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Pressure Reduction (pressure + reduction)

Distribution by Scientific Domains
Medical Sciences92%
2 Other Domains8%
Distribution within Medical Sciences
Cardiovascular Disease18%
Diabetes15%
11 Other Subdomains49%

Kinds of Pressure Reduction

  • blood pressure reduction
    		•

    Selected Abstracts

    Beyond the Usual Strategies for Blood Pressure Reduction: Therapeutic Considerations and Combination Therapies

    JOURNAL OF CLINICAL HYPERTENSION, Issue 6 2001
    Thomas D. Giles MD
    Rapidly accumulating clinical data have repeatedly demonstrated not only the critical importance of even small increases in blood pressure as a pathophysiologic factor in the development of cardiovascular disease, particularly in individuals with diabetes mellitus, but also the therapeutic necessity of more aggressive blood pressure reduction and the achievement of progressively lower blood pressure targets in reducing cardiovascular event rates. JNC VI has defined optimal blood pressure as ,120/80 mm Hg, and Stage 1 hypertension as ,140/80 mm Hg. Target blood pressures are now ,130/80 mm Hg in patients with diabetes and <125/75 mm Hg for patients with hypertensive renal disease with proteinuria of>1 gm/24 hours. Achieving such target pressures is increasingly difficult, particularly in diabetic patients with chronic renal disease, who require complex multidrug antihypertensive regimens. This review attempts to provide some suggestions for constructing such antihypertensive regimens, and provides considerations for the appropriate use of diuretics and the most effective drug combinations. Factors potentially contributing to drug resistant hypertension include such problems as failure to maximize drug dosing, suboptimal diuretic use, noncompliance, and possible confounding effects of such concomitant medications as nonsteroidal and anti-inflammatory drugs or decongestants. The issues underlying drug-resistant hypertension are listed, together with strategies for overcoming this problem. [source]

    The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review

    DIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue S1 2008
    S. A. Bus
    Abstract Background Footwear and offloading techniques are commonly used in clinical practice for the prevention and treatment of foot ulcers in diabetes, but the evidence base to support this use is not well known. The goal of this review was to systematically assess the literature and to determine the available evidence on the use of footwear and offloading interventions for ulcer prevention, ulcer treatment, and plantar pressure reduction in the diabetic foot. Methods A search was made for reports on the effectiveness of footwear and offloading interventions in preventing or healing foot ulcers or reducing plantar foot pressure in diabetic patients published prior to May 2006. Both controlled and uncontrolled studies were included. Assessment of the methodological quality of studies and data extraction was independently performed by two reviewers. Interventions were assigned into four subcategories: casting, footwear, surgical offloading and other offloading techniques. Results Of 1651 articles identified in the baseline search, 21 controlled studies were selected for grading following full text review. Another 108 uncontrolled and cross-sectional studies were examined. The evidence to support the use of footwear and surgical interventions for the prevention of ulceration is meagre. Evidence was found to support the use of total contact casts and other non-removable modalities for treatment of neuropathic plantar ulcers. More studies are needed to support the use of surgical offloading techniques for ulcer healing. Plantar pressure reduction can be achieved by several modalities including casts, walkers, and therapeutic footwear, but the diversity in methods and materials used limits the comparison of study results. Conclusions This systematic review provides support for the use of non-removable devices for healing plantar foot ulcers. Furthermore, more high-quality studies are urgently needed to confirm the promising effects found in both controlled and uncontrolled studies of footwear and offloading interventions designed to prevent ulcers, heal ulcers, or reduce plantar pressure. Copyright © 2008 John Wiley & Sons, Ltd. [source]

    Plantar pressures in diabetic patients with foot ulcers which have remained healed

    DIABETIC MEDICINE, Issue 11 2009
    T. M. Owings
    Abstract Aims, The recurrence of foot ulcers is a significant problem in people with diabetic neuropathy. The purpose of this study was to measure in-shoe plantar pressures and other characteristics in a group of neuropathic patients with diabetes who had prior foot ulcers which had remained healed. Methods, This was an epidemiological cohort study of patients from diabetes clinics of two Swedish hospitals. From a database of 2625 eligible patients, 190 surviving patients with prior plantar ulcers of the forefoot (hallux or metatarsal heads) caused by repetitive stress were identified and 49 patients agreed to participate. Barefoot and in-shoe plantar pressures were measured during walking. Data on foot deformity, activity profiles and self-reported behaviour were also collected. Results, Mean barefoot plantar peak pressure at the prior ulcer site (556 kPa) was lower than in other published series, although the range was large (107,1192 kPa). Mean in-shoe peak pressure at this location averaged 207 kPa when measured with an insole sensor. Barefoot peak pressure only predicted ,35% of the variance of in-shoe peak pressure, indicating variation in the efficacy of the individual footwear prescriptions (primarily extra-depth shoes with custom insoles). Conclusions, We propose that the mean value for in-shoe pressures reported in these patients be used as a target in footwear prescription for patients with prior ulcers. Although plantar pressure is only one factor in a multifaceted strategy to prevent ulcer recurrence, the quantitative focus on pressure reduction in footwear is likely to have beneficial effects. [source]

    The effect of spironolactone, cilazapril and their combination on albuminuria in patients with hypertension and diabetic nephropathy is independent of blood pressure reduction: a randomized controlled study

    DIABETIC MEDICINE, Issue 5 2004
    R. Rachmani
    Abstract Objective The effect of spironolactone, cilazapril and their combination on albuminuria was examined in a randomized prospective study in female patients with diabetes and hypertension. Patients and methods Sixty female diabetic patients aged 45,70 years with blood pressure (BP) 140,180/90,110 mmHg, serum creatinine (sCr) , 160 µmol/l, HbA1c , 10%, and albuminuria were treated by atenolol 12.5,75 mg/d and hydrochlorothiazide 6.25,25 mg/d. Titration-to-target helped to reach BP values , 135/85 mmHg in 46 patients after 12 weeks. These patients were randomized to spironolactone 100 mg/d or cilazapril 5 mg/d for 24 weeks. Then both groups received spironolactone 50 mg/d and cilazapril 2.5 mg/d for 24 weeks. BP was stabilized by tapering the dose of the initial agents. Urinary albumin/creatinine ratio (ACR), BP, K+. sCr and HbA1c were assessed at baseline and at weeks 12, 16, 36 and 60. Results The average BP at week 12 was 128 ± 4/81 ± 3 mmHg and remained constant, in both groups, throughout the study. ACR declined on spironolactone from a median value (range) of 452 (124,1571) to 216 (64,875) mg/g (P = 0.001), and on cilazapril to 302 (90,975) mg/g (P = 0.001). The difference between spironolactone and cilazapril was significant (P = 0.002). Combined treatment resulted in a further modest decline in ACR. Serum creatinine was unaltered by spironolactone and rose slightly (121 to 126 µmol/l, P = 0.02) on cilazapril. Conclusion At the doses tested, spironolactone was superior to cilazapril in reducing albuminuria. Combined administration was more effective than either drug alone. These effects were independent of BP values. Hyperkalaemia was the main side-effect. [source]

    The effects of applied felted foam on wound healing and healing times in the therapy of neuropathic diabetic foot ulcers

    DIABETIC MEDICINE, Issue 8 2003
    S. Zimny
    Abstract Aims The application of felted foam is a promising method for plantar pressure reduction in the ulcer region of diabetic foot ulcers, but knowledge of its effects on wound healing is sparse. The objective of this study was to evaluate the effects of felted foam on wound healing in diabetic foot ulcers compared with a standard method of plantar pressure relief. Materials and methods A total of 54 Type 1 or Type 2 diabetic patients with neuropathic diabetic foot ulcers were evaluated in this prospective randomized controlled study. Ulcer healing was assessed by planimetric measurement of the wound area at beginning of the study and after 10 weeks and at least until wound healing. The patients were consecutively enrolled in the study; 24 patients were randomized to the felted foam therapy, and 30 patients were randomized to conventional therapy. Results In the felted foam group, the initial average wound area was 102.3 ± 45.3 mm2 (mean ± sd), and 5.4 ± 3.1 mm2 after 10 weeks with an average healing time of 75 days [95% confidence interval (CI) 67,84]. In the conventional therapy group, the initial average wound area was 112.5 ± 50.8 mm2, and 10.6 ± 4.2 mm2 after 10 weeks with an average healing time of 85 days (95% CI 79,92) (P = 0.03). The mean wound radius decreased by 0.48 mm (95% CI 0.42,0.56) per week in the felted foam group and by 0.39 mm (95% CI 0.35,0.42) per week in the conventional group (P = 0.005). Conclusions The felted foam technique appears to be at least as effective as conventional plantar ulcer treatment. It may be a useful alternative in treating neuropathic foot ulceration, especially in patients who are not able to avoid weight-bearing reliably. [source]

    Stroke secondary prevention and blood pressure reduction: an observational study of the use of PROGRESS therapy

    FUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 2 2008
    Jean-Marc Bugnicourt
    Abstract The Perindopril pROtection aGainst REcurrent Stroke Study (PROGRESS) showed the efficacy of blood pressure reduction in secondary stroke prevention. This anti-hypertensive treatment (perindopril 4 mg daily plus indapamide 1.5 mg daily) is now routinely proposed to patients referred to our department for stroke or transient ischaemic attack (TIA). The aim of this study was to evaluate the prescription of PROGRESS therapy during hospitalization and to identify the predictors of therapy discontinuation after discharge. Eligible patients admitted to the Amiens University hospital for acute stroke or TIA from January to April 2003 were included (n = 101). At 1 year, the use of PROGRESS therapy was evaluated by structured phone interviews. In addition, each patient's general practitioner (GP) was also contacted to provide information. PROGRESS therapy was mentioned on the hospital discharge summary significantly less frequently after cardioembolic stroke (OR: 0.15; 95% CI: 0.05,0.5; P = 0.001) and TIA (OR: 0.12; 95% CI: 0.02,0.7; P = 0.02). At 1 year, only 25.7% of patients were treated with optimal PROGRESS therapy (perindopril 4 mg daily plus indapamide 1.5 mg daily). Mention of PROGRESS therapy in the discharge summary was the main predictor of optimal PROGRESS therapy at 1 year (OR: 10.8; 95% CI: 1.3,88.3; P = 0.03). This study shows that mention of PROGRESS therapy in the discharge summary must be improved as it is associated with a higher use of these anti-hypertensive agents 1 year after stroke/TIA. [source]

    Rationale, design and methods of the OSCAR study: observational study on cognitive function and systolic blood pressure reduction in hypertensive patients

    FUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 2 2007
    Atul Pathak
    Abstract Data from several recent clinical trials have suggested a beneficial effect of antihypertensive medications on preservation of cognitive function. Eprosartan, an angiotensin type-1 receptor antagonist (ARA) with dual action on both pre- and postsynaptic angiotensin type 1 receptors, may be effective in the control of SBP and the prevention of cognitive decline. The OSCAR (Observational Study on Cognitive function And SBP Reduction) study is an international longitudinal observational study with a duration of 6 months intended to examine the impact of the ARA eprosartan on cognitive function (assessed using the Mini-Mental State Examination [MMSE]) and control of systolic blood pressure (SBP) in a large international population of hypertensive patients managed in a standard primary care setting. A total of 100 000 hypertensive patients, aged ,50 years and with SBP of >140 mmHg will be recruited by more than 20 000 primary care physicians in 27 countries. These patients will receive eprosartan 600 mg once a day for 6 months. The MMSE, a globally validated cognitive screening test, will be performed at baseline, and after 6 months of treatment. After the first month of monotherapy, eprosartan treatment may, at the absolute discretion of individual investigators, be supplemented with other antihypertensive medications for the remainder of the study. The primary outcome indices are the mean relative change in MMSE score and the absolute change from baseline in SBP in the study population as a whole and in subsets of patients according to various factors among them: ethnicity, comorbidities (i.e. target organ damage, diabetes), baseline cognitive level and baseline blood pressure level. The secondary objectives are to identify factors influencing SBP and MMSE changes. The OSCAR trial is the first international observational study focusing on MMSE in a wide international cohort of hypertensive patients. The results are expected in 2007. [source]

    Beyond the Usual Strategies for Blood Pressure Reduction: Therapeutic Considerations and Combination Therapies

    JOURNAL OF CLINICAL HYPERTENSION, Issue 6 2001
    Thomas D. Giles MD
    Rapidly accumulating clinical data have repeatedly demonstrated not only the critical importance of even small increases in blood pressure as a pathophysiologic factor in the development of cardiovascular disease, particularly in individuals with diabetes mellitus, but also the therapeutic necessity of more aggressive blood pressure reduction and the achievement of progressively lower blood pressure targets in reducing cardiovascular event rates. JNC VI has defined optimal blood pressure as ,120/80 mm Hg, and Stage 1 hypertension as ,140/80 mm Hg. Target blood pressures are now ,130/80 mm Hg in patients with diabetes and <125/75 mm Hg for patients with hypertensive renal disease with proteinuria of>1 gm/24 hours. Achieving such target pressures is increasingly difficult, particularly in diabetic patients with chronic renal disease, who require complex multidrug antihypertensive regimens. This review attempts to provide some suggestions for constructing such antihypertensive regimens, and provides considerations for the appropriate use of diuretics and the most effective drug combinations. Factors potentially contributing to drug resistant hypertension include such problems as failure to maximize drug dosing, suboptimal diuretic use, noncompliance, and possible confounding effects of such concomitant medications as nonsteroidal and anti-inflammatory drugs or decongestants. The issues underlying drug-resistant hypertension are listed, together with strategies for overcoming this problem. [source]

    Potential roles of melatonin and chronotherapy among the new trends in hypertension treatment

    JOURNAL OF PINEAL RESEARCH, Issue 2 2009
    Fedor Simko
    Abstract:, The number of well-controlled hypertensives is unacceptably low worldwide. Respecting the circadian variation of blood pressure, nontraditional antihypertensives, and treatment in early stages of hypertension are potential ways to improve hypertension therapy. First, prominent variations in circadian rhythm are characteristic for blood pressure. The revolutionary MAPEC (Ambulatory Blood Pressure Monitoring and Cardiovascular Events) study, in 3000 adult hypertensives investigates, whether chronotherapy influences the cardiovascular prognosis beyond blood pressure reduction per se. Second, melatonin, statins and aliskiren are hopeful drugs for hypertension treatment. Melatonin, through its scavenging and antioxidant effects, preservation of NO availability, sympatholytic effect or specific melatonin receptor activation exerts antihypertensive and anti-remodeling effects and may be useful especially in patients with nondipping nighttime blood pressure pattern or with nocturnal hypertension and in hypertensives with left ventricular hypertrophy (LVH). Owing to its multifunctional physiological actions, this indolamine may offer cardiovascular protection far beyond its hemodynamic benefit. Statins exert several pleiotropic effects through inhibition of small guanosine triphosphate-binding proteins such as Ras and Rho. Remarkably, statins reduce blood pressure in hypertensive patients and more importantly they attenuate LVH. Addition of statins should be considered for high-risk hypertensives, for hypertensives with LVH, and possibly for high-risk prehypertensive patients. The direct renin inhibitor, aliskiren, inhibits catalytic activity of renin molecules in circulation and in the kidney, thus lowering angiotensin II levels. Furthermore, aliskiren by modifying the prorenin conformation may prevent prorenin activation. At present, aliskiren should be considered in hypertensive patients not sufficiently controlled or intolerant to other inhibitors of renin,angiotensin system. Third, TROPHY (Trial of Preventing Hypertension) is the first pharmacological intervention for prehypertensive patients revealing that treatment with angiotensin II type 1 receptor blocker attenuates hypertension development and thus decreases the risk of cardiovascular events. [source]

    New developments in incretin-based therapies: The current state of the field

    JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 2009
    CDE Diabetes Nurse Educator, Carolyn Robertson APRN
    Abstract Purpose: To update readers on developments in incretin therapies since the previous JAANP supplement in 2007; specifically, to describe clinical data for currently available incretin-based therapies as well as those under consideration by regulatory agencies. Data source: Medline search for peer-reviewed publications. Conclusions: Incretin-based therapies have pharmacologic properties that avoid some key limitations of previous treatments, such as hypoglycemia and weight gain. Certain agents also lower blood pressure and have the potential to reduce cardiovascular risk. The insulin-secreting action of incretin-based therapies only occurs under hyperglycemic conditions, thus minimizing the risk of hypoglycemia, unless combined with a sulfonylurea. The DPP-4 inhibitors are orally administered and demonstrate modest A1c reductions (0.6%,0.8%); the best results occur when combined with metformin. Glucagon-like peptide-1 (GLP-1) receptor agonists liraglutide and exenatide have shown greater A1c reductions (typically , 1.1% and as high as 1.7%), and these agents have beneficial ancillary effects, including weight and systolic blood pressure reduction. Both DPP-4 inhibitors and GLP-1 receptor agonists have shown the ability to improve pancreatic beta-cell function in early studies. Implications for practice: Data are provided on the efficacy and tolerability of approved incretin therapies, and on treatments currently in regulatory review, in order to inform readers and guide their practice. [source]

    Review article: the therapeutic and prognostic benefit of portal pressure reduction in cirrhosis

    ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 8 2008
    C. K. TRIANTOS
    Summary Background, Hepatic venous pressure gradient (HVPG) measurement is not a routinely used technique, despite its therapeutic and prognostic value. Aim, To review the role of HVPG from published literature. Methods, Systematic literature review. Results, In acute variceal bleeding, HVPG is prognostic identifying ,difficult to treat' group, which now has defined clinical correlations. In secondary prevention of portal hypertensive bleeding, a reduction to ,12 mmHg confers near complete protection against rebleeding. The target of ,20% HVPG reduction from baseline needs prospective assessment to test a change of therapy, if no reduction occurs. The acute HVPG response to beta-blockade needs further assessment. In primary prevention, the cost-effectiveness of HVPG measurement is not favourable given the efficacy of medical therapy. In chronic liver disease, wedge hepatic venous pressure (WHVP) is prognostic for survival. Pharmacological reduction in portal pressure decreases complications and improves survival, possibly independent of a concomitant improvement in liver function. This latter requires urgent confirmation as it is clinically very relevant. HVPG monitoring can be used to assess anti-viral therapy particularly in cirrhosis, ergonomically combined with transjugular biopsy. Conclusions, The prognostic and therapeutic value of HVPG is established beyond portal hypertensive bleeding for which there are some clinical surrogates. HVPG measurement should now be part of everyday clinical practice. [source]

    Effects of probiotic therapy on portal pressure in patients with cirrhosis: a pilot study

    LIVER INTERNATIONAL, Issue 7 2009
    Puneeta Tandon
    Abstract Background: Recent literature has supported the role of bacterial translocation as a mediator of splanchnic vasodilatation and portal hypertension. The objective of this study was to determine whether the probiotic VSL#3 would reduce portal pressure in patients with cirrhosis. Methods: Eight patients with compensated or very early decompensated cirrhosis and hepatic venous pressure gradient (HVPG) >10 mmHg, received 2 months of VSL#3 (3600 billion bacteria daily). The HVPG, intestinal permeability, endotoxin, tumour necrosis factor (TNF)-,, interleukin (IL)-6, IL-8, renin and aldosterone were measured at baseline and study end. Results: There was no change in the HVPG or intestinal permeability from baseline to study end but there was a trend to reduction in plasma endotoxin (P=0.09), a mild but significant increase in serum TNF-, (P=0.02) and a significant reduction in plasma aldosterone (P=0.03). Conclusions: Within the limitations of small sample size, there does not appear to be a benefit of probiotic therapy for portal pressure reduction in patients with compensated or early decompensated cirrhosis. The reductions in endotoxin and aldosterone suggest possible beneficial effects of probiotics for this patient population. The clinical significance of the small but unexpected increase in TNF-, is unclear. Future studies are planned in patients with decompensated cirrhosis. [source]

    An In-Vivo Analysis of Capillary Stasis and Endothelial Apoptosis in a Model of Hypertension

    MICROCIRCULATION, Issue 8 2007
    Edward D. Tran
    ABSTRACT Objective: Recent evidence suggests endothelial apoptosis may be a mechanism for capillary rarefaction in hypertensives. The objective of this study was to examine the early phase of endothelial apoptosis and capillary blood flow in the spontaneously hypertensive rat (SHR) and the normotensive Wistar-Kyoto (WKY) rat. Methods: Since hypertension in SHR is dependent on glucocorticoids, the animals were treated with dexamethasone (DEX), by intraperitoneal injection and then by superfusion on exposed mesentery. Selected capillaries were continuously observed. Annexin V and propidium iodide were used to detect apoptosis. Results: Without central pressure reduction, permanent capillary stasis was initiated by the entrapment of leukocytes at the location of an endothelial cell that had platelets attached to it. Apoptosis of the endothelial cell was followed by apoptosis in other endothelial cells of the obstructed capillary. The incidence of stasis and total cell death in WKY+DEX were higher than WKY, whereas there were no differences between SHR+DEX and SHR. Blockade of the lectin domain of L-selectin or a platelet membrane adhesion molecule (glycoprotein IIb/IIIa) blocked the development of stasis. Conclusions: Glucocorticoid facilitates cell death and microvessel stasis. Immobilized platelets and leukocytes play a central role in capillary stasis, which leads to progression of endothelial apoptosis. [source]

    Management of membranous nephropathy

    NEPHROLOGY, Issue 4 2000
    Daniel Cattran
    SUMMARY: The Management of membranous nephropathy requires a recognition of its natural history and an ability to predict those pationts with the worst prognosis. Treatment of those at risk of progression with immunosuppressive drugs should be accompanied by additional conservative risk reduction strategies such as dietary protein restriction, blood pressure reduction, angiotensin-converting enzyme inhibitors and lipid-lowering agents. Anticoagulants should also be considered as well as medications to reduce drug toxicity. [source]

    The Emerging Role of Flavonoid-Rich Cocoa and Chocolate in Cardiovascular Health and Disease

    NUTRITION REVIEWS, Issue 3 2006
    Mary B. Engler PhD
    Cocoa and chocolate have recently been found to be rich plant-derived sources of antioxidant flavonoids with beneficial cardiovascular properties. These favorable physiological effects include: antioxidant activity, vasodilation and blood pressure reduction, inhibition of platelet activity, and decreased inflammation. Increasing evidence from experimental and clinical studies using cocoa-derived products and chocolate suggest an important role for these high-flavanol-containing foods in heart and vascular protection. [source]

    Pathogenesis of diabetic retinopathy and the renin-angiotensin system

    OPHTHALMIC AND PHYSIOLOGICAL OPTICS, Issue 6 2003
    Hideharu Funatsu
    Abstract Despite the beneficial effects of good glycaemic control, loss of vision because of diabetic retinopathy (DR) still occurs. Recent studies have suggested that hypertension is a risk factor for the development and progression of DR and that blood pressure reduction can delay the progression of retinopathy. The renin-angiotensin system is activated by chronic hyperglycaemia, and the vitreous fluid level of angiotensin II (AII) is elevated in patients with proliferative diabetic retinopathy and diabetic macular oedema. AII increases vascular permeability and promotes neovascularization. It has been suggested that an autocrine-paracrine relationship may exist between AII and vascular endothelial growth factor in the ocular tissues. Accordingly, angiotensin-converting enzyme inhibitors or AII Type 1 (AT1) receptor blockers may be useful therapeutic agents for preventing the progression of DR. [source]

    Latest news and product developments

    PRESCRIBER, Issue 11 2008
    Article first published online: 18 JUN 200
    New asthma guideline The BTS/SIGN guideline for the management of asthma has been updated. The diagnosis section has been rewritten, there is a new section on difficult asthma and the treatment sections have been updated. A new option at Step 3 (initial add-on therapy) is now the use of a combined budesonide/formoterol inhaler (Symbicort) as a reliever in addition to regular use as a preventer. This reflects evidence from the SMART trials, which showed that an average of one extra puff per day significantly reduced exacerbations and admissions (Br Med J 2007;335:513). Metformin matches insulin in pregnancy Metformin does not worsen perinatal outcomes compared with insulin in gestational diabetes and mothers prefer it, a study from Australia and New Zealand shows (N Engl J Med 2008;358:2003,15). Of the women randomised to metformin treatment, 93 per cent were still taking it at term and 46 had supplemental insulin. The combined incidence of neonatal hypoglycaemia, respiratory distress, need for phototherapy, birth trauma, five-minute Apgar score less than 7 or prematurity was 32 per cent with both treatments. There were no serious adverse events. More women said they would choose the same treatment again for metformin than insulin (77 vs 27 per cent). Same CV protection with antihypertensives There is no difference in protection against major cardiovascular events between different types of antihypertensives in young or older (65 or over) adults, according to the Blood Pressure Lowering Treatment Trialists' Collaboration. Its meta-analysis of 31 trials involving over 190 000 patients (BMJ Online 2008; doi:10.1136/bmj.39548.738 368.BE) found no significant difference by age on blood pressure reduction or risk reduction. Treatment may be chosen according to tolerability and cost as long as effective blood pressure reduction is achieved, the authors conclude. Older people are at greater absolute risk and treatment therefore offers larger reductions in serious vascular events. HPV vaccination starts in September Vaccination against human papilloma virus will be part of the national immunisation programme from the start of the new school year in September. The vaccine, administered as three doses over six months, will initially be offered to girls aged 12,13 (school year 8) to reduce their risk of cervical cancer. A two-year catch-up campaign for all girls up to 18 years old will begin in 2009. MHRA: pancreatitis with exenatide warning The incretin mimetic exenatide (Byetta), licensed for the treatment of type 2 diabetes, may rarely be associated with pancreatitis, warns the MHRA (Drug Safety Update 2008;1:Issue 10). One case has been reported in the UK and 89 in the USA and Germany. The MHRA advises that patients should be warned of the symptoms of pancreatitis (severe abdominal pain, back pain). Treatment should be discontinued if pancreatitis is suspected and the case reported on a yellow card. 2007 prescribing bill Primary-care expenditure on drugs in England in 2007 totalled £8.37 billion, only 2 per cent more than in 2006, according to the latest statistics from the Information Centre (www.ic.nhs.uk). Prescription numbers increased by almost 6 per cent. Prescribing increased in most BNF categories but changed little in musculoskeletal drugs and immunological products and vaccines. Calceos: calcium/ vitamin D3 price match Manufacturer Galen has pledged to continue to price-match its calcium/vitamin D3 supplement Calceos with Adcal-D3 or Calcichew D3 Forte. If the price of either product falls below that of Calceos chewable tablets, Galen will match it within six months. The company says it will honour the pledge until at least 2011. Copyright © 2008 Wiley Interface Ltd [source]

    Latest news and product developments

    PRESCRIBER, Issue 14 2007
    Article first published online: 19 OCT 200
    Studies suggest risk of bone loss with SSRIs Two cross-sectional studies have suggested the SSRI antidepressants may be associated with an increased risk of bone loss (Arch Intern Med 2007;167:1240,5 &1246,51). In 2722 older women (mean age 79) living in the community who were participating in the Study of Osteoporotic Fractures cohort study, use of SSRIs was associated with a significant increase in the rate of loss of hip bone density compared with nonusers(0.82 vs 0.47 per cent per year). The rate of loss among women taking a tricyclic antidepressant was also 0.47 per cent per year. Excluding women with more severe depression did not alter the findings. In 5995 men aged 65 or older taking an SSRI in another study, mean bone density was 3.9 per cent lower at the hip and 5.9 per cent lower in the lumbar spine compared with no use of antidepressants. Use of a tricyclic antidepressant or trazodone was not associated with increased bone loss. The authors comment that the degree of bone loss is comparable with that associated with corticosteroids. Serotonin transporters have been identified in osteoblasts and osteocytes. Risk of rare birth defects with SSRIs Two US case-control studies have found qualified evidence that use of SSRIs during the first trimester may be associated with a small increase in the risk of rare neonatal defects (N Engl J Med 2007;356:2675,83 & 2684,92). The Slone Epidemiology Center Birth Defects Study identified 9849 infants with birth defects and 5860 without and found no significant association between SSRI use overall and defects previously attributed to SSRIs (craniosynostosis, omphalocele or heart defects). There was some evidence that sertraline and paroxetine may cause specific defects, but this was based on few cases and the absolute risk remained low. The National Birth Defects Prevention Study identified 9622 infants with major birth defects and 4092 controls. There was no significant association with heart defects but the odds of anencephaly, craniosynostosis and omphalocele were each significantly increased by a factor of 2,3. The authors say the absolute risk remains small and their findings require confirmation. UK data do not support MI link with rosiglitazone An interim analysis of a UK clinical trial of rosiglitazone (Avandia) has found no evidence that it is associated with an increased risk of myocardial infarction (N Eng J Med 2007;357:28,38). A US meta-analysis (N Engl J Med 2007;356:2457,71) recently suggested that the odds of an MI or cardiovascular (CV) death in patients taking rosiglitazone were increased by 40,60 per cent compared with controls. The UK analysis of an ongoing nonblinded trial comparing rosiglitazone plus a sulphonylurea or metformin with sulphonylurea/metformin found no significant differences in the risk of MI or CV death. The risk of heart failure was doubled in patients taking rosiglitazone. The authors comment that, with a mean follow-up of 3.75 years, they had too few data to reach a conclusive finding. Switch piroxicam users to another NSAID The European Medicines Agency has advised prescribers to switch patients who are taking oral piroxicam to another NSAID. The advice follows a reappraisal of the safety of piroxicam when the 2006 review of all nonselective NSAIDs suggested it may be associated with increased risks of GI adverse effects and serious skin reactions. The advice does not apply to topical formulations. Piroxicam should not be prescribed for acute conditions and should not be first-choice for osteoarthritis, rheumatoid arthritis and ankylosing spondylitis. The maximum dose should be 20mg per day and treatment should be reviewed after 14 days. The MHRA states there is no need for urgent action; long-term treatment should be reviewed at the next routine appointment. OTC azithromycin? The MHRA is consulting on a request by a pharmaceutical company to reschedule azithromycin to pharmacy-only status for the treatment of known or suspected Chlamydia trachomatis infection in individuals aged 16 years or older. The applicant envisages supplies being made only when a nucleic acid amplification test (NAAT) is positive. Responses should be submitted to the MHRA (www.mhra.gov.uk) by 2 August. Computers can reduce prescribing errors Computerised prescribing reduces by two-thirds the rate of medication errors associated with handwritten prescriptions, a new review has found (Health Services Research 2007; online doi:10.1111/j.1475,6773. 2007.00751.x). There was some evidence that the risk of all errors, dose errors and adverse effects were reduced by computerisation. The greatest impact was seen in settings with very high error rates (>12 per cent) associated with handwritten prescriptions. However, the studies included produced heterogeneous results and the reduction in errors in prescribing for children was not statistically significant. Furthermore, computerisation did not reduce the rate of prescribing the wrong drug. Echinacea works for colds, new study finds The herbal remedy Echinacea does reduce the risk of catching a cold, according to a new metaanalysis (Lancet Infect Dis 2007;7:473,80). In 2006, a Cochrane review found insufficient evidence to support the benefits claimed for Echinacea. The new study, which additionally included experimentally-induced infections among the 14 trials analysed, found that Echinacea reduced the odds of catching a cold by about half and reduced the average duration of a cold by 1.4 days. Though inconclusive, the possibility of publication bias and heterogeneity between the trials could not be excluded. HRT may reduce cardiovascular risk after all A subgroup analysis of the Women's Health Initiative (WHI) suggests that HRT may reduce the risk of coronary heart disease if started soon after the menopause (N Engl J Med 2007;356:2591,602). The main analysis of WHI showed no cardiovascular benefit for HRT, a finding attributed to the relatively old mean age of participants (59). In the new analysis of 1064 women aged 50,59, HRT use was associated with a significant reduction in coronary artery calcification compared with nonuse, with greater effect associated with greater adherence. Reducing BP key to avoiding heart failure An angiotensin,II receptor blocker (ARB) is no better than other antihypertensives at avoiding the development of heart failure in individuals with hypertension, say US investigators (Lancet 2007;369:2079,87). Drugs that affect the renin-angiotensin system can reduce ventricular hypertrophy and may therefore prevent the development of heart failure in patients with hypertension. This study found similar improvements in diastolic function in 384 patients with hypertension and left ventricular dysfunction randomised to valsartan (Diovan) or placebo in addition to standard antihypertensive treatment for 38 weeks. The authors conclude that blood pressure reduction, not choice of drug, is the most important factor. Copyright © 2007 Wiley Interface Ltd [source]

    Quantifying the effect of intraocular pressure reduction on the occurrence of glaucoma

    ACTA OPHTHALMOLOGICA, Issue 1 2010
    Andrea Peeters
    Abstract. Purpose:, To estimate the effect of reducing intraocular pressure (IOP) on: (i) the incidence of primary open-angle glaucoma (POAG) in patients with ocular hypertension (OH), and (ii) the progression of glaucoma. Methods:, A meta-analysis of relevant randomized controlled trials was conducted. A literature search was performed to identify trials with: a randomized comparison of IOP-lowering intervention versus placebo or no treatment; visual field loss or optic disc changes as outcome; and follow-up >6 months. A pooled relative risk (RR) was calculated by a random effects model. Risk reduction of glaucoma conversion per mmHg of IOP reduction was quantified in a meta-regression model. Results:, We identified nine OH and one POAG trials. A meta-analysis of OH trials gives a pooled RR of 0.61 [95% confidence interval (CI) 0.45,0.83]. A meta-regression shows a decrease of the RR of glaucoma conversion by 14% with each mmHg extra IOP reduction (P = 0.045). No meta-analysis of POAG trials was performed because only one study has been identified. Conclusion:, There is sufficient evidence that OH therapy reduces the risk of conversion to glaucoma. This risk reduction increases with greater IOP reduction. [source]

    A comparison of the effects of dorzolamide/timolol fixed combination versus latanoprost on intraocular pressure and pulsatile ocular blood flow in primary open-angle glaucoma patients

    ACTA OPHTHALMOLOGICA, Issue 6 2004
    I. Janulevicienė
    Abstract. Purpose:,To evaluate the effects of dorzolamide/timolol fixed combination (D/T) compared to latanoprost on intraocular pressure (IOP) and pulsatile ocular blood flow (POBF) in primary open-angle glaucoma (POAG) patients. Methods:,Thirty patients with POAG were randomized in an open-label, cross-over study. Intraocular pressure reduction was achieved by 4 weeks medical therapy with D/T twice daily or latanoprost 0.005% dosed once in the evening. During a 4-week run,in and a 4-week wash-out period between study arms, patients ceased use of all other glaucoma medications and used timolol maleate 0.5% twice daily. Primary efficacy variables were IOP and POBF. Results:,There was no difference in baseline IOP and POBF parameters between the two study arms. Both D/T and latanoprost statistically significantly reduced IOP by 4.6 mmHg (p < 0.0001) and 3.75 mmHg (p < 0.0001) and increased POBF by 2.048 µl/second (p = 0.0030) and 2.147 µl/second (p = 0.0009), respectively. Repeated measures anova detected significant changes in POBF with treatment (p = 0.0361). Dorzolamide/timolol fixed combination statistically significantly increased pulse volume by 0.767 µl (p = 0.0087), while latanoprost therapy had no significant effect (p = 0.2407). Conclusions:,Both drugs had similar effects in terms of IOP reduction. Dorzolamide/timolol significantly increased pulse volume while latanoprost had no effect. Further studies are necessary to establish whether the enhancement of choroidal blood flow can prevent glaucoma progression. [source]

    Impact of Human Factor Design on the Use of Order Sets in the Treatment of Congestive Heart Failure

    ACADEMIC EMERGENCY MEDICINE, Issue 11 2007
    Stewart Reingold MD
    Background Although standardized physician order sets are often part of quality improvement projects, the specific design elements contributing to increased adoption and compliance with use often are not considered. Objectives To evaluate the impact of human factor design elements on congestive heart failure (CHF) order set utilization, and compliance with recommended CHF clinical practice guidelines (CPG). Methods This was a descriptive retrospective medical record review of adult patients who were admitted from our emergency department with the primary diagnosis of CHF. We collected data on acuity and CPG parameters before and after the introduction of a new CHF order set. The new orders were succinct and visually well organized, with narrative information to encourage use of CPG. Results Eighty-seven patients were studied before, and 84 after, the introduction of new orders. There were no differences in the use of the order sets based on patient acuity before or after the intervention. Order set use significantly increased by the first postintervention interval (POST) and reached 72% (95% confidence interval [CI] = 52% to 86%) during the third POST, compared with a baseline utilization of 9% (95% CI = 5% to 17%; p < 0.001). Compliance with CPG for angiotensin-converting enzyme reached significance in the second POST and was maintained in the third at 83% (95% CI = 61% to 94%), compared with a baseline value of 25% (95% CI = 7% to 59%; p = 0.008). Intravenous nitroglycerin also increased significantly from the first POST and reached 78% (95% CI = 55% to 91%) in the third POST, compared with baseline of 12% (95% CI = 2% to 47%; p < 0.003). Furosemide dosing, systolic blood pressure reduction, and urine output did not significantly change. Conclusions Introduction of an order set for CHF with attention to human factor design elements significantly improved utilization of the orders and compliance with CPG. [source]

    Effects of mild aerobic physical exercise on membrane fluidity of erythrocytes in essential hypertension

    CLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY, Issue 5-6 2003
    Kazushi Tsuda
    Summary 1.,The present study was undertaken to investigate the effects of aerobic physical exercise on membrane function in mild essential hypertension. 2.,Hypertensive patients were divided into an exercise group (n = 8) and a non-exercise (control) group (n = 8). Physical exercise within the intensity of the anaerobic threshold level was performed twice a week for 6 months. Membrane fluidity of erythrocytes was examined by means of electron paramagnetic resonance (EPR) and spin-labelling methods before and after the trial period in both groups. 3.,After physical exercise, blood pressure decreased significantly. 4.,Compared with the non-exercise group, in the exercise group both the order parameter (S) and the peak height ratio (ho/h -1) in the EPR spectra of erythrocytes were significantly reduced (S, 0.717 ± 0.004 vs 0.691 ± 0.008, respectively (n = 8), P < 0.05; ho/h -1, 5.38 ± 0.06 vs 4.89 ± 0.06, respectively (n = 8), P < 0.05). These findings indicated that exercise increased membrane fluidity and improved the membrane microviscosity of erythrocytes. 5.,There was no direct correlation between blood pressure reduction and the exercise-induced increase in membrane fluidity of erythrocytes. 6.,In the non-exercise (control) group, blood pressure and membrane fluidity were not changed after a 6 month follow-up period. 7., The results show that aerobic physical exercise increased erythrocyte membrane fluidity and improved the rigidity of cell membranes in hypertensive patients. The improvement of rheological properties of erythrocytes may explain, in part, the cellular mechanisms for the beneficial effects of physical exercise in hypertension. [source]

    Large Artery Stiffness: Implications For Exercise Capacity And Cardiovascular Risk

    CLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY, Issue 3 2002
    Bronwyn A Kingwell
    SUMMARY 1. Large artery stiffness, or its inverse, compliance, determines pulse pressure, which, in turn, influences myocardial work capacity and coronary perfusion, both of which impact on exercise capacity and cardiovascular risk. 2. In support of a role for arterial properties in exercise performance, aerobically trained athletes (aged 30,59 years) have lower arterial stiffness than their sedentary counterparts. Furthermore, in healthy older subjects (aged 57,80 years), time to exhaustion on treadmill testing correlated positively with arterial compliance. 3. Arterial stiffness is more closely linked to exercise capacity and myocardial risk in patients with coronary disease where, independently of degree of coronary disease, those with stiffer proximal arteries have a lower exercise-induced ischaemic threshold. 4. Moderate aerobic training elevates resting arterial compliance by approximately 30%, independently of mean pressure reduction, in young healthy individuals but not in isolated systolic hypertensive patients. Rat training studies support a role for exercise training in structural remodelling of the large arteries. 5. High-resistance strength training is associated with stiffer large arteries and higher pulse pressure than matched controls. 6. Large artery stiffness is an important modulator of the myocardial blood supply and demand equation, with significant ramifications for athletic performance and ischaemic threshold in coronary disease patients. Moderate aerobic training, but not high-resistance strength training, reduces large artery stiffness in young individuals whereas older subjects with established isolated systolic hypertension are resistant to such adaptation. [source]

    Transforming growth factor ,1 genotype and change in left ventricular mass during antihypertensive treatment,results from the swedish irbesartan left ventricular hypertrophy investigation versus atenolol (Silvhia)

    CLINICAL CARDIOLOGY, Issue 3 2004
    Pär Hallberg M.D.
    Abstract Background: Angiotensin II, via the angiotensin II type 1 (AT1) receptor, may mediate myocardial fibrosis and myocyte hypertrophy seen in hypertensive left ventricular (LV) hypertrophy through production of transforming growth factor ,1(TGF-,1); AT1-receptor antagonists reverse these changes. The TGF-(,1 G + 915C polymorphism is associated with in-terindividual variation in TGF- ,1 production. No study has yet determined the impact of this polymorphism on the response to antihypertensive treatment. Hypothesis: We aimed to determine whether the TGF- ,1 G + 915C polymorphism was related to change in LV mass during antihypertensive treatment with either an AT1 -receptor antagonists or a beta1 -adrenoceptor blocker. The polymorphism was hypothesized to have an impact mainly on the irbesartan group. Methods: We determined the association between the TGF-,1 genotype and regression of LV mass in 90 patients with essential hypertension and echocardiographically diagnosed LV hypertrophy, randomized in a double-blind study to receive treatment for 48 weeks with either the AT1 -receptor antagonist irbesartan or the beta1 -adrenoceptor blocker atenolol. Results: Irbesartan-treated patients who were carriers of the C-allele, which is associated with low expression of TGF-,1, responded with a markedly greater decrease in LV mass index (LVMI) than subjects with the G/G genotype (adjusted mean change in LVMI ,44.7 g/m2 vs. ,22.2 g/m2, p = 0.007), independent of blood pressure reduction. No association between genotype and change in LVMI was observed in the atenolol group. Conclusions: The TGF- ,1 G + 915C polymorphism is related to the change in LVMI in response to antihypertensive treatment with the AT1 -receptor antagonist irbesartan. [source]

    Clinical trial experience around the globe: Focus on calcium-channel blockers

    CLINICAL CARDIOLOGY, Issue S2 2003
    William B. White M.D.
    Abstract Although certain classes of drugs appear to possess benefits apart from their blood-pressure lowering capability, reduction of blood pressure remains the single most important action of antihypertensive therapy. Calcium-channel blockers (CCBs) have long been recognized as potent agents for hypertension therapy. This is especially true for the prevention of stroke in hypertensive patients as evidenced from the Systolic Hypertension in Europe (Syst-Eur) and Systolic Hypertension in China (Syst-China) trials with a long acting dihydropyridine CCB. The same can be said for beta blockers in patients post myocardial infarction. However, most recent clinical trials have underscored the necessity of multiple drug therapy to achieve the goals of blood pressure reduction coupled with outcomes reduction. For example, the many recent large-scale clinical trials have required an average of three or more agents to achieve goal. Thus, the paradigm for hypertension management has been altered to determine the best treatment regimen rather than the best initial agent. While response rates to individual agents across a wide spectrum of patients vary little, not all drugs are equally suited as companion products. In this article, we discuss the most recent outcome trials with the long acting CCBs alone or in combination with other drugs. The evidence shows that calcium antagonists remain an important part of hypertension management, including in those individuals at risk of cardiac and cerebrovascular events. [source]

    Heel skin hyperaemia: direct compression versus vascular occlusion

    CLINICAL PHYSIOLOGY AND FUNCTIONAL IMAGING, Issue 6 2003
    Harvey N. Mayrovitz
    Summary Vulnerability of the heel to ulceration in bed-bound persons is related to direct pressure-induced blood flow decreases. Periodic pressure reduction is a clinical strategy to help prevent ulcers by allowing flow-repayment hyperaemia that has a magnitude and duration thought to be related to the duration of the prior interval of ischaemia. However, there are reasons to question whether effects of flow stoppages caused by direct tissue loading are similar to those because of ischaemia without superimposed direct pressure. This question was investigated by comparing posterior heel skin blood flow responses via laser-Doppler perfusion monitoring of 27 supine-lying subjects in whom blood flow was reduced by 5-min of direct heel loading on a support surface and by 5-min of ankle-cuff compression. Results showed that blood flow reductions were the same for both methods but the hyperaemia was significantly greater when flow reduction was produced by direct heel loading. This was true for ratio of peak hyperaemic flow to baseline (8·20 ± 1·32 s versus 4·68 ± 0·80 s, P,0·001), hyperaemic to baseline 3-min flow-time area ratios (4·70 ± 0·65 s versus 1·95 ± 0·29 s, P,0·001) and for total hyperaemia durations (352 ± 39 s versus 181 ± 14 s, P<0·001). These findings raise new questions regarding the precise physiological effects of heel and tissue loading in general, the factors that contribute to the hyperaemic response and their clinical impact and interpretation. Possible sources of the observed greater post-loading hyperaemia responses are discussed. [source]

    Optimizing blood pressure reduction: predicting success in the home environment

    CLINICAL PSYCHOLOGY AND PSYCHOTHERAPY (AN INTERNATIONAL JOURNAL OF THEORY & PRACTICE), Issue 1 2001
    A. R. Craig
    Transferring skills to non-clinic contexts remains a challenge for clinical psychologists. Research is needed that investigates strategies of transferring clinic skills as well as factors that are associated with successful transfer. This paper presents research that involved training clients to reduce blood pressure (BP) in the home environment and isolating factors related to successful BP reduction. Subjects diagnosed with mild hypertension participated in a controlled trial investigating the efficacy of continuous BP feedback in helping to reduce systolic BP in the clinic and home environment. While the benefits of learning BP feedback in the clinic was not shown to be beneficial over a control, training in the home environment was shown to reduce BP significantly in comparison to controls. Factors shown to be associated consistently and reliably with reduction of BP in the home were those that involved beliefs or expectations of self-control. Expectations (self-efficacy) and an internal locus of control consistently predicted the ability to reduce both systolic and diastolic BP in the home environment. Implications for the behavioural treatment of hypertension are discussed. Copyright © 2001 John Wiley & Sons, Ltd. [source]