Hypertension: Hall M

Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Irazusta J, Lin J, Lorts A, Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M, Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R, Schnitzler E, Shanley T, Kache S, Skache S, Skippen P, Torres A, von Dessauer B, Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A. · No affiliation provided · Crit Care Med. · Pubmed #19325359 No free full text.

Abstract: BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS: Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS: The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS: The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill <or=2 secs, and 2) subsequent intensive care unit hemodynamic support directed to goals of central venous oxygen saturation >70% and cardiac index 3.3-6.0 L/min/m.

Jennings JR, Muldoon MF, Hall M, Buysse DJ, Manuck SB. · Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA. · Sleep. · Pubmed #17326548 No free full text.

Abstract: STUDY OBJECTIVES: To determine whether a simple, structured self-report of overall sleep quality is associated with the presence of the metabolic syndrome and its component risk factors. DESIGN: An observational, cross-sectional study comparing global scores on the Pittsburgh Sleep Quality Index with concurrently collected measures of the components of the metabolic syndrome and presence or absence of the syndrome. The metabolic syndrome criterion of the American Heart Association/National Heart, Blood, and Lung Institute was adopted. SETTING: University laboratory. PATIENTS/PARTICIPANTS: Two hundred ten volunteers with a mean age of 46 years (57% men) screened for the presence of serious illness and related medications. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: All analyses were adjusted for sex and age. Logistic regression showed that poor global sleep-quality scores on the Pittsburgh Sleep Quality Index were related significantly to the presence of the metabolic syndrome-an increase of the global sleep score of 2.6 points (approximately 1 SD) was associated with an odds of having the metabolic syndrome of 1.44 (p = .04, confidence interval = 1.01-2.06). Linear-regression results showed that the Pittsburgh Sleep Quality Index global sleep-quality score was related significantly to waist circumference, body mass index, percentage of body fat, serum levels of insulin and glucose, and estimated insulin resistance. CONCLUSIONS: Self-reported global sleep quality is significantly related to the metabolic syndrome and several of its core components.

Mahmud A, Mahgoub M, Hall M, Feely J. · Department of Therapeutics and Hypertension Clinic, Trinity Centre for Health Sciences, St. James' Hospital, Dublin, Ireland. · Am J Hypertens. · Pubmed #16364838 No free full text.

Abstract: BACKGROUND: The recognition that some 10% to 15% of the hypertensive population may have aldosterone excess has increased the frequency of measurement of the aldosterone-to-renin ratio (ARR) and the use of aldosterone antagonists. Whether this ratio will predict the blood pressure (BP) response to spironolactone is not clear. METHODS: We correlated the BP response to spironolactone 50 mg/day to baseline ARR in 69 hypertensive patients (mean [+/-SD] age 57 +/- 2 years, 65% male), consisting of 39 subjects with long-standing hypertension (4.0 +/- 0.2 years) whose hypertension was uncontrolled on at least three antihypertensive medications and 30 previously untreated patients who were randomized in a cross-over design to receive either spironolactone 50 mg/day or bendroflumethiazide 2.5 mg/day for 4 weeks. RESULTS: After 4 weeks of spironolactone, BP in patients with never-treated hypertension was reduced by 18 +/- 3 / 11 +/- 1 mm Hg. There was a highly significant correlation between log ARR and the fall in systolic BP (r = 0.69, P < .001) and diastolic BP (r = 0.45, P < .05). Nine of ten patients with low renin activity (< or =0.5 ng/mL/h) showed a >20-mm Hg fall in systolic BP. No such correlations were seen when BP was reduced by bendroflumethazide 2.5 mg. For patients with resistant hypertension, despite a BP reduction of 28 +/- 3 / 13 +/- 2 mm Hg after 14 weeks of spironolactone, there was no relationship between the reduction in BP and the ARR; however, subjects with pretreatment potassium <4.0 mmol/L had a greater response than those with levels > or =4.0 mmol/L (34 +/- 3 / 16 +/- 2 v 20 +/- 6 / 8 +/- 3 mm Hg, P < .05) CONCLUSIONS: Based on the study results, ARR and low renin activity may predict the response to spironolactone in never-treated hypertensive patients but not in patients taking antihypertensive drugs, possibly because of the effect of these agents on ARR. In such patients a trial of spironolactone is required to assess the BP response.

Hall M, McGettigan M, O'Callaghan P, Graham I, Shelley E, Feely J. · Department of Therapeutics and Hypertension Clinic, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8. · Ir Med J. · Pubmed #12469998 No free full text.

Abstract: We compared the implementation of secondary prevention some 18 months following acute myocardial infarction or coronary artery bypass surgery in Ireland in 1994 to that in 15 European countries, including Ireland, in 2000. While there were substantial improvements in the use of statins, b-blockers and the availability of rehabilitation programmes since the early 1990s, more patients now smoke, take no exercise and are overweight. The prevalence of non-insulin dependent diabetes has increased by 70%. In comparison with other European countries, we have the highest use of aspirin and the highest prevalence of smoking in women. Despite a considerable improvement in the use of drug therapy we will not achieve the full potential of secondary prevention unless lifestyle factors, including smoking, overweight and exercise receive greater attention by patients with coronary heart disease.

Avni FE, Guissard G, Hall M, Janssen F, DeMaertelaer V, Rypens F. · Department of Paediatric Imaging, Children University Hospital Queen Fabiola ULB, Brussels, Belgium. · Pediatr Radiol. · Pubmed #12164348 No free full text.

Abstract: OBJECTIVE: To determine which US changes occur with time in children affected by autosomal recessive (ARPKD) and autosomal dominant polycystic kidney disease (ADPKD) and whether any of these changes correlate with the onset of renal failure. MATERIALS AND METHODS: We reviewed the US features of 29 patients (16 ARPKD, 13 ADPK) imaged by at least two US examinations. We analysed the size and echogenicity of the kidneys, corticomedullary differentiation (CMD), the presence, location and size of cysts and any other anomaly that developed with time. In order to determine whether a relationship could be found between any of the US changes and the onset of the renal failure (based on a glomerular filtration rate < 50 ml/min per 1.73 m2), a Pearson exact chi-square test was calculated. RESULTS: For ARPKD, renal size was above 4 standard deviations (SD) in 10 of 16 patients, but it remained stable during evolution (10/16). The kidneys appeared hyperechoic (16/16), without CMD in the majority (11/16) of patients. Changes in the appearance of CMD over time were observed in five patients. Small cysts (< 1 cm) were present at the time of diagnosis in seven patients, larger cysts (> 1 cm) in three. A diffuse microcystic pattern was observed in three patients. Diffuse hyperechoic foci developed in 14 patients--13 of whom had developed renal failure at the time of the examination or rapidly thereafter (statistical correlation P=0.0125). For ADPKD, renal size was between 0-2 SD in 7 of 13 patients and above 2 SD in the other 6. Renal echogenicity was normal in five, difficult to assess in five and the kidneys appeared hyperechoic without CMD in three patients. Cysts larger than 1 cm were present in 8 of 12 patients (> 3 cm in 5). In four patients, the cysts measured less than 1 cm. In the last child, the diagnosis had been made antenatally and the first cysts appeared at the age of 6 months. The size of the kidneys (13/13) and of the cysts (11/13) remained stable. No renal failure occurred. CONCLUSIONS: ARPKD may manifest with various US patterns and there may be evolution in the appearances over time. Our study confirms a significant relationship between the development of diffuse hyperechoic foci and the onset of renal failure. In older children, ARPKD and ADPKD may closely resemble each other. Large (> 3 cm) cysts are the US hallmark for the diagnosis of ADPKD; furthermore, fewer US changes occur with time during childhood in ADPKD.