BP-f4 and Nav-8 QTLs. We developed two congenic strains, S.R2A and S.R2B introgressing Dahl R-chromosome 2 segments into Dahl S chromosome 2 region spanning BP-f4 and Nav-8 QTLs. Radiotelemetric blood pressure analysis identified only S.R2A congenic rats with lower systolic blood pressure , diastolic blood pressure , and mean arterial pressure  compared with corresponding Dahl S controls, confirming the presence of BP-f4 QTL on rat chromosome 2. The S.R2B congenic segment did not affect blood pressure. Testing of S.R2A, S.R2B, and Dahl S male rats in the Morris water maze (MWM) task revealed significantly decreased spatial navigation performance in S.R2A male congenic rats when compared with Dahl S male controls (P<0.05). The S.R2B congenic segment did not affect performance of the MWM task in males. The S.R2A female rats did not differ in spatial navigation when compared with Dahl S female controls, indicating that the Nav-8 effect on spatial navigation is male-specific. Our results suggest the existence of a single QTL on chromosome 2 176.6–179.9 Mbp region which affects blood pressure in both males and females and cognition solely in males.Epidemiological studies have consistently found that hypertension is associated with poor cognitive performance. We hypothesize that a putative causal mechanism underlying this association is due to genetic loci affecting both blood pressure and cognition. Consistent with this notion, we reported several blood pressure (BP) quantitative trait loci (QTLs) that co-localized with navigational performance (Nav)-QTLs influencing spatial learning and memory in Dahl rats. The present study investigates a chromosome 2 region harboring  Essential hypertension is a leading risk factor for myocardial infarction and stroke HS) and Dahl salt-sensitive (Dahl S/jrHS) inbred rat lines. We detected several blood pressures (BP)-QTLs BP-f4Nav-8BP-f4 and Nav-8 QTLs would remain within that same congenic segment, a finding that would support the hypothesis that a single gene variant might affects both traits.Hypertension and dementia are conditions that exhibit highly complex inheritance involving environmental, genetic, and epigenetic mechanisms. These disorders are further compounded by phenotype variation due to its relatively late onset, variable disease course, sex-specific differences, and emerging impact of gestational environmental factors. Thus, animal models offer the ability to eliminate major confounds from diet and developmental programming and conduct controlled genetic experiments to localize quantitative trait loci (QTLs) on their genomes affecting blood pressure BP-f4) Nav-8) BP-f4/Nav-8 QTLs onto the Dahl S genetic background (Our two previous linkage studies performed on two F2 (Dahl S×R)-intercross rat populations, one cohort phenotyped for blood pressure ckground . We succckground  congenicBP-f4 and Nav-8 QTLs -intercross male population Since we detected the 2,336 = 1.39, P>0.2). In the probe trial for spatial memory, all three groups exhibited target selectivity, showing enhanced preference for the target quadrant over other quadrants . However, direct comparison of selectivity for the target quadrant in the probe trial showed better performance of Dahl S male controls compared with S.R2A male subjects  or in the probe trial performance between S.R2A female rats and Dahl S female controls. Both female groups demonstrated target selectivity  at 176.74 Mbp, was shown to be a candidate gene underlying the BP-f4 and Nav-8 QTL-effects on blood pressure and spatial learning and memory. The remaining 35 annotated genes did not reveal obvious potential biological roles in blood pressure regulation or cognitive function. Several lines of evidence support that DEspR has pleiotropic effects on blood pressure and cognition: 1) the existence of one specific S44P/M74T DEspR variant that has been associated with salt-sensitive hypertension in Dahl rats DEspR- T/CATAAAA-box promoter variant that decreases DEspR transcription has been associated with increased blood pressure in a male Sardinian population DEspR as the gene underlying BP-f4 and Nav-8 QTLs.Inspection of the chromosome 2 176.6–179.9 Mbp region spanning the ed genes . One genDEspR maps to chromosome 4 153.26 Mbp and is a candidate gene underlying some of the observed chromosome 4 QTL effects on general cognitive ability DEspR has pleiotropic effects on both blood pressure and cognition.Interestingly, a chromosome 4 scan for QTLs affecting general cognitive ability in humans detected several QTLs within the chromosome 4 120–180 Mbp region DEspR at chromosome 2 176.73 Mbp as a prime candidate gene underlying this QTL. The successful trapping of the chromosome 2 BP-f4/Nav-8 QTL present in the S.R2A congenic line will form the basis to further fine map this QTL region to less than 0.1 Mbp via sub-strain construction and identify the specific gene variant accounting for this QTL. This would establish pleiotropy as an important genetic mechanism contributing to onset and development of different complex disorders and would explain in part the relationship between high blood pressure and poor cognitive performance observed in numerous epidemiological studies Our study demonstrates the existence of either two closely linked QTLs or a single QTL on chromosome 2 176.6–179.9 Mbp region affecting blood pressure in both male and female Dahl S rats and influencing spatial learning and memory only in Dahl S male rats. Our results suggest the existence of a single QTL in the chromosome 2 176.6–179.9 Mbp region exhibiting pleiotropic effects on blood pressure and cognition with a priori basis for novel prevention and intervention strategies for complex disorders such as essential hypertension and cognitive impairment affecting the aging human population.We detected three additional overlapping blood pressure and spatial navigation QTLs on chromosomes 1, 11, and 20, suggesting the existence of additional loci concomitantly affecting blood pressure and cognitive performance in Dahl rats. Thus, the elucidation of genetic mechanisms in complex traits would form an This study was performed in strict accordance with the recommendations in the Guide for the Care and Use of Laboratory Animals of the National Institutes of Health. The protocol was approved by the Committee on the Ethics of Animal Experiments of Boston University School of Medicine (Permit Number: AN-14966). All surgery was performed under sodium pentobarbital anesthesia, and every effort was made to minimize suffering.BP-f4/Nav-8 onto the Dahl S genetic background. We implemented a “speed congenic” strategy BP-f4/Nav-8 “carriers” from 300 BC1 subjects by genotyping the BC1 male progeny with flanking markers of the chromosomal segments planned to be transferred. For S.R2A: sr heterozygous at SNP2786619 and SNP2786747, and ss homozygous at nearby flanking markers, i.e. D2Rat352 and SNP2786811. For S.R2B: sr heterozygous at SNP2786652 and SNP2786747, and ss homozygous at nearby flanking markers, i.e. SNP2786619 and SNP2786811. We produced 20 BC2 male subjects per congenic line and proceeded to screen subjects with 85 informative SNPs. One “best” male breeder per congenic line was chosen to continue with the inbreeding program. We performed back-crosses up to BC6 and established homozygous congenic lines for blood pressure measurements and Morris Water Maze performance. The SR2A congenic line was greater than 99.70% of Dahl S genetic background and the S.R2B congenic line was greater than 99.77% of Dahl S genetic background.All rats utilized in this study were bred in-house. Inbred Dahl S/jrHsd and Dahl R/jrHsd rats were obtained from Harlan . We transferred two Dahl R chromosomal segments spanning We selected the following single nucleotide polymorphisms (SNPs) for congenic rat development from the rat genome data base (RGD): markers for S.R2A and S.R2B congenic fragments; SNP2786619, SNP2786747, D2Rat352, SNP2786811, SNP2786652. SNPs for implementation of “speed congenic” strategy, chr1: SNP2783361, SNP2783513, SNP2783573, SNP2783925, SNP2784073, SNP2784200, SNP2784723, SNP2784895, SNP2785046; chr2: SNP2785301, SNP2785499, SNP2785693, SNP2785860, SNP2786134, SNP2786276, SNP2786350, SNP2786619, SNP2786811, SNP2786979, SNP2787226; chr3: SNP2787599, SNP2787751, SNP2787947, SNP2788108, SNP2788217, SNP2788416; chr4: SNP2789191, SNP2789416, SNP2789717, SNP2789952, SNP2790223, chr5: SNP2790571, SNP2790733, SNP2790960, SNP2791234, SNP2791496, SNP2791711, SNP2791834; chr6: SNP2792065, SNP2792467, SNP2792754; chr7: SNP2793338, SNP2793565, SNP2793757, SNP2793904; chr8: SNP2794281, SNP2794450, SNP2794721, SNP2794865; chr9: SNP2795738, SNP2795947; chr10: SNP2796278, SNP2796474, SNP2796739, SNP2796966; chr11: SNP2797258, SNP2797443, SNP2797742; chr12: SNP2797924, SNP2798115; chr13: SNP2798475, SNP2798659, SNP2798785, SNP2798926; chr14: SNP2799254, SNP2799430, SNP2799825; chr15: SNP2800105, SNP2800195; chr16: SNP2800810, SNP2801108; chr17: SNP2801413, SNP2801584, SNP2801868, SNP2801948; chr18: SNP2802358, SNP2802507, SNP2802706; chr19: SNP2802997, SNP2803270; chr20: SNP2803540, SNP2803747; chrX: SNP2804065, SNP2804185, SNP2804233.DNA was extracted from tail biopsies using the QIAamp Tissue Kit . SNP genotyping was carried out on a Life Technologies 7900 Real-Time PCR System . All SNP assays (TaqMan assays) were procured from Life Technologies and were validated in our laboratory. Microsatellite markers were PCR genotyped and detected by 6% denaturing polyacrylamide gel electrophoresis.ad libitum. Blood pressure was measured essentially as described Animals were maintained on a Harlan 2018 rodent chow  containing 0.23% NaCl from weaning until the high salt diet begun at 12 weeks of age. The food pellets and water were made available ±0.5), and a computer tracking system . Distance was used to evaluate performance. Twelve swim trials were conducted per day (for 2 consecutive days). Animals were placed into the maze  and were allowed to traverse the maze in search of the escape platform. During each trial, a maximum swim time of 60 s was imposed. Between trials, a 35 s interval was imposed with the rat on the platform. At the end of the 24th trial, rats were removed to the home cage for 10 min, then the platform was removed  and the rat was allowed to search for 1 min. Sixteen Dahl S males, 16 S.R2A males, 13 S.R2B males, 13 Dahl S females, and 16 S.R2A females were characterized in this MWM task for subsequent comparative analysis. Spatial accuracy was define as the ratio of % distance traveled in platform counter over the sum of % distance traveled over four counters localized at analogous positions on corresponding quadrants .The MWM task was performed as described We performed a one-way analysis of variance (ANOVA) followed by all pairwise multiple comparisons using the Holm-Sidak test for blood pressures. We used a two-way repeated measures ANOVA followed by Holm-Sidak test for acquisition performance comparisons and a one-way ANOVA followed by Holm-Sidak test to analyze navigational performance on the probe trial.


Low body mass index (BMI) is associated with a poor outcome in chronic heart failure (CHF). An inverse association between BMI and adiponectin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been reported. The aim of the present study was to investigate whether novel markers of neurohormonal activation, inflammation, and endothelial dysfunction are associated with BMI in CHF.In a cross-sectional study including 171 patients with CHF and a left ventricular ejection fraction (LVEF) ≤45% the impact of BMI on circulating plasma concentrations of adiponectin, α-defensins, high sensitivity C-reactive protein (hsCRP), copeptin, mid-regional pro-adrenomedullin (MR-proADM), NT-proBNP, and mid-regional pro-A-type natriuretic peptide (MR-proANP) were evaluated.In multivariable linear regression analysis including age, sex, LVEF, New York Heart Association functional classification (NYHA), estimated glomerular filtration rate (eGFR), and diabetes, only NT-proBNP (β = −0.32) and adiponectin (β = −0.39) remained independently associated with BMI. MR-proANP was associated with BMI but adjusting for age attenuated the relation being no longer significant.Among biomarkers typically increased in patients with CHF only adiponectin and NT-proBNP demonstrated independent inverse associations with BMI. This indicates a direct effect of these two biomarkers enhancing the wasting process seen in CHF. Low body mass index (BMI) is associated with a poor outcome in chronic heart failure (CHF) and survival is further impaired if CHF progresses to cardiac cachexia,2. The uHigh levels of the adipocytokine adiponectin reflect low BMI as well as high insulin sensitivity in healthy subjects and patients with type 2 diabetes mellitus (DM). Although adiponectin correlates to BMI in CHF, a paradox seems to be present, since high adiponectin levels have been reported to be associated with increased risk of mortality in CHF,10,11, aThe development of novel assays targeting pro-hormones and stable fragments of peptides associated with cardiovascular disease (CVD) presents several new biomarkers with a potential for clinical use. Adrenomedullin (ADM) is a 52-amino-acid peptide that is expressed in various tissues and its secretion is stimulated in CHF where high concentrations reflect poor survival. CirculaIncreased low-grade inflammation is an important characteristic in CHF. The traWe have previously reported of an association between BMI and NT-proBNP as well as adiponectin in CHF. HoweverFrom 2000 through −2003, we enrolled 171 patients with confirmed systolic CHF defined as left ventricular ejection fraction (LVEF) ≤45% by echocardiography in combination with symptoms. All patients were recruited at a specialized CHF clinic at Frederiksberg University Hospital, Copenhagen, Denmark. Data on BMI and biomarkers were available in 171 patients. The original design of the cohort study as well as baseline characteristics have been published previously. The inv125I-labeled α-defensins (∼10.000 cpm) and 100 μL (200 μg/L) of a specific monoclonal antibody, which recognizes α-defensins-1, -2, and −3 . The intra- and inter-assay coefficients of variation (CVs) were 6% and 9%, respectively. Repetitive freezing and thawing (nine cycles) on serum and plasma levels of α-defensins did not affect the α-defensins levels[All patients met at the outpatient clinic for blood sampling following an overnight fast (8 hrs). Venous blood was drawn and stored as EDTA-plasma at −80°C in aliquots until analysis. A urine sample was collected. To determine the plasma level of α-defensins we used a validated, in-house, solid-phase RIA. Using microtiter plates  incubated overnight at 5 C with anti-mouse IgG . After washing, all wells were added 50 μL of standard  or diluted plasma 1 in 25), 50 μL of d 100 μL 0 μg/L ofs levels. To detes levels. Plasma s levels-25., 50 μL o2 21–25 kg/m2, and >25 kg/m2. The cut point of BMI of 21 kg/m2 was pre-specified and used to facilitate comparison with previous studies in patients with cardiac cachexia[We categorized patients according to BMI levels ≤21 kg/m2) was associated with markedly elevated hsCRP concentrations. Fifty-seven% of the patients had ischemic heart disease (IHD).Clinical characteristics according to BMI are presented in TableBoth inflammatory biomarkers correlated to MR-proADM . Adiponectin concentrations were positively associated with MR-proANP .The univariable linear correlation between BMI and adiponectin, NT-proBNP, MR-proANP, MR-proADM, copeptin, α-defensins, and hsCRP concentrations was evaluated. A significant inverse relationship was found between BMI and adiponectin β = −0.42), NT-proBNP (β = −0.33), and MR-proANP β = −0.19) levels. We did not find any association with the other biomarkers examined. Plasma levels of biomarkers according to BMI categories are shown in Figure9 levels., NT-proBWe have previously reported that BMI has an effect on plasma NT-proBNP concentrations in CHF. In the Low BMI is associated with an unfavourable survival in CHF and accordingly it may be hypothesized that biomarkers significantly associated with BMI are mechanistically linked to the weight loss. In line with this the interest in the lipolytic role of natriuretic peptides is expanding. Recently, NPs have been shown to enhance lipolysis of adipose tissue though activation of the hormone sensitive lipase. Furtherpost hoc analysis from The BACH trial reported significant differences in MR-proANP levels between acute HF patients with highest vs. lowest BMI[In the present study decreasing BMI was associated with advanced age and when eliminating age from the base model, MR-proANP became independently related to BMI. A recent west BMI.Atrial NP promotes adiponectin release in healthy subject. This asThe inverse association between adiponectin levels and BMI found in this study has been documented in both healthy populations and in cohort of CHF patients. Increased levels of adiponectin have been identified in patients with extremely low BMI as in cardiac cachexia, a syndrChronic low grade inflammation is involved in the pathophysiology of CHF. We have recently reported that elevated levels of the novel biomarker α-defensins, reflecting the innate immune system, have prognostic implications in CHF patients. Plasma 2. In contrast to our findings, recent data on MR-proADM levels in lean as well as obese individuals demonstrated a positive correlation to BMI, with a progressive decrease in plasma levels during weight reduction after gastric by-pass surgery[Circulating concentrations of biomarkers reflecting low-grade inflammation and hsCRP, endothelial dysfunction, MR-proADM, and water homeostasis copeptin were not associated with BMI in the present study, even though hsCRP concentrations were increased by a factor 2 in CHF with BMI < 21 kg/m surgery,28. NoneThere are some limitations to this study. First, there are a limited number of patients enrolled in the current study, which might diminish the statistical power of detecting associations between BMI and biomarkers. Second, this study was monocentric and only BMI and no other anthropometric data were available in this CHF cohort. Finally, it should be noted that the present analyses are post hoc analyses on data collected for other purposes. This maAmong the biomarkers which have been shown to be of prognostic importance in patients with CHF only NPs and adiponectin were associated with BMI, as concentrations of the biomarkers increased by decreasing BMI. As this is a cross sectional study, our data do not allow us to make any conclusions about causality, but nevertheless, we speculate that these peptides may participate in the mechanisms responsible for the accelerated weight loss seen in patients with severe CHF.The authors declare that they have no competing interests.CK, JF, MS, and HMC participated in the design of this study. HMC, CK, MS, and JF performed the statistical analyses. HMC, CK, JF, and MS drafted the manuscript. CK, MS, JF, JPG, JFR, and AF were involved in data collection and/or made important intellectual contributions to the interpretation of data and the writing of paper. All authors critically revised and approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/13/80/prepub


Hypertension (HTN) is a modifiable, highly prevalent risk factor for cardiovascular morbidity and renal dysfunction worldwide. In the United States, HTN affects one in three adults, contributes to one out of every seven deaths and to nearly half of all cardiovascular disease-related deaths. HTN is considered resistant when the blood pressure remains above goal despite lifestyle modification and administration of three antihypertensive agents of different classes including a diuretic. Large population-based studies have suggested that obstructive sleep apnea (OSA) is a risk factor for resistant HTN. The mechanism proposed is a pattern of intermittent hypoxia associated with hyperaldosteronism, increased sympathetic tone, endothelial dysfunction, and inflammation. In this review we discuss the association between OSA and resistant HTN, the physiologic mechanisms linking OSA with resistant HTN, and the effect of continuous positive airway pressure therapy (CPAP) on blood pressure in patients with resistant HTN. While the reduction in blood pressure with CPAP is usually modest in patients with OSA, a decrease of only a few mmHg in blood pressure can significantly reduce cardiovascular risk. Patients presenting to a center specializing in management of hypertension should be screened and treated for OSA as a potentially modifiable risk factor. Hypertension (HTN) is a modifiable, highly prevalent, risk factor for cardiovascular morbidity and renal dysfunction worldwide and is increasing in incidence –3. DurinSecondary causes of resistant hypertension:obstructive sleep apnearenal parenchymal diseaserenal artery stenosis primary aldosteronismCushing's diseasehyperparathyroidismcoarctation of aortapheochromocytomaintracranial tumors.HTN is considered resistant when the blood pressure (BP) remains above goal ≥140/90 mmHg) despite lifestyle modification and administration of three antihypertensive agents of different classes including a diuretic 0/90 mmHg.Obstructive sleep apnea (OSA) is the intermittent cessation (apnea) or decrease (hypopnea) of airflow during sleep leading to oxygen desaturation and/or arousal and is classified as mild, moderate, or severe based on the number of these flow-limited breathing events per hour, the apnea-hypopnea index (AHI): mild AHI 5–<15), moderate (AHI 15–<30), and severe (AHI ≥30) . OSA aff, moderatP = 0.005) compared to those with AHI <1.5 [In the Sleep Heart Health Study, a prospective population-based cohort study designed to study the effect of OSA, patients with apnea hypopnea index (AHI) >15 had three times the odds of having HTN at baseline compared to controls . After aAHI <1.5 . In the AHI <1.5 . Both thAHI <1.5 .While population studies on the association between resistant HTN and OSA are lacking, multiple clinic-based studies have shown a significant association between resistant HTN and OSA , 26–29. In a case series by Gus et al., the risk for OSA as assessed by the Berlin Questionnaire was significantly increased in the subjects with resistant HTN as compared to those with HTN adequately controlled by medication . In a siWhile these studies are based on case series and clinic-based cohorts, which are likely to have a higher prevalence of both resistant HTN and OSA, they suggest a strong association between the two conditions. The major pathogenic mechanism linking resistant HTN with OSA may be hyperaldosteronism, although increased sympathetic tone, intermittent hypoxia, endothelin- and hypoxia-mediated vasoconstriction, and obesity may also play a role in the pathogenesis. We will next discuss these mechanisms in detail.Aldosterone excess may play a pathophysiological role in the relation between HTN and OSA , 33, 34.P < 0.05) with low plasma renin activity (1.2 ± 1.8 ng/mL/hr versus 1.9 ± 4.1 ng/mL/hr) and significantly greater 24 hr urinary aldosterone excretion  compared to subjects at low risk of OSA, suggesting an association between primary hyperaldosteronism and OSA [In an observational study of consecutive subjects with resistant HTN, subjects were evaluated for primary hyperaldosteronism using plasma rennin activity <1.0 ng/mL/hr and 24 hr urinary aldosterone excretion >12 micro g during high urinary sodium excretion (>200 mEq/24 hr) and risk of sleep apnea using the Berlin Questionnaire. Patients at high risk for OSA were almost two times more likely to have primary hyperaldosteronism  and diastolic BP (DBP) by 1.52 mmHg . The impact was greater in individuals with severe OSA and improved with better CPAP compliance.OSA can be treated with positive airway pressure therapy, either CPAP or bilevel positive airway pressure (BPAP), oral appliance/mandibular advancement therapy, upper airway surgery, and tracheotomy . CPAP isIn a population-based study Marin et al. showed that in the Zaragoza Sleep Cohort Study treatment of OSA with CPAP was associated with a lower risk of associated HTN. Subjects were followed for a median of 12.2 years with a 37.3% incidence of HTN. Subjects with OSA ineligible for CPAP due to lack of sleepiness and AHI <15, or those declined or those who were noncompliant with CPAP had a higher incidence of HTN .In a small study of 11 patients with resistant HTN by Logan et al., the use of nightly CPAP for two months was associated with a significant decrease in both systolic and diastolic BP . SimilarIn a randomized prospective parallel trial, Lozano et al. randomized 75 patients with an AHI ≥15 to receive either CPAP and conventional treatment or conventional medical treatment alone. 24 hr ABP was repeated at three months. Patients who used CPAP ≥ 5.8 hr per night had clinically significant improvements in BP  and also had a clinically significant improvement in nocturnal dipping pattern compared to the control group [P = 0.01) and diuretic therapy , but not AHI or hours of CPAP use, were independently associated with a decrease in mean arterial pressure after 12 months of CPAP therapy [In a study of subjects with resistant HTN, Dernaika et al. used a retrospective cohort of subjects with OSA and resistant HTN (42 subjects) and controlled HTN (56 subjects) and showed that the use of CPAP permitted deescalation of antihypertensive treatment in 71% of subjects with resistant HTN but did not significantly alter the antihypertensive regimen in the control group . MultivaThe evidence from these studies suggests that treatment of OSA with CPAP leads to modest reduction in BP in individuals with resistant HTN. This is significant because a decrease of only a few mmHg in BP is enough to significantly reduce cardiovascular risk .HTN is highly prevalent in the adult population; up to 31% of adults >18 years old in the United States have been found to have high BP. Resistant HTN, when the BP remains above goal (≥140/90 mmHg) despite lifestyle modification and administration of three antihypertensive agents of different classes, can be present in up to 8.9% of individuals with HTN and 12.8% of individuals on antihypertensive medications. OSA is present in 2% to 4% of adults and is a common modifiable risk factor for resistant HTN. OSA may predispose predispose to resistant HTN via hyperaldosteronism, obesity, increased sympathetic drive, endothelin, or hypoxic vasoconstriction.Studies have shown that treatment of OSA with CPAP can lead to improvement in BP control in patients with resistant HTN. While the reduction is usually modest, a decrease of only a few mmHg in BP can significantly reduce cardiovascular risk. Patients presenting for the management of resistant HTN should be screened for OSA as a modifiable risk factor. Referral to a sleep center can help improve BP control by early diagnosis and treatment of OSA when present, and improving compliance with CPAP in individuals who have OSA.


Depression is known to be a risk factor for cardiovascular diseases but the underlying mechanisms remain unclear. Since recent preclinical evidence suggests that endogenous agonists of cannabinoid receptors (endocannabinoids) are involved in both cardiovascular function and depression, we asked whether endocannabinoids correlated with either in humans.N-arachidonylethanolamine (anandamide) and 2-arachidonoylglycerol. There was no correlation between blood pressure and endocannabinoids in control subjects. Furthermore, depressed women had significantly higher systolic blood pressure than control subjects. A larger body mass index was also found in depressed women, however, it was not significantly correlated with serum endocannabinoid contents.Resting blood pressure and serum content of endocannabinoids in ambulatory, medication-free, female volunteers with depression (n = 28) and their age- and ethnicity-matched controls (n = 27) were measured. In females with depression, both diastolic and mean arterial blood pressures were positively correlated with serum contents of the endocannabinoids, This preliminary study raises the possibility that endocannabinoids play a role in blood pressure regulation in depressives with higher blood pressure, and suggests an interrelationship among endocannabinoids, depression and cardiovascular risk factors in women. These hydrophobic molecules are produced 'on demand' in the central and peripheral system by stimuli, such as depolarization, increases in intracellular Ca2+ and activation of G protein-coupled receptors linked to phospholipase cascades -AEA (16.9 pmol) and [2H8]-2-AG (46.5 pmol)  were added. Samples were vortexed and centrifuged at 1000 × g for 4 min. The supernatant was loaded on C18 columns, which have been conditioned with 1 ml redistilled ethanol and 3 ml of double distilled water (ddH2O). The remaining pellet was washed with 100 μl of 15% ethanol and centrifuged again for 3 min. The resulting supernatant was also loaded onto the C18 column. Columns were washed with 5 ml ddH2O and eluted with 1 ml of ethyl acetate. The ethyl acetate layer in the resulting elute was removed and dried under N2. Lipids in the residual ddH2O phase were extracted by mixing with an additional 1 ml of ethyl acetate, which was added to the original ethyl acetate solution. Once dried, samples were resuspended in 20 μl of methanol and stored at -80°C. AEA and 2-AG were quantified using isotope-dilution, atmospheric pressure, chemical ionization liquid chromatography/mass spectrometry (LC-APCI-MS) as described previously -2-AG .5 pmol . Correlations between eCB content and blood pressure were analyzed by bivariate, Pearson's correlation tests . Influences of potential confounders on these correlations were tested by controlling for a third variable, for example tobacco use, body mass index (BMI) and serum cholesterol level, using partial correlation tests . 1: Cannabinoid receptor type 1; eCB: Endocannabinoids; DSM-IV: Diagnostic and Statistical Manual; HDL: High-density lipoprotein; LDL: Low-density lipoproteins.2-AG: 2-arachidonoylglycerol; AEA: Anandamide; BMI: Body mass index; CBThe authors declare that they have no competing interests.MNH, GEM, BBB and CJH designed the study; WSVH, MNH and GEM performed the experiments; WSVH, MNH and CJH wrote the paper. All authors read and approved the final manuscript.


Uncontrolled high blood pressure (HBP) is a significant health problem and often goes undetected. In the prehospital care-delivery system of 9-1-1 emergency medical services (EMS) calls, emergency medical technicians (EMTs) routinely collect medical information, including blood pressure values, that may indicate the presence of chronic disease. This information is usually archived without any further follow-up. We conducted several planning activities during the fall of 2006 to determine if a partnership between researchers at the Health Marketing Research Center at the University of Washington, Public Health Seattle King County EMS division, and several large fire departments could be developed to help identify community residents with uncontrolled HBP and determine the most effective way to communicate HBP information to them.We partnered with 4 King County, Washington, fire departments that provide 9-1-1 EMS to develop an intervention for people with uncontrolled HBP who were attended by EMTs in response to a 9-1-1 call for assistance. On the basis of discussions with EMS personnel at all levels, we developed a system by which we could identify at-risk community residents by using medical incident report forms that EMS personnel completed; we consulted with EMS personnel to determine the most effective means of reaching these people. In addition we developed a survey to assess community residents' beliefs about blood pressure control, the role of EMTs as health care providers, and the convenience of fire stations as places to have blood pressure checked. Using contact information that EMS personnel obtained, we surveyed 282 community residents from a total of 794 people whom EMTs had identified as at risk for uncontrolled HBP to help us understand our target audience.In consultation with EMS personnel, we determined that direct mail was the most effective way to reach people with uncontrolled HBP identified from EMS records to advise them of their risk. On the basis of the number with a known response to each question, 67% (n = 180/269) of the respondents reported that a doctor or other health professional had told them they had HBP, 95% (246/259) believed that regular screening for HBP was important, 65% (166/254) said that EMTs were highly credible health care providers, and 82% (136/165) said that they would feel comfortable receiving blood pressure screening at a local fire station.Partnering with local EMS may be an effective way to identify and reach community residents with uncontrolled HBP with information on their medical condition and to encourage them to have follow-up screening. High blood pressure (HBP) is a risk factor for heart attack and stroke . In the Because blood pressure screening is an inexpensive and effective diagnostic method, the National Commission on Prevention Priorities has listed it as a priority clinical preventive service based on their criteria of clinical burden and cost-effectiveness . NonetheParticipation in screening for a disease is related, in part, to a person's perceived risk of the disease and the benefits of recommended action . The HeaMeasuring blood pressure is usually part of routine patient evaluation in health care facilities. However, people without a regular source of health care are less likely to be screened for chronic disease and are more likely to use emergency care as a source of health care ,12. In tBecause EMS is available in most communities, people who have uncontrolled HBP could be identified by these first responders and referred to treatment. Thousands of people receive EMS every year ; many haThe objective of our study was to develop an intervention that would provide community residents identified by EMS as having uncontrolled HBP (systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg) with information on their medical condition, to offer residents follow-up blood pressure screening, and to determine if a partnership between researchers at the Health Marketing Research Center at the University of Washington, Public Health Seattle King County EMS division, and several large fire departments was an effective way to construct and implement this intervention. As part of our formative research, which aids in identifying target audiences, effective communication strategies, and feasibility of implementation strategies, we developed an intervention designed to report back to EMS patients their medical information  obtained by EMTs during a response to a 9-1-1 EMS call and to facilitate additional blood pressure screening.The study consisted of 3 parts: 1) informal planning with EMS and other fire service personnel, 2) conducting telephone surveys of community residents who were identified by 9-1-1 EMS responders as being at risk for uncontrolled HBP to assess attitudes and beliefs, and 3) developing an intervention for reaching residents with information about controlling HBP. This study was reviewed and approved by the Human Subjects Division of the University of Washington.We conducted our study in a large metropolitan area in the Pacific Northwest. We partnered with 4 fire departments in King County, Washington, that served a combined population of 403,260. The smallest department had a population of 49,167 and the largest, a population of 133,543 . TogetheTo develop an intervention that was both feasible in an acute care delivery system and acceptable to EMS providers, we conducted informal discussions with EMS personnel at all levels. The medical director of the EMS division of the county health department and study staff met with the fire chiefs of the 4 participating fire departments to discuss how the fire departments' EMS division and the fire departments could collaborate to develop the intervention. Study staff then met with the 4 EMT trainers of the participating fire departments and with individual EMTs and administrative staff.We did not use a standardized questionnaire in our discussions; however, discussion objectives were the same for each encounter: to assess the feasibility of providing free blood pressure checks at all fire stations, to assess the best intervention delivery method , to stress the importance of complete patient contact information on the medical incident report forms for use in surveys and intervention evaluation, to agree on the proper inclusion criteria for the study, to determine what feedback EMTs would like to receive throughout the process, and to obtain the advice of EMS personnel about the intervention print materials. Study staff used notes of the discussions to design the intervention and develop study strategies. To better understand the daily activities of EMTs, the study coordinator rode with an EMS crew for 1 day.To define the target audience for the study, we conducted a telephone survey over 3 months with 282 people residing in the areas served by the 4 participating fire departments who had had very high HBP values (systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg) during a non–life-threatening 9-1-1 EMS event. The objective of this survey was to assess prior history of HBP, beliefs as indicated by the Health Belief Model , and attitudes toward fire stations as a place for having blood pressure checked.2 for frequencies and the Mann-Whitney U test for means). Survey questions (available upon request) assessed demographics; questions based on the Health Belief Model, such as risk perceptions regarding HBP; perceived benefits and barriers to blood pressure control; current blood pressure–control behaviors; and attitudes, and beliefs about 9-1-1 EMS care providers and delivery systems. Data were analyzed with SPSS version 18  by using descriptive statistics  fire stations in participating departments. We decided it would be too complicated to ask fire personnel to write down contact information for each person coming to their fire station for a blood pressure check, so we evaluated this behavior via telephone survey rather than extensive logs at fire stations.We contacted 794 people whom EMTs had identified as at risk for uncontrolled HBP for our interviews. Of the 794 interviews attempted, 282 (35.5%) community residents began the survey, and 270 (34%) finished it; 12 persons began the survey but dropped out during the interview. The denominator for individual questions is based on the number who answered that question, and thus the denominators vary slightly because of the drop-outs, those who declined to answer a particular question, and those who answered a question as "unknown" or "do not remember." Age and sex were available for all participants from the information recorded by EMTs on their incident reports, if not answered on the survey.Demographic information included age, sex, marital status, health insurance status, race/ethnicity, and educational attainment. Sixty-six percent (n = 186/282) of participants were women. The mean (standard deviation [SD]) age was 64.1 (16.6) (n = 282); 70% (n = 173/245) had more than a high school diploma, and 86% (n = 204/238) were white. These demographics helped us develop a target profile of an older, white, fairly well educated, mostly female study population.Of the 512 who were not interviewed, 28% (n = 144) refused, 22% (n = 111) had a busy telephone line or answering machine, 18% (n = 92) had incorrect or disconnected telephone numbers, 14% (n = 71) were unable to participate because of a disability, 8% (n = 41) were unable to participate because of a language barrier, approximately 2% (n = 11) were deceased, approximately 1% (n = 7) were hospitalized, and 7% (n = 35) were "other." Selected variables were recorded as part of the medical incident reports and were available to compare the 282 participants who began the survey with the 512 who were not interviewed: age, sex, location of the 9-1-1 EMS visit (home vs away from home), and whether the patients were transported from the scene for further care. The 282 subjects were found to be representative of the 512 for whom an interview was attempted unsuccessfully on all comparisons except age; the 282 were younger  than the 512 participants who were not interviewed .Most  respondents reported a history of hypertension, were medicated for HBP , and believed HBP to be a serious health threat . Nearly all participants  believed that regular screening was important for personal health. On the basis of this information, we determined our target audience would likely be mostly undercontrolled hypertensive patients, as all these patients were selected for the interview on the basis of extremely high blood pressure values in the medical incident reports. However, a significant proportion, about one-third, might be at risk for being newly diagnosed patients as they had not received a diagnosis by a health care provider but had extremely high blood pressure values during a recent 9-1-1 visit.Because we wanted to improve access to screening for all patients, particularly those without regular access to care, we asked about patients' familiarity and comfort with local fire stations as a place for follow-up blood pressure screening. Almost every survey participant  knew of a nearby fire station and reported it would be easy to go there . Forty-four percent (n = 115/262) reported ever having visited a local fire station. Sixty-five percent (n = 138/211) reported that they believe a fire station would be a good place to learn about health, and most  reported they would feel comfortable having their blood pressure checked at a local fire station. Furthermore, 96% (n = 239/250) of participants viewed EMTs as competent to evaluate and treat medical problems. Sixty-five substantial (n = 166/254) strongly agreed they would trust EMTs to evaluate and treat their medical problems.On the basis of survey results and discussions with EMS personnel, we determined that a partnership may be feasible between researchers at an academic institution, the EMS division of the local health department, and 4 fire departments to increase community awareness of uncontrolled HBP. Data showed that the health beliefs as posited in the Health Belief Model were held strongly in our target audience. Furthermore, EMTs were perceived as credible spokespeople, and the majority of participants reported that they would feel comfortable visiting a fire station for a blood pressure check. On the basis of our research, we developed an intervention for reaching people with uncontrolled HBP identified during a 9-1-1 EMS event. On the basis of conversations with EMS providers, the intervention will be conducted via direct mail. We developed a brochure mailer  that notOur intervention strategy has been tested and shown to be successful in the past in a similar setting. A direct-mail campaign to urge people to call 9-1-1 EMS for symptoms of myocardial infarction resulted in a significant increase in calls for chest pain among patients with a history of heart disease . A commeThere are limitations to our study. The intervention developed and reported here was designed for a specific community. Fire departments in King County, Washington, have a history of participation in patient and community outreach ,19 and wThe intervention we developed will give participants health information they may not have known about, on which they may choose to act. In addition, patients will be given the opportunity to receive a free blood pressure check at a local fire station, which will allow access to screening for all residents of our community.Our study showed that a partnership is feasible between researchers at the Health Marketing Research Center at the University of Washington, Public Health Seattle King County EMS division, and community EMS and that such a partnership can provide community residents with information on their health and health risk factors that may not be otherwise available to them. Fire stations are conveniently located in most neighborhoods, and fire station EMS personnel can serve a useful role in providing blood pressure screening to their community.


Subjects with Polycystic ovarian syndrome (PCOS) are at increased risk of Type 2 diabetes mellitus (T2DM). The mechanism of this enhanced risk is unclear. Circulating vascular progenitor cells (VPC) are immature bone marrow derived cells capable of differentiating into mature endothelial cells. VPC number/function and central arterial stiffness predict cardio-metabolic disease in at-risk populations.We studied VPC and arterial stiffness measures in non-obese PCOS subjects as compared to age and body mass index (BMI) matched healthy controls in a cross–sectional study.2) and metabolic profile were studied. VPC number and in vitro function were studied by flow cytometry and tube formation assays respectively. Augmentation index (AIx), a measure of central arterial stiffness, and central (aortic) blood pressures (BP) were measured by applanation tonometry.Fourteen subjects with PCOS and 12 controls of similar age, BMI  and impaired in vitro tube formation (completed tube area 1.0±0.06 vs. 1.2±0.05×106 µm2 p = 0.02). PCOS subjects had significantly higher AIx (18.4±1.9% vs. 4.9±2.0%) and this difference remained significant even after adjustments for age, BMI and smoking (p = 0.003) in multivariate analyses. Central systolic and pulse pressure were higher in PCOS subjects but these differences were not statistically significant after adjustment for age. Brachial systolic and pulse pressures were similar. VPC number/function and arterial stiffness or BP measures were not correlated.Subjects with PCOS had a reduced number, mean±SEM, of circulating CD34Non-obese PCOS is characterized by a reduced VPC number, impaired VPC function and increased central arterial stiffness. These changes in novel vascular risk markers may explain the enhanced risk of T2DM and CVD in PCOS. The pathophysiology of the enhanced cardio-metabolic risk in PCOS is not fully explained by traditional risk factors Whether there are differences in VPC and central aortic pressures, two emerging vascular bio-markers of cardio-metabolic risk, in non-obese PCOS subjects is unknown.2 and were normotensive [brachial systolic (SBP) and diastolic blood pressure (DBP) <130/90 mmHg respectively]. Total cholesterol, mean±standard error of the mean, (4.6±0.2 vs. 4.0±0.1 mmol/l p = 0.055), plasma triglycerides (1.0±0.1 vs. 0.7±0.1 mmol/l p = 0.055) were higher in the PCOS group. Serum total testosterone was 27% higher in PCOS but this difference did not reach conventional statistical significance (2.6±0.3 vs. 1.9±0.2 p = 0.06). Fasting plasma glucose (4.7±0.1 vs. 4.5±0.1 mmol/l p = 0.2) did not differ between the two groups. Insulin resistance estimated by HOMA was higher (nearly 36%) in the PCOS group (2.5±0.4 vs. control 1.6±0.3) but this difference was not significant (p = 0.2). Of note all subjects had fasting plasma glucose <6.0 mmol/l.Fourteen subjects with PCOS and 12 healthy controls were studied. More than 2/3rds of subjects in each group were Caucasian and the number of smokers (n = 2 in PCOS and n = 1 control) was similar. The clinical and biochemical characteristics' of PCOS subjects and healthy controls are shown in PCOS subjects had an almost a three fold higher AIx. Mean brachial arterial blood pressure , brachial SBP and pulse pressures were not elevated and similar in both groups .As age and smoking can affect circulatory parameters, univariate correlations of AIx, central arterial pressures and CD34+CD133+ VPC number with PCOS diagnosis, age and smoking were performed . These a2 value from this model suggests that 55% of the variance of AIx is predicted by PCOS and age. In independent samples (unpaired) t-tests analyses, PCOS subjects had higher central aortic systolic blood pressure (103.7±2.4 vs. 94.9±2.2 mmHg p = 0.03), central aortic diastolic blood pressure (75.6±1.8 vs. 69.7±2.4 mmHg p = 0.08), central aortic pulse pressure (28.2±1.0 vs. 25.1±1.1 p = 0.04). However these differences were not statistically significant after adjustment for age. When central aortic SBP was entered as the dependent variable, the multivariate regression model results indicated that PCOS independent of age, BMI and smoking does have some effect albeit not reaching conventional statistical significance . CD34+CD133+KDR+ and CD34+KDR+ cells per 106 lymphomonocyte events were very small in both groups with no statistically significant differences noted between PCOS subjects and healthy controls. Age and smoking status were not significantly associated with CD34+CD133+ VPC number in univariate correlation analyses (6 µm2 p = 0.02) with VEGF-A compared to controls  and controls et al reported increases in arterial stiffness in PCOS in the absence of obesity and hypertension in non-obese PCOS (mean BMI 22.7) subjects as compared to matched healthy controls Recent evidence is that central arterial stiffness and blood pressures may be more clinically relevant than peripheral  pressures for the pathogenesis of CVD and T2DM Vascular ageing is characterized by the loss of elasticity in the wall of the aorta and as a consequence there is increased central arterial (aortic) stiffness. This results in the faster return of pressure waves from distal sites (resistance vessels) where impedance mismatch occurs, which shifts augmentation of blood pressure from diastole to systole resulting in elevated central SBP and AIx. The value of arterial stiffness as a therapeutic target in PCOS was recently demonstrated by the reduction in AIx, brachial and central blood pressures with metformin The study was approved by the research ethics committee of Guy's and St. Thomas' Hospitals and was undertaken in adherence to the Declaration of Helsinki. Written consent was obtained from all patients who participated to this study.Inclusion/exclusion criteria and subject characteristics: Subjects with a confirmed diagnosis of PCOS by the Rotterdam Criteria Exclusion criteria included a history of T2DM, other endocrine illnesses , CVD and hypertension. All controls were healthy with no clinical or biochemical features/characteristics of PCOS and had regular menstrual cycles. Control subjects were not on any medications and had measurements performed in the follicular phase of the menstrual cycle.R Roche E170, Roche Diagnostics GmbH, Mannheim, Germany) and insulin  were measured after an overnight fast. Insulin resistance was estimated using the homeostasis model assessment of insulin resistance (HOMA-IR) and calculated as fasting insulin x fasting glucose/22.5 Central aortic blood pressure and AIx were measured by applanation tonometry  using the Sphygmocor system  at the radial artery as previously described 6) were plated in 2 ml endothelial growth medium , on fibronectin-coated six-well plates at 37°C in a 5% CO2 humidified incubator. Under daily observation, after 4 days of culturing, medium were changed and non-adherent cells removed. Adherent VPC at 7 days of culture appear elongated and spindle shaped. Thereafter, medium were replaced every 3 days, and cell differentiation followed for 14 days in total.Circulating VPC were isolated and cultured as follows. Mononuclear cells (MNCs) were isolated from 40 ml peripheral blood from healthy or PCOS subjects by density gradient centrifugation with Ficoll Paque PLUS  according to manufacturer recommendations. MNCs -A + cells, CD34+133+ cell numbers were skewed, and log transformation of data resulted in a normal distribution. Comparisons between PCOS and control group of variables which were normally distributed was made using the unpaired (independent samples) Student's t-test. CD34+CD133+KDR+ and CD34+KDR+ cell counts were not normally distributed and differences between groups were tested by the Kruskall-Wallis test. As age, BMI and smoking may affect circulatory parameters, univariate regression analysis appropriate for the normal (Pearson's correlation) or not normal distribution (Spearman's correlation) of the variable was performed to test for associations of AIx, central arterial pressures and CD34+CD133+ VPC number with smoking, age, BMI and PCOS diagnosis.All measurements were performed blinded to group allocation. The primary aim/endpoint of the study was to evaluate if there were differences in VPC number between non-obese PCOS subjects and age and BMI matched healthy controls. As this was a proof of concept study no formal power calculation was performed. Shapiro-Wilk test was used to test if the distribution of the variable was normal. HOMA-IR, CD34Correlations which were significant at less than the 10% level were entered in a multiple regression model with AIx, central aortic systolic blood pressure and central aortic pulse pressure as the dependent variable, to determine which variables independently best predicted circulatory parameters. All analyses were performed with SPPS version 15.0. p<0.05 was taken as indicating statistical significance, and all tests were 2-tailed.


Asthma is a prevalent disease that is considered a health problem worldwide. The aim of this study was to analyze the clinical and socioeconomic characteristics of a cohort of asthmatics receiving specialized outpatient treatment in a tertiary/teaching public hospital in Brazil.Persistent asthmatics older than 5 years old were consecutively included. They received clinical treatment at 3- to 4-month intervals and were interviewed 2 times at 6-month intervals over a 12-month observation period. The data were collected directly from the patients or their parents by 2 researchers who did not participate in their clinical care. The primary variables were age, gender, education level, monthly family income, place of residence, number of lost days of school or work, BMI, the severity and control level of asthma, the number of scheduled and non-scheduled visits and hospitalization days and the best peak-flow measurement.Of the 117 participants, 108 completed the study. Of the participants, 73.8% were women, and 25.0% lived outside the county. Of those who lived within the county, 60.1% lived in areas far from the health care unit. The majority (83.3%) had associated rhinitis, and more than 50.0% were overweight or obese, in whom the prevalence of severe asthma was greater (p = 0.001). The median monthly income was US$ 536.58 and was greater among the patients with controlled asthma . In the initial evaluation, 16 participants had severe asthma, and in the final evaluation, 8 out of 21 patients with uncontrolled asthma had improved. Three-quarters of the students and half of the workers had missed days of school or work, respectively. The asthmatic population in this study had medium to low socioeconomic status in Brazil and socioeconomic status was associated with overweigth/obesity and with poor control of asthma.Asthma has a great impact on absenteeism in Brazil. Lower monthly family income and body weight above the ideal level were associated with greater severity and worse control of asthma. Asthma is one of the most prevalent chronic diseases in the world and is considered a public health problem worldwide ,2. The pAsthma is often associated with chronic rhinitis, which can be allergic or not. Studies indicate that 75% to 80% of the individuals with asthma have allergic rhinitis, and 40% to 50% of the individuals with allergic rhinitis and eosinophilic non-allergic rhinitis have bronchial hyperresponsiveness (BHR) -4. ConseIn Brazil, the data from the International Study of Asthma and Allergies in Childhood (ISAAC), conducted in various capital cities, showed that the average prevalence rates of allergic rhinitis were 12.6% and 14.6% in children and adolescents, respectively, and the respective prevalence rates of active asthma were 24.3% and 19% ,8. ThereSistema Único de Saúde – SUS], even large urban centers have not been able to guarantee access for the entire population to the most appropriate level of treatment for the severity of their disease. This obstacle prevents optimal control of asthma and thus prevents reducing its associated morbidity and mortality.The Brazilian health system executes the principles defined in the Brazilian Constitution of 1988, which characterized health as a “citizenship right and a duty of the State”. According to the guidelines defined by Law no. 8080/1990 , the heaBroad knowledge on the various aspects of chronic diseases, including their clinical and socio-demographic characteristics and the care-seeking behavior of the individuals affected who require health services at different levels of complexity, can optimize the allocation of resources for primary, secondary and tertiary prevention in the Brazilian health system.The objective of this study was to describe the characteristics of a cohort of patients with persistent asthma who sought specialized treatment in a secondary/tertiary ambulatory care center linked to a university hospital in a large city in Brazil. We analyzed socio-demographic and clinical variables as potential indicators of patient care-seeking behavior at the local health care facilities.Patients older than 5 years of age with a diagnosis of persistent asthma based on previously established consensus criteria ,9 and whThe following variables were collected:–socio-demographic variables: age, gender, education level, monthly family income, the neighborhood where the patients were residing on the day of the interview and the number of days the patient was absent from school or work in the 3 months preceding the interview ;–clinical variables: BMI on the day of the interview, the severity and control of the patient’s asthma in the month preceding the interview, the number of scheduled appointments the patient attended and the number of days of hospitalization in the 6 months preceding the interview and the number of unscheduled/emergency visits in the 3 months preceding the interview ;–functional variable: the highest of 3 peak expiratory flow (PEF) readings on the day of the interview.The severity  and the control of the patient’s asthma  were assessed by the attending physician at the time of the interview using clinical data from the past 4 weeks in accordance with international guidelines ,9. The tOverweight and obesity were defined as BMI ≥ 25 and BMI ≥ 30, respectively, for individuals older than 18 years and as weight-for-the age > Z score + 1 SD and weight-for-age > Z score + 2 SD, respectively, for those less than 18 years of age . Annual Comissão Nacional de Ética em Pesquisa - CONEP] under number FR413262 and approved by the local REC on 05/03/2011.The patients who dropped out of treatment  and the patients with chronic cardiopulmonary disease that could cause respiratory symptoms similar to asthma and influence the use of treatment resources were excluded from the study. Before the data collection, the patients (or the guardians if the patient was under 18 years old) signed the free informed consent form after being informed about the study. The study was approved by the local Research Ethics Committee (REC). The project was registered with the Brazilian National Research Ethics Committee [All of the data were entered in spreadsheets  by the first author of the present study. GraphPad Prism version 6.0  was used for statistical analysis. The chi-square test (with Fisher’s correction when necessary) and the Mann–Whitney test were used to compare the differences between categorical variables and the differences between continuous unpaired variables, respectively. The paired t-test and Wilcoxon’s test were used to compare continuous paired variables. A significance level of 5% was used.During the study period, 117 patients were enrolled. Nine patients did not complete the study (7.7% loss): 1 patient died of a cause unrelated to asthma, 1 patient asked to be discharged and 7 patients dropped out of treatment before the second interview. The final study population  included 80 patients who were followed at the Allergy/Immunology Service and 28 patients from the Pneumology Service. Of the participants, 79 were women (73.8%) and 29 were men (27.1%). This female gender predominance was absent among patients under 20 years-old. Most of the patients (75.0%) resided in Rio de Janeiro city; however, 60.1% of these residents lived in remote areas .The median monthly family income was R$ 1,100.00 , which falls into the economic classes C1 and C2 , consideNinety patients (83.3%) had chronic rhinitis associated with asthma. The proportion of asthma cases associated with rhinitis was higher among the patients from the Allergy-Immunology Service (p = 0.0001), whereas the patients from the Pneumology Service were older, had asthma for a longer duration, experienced more severe asthma and had a greater prevalence of overweight/obesity .Sixty-seven patients  had another medical comorbidity: 41 out of them (61.2% of patients with comorbidities) had systemic arterial hypertension (SAH), none were using beta-blockers, 11 (16.4%) had diabetes mellitus (DM), and 11 (16.4%) had degenerative joint disease. Other less common comorbidities included thyroid disease, depression, dyslipidemia and gastro-esophageal reflux. Table Of the patients whose body weight was above the healthy weight range , 35 (32.4%) were overweight and 29 (26.8%) were obese. None of children and teenagers were obese and only 2 (9.5%) were overweight, while obesity and overweight predominated among other age ranges Table .At the beginning of the study, 53 patients (49.08%) were classified as having mild asthma, 39 (36.11%) had moderate asthma and 16 (14.81%) had severe asthma. By the final evaluation, the classification of 42 patients (38.90%) had changed to intermittent asthma, and 8 (38.09%) of the 21 patients who initially had uncontrolled asthma demonstrating the intra-individual variability of the disease and improvements in their control after 6 months of treatment. The average PEF measurements increased significantly during the study (p < 0.0001), and the changes in severity were statistically significant (p < 0.0001) . There were 108 visits without an appointment (ambulatory care or urgent care/emergency) in the 3 months prior to the first interview and 49 in the 3 months prior to the second interview . The median expenditure with public or private transport to attend these visits was US$ 9.76 per patient (IQR25-75 = 5.37-14.63). Only one and two patients went to visits by foot in the first and second interviews/clinical visits, respectively. In the 6 months preceding the first data collection, 3 patients were hospitalized due to asthma , and 2 patients  were hospitalized within the 6 months preceding the second data collection.versus controlled asthma: median = U$ 604.65). Regarding severity in the two points of observation, the mean annual family income of patients with severe, moderate, mild and intermittent asthma was U$ 8,115.06, U$ 8,327.64, U$ 10,409.82 and U$ 9,563.76, respectively. Patients with severe and moderate asthma reduced their mean family incomes during the study, whereas mild asthmatics did not. Estimative of annual costs of asthma treatment per patient showed that severe ones expend 12% of family annual income, whereas the moderate asthmatics expend 4.8%, mild patients 3.6% and intermittent ones 3.7% of annual income treating their asthma.Monthly family income was lower among the patients with uncontrolled asthma both at the beginning and at the end of the study , however we don’t know if it would be different with a greater sample. Of the patients treated at the Pneumology Service , the proportion of patients with partially controlled or uncontrolled asthma was higher among the overweight/obese patients compared with those of normal weight  of the 24 students missed school because of asthma, and 13 patients missed work because of their illness (38.3% of employees outside home). Including the 4 employees who were absent from work to take care of their children with asthma, a total of 17 employees  missed work because of asthma in the 3-month periods prior to each interview. The participants missed an estimated total of 163 school days/year and 164 working days/year, or an average of 6.79 days/student/year and 9.64 days/employee/year.In the first assessment, 4 patients were not working and collecting sickness benefits, including 1 with severe uncontrolled asthma and 3 patients with moderate disease. In the second evaluation, 2 of these patients had retired because of disability related to their asthma, one remained out of work, another one lost her job, and another patient  had also stopped working and was collecting sickness benefits.Few published studies with different main objectives have described the profile of asthmatic patients receiving specialized monitoring in medium to high complexity hospitals. It is estimated in published guidelines that 60.0% of asthma cases are intermittent or mild persistent, 25.0% to 30.0% are moderate, and only 5.0% to 10.0% are severe . This miAt the beginning of the study, our results showed that nearly 15.0% of the patients had severe asthma, which was higher than the estimated proportion for the general population of asthmatics but still small for a specialized ambulatory care center in a moderate- to high-complexity unit. We observed a large proportion of patients with mild asthma in this population. In part, this result may be related to the large number of patients followed in Allergy/Immunology Services, where allergic asthma is predominant and the proportion of patients with more severe disease is lower than the proportion of adult patients with non-allergic asthma. Part of the demand from patients with less severe disease could be absorbed by units in the basic health care network if all or most of the local network had health care teams properly prepared to address the disease. Asthma care programs already exist in other regions of the country, which may be one of the reasons why fewer patients are admitted with moderate/severe asthma that requires specialized assistance with more diagnostic and therapeutic resources.In a study with 90 participants that compared the direct costs of treating patients with controlled and uncontrolled asthma (45 per group) in a Brazilian tertiary health care unit, the mean age was similar to the age of our population, but the average monthly family income was lower . Thirty-The data from the second evaluation of our patients show that a large proportion of the patients were able to control and/or reduce the severity of their asthma after 6 months. Some of these patients should be referred to less complex units close to their homes, providing greater comfort to the patients and opening up spaces to admit and treat patients with more severe disease. This issue reflects the difficulties in referring patients between the health care units of varying complexity in the health care system.Approximately 10.0% of the patients did not achieve total or partial control of the disease, even while undergoing treatment in a university hospital where, theoretically, more comprehensive approaches are applied in accordance with the latest guidelines and the access to many diagnostic resources is unrestricted. Limited access to medications for treatment may have contributed to this problem because most of the patients depended on obtaining free samples or buying medications with their own resources.A retrospective study performed in a Brazilian university reported results similar to ours in terms of the mean age, the proportion of women and the proportion of patients with severe asthma among the patients in treatment . Based oExacerbating the problem of inappropriate prescription practices, there are high rates of non-adherence and inadequate adherence to the treatment regimen , and the dropout rate from control medications can reach 92.0% after 1 year -19. Our In another study that retrospectively analyzed 434 asthmatic children and adolescents included in the assistance program in Brazilian primary health care units between 1988 and 1993 , more thversus US$ 764.39/SD = 746.34; p = 0.21). The proportion of non users of inhaled corticosteroids dropped to 3.0%  of the 66 patients with persistent asthma at the end of the study. In addition, the number of unscheduled visits to the ambulatory care unit or emergency care decreased throughout the study. The study was observational; there was no active attempt by the researchers to change the patients’ therapy because they had already been receiving treatment for at least 3 months when they joined the study. These data suggest that the local teams are capable of providing competent care in alignment with the current recommendations for drug treatment for asthma [In our population of patients with persistent asthma, 11 (10.1%) were not taking continued inhaled corticosteroid at the beginning of the study . The mean monthly income of them was not significantly different from the rest of patients using inhaled corticosteroids  in Brazil sought to evaluate the factors associated with severe asthma in the population [Another study conducted by the Bahia State Asthma and Allergic Rhinitis Control Program (pulation . ClinicaThe increasing prevalence of overweight/obesity in Western societies has been identified as a factor associated with the increased prevalence of asthma. Data from the USA show that the prevalence rates of asthma and obesity increased to a similar extent between 1980 and 2000 . Data ofThese results reinforces that, besides providing free access to control medication, which recently was became available by Brazilian government, the public health system needs to make efforts to provide primary health facilities with interdisciplinary teams prepared to approach the various educational, socioeconomic and clinical aspects of asthma and its comorbidities to medium/lower income population. Focus in drug treatment as defined by international guidelines, continuing clinical and functional monitoring and adequate approaching to rhinitis and obesity are needed.The population of individuals with asthma followed in this moderate- to high-complexity health care unit had medium-low socioeconomic status in Brazil, a high prevalence of associated chronic rhinitis and a high prevalence of overweight/obesity. A large proportion of the patients have missed days of school or work for reasons were directly or indirectly related to the disease. Lower monthly family income and body weight above the ideal level were associated with greater severity and worse control of asthma. In Brazil, there are difficulties in building a regional and hierarchical public health system, which may be the consequence of an inadequate supply of services.There aren’t any competing interests of the authors in this manuscript.All authors read and approved the final manuscript.


Dear Editor,Pulmonary thromboembolism (PTE) is a relatively common and hazardous emergency that may lead to acute life-threatening but potentially reversible right ventricular failure. Three months mortality rate in patients with massive pulmonary embolism and a systolic blood pressure of <90 mmHg is approximately 50%, with most deaths occurring within the first few days after diagnosis.2]2]For practical purposes and risk markers useful for risk stratification in PTE can be classified into three groups including (i) Clinical markers such as hypotension and shock, defined as systolic blood pressure <90 mmHg or a drop of pressure ≥ 40 mmHg for >15 minutes if not caused by new onset arrhythmia, hypovolemia and sepsis, (ii) Markers of right ventricular (RV) dysfunction that is shown by RV dilatation, hypokinesia or pressure overload on echocardiography, RV dilatation on spiral chest computed tomography, elevated right heart pressure at right heart catheterization and brain natriuretic peptide (BNP) or N terminal Pro- BNP (NT-proBNP) elevation and (iii) Markers of myocardial injury like positive cardiac troponin T or I.3]3]In patients with massive PTE, systemic thrombolysis or surgical embolectomy in addition to anticoagulation can improve mortality with reversing the cardiogenic shock and right ventricular failure.3]4]5][4][5]3][[5][4][5][4][5]3]7]7]All patients with PTE were registered in Shiraz, CT scan and Doppler sonography of both extremities, and echocardiography were performed for all. Those with persistent BP less than 90 mmhg in spite of ionotrope use or drop of systolic pressure more than 40 mmhg were considered as the cases of hemodynamically significant PTE. Thrombolysis was started for those who were eligible to thrombolysis after consultant visit. Those with contraindication for thrombolysis were consulted for surgical thrombectomy and if they were rejected by surgeons were considered as eligible cases for catheter based embolectomy.Complete pressure and saturation study and selective left and right pulmonary angiography before and after procedure were done in all patients. Through the 8 French sheath over 0.018 guide wire Aspirex (Straus) embolectomy catheter was used and procedure was continued till hemodynamic improvement was seen. Catheter embolectomy was performed for 7 patients with mean age of 61 years that 57% were female from February 2008 till August 2010. Two of patients had remaining clot in pulmonary while the procedure was stopped due to hemodynamic improvement. Inferior Vena Cava (IVC) filter Optease (Cordis) was inserted for all patients. In our registry, all patients developed hemodynamic improvement post procedure without any complications and 6 of them (88%) were discharged home . The firThrombolysis was contraindicated in 30-50% of cases post-massive PTE. One of tIn a review of the available literature, the overall clinical success rate, defined as immediate hemodynamic improvement, was > 80% for catheter embolectomy, and mortality rate ranged from 0 to 25% for the various techniques.Catheter intervention is currently being performed in patients with acute PTE and in shock state that an increased bleeding risk precludes the administration of thrombolysis, and surgical thrombectomy is not rapidly available or feasible. More researches are needed to investigate about other indications of catheter thrombectomy.


The aim of this study was to assess the effect of acute bilateral jugular vein compression on: (1) pial artery pulsation (cc-TQ); (2) cerebral blood flow velocity (CBFV); (3) peripheral blood pressure; and (4) possible relations between mentioned parameters.2 was measured using medical gas analyser. Bilateral jugular vein compression was achieved with the use of a sphygmomanometer held on the neck of the participant and pumped at the pressure of 40 mmHg, and was performed in the bend-over (BOPT) and swayed to the back  position.Experiments were performed on a group of 32 healthy 19–30 years old male subjects. cc-TQ and the subarachnoid width (sas-TQ) were measured using near-infrared transillumination/backscattering sounding (NIR-T/BSS), CBFV in the left anterior cerebral artery using transcranial Doppler, blood pressure was measured using Finapres, while end-tidal CO2 remained stable during BOPT and venous compression in both groups. Significant interdependence between changes in cc-TQ and PP after bilateral jugular vein compression in the initial position was found (r = −0.74).In the first group (n = 10) during BOPT, sas-TQ and pulse pressure (PP) decreased  and CBFV increased (+35.0%), while cc-TQ did not change (+1.91%). In the second group, in the initial position (n = 22) cc-TQ and CBFV increased , while sas-TQ and PP decreases were not statistically significant . End-tidal COAcute bilateral jugular venous insufficiency leads to hyperkinetic cerebral circulation characterised by augmented pial artery pulsation and CBFV and direct transmission of PP into the brain microcirculation. The Windkessel effect with impaired jugular outflow and more likely increased intracranial pressure is described. This study clarifies the potential mechanism linking jugular outflow insufficiency with arterial small vessel cerebral disease. A stable increase in cerebral venous pressure induces arteriolar vasodilation, which averages 6% to 12% of the control diameter in cats The amplitude of pial artery pulsation (cc-TQ) can be measured non-invasively using near-infrared transillumination/backscattering sounding (NIR-T/BSS), a new method based on infrared radiation (IR) that has been developed in the last decade by our team We hypothesised that impaired venous outflow would lead to pial artery dilation caused by a metabolic and/or autoregulatory mechanism due to decreased oxygen supply and/or increased intracranial pressure, respectively. Augmented pial artery compliance should result in increased cc-TQ and hyperdynamic brain circulation characterised by augmented cerebral blood flow velocity (CBFV). The investigated topic is not a purely theoretical concept, as increased cerebral venous blood volume has been recently reported during sympathetic activation  and gave written informed consent to participate in the study. The experimental protocol and the study were approved by the ethical committee of the Medical University of Gdansk (TKEBN/259). Subjects did not have any disorders and were not taking any medication. Before the experiment, each subject underwent a general and neurological examination. No nicotine, coffee, tea, cocoa or any methylxanthine-containing food or beverages were permitted for 8 hours before the tests. Additionally, prior to each test, the volunteers were asked to sit comfortably and rest for 30 minutes.Initial position: subject set comfortably for 10 minutes with head swayed to the back at 20° angle.BOPT: subject bends forwards at 45° angle (the trunk and the head) from the initial half-lying position on the back Then, for bilateral jugular vein compression participants were divided into two groups.Jugular veins were completely compressed 3 minutes after starting BOPT for 3 minutes.Subject returned to initial position.Subject returned to initial position 3 minutes after starting BOPT.Subject set comfortably in initial position for 3 minutes.Jugular veins were completely compressed for 3 minutes.The numerical values for statistical analysis were taken just before the end of each three-minute procedure. After bilateral jugular vein compression all subject were asked to sit comfortably in the initial position for 10 minutes.2.Bilateral jugular vein compression was achieved with the use of a sphygmomanometer held on the neck of the participant and pumped to a pressure of 40 mmHg. Blood pressure in jugular veins in the initial position should be close to zero, or even negative, so it can be assumed that compression was complete. The subjects were asked to breathe normally to avoid changes in PaCOTranscranial Doppler (TCD) measurement of cerebral blood flow velocity (CBFV) in the left anterior cerebral artery was performed with a Doppler ultrasound device TDS 4 . A pulse probe of 2 MHz was used and analysis of the results was carried out on a built-in IBM PC computer. To assure the best possible reproducibility of the recordings, the Doppler probe was mounted on the head with a special stabilising strip.Recording of changes in systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and HR were measured using Finapres . The Finapres sensor was mounted onto the middle finger of the non-dominant hand resting on the table. Beat-to-beat blood pressure was transferred to a computer console continuously displaying SAP, DAP and HR. Pulse pressure (PP) was calculated from the following equation: PP = SAP−DAP.2 was measured in mmHg with a medical gas analyser . The instrument was calibrated using a certified standard gas mixture before each experiment. End-tidal CO2 was recorded and printed continuously in real time. Values for subsequent analysis were read from the printouts and entered manually into a Statistics for Windows 8.0 database.End-tidal CORecording of changes in the amplitude of pial artery pulsation and in the width of SAS with NIR-T/BSS were performed with a head-mounted SAS 100 Monitor . The sensor unit consists of the emitter (E) and two photo-sensors located at different distances from the emitter. The NIR-T/BSS emitter is a near-infrared light-emitting diode (LED). The proximal sensor (PS) is located close to the emitter, while the distal sensor (DS) is located at a larger distance from the emitter. The stream of IR generated by the emitter penetrates the highly perfuse layer of the skin of the head, the skull bones and the SAS. The stream of radiation reflects from the surface of the brain and reaches the sensors, crossing the aforementioned layers of tissues in reverse order. Signals from the sensors undergo analogue-digital conversion in a specialised data acquisition system and are recorded on the microcomputer' s hard disk for subsequent analysis with on-line presentation on the computer monitor.Theoretical and practical foundations of the NIR-T/BSS method were provided in the model studies by our team Thus, in the transillumination quotient (TQ) we can identify three main components:constant or a non-pulsatile component, further referred to as the subarachnoid component (sas-TQ); its value depending on the width of the CSF-filled SAS,slow-variable pulsation, further referred to as the subcardiac component (scc-TQ); including, but not limited to, pulsation of a respiratory origin,fast-variable pulsation, further referred to as the cardiac component (cc-TQ); resulting from heart-generated arterial pulsation that is the cause of fast oscillations of the width of SAS.For further analysis, the first harmonic of the arterial pulsation-dependent oscillations of TQ was extracted through appropriate filtering, along with its modulation. Modulation of that harmonic is a fast-variable component (or cardiac component) of principal, second, and third harmonics of cardiac component waveform, respectively.2 responses were compared to baseline values. Correlation and regression analysis was performed to assess interdependences between SAP, DAP, PP, HR, CBFV, end-tidal CO2, sas-TQ and cc-TQ. All statistical calculations were performed using the Statistics for Windows 8.0 commercial package.W Shapiro-Wilk W, Mann-Whitney U and ANOVA tests were used to analyse the differences between average values. Changes in sas-TQ, cc-TQ, CBFV, SAP, DAP, PP, HR and end-tidal CO2 remained stable during BOPT and venous compression in both groups. Detailed descriptive statistics are provided in Both groups  were well-matched at baseline in terms of CBFV and BP. The BOPT test caused sas-TQ, cc-TQ, CBFV and PP decrease in both investigated groups (n = 10 and n = 22). However, acute bilateral jugular vein compression brought different results between the investigated groups. In the first group (n = 10) during BOPT sas-TQ and PP further decreased, CBFV increased while cc-TQ did not change . In the Correlation and regression analysis revealed significant interdependence between changes in cc-TQ and PP after bilateral jugular vein compression in the initial position  or in the abdominal-lying position, the brain floats forward toward the inner surface of the frontal bones and the SAS in the frontal region assumes its minimum value Bilateral jugular vein compression resulted in enhanced CBFV in both groups. We may assume that hampered jugular outflow results in decreased oxygen supply, which in turn lead to arteriole dilation and subsequent increase in cerebral blood flow etal. etal. Acute cerebral venous congestion produced significant cc-TQ increase in the initial position. Such a result is in line with the above-presented reasoning. In the initial position the SAS was insignificantly reduced by enhanced intracranial blood volume, and remained wide enough to allow for proper registration of the amplitude of pial artery pulsation . IncreasThe following study limitations should be taken into account. Only young, healthy males were investigated and acute jugular vein insufficiency was analysed. Therefore, any extrapolations to patients suffering from chronic cerebral venous insufficiency or normal pressure hydrocephalus should be viewed with caution. In our study the SAS decrease during bilateral jugular vein compression in the initial position was not statistically significant, which may suggest that even during bilateral jugular vein congestion the brain may be decompressed through the vertebral plexus In summary, acute bilateral jugular venous insufficiency leads to hyperkinetic cerebral circulation characterised by augmented pial artery pulsation and CBFV and direct transmission of PP into the brain microcirculation. From the mechanistic point of view, the Windkessel effect with impaired jugular outflow and most likely increased intracranial pressure is described. Impaired jugular outflow does not allow for dampening the pulsation energy and actually exaggerates the pulsatile flow, which in turn creates a hazardous environment for the brain microcirculation. Therefore, this study clarifies the potential mechanism linking jugular outflow insufficiency with small vessel arterial cerebral disease.


Asthma is a chronic disease increasingly found in children. In order to find more economical and efficient alternatives to treat pediatric asthma, the Bureau of National Health Insurance of Taiwan launched the Traditional Chinese Medicine Holistic Treatment Program (TCMHTP). Based on the data collected during the program, we evaluated the effect of TCM holistic treatments on pediatric asthma.We performed a retrospective study by analyzing a dataset from Changhua Christian Hospital in Taiwan during January 1, 2006 and December 1, 2010. Patients aged between 2 and 15 years old who were diagnosed with asthma and have participated in TCMHTP were recruited, while those with other severe diseases were excluded. We analyzed the frequency of emergency department visits (EDV), inpatient admission rate (IAR), and length of hospitalization (LH) of the patients before and after TCM treatments. We also carried out spectral analysis of heart rate variability (HRV).Fifty-eight patients were recruited. The average age of the patients receiving TCM treatments is 5.67±3.03 years old. The frequency of EDV reduced from 0.97±0.85 to 0.69±1.22 times annually (p=0.095), the IAR decreased from 0.86±0.81 to 0.36±0.77 times annually (p=0.001) and the average LH reduced from 4.59±4.43 to 1.10±1.86 (p=0.000) days per year. Parasympathetically mediated HRV reduced significantly from 60.42±15.33 to 54.89±16.45nu (p=0.016).In the present study, we found that an appropriate period of TCM holistic treatment intervention can not only significantly lower exacerbations and hospitalization frequency but also decrease vagal tone of the asthmatic children.


Haemodialysis patients have an increased prevalence of hypertension and risk of cardiovascular mortality and stroke. Higher dialysate calcium concentrations have been reported to cause both an acute and chronic increase in arterial stiffness. We therefore looked at changes in arterial stiffness in established haemodialysis patients to determine whether there was a threshold effect of dialysate calcium concentration linked to change in arterial stiffness.We performed pulse wave velocity measurements six months apart in patients dialysing with calcium concentrations of 1.0, 1.25, 1.35 and ≥1.5 mmol/l.2 ,47.9% diabetic were studied. Systolic blood pressure (SBP) was 148.4 ± 28.6 mmHg and diastolic blood pressure (DBP) 80.2 ± 15.5 mmHg. Mean pulse wave velocity increased over time , but there was no change in aortic augmentation index (38.7 ± 16.3 vs 39.8 ± 15.6%) or central aortic pressure (149.6 ± 33.3 vs 150.4 ± 31.9 mmHg).289 patients, 62.2% male, mean age 65.5 ± 15.7 years, weight body mass index 25.8 ± 5.4 kg/mPulse wave velocity did not differ between the four groups either at start or end of the study, but increased both in the groups dialysing with a calcium concentration of 1.0 mmol/l  and also with 1.35 mmol/l .Pulse wave velocity increased over the six months study. As pulse wave velocity increased in the group dialysing using the lowest dialysate calcium, it is likely that factors, other than simple net calcium influx and efflux during dialysis according to dialysate calcium concentration are involved with vascular stiffening. Although haemodialysis is an established outpatient treatment for patients with chronic kidney disease, mortality, in particular cardiovascular mortality, remains high. Whereas atheromatous coronary artery disease is the predominant cardiovascular risk factor for the general population, arterio-sclerosis is more commonly found in the haemodialysis patient, leading to increased risk of sudden cardiac arrhythmic death, heart failure and stroke.Vascular calcification, in particular medial calcification, is more common in haemodialysis patients, and although the pathogenesis of soft tissue calcification is multifactorial, it has been suggested that repeated episodes of hypercalcaemia can increase the risk of vascular calcification.Calcification of major arteries increases arterial stiffness and pulse wave velocity. Increased aortic stiffness and the associated elevated pulse pressure in central arteries has been shown to be a strong and independent predictor of cardiovascular events in both the general population and also patients with chronic kidney disease. Several289 adult patients who had pulse wave velocity (PWV) measurements predialysis 6 months apart and had continued to dialyse with the same dialysate calcium concentration were reviewed. Aortic-brachial pulse wave velocity was measured using the Tensio Clinic Ateriograph  an applanation oscillometric device which has been validated against direct invasive measurements. The disPatients were dialysed thrice weekly, targeted to achieve an on-line clearance of ≥1.4 , mean session time 3.96 ± 0.38 hours, using polysulfone dialyzers  with ultBiochemical investigations were performed using standard automated multichannel analyser, with albumin measured by the bromcresol green method . Hypotensive episodes during dialysis requiring changing ultrafiltration rates and intravenous fluid administration were recorded. Standard 2 dimensional echocardiograms were performed on a non-dialysis day .This retrospective audit complied with the UK NHS guidelines for audit and clinical service development. Measurement of pulse wave velocity was introduced into clinical practice in 2011 and measured as part of an audit of blood pressure control in haemodialysis patients. Echocardiograms were performed as part of transplant assessment.Statistical analysis used paired students’ t test and Wilcoxon rank sum pair tests for analysis of the whole study cohort , and by Chi square and one way anova with Tukey post hoc analysis correction, for intergroup analysis . Data are expressed as mean ± standard deviation, median and inter-quartile range, or percentages. Statistical significance was taken at or below the 5% level.2 and 47.9% diabetic. 79.5% had a past medical history of hypertension, 29.2% ischaemic heart disease, 19.1% peripheral vascular disease, 14.1% cerebrovascular disease and 5.6% had previous parathyroidectomy. Systolic blood pressure (SBP) 148.4 ± 28.6 mmHg, diastolic blood pressure (DBP) 80.2 ± 15.5 mmHg, with 28.6% prescribed angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), 27.2% beta-blockers and 20.9% calcium channel blockers.Data was available on 289 patients, 62.2% male, mean age 65.5 ± 15.7 years, weight 71.4 ± 16.7 kg, body mass index 25.8 ± 5.4 kg/mSerum albumin was 39.7 ± 3.9 g/l, calcium 2.27 ± 0.17 mmol/l, corrected calcium 2.44 ± 0.16 mmol/l, phosphate 1.48 ± 0.48 mmol/l, alkaline phosphatase 97 (72–135) Iu/l and parathyroid hormone (PTH) 26.8 (13.9-53.5) pmol/l. Median weekly dose of calcitriol prescribed was 2 (0.75-4.5) ug, with 52.9% prescribed calcium containing phosphate binders, 15.6% sevelamer, 13.9% lanthanum carbonate and 7.6% cinacalcet. Serum total cholesterol (TChol) was 3.97 ± 1.1 mmol/l, high density lipoprotein (HDL) 1.27 ± 0.48, low density lipoprotein (LDL) 2.0 ± 0.9 mmol/l and triglycerides 1.3 (0.9-1.9) mmol/l, with 58.2% prescribed HMG CoA 3 reductase inhibitors (statin).Mean pulse wave velocity increased over time , but there was no change in aortic augmentation index (38.7 ± 16.3 vs 39.8 ± 15.6%), or central aortic pressure (149.6 ± 33.3 vs 150.4 ± 31.9 mmHg).As this an audit of clinical practice and not a prospective trial a range of dialysate calcium concentrations were used with different numbers of patients using each of the diaysates, with 18.8% patients using a dialysate calcium concentration of 1.0 mmol/l, 20.9% 1.25 mmol/l, 53% 1.35 mmol/l, 5.9% 1.5 mmol/l and 1.4% 1.75 mmol/l respectively. The groups were well matched for demographics and serum biochemistries (Tables Peripheral and central blood pressure measurements were not different between the calcium dialysate cohorts, at baseline or after six months, there were no differences in antihypertensive medication prescription, and similarly no significant differences were observed on follow up after 6 months Table . In addiRecorded episodes of symptomatic intradialytic hypotension were greater on follow up for those dialysing against the lowest calcium dialysate, but there were no differences when episodes were averaged between the two pulse wave velocity measurements Table .Over the last decade there has been increased recognition of the clinical importance of vascular stiffness in dialysis patients due to both the high prevalence of hypertension in the dialysis patient with increased risk of stroke on one hand, and epiPrevious small series comparing dialysate calcium concentrations of 1.0, 1.25 and 1.5 mmol/l, have suggested that using higher dialysate calcium concentration for a single haemodialysis session, can increase vascular stiffness measured by pulse wave velocity with a reduction in augmentation index. This waPulse wave velocity is well known to be affected by systolic hypertension, age, sex, body mass index and comorbid conditions including type 2 diabetes. As this was an audit of clinical practice, a range of dialysate calcium concentrations were used by differing numbers of patients. However despite this, our groups were well matched for those demographic factors which affect pulse wave velocity and baseline blood pressure. Unlike the previous reports, typically of 30 patients or fewer, we studied almost 290 patients, divided into 4 groups according to dialysate calcium concentrations. Whereas previous reports have observed increases in aortic stiffness comparing calcium dialysates of 1.0, 1.25 and 1.50 mmol/l; 1.25 anAs with other reports, patients dialysing against lower dialysate calcium had higher serum phosphate and parathyroid concentrations compared to those using higher dialysate calcium concentrations. AlthougIn this study although there was a small but significant increase in pulse wave velocity for the whole cohort, we were unable to demonstrate any major difference in blood pressure, pulse wave velocity or derived indices according to calcium containing dialysates over a six month period. As our report is an audit of clinical practice, rather than a prospective trial, it was not designed to identify which factors were responsible for the increase observed. Although calcium containing microparticles are key to the initiation of soft tissue vascular calcification, the propensity for vascular calcification is somewhat more complex than simply reflecting changes in calcium influx and efflux during a dialysis session at the macro level. We were unable to demonstrate any differences in pulse wave velocity over 6 months associated with different dialysate calcium concentrations.Our findings however, do not imply that higher dialysate calcium concentrations cannot result in changes in vascular stiffness in the longer term as we investigated changes for only six months, and the differences in pulse wave velocity were small. Although our study may have been too short a period to demonstrate any measurable differences of different calcium dialysates, the increase in pulse wave velocity observed over time with the lowest calcium dialysate group does suggest that factors other than dialysate calcium may be more important in determining vascular stiffness in haemodialysis patients.The authors declare that they have no competing interests.EC – measurements, data collection and writing manuscript AD – study design, analysis and writing manuscript. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2369/14/189/prepub


Pazopanib is a new cancer drug that works by limiting the growth of new blood vessels in tumours. About half of patients who take pazopanib develop high blood pressure (hypertension). This side effect can make patients have to reduce or stop their cancer treatment, and can cause other health problems.Understanding how pazopanib causes high blood pressure will help us to advise doctors how to treat the high blood pressure effectively, so that patients can continue to take their cancer treatment safely. A proposed explanation is that hypertension is caused by endothelial dysfunction as a consequence of reduced nitric oxide (NO) bioavailability.The aim of a study (HYPAZ) is to investigate the relationship between blood pressure and NO bioavailability in cancer patients treated with pazopanib, who develop hypertension. The predictor variable observed is the change in blood pressure from baseline. The response variable will be change in NO bioavailability measured through the change in forearm blood flow ratio (of infused versus control forearm) in response to intra-arterial acetylcholine infusion. These data will give a greater understanding to aspects of pazopanib’s mechanism and relationship to hypertension. The primary analysis for the study is to model and quantify the relationship between NO bioavailability and blood pressure.a priori evidence to suggest the shape, nor to quantify the strength, of any relationship. Hence an adaptive design is proposed to assess the evidence for any relationship and judge possible sample size revisions at an interim analysis. To perform model selection at an interim analysis is a novel feature of this adaptive design. We consider some of the operating characteristics of the proposed design.In planning the study there is little