Blood pressure control by home monitoring : meta-analysis of randomised trials

Objective To determine the effect of home blood pressure monitoring on blood pressure levels and proportion of people with essential hypertension achieving targets. Design Meta-analysis of 18 randomised controlled trials. Participants 1359 people with essential hypertension allocated to home blood pressure monitoring and 1355 allocated to the "control" group seen in the healthcare system for 2-36 months. Main outcome measures Differences in systolic (13 studies), diastolic (16 studies), or mean (3 studies) blood pressures, and proportion of patients achieving targets (6 studies), between intervention and control groups. Results Systolic blood pressure was lower in people with hypertension who had home blood pressure monitoring than in those who had standard blood pressure monitoring in the healthcare system (standardised mean difference 4.2 (95% confidence interval 1.5 to 6.9) mm Hg), diastolic blood pressure was lower by 2.4 (1.2 to 3.5) mm Hg, and mean blood pressure was lower by 4.4 (2.0 to 6.8) mm Hg. The relative risk of blood pressure above predetermined targets was lower in people with home blood pressure monitoring (risk ratio 0.90, 0.80 to 1.00). When publication bias was allowed for, the differences were attenuated: 2.2 ( − 0.9 to 5.3) mm Hg for systolic blood pressure and 1.9 (0.6 to 3.2) mm Hg for diastolic blood pressure. Conclusions Blood pressure control in people with hypertension (assessed in the clinic) and the proportion achieving targets are increased when home blood pressure monitoring is used rather than standard blood pressure monitoring in the healthcare system. The reasons for this are not clear. The difference in blood pressure control between the two methods is small but likely to contribute to an important reduction in vascular complications in the hypertensive population

Application of Framingham risk estimates to ethnic minorities in United Kingdom and implications for primary prevention of heart disease in general practice : cross sectional population based study

Objective To compare the 10 year risk of coronary heart disease (CHD), stroke, and combined cardiovascular disease (CVD) estimated from the Framingham equations. Design Population based cross sectional survey. Setting Nine general practices in south London. Population 1386 men and women, age 40­59 years, with no history of CVD (475 white people, 447 south Asian people, and 464 people of African origin), and a subgroup of 1069 without known diabetes, left ventricular hypertrophy, peripheral vascular disease, renal impairment, or target organ damage. Main outcome measures 10 year risk estimates. Results People of African origin had the lowest 10 year risk estimate of CHD adjusted for age and sex (7.0%, 95% confidence interval 6.5 to 7.5) compared with white people (8.8%, 8.2 to 9.5) and south Asians (9.2%, 8.6 to 9.9) and the highest estimated risk of stroke (1.7% (1.5 to 1.9), 1.4% (1.3 to 1.6), 1.6% (1.5 to 1.8), respectively). The estimate risk of combined CVD, however, was highest in south Asians (12.5%, 11.6 to 13.4) compared with white people (11.9%, 11.0 to 12.7) and people of African origin (10.5%, 9.7 to 11.2). In the subgroup of 1069, the probability that a risk of CHD >15% would identify risk of combined CVD >20% was 91% in white people and 81% in both south Asians and people of African origin. The use of thresholds for risk of CHD of 12% in south Asians and 10% in people of African origin would increase the probability of identifying those at risk to 100% and 97%, respectively. Conclusion Primary care doctors should use a lower threshold of CHD risk when treating mild uncomplicated hypertension in people of African or south Asian origin

A community programme to reduce salt intake and blood pressure in Ghana

Background In Africa hypertension is common and stroke is increasing. Detection, treatment and control of high blood pressure (BP) is limited. BP can be lowered by reducing salt intake. In Africa salt is added to the food by the consumer, as processed food is rare. A population-wide approach with programmes based on health education and promotion is thus possible. Methods We carried out a community-based cluster randomised trial of health promotion in 1,013 participants from 12 villages (628 women, 481 rural dwellers); mean age 55 years to reduce salt intake and BP. Average BP was 125/74 mmHg and urinary sodium (UNa) 101 mmol/day. A health promotion intervention was provided over 6 months to all villages. Assessments were made at 3 and 6 months. Primary end-points were urinary sodium excretion and BP levels. Results There was a significant positive relationship between salt intake and both systolic (2.17 mmHg [95% CI 0.44 to 3.91] per 50 mmol of UNa per day, p < 0.001) and diastolic BP (1.10 mmHg [0.08 to 1.94], p < 0.001) at baseline. At six months the intervention group showed a reduction in systolic (2.54 mmHg [-1.45 to 6.54]) and diastolic (3.95 mmHg [0.78 to 7.11], p = 0.015) BP when compared to control. There was no significant change in UNa. Smaller villages showed greater reductions in UNa than larger villages (p = 0.042). Irrespective of randomisation, there was a consistent and significant relationship between change in UNa and change in systolic BP, when adjusted for confounders. A difference in 24-hour UNa of 50 mmol was associated with a lower systolic BP of 2.12 mmHg (1.03 to 3.21) at 3 months and 1.34 mmHg (0.08 to 2.60) at 6 months (both p < 0.001). Conclusion In West Africa the lower the salt intake, the lower the BP. It would appear that a reduction in the average salt intake in the whole community may lead to a small but significant reduction in population systolic BP

Association between C-reactive protein with all-cause mortality in ELSA-Brasil cohort

Background: High-sensitive C-reactive protein (hsCRP) has been proposed as a marker of incident cardiovascular disease and vascular mortality, and it may also be a marker of non-vascular mortality. However, most evidence comes from either North American or European cohorts. The present proposal aims to investigate the association of high-sensitive C-reactive protein with the risk of all-cause mortality in a multi-ethnic Brazilian population Methods: Cohort data from baseline (2008–2010) of 14 792 subjects participating in the Brazilian Longitudinal Study of Adult Health were used. HsCRP was assayed with Immunochemistry. The association of baseline covariates with all-cause mortality was calculated by Cox regression for univariate model and adjusted for different confounders after mean follow-up of 8.0 ± 1.1 years. The final model was adjusted for age, sex, self-rated race/ethnicity, schooling, health behaviours and prevalent chronic disease. Results: The risk of death increased steadily by quartiles of hsCRP from 1.45 (95% Confidence Interval: 1.05, 2.01) in Quartile 2 to 1.95 (1.42, 2.69) in Quartile 4 compared to Quartile 1. Furthermore, the persistence of a significant graded association after the exclusion of deaths in the first year of follow-up suggests that these results are unlikely to be due to reverse causality. Finally, the hazard ratios were unaffected by the exclusion of participants that had self-reported past medical history for diabetes, cancer and chronic obstructive pulmonary disease. Conclusions: Our study shows that hsCRP levels is associated with mortality in a highly admixed population, independently of a large set of lifestyle and clinical variables

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients’ safety : assessor-blind pilot comparison

Background: There are currently no field data about the effect of implementing European Working Time Directive (EWTD)-compliant rotas in a medical setting. Surveys of doctors’ subjective opinions on shift work have not provided reliable objective data with which to evaluate its efficacy. Aim: We therefore studied the effects on patient's safety and doctors’ work-sleep patterns of implementing an EWTD-compliant 48 h work week in a single-blind intervention study carried out over a 12-week period at the University Hospitals Coventry & Warwickshire NHS Trust. We hypothesized that medical error rates would be reduced following the new rota. Methods: Nineteen junior doctors, nine studied while working an intervention schedule of <48 h per week and 10 studied while working traditional weeks of <56 h scheduled hours in medical wards. Work hours and sleep duration were recorded daily. Rate of medical errors (per 1000 patient-days), identified using an established active surveillance methodology, were compared for the Intervention and Traditional wards. Two senior physicians blinded to rota independently rated all suspected errors. Results: Average scheduled work hours were significantly lower on the intervention schedule [43.2 (SD 7.7) (range 26.0–60.0) vs. 52.4 (11.2) (30.0–77.0) h/week; P < 0.001], and there was a non-significant trend for increased total sleep time per day [7.26 (0.36) vs. 6.75 (0.40) h; P = 0.095]. During a total of 4782 patient-days involving 481 admissions, 32.7% fewer total medical errors occurred during the intervention than during the traditional rota (27.6 vs. 41.0 per 1000 patient-days, P = 0.006), including 82.6% fewer intercepted potential adverse events (1.2 vs. 6.9 per 1000 patient-days, P = 0.002) and 31.4% fewer non-intercepted potential adverse events (16.6 vs. 24.2 per 1000 patient-days, P = 0.067). Doctors reported worse educational opportunities on the intervention rota. Conclusions: Whilst concerns remain regarding reduced educational opportunities, our study supports the hypothesis that a 48 h work week coupled with targeted efforts to improve sleep hygiene improves patient safety

Sleep and Cognition

Sleep is an ancestral and primitive behaviour, an important part of life thought to be essential for restoration of body and mind. As adults, we spend approximately a third of our lives asleep and as we progress through life there are certain shifts in sleep architecture, most notably in sleep quantity. These biological or physiological age-dependent changes in sleep are well documented [1], and alongside the shifts in sleep architecture there is an increased susceptibility to certain sleep disorders. Sleep disturbances and sleep deprivation are common in modern society. Most studies show that since the beginning of the century, populations have been subjected to a steady constant decline in the number of hours devoted to sleep. This is due to changes in a variety of environmental and social conditions (e.g. less dependence on daylight for most activities, extended shift work and 24/7 round-the-clock activities

Polycapillary based μXRF station for 3D colour tomography

The “Rainbow X-Ray” (RXR) experimental station at XLab Frascati of the Frascati’s National Laboratories (LNF) INFN is a dedicated station for X-ray fluorescence studies based on the use of polycapillary lenses in a confocal geometry. The flexible RXR layout allows investigating specimens of the dimensions ranging from several millimeters up to half meter and weighting up to several tens of kilograms. Compared to similar existing XRF stations, apart of the possibility for investigating large samples, the main advantage of this equipment is the detection system with two spectrometers optimized to work separately at high and at low X-ray energie

Gender-specific associations of short sleep duration with prevalent and incident hypertension : the Whitehall II Study

Sleep deprivation (5 hour per night) was associated with a higher risk of hypertension in middle-aged American adults but not among older individuals. However, the outcome was based on self-reported diagnosis of incident hypertension, and no gender-specific analyses were included. We examined cross-sectional and prospective associations of sleep duration with prevalent and incident hypertension in a cohort of 10 308 British civil servants aged 35 to 55 years at baseline (phase 1: 1985-1988). Data were gathered from phase 5 (1997-1999) and phase 7 (2003-2004). Sleep duration and other covariates were assessed at phase 5. At both examinations, hypertension was defined as blood pressure 140/90 mm Hg or regular use of antihypertensive medications. In cross-sectional analyses at phase 5 (n5766), short duration of sleep (5 hour per night) was associated with higher risk of hypertension compared with the group sleeping 7 hours, among women (odds ratio: 2.01; 95% CI: 1.13 to 3.58), independent of confounders, with an inverse linear trend across decreasing hours of sleep (P0.003). No association was detected in men. In prospective analyses (mean follow-up: 5 years), the cumulative incidence of hypertension was 20.0% (n740) among 3691 normotensive individuals at phase 5. In women, short duration of sleep was associated with a higher risk of hypertension in a reduced model (age and employment) (6 hours per night: odds ratio: 1.56 [95% CI: 1.07 to 2.27]; 5 hour per night: odds ratio: 1.94 [95% CI: 1.08 to 3.50] versus 7 hours). The associations were attenuated after accounting for cardiovascular risk factors and psychiatric comorbidities (odds ratio: 1.42 [95% CI: 0.94 to 2.16]; odds ratio: 1.31 [95% CI: 0.65 to 2.63], respectively). Sleep deprivation may produce detrimental cardiovascular effects among women. (Hypertension. 2007;50:694-701.) Key Words: sleep duration blood pressure hypertension gender differences confounders comorbiditie

Combined effects of time spent in physical activity, sedentary behaviors and sleep on obesity and cardio-metabolic health markers: a novel compositional data analysis approach

<div><p>The associations between time spent in sleep, sedentary behaviors (SB) and physical activity with health are usually studied without taking into account that time is finite during the day, so time spent in each of these behaviors are codependent. Therefore, little is known about the combined effect of time spent in sleep, SB and physical activity, that together constitute a composite whole, on obesity and cardio-metabolic health markers. Cross-sectional analysis of NHANES 2005–6 cycle on N = 1937 adults, was undertaken using a compositional analysis paradigm, which accounts for this intrinsic codependence. Time spent in SB, light intensity (LIPA) and moderate to vigorous activity (MVPA) was determined from accelerometry and combined with self-reported sleep time to obtain the 24 hour time budget composition. The distribution of time spent in sleep, SB, LIPA and MVPA is significantly associated with BMI, waist circumference, triglycerides, plasma glucose, plasma insulin (all p<0.001), and systolic (p<0.001) and diastolic blood pressure (p<0.003), but not HDL or LDL. Within the composition, the strongest positive effect is found for the proportion of time spent in MVPA. Strikingly, the effects of MVPA replacing another behavior and of MVPA being displaced by another behavior are asymmetric. For example, re-allocating 10 minutes of SB to MVPA was associated with a lower waist circumference by 0.001% but if 10 minutes of MVPA is displaced by SB this was associated with a 0.84% higher waist circumference. The proportion of time spent in LIPA and SB were detrimentally associated with obesity and cardiovascular disease markers, but the association with SB was stronger. For diabetes risk markers, replacing SB with LIPA was associated with more favorable outcomes. Time spent in MVPA is an important target for intervention and preventing transfer of time from LIPA to SB might lessen the negative effects of physical inactivity.</p></div

A cross-sectional study of vascular risk factors in a rural South African population : data from the Southern African Stroke Prevention Initiative (SASPI)

Background: Rural sub-Saharan Africa is at an early stage of economic and health transition. It is predicted that the 21st century will see a serious added economic burden from non-communicable disease including vascular disease in low-income countries as they progress through the transition. The stage of vascular disease in a population is thought to result from the prevalence of vascular risk factors. Already hypertension and stroke are common in adults in sub-Saharan Africa. Using a multidisciplinary approach we aimed to assess the prevalence of several vascular risk factors in Agincourt, a rural demographic surveillance site in South Africa. Methods: We performed a cross sectional random sample survey of adults aged over 35 in Agincourt (population ≈ 70 000). Participants were visited at home by a trained nurse who administered a questionnaire, carried out clinical measurements and took a blood sample. From this we assessed participants' history of vascular risk, blood pressure using an OMRON 705 CP monitor, waist circumference, body mass index (BMI), ankle brachial index (ABI), and total and HDL cholesterol. Results: 402 people (24% men) participated. There was a high prevalence of smoking in men, but the number of cigarettes smoked was small. There was a striking difference in mean BMI between men and women (22.8 kg/m2 versus 27.2 kg/m2), but levels of blood pressure were very similar. 43% of participants had a blood pressure greater than 140/90 or were on anti-hypertensive treatment and 37% of participants identified with measured high blood pressure were on pharmacological treatment. 12% of participants had an ABI of < 0.9, sugesting the presence of sub-clinical atheroma. 25.6% of participants had a total cholesterol level > 5 mmol/l. Conclusion: We found a high prevalence of hypertension, obesity in women, and a suggestion of subclinical atheroma despite relatively favourable cholesterol levels in a rural South African population. South Africa is facing the challenge of an emerging epidemic of vascular disease. Research to establish the social determinates of these risk factors and interventions to reduce both individual and population risk are required