (skin exanthema, headache and atrial fibrillation) and 1 during placebo treatment (angina pectoris). No negative effect on diabetes control was observed. Thus, diltiazem could be used for treatment of hypertension in diabetic patients.

Calcium antagonists combined with beta-blockers or ACE inhibitors in the treatment of hypertension

During the last few years, there has been a growing awareness that treated hypertensive patients are still at substantially increased risks for cardiovascular morbidity and mortality and that one conceivable explanation for this is that their blood pressure has not been lowered to strictly normotensive levels. To obtain normotensive blood pressures, it may be necessary to skillfully combine antihypertensive drugs much more frequently than has been common so far. In this context, calcium antagonists in combination with beta-blockers are of special interest, since several controlled studies have shown that a combination between a beta-blocker and nifedipine, nitrendipine, isradipine, or felodipine have been remarkably potent as regards their antihypertensive effect. In controlled trials, such combinations have also been shown to be more effective and better tolerated than a combination between a beta-blocker and hydralazine. Marked efficacy has also been noted when a calcium antagonist has been combined with an angiotensin converting enzyme (ACE) inhibitor. So far, most studies have dealt with small numbers of patients and study design has not always been optimal. Results from controlled studies will presumably be ready for presentation in the near future. It can be concluded that combination therapy between calcium antagonists and beta-blockers or ACE inhibitors appear to be markedly effective and well tolerated. This would offer the possibility of reducing elevated arterial pressure to normotensive levels in many hypertensive patients.

Influence on blood pressure of oestrogen substitution therapy in the menopause

In a Swedish health centre an analysis was made of the effect on blood pressure of oestrogen substitution therapy in 33 normotensive women in the menopause. Comparisons were made with a control group of 33 normotensive women of the same ages but left without oestrogen therapy. Following three years of therapy with oestrogen alone or in combination with progesterone, there were no significant changes in blood pressure. This was true also when a subgroup consisting of 11 women treated with equinous oestrogens was analysed separately. These results could therefore indicate that chronic treatment with oestrogens in postmenopausal women probably has small effect on the general blood pressure level and that the risk of inducing arterial hypertension must be low.

Potentiation of the antihypertensive effect of enalapril by randomized addition of different doses of hydrochlorothiazide

The purpose of this study was to evaluate the potentiating effect of hydrochlorothiazide (HCTZ) 12.5 or 25 mg once daily when added in a placebo-controlled double-blind randomized study of patients with essential hypertension, whose diastolic blood pressure (DBP) was not adequately controlled (DBP > 90 mmHg) following 6 weeks of single-blind treatment with the angiotensin converting enzyme (ACE) inhibitor enalapril, 20 mg once daily. Forty-eight patients started the first period with enalapril after 4 weeks on placebo. In 13 patients DBP fell to < or = 90 mmHg after enalapril for 6 weeks. In this group supine mean arterial pressure (MAP) was reduced by 13% (P < 0.01). In the patients whose DBP was > 90 mmHg after 6 weeks on enalapril (n = 32) the average supine MAP fell by 9% (P < 0.001). After 3 weeks there was no further drop in blood pressure (BP). Addition of HCTZ to the 32 patients with DBP > 90 mmHg caused a significant further drop in supine BP by 13/7 mmHg with 12.5 mg and by 15/7 mmHg with 25 mg. Seven patients discontinued the study, none due to side effects on enalapril alone. Well-being, assessed with a special questionnaire, was significantly better with enalapril as monotherapy compared with previous treatment, but not different from well-being during the placebo periods. It is concluded that 20 mg enalapril once daily lowered BP effectively and was well tolerated. The maximum BP lowering effect was seen within 3 weeks. Addition of HCTZ caused a significant, and clinically relevant, further drop in BP.(ABSTRACT TRUNCATED AT 250 WORDS)

Vasodilators in hypertension--a review with special emphasis on the combined use of vasodilators and beta-adrenoceptor blockers

This paper presents a review of studies dealing with combined beta-adrenoceptor blockade and vasodilatation in the treatment of hypertension. This therapy can be achieved either through the combined use of conventional beta-adrenoceptor blocking compounds given together with vasodilator drugs or with agents which show multiple action of this kind. From a hemodynamic point of view this therapeutic approach is quite logical since most forms of established hypertension are characterized by increased vascular resistance. It can therefore be concluded that combined beta-adrenoceptor blockade and vasodilation offers a rational and useful treatment of hypertension.

Haemodynamic effects of carvedilol, a new beta-adrenoceptor blocker and precapillary vasodilator in essential hypertension

Carvedilol (BM 14190) is a new antihypertensive compound which combines beta-adrenoceptor blocking and precapillary vasodilating properties but is devoid of intrinsic sympathomimetic activity. The acute and long-term effects on blood pressure and regional haemodynamics (forearm plethysmography) were studied with carvedilol 25 mg b.i.d. or 50 mg b.i.d. Comparisons were made with propranolol 80 mg b.i.d. in a randomized double-blind placebo controlled trial comprised of 30 patients with essential hypertension. After a four-week placebo period active therapy was given for four weeks. Carvedilol administered acutely reduced blood pressure at both doses, delta 13/6 mmHg (P less than 0.001/P less than 0.01) and 17/10 mmHg (P less than 0.001/P less than 0.01). Resistance in the forearm fell significantly with the higher dose. This was in contrast to propranolol which only reduced heart rate acutely, and as expected caused a rise in forearm resistance. After four weeks both compounds had reduced blood pressure significantly and to the same extent. Blood flow was still significantly reduced with propranolol in contrast to the findings with carvedilol. We conclude that carvedilol given orally has a useful antihypertensive effect both acutely and during prolonged treatment. It is well tolerated and its haemodynamic profile is attractive.

Haemodynamic effects of loud noise in hypertensive patients treated with combined beta-adrenoceptor blockade and precapillary vasodilatation

The effects of acute exposure to noise on central and regional (calf and forearm) haemodynamics were studied during placebo therapy and during combined nonselective beta-adrenoceptor blockade and precapillary vasodilatation in 9 patients with essential hypertension. On placebo therapy a loud noise (105 dBA for 10 min) caused a significant increase in diastolic and mean arterial pressure due to vasoconstriction. There was also a significant increase of vascular resistance in the calf. After combined precapillary vasodilatation and non-selective beta-adrenoceptor blockade, the increase in blood pressure during stimulation with noise was not prevented. Thus, systolic as well as diastolic and mean arterial pressures increased significantly. This indicates a temporary resetting of the baroreceptors, allowing a higher level of blood pressure during stimulation with noise. Such a resetting would involve the central nervous system pathways of the baroreflex and this would explain why the peripherally active therapeutic principle--precapillary vasodilatation and beta-adrenoceptor blockade--was unable to inhibit the blood pressure response induced by noise.

Effects of treatment with nifedipine and metoprolol in essential hypertension

In a double-blind trial 26 patients with essential hypertension were treated with nifedipine or placebo for 8 weeks, following a 4-week run-in-placebo period in all patients. The daily dosage of nifedipine during this phase was 10 mg 3 times daily. Metoprolol was then added to the therapeutic regimen of both groups for a further 12 weeks. Both nifedipine and metoprolol used as mono-therapy caused statistically significant reductions of arterial pressure. The addition of metoprolol to nifedipine tended to reduce blood pressure further, but blood pressures were not significantly lower than during nifedipine mono-therapy. Side-effects were few and only two patients had to be withdrawn during active therapy, one for headaches during nifedipine therapy, and another for asthma during metoprolol treatment. Combined therapy with a beta-adrenoceptor blocking agent, such as metoprolol, and a calcium antagonist with vasodilation properties, such as nifedipine, offers a theoretically interesting approach in the treatment of hypertension, even though the practical outcome in the present study probably suffered from an inadequate dose of nifedipine during the period of combined therapy.