P. Boli and R. Campbell discuss whether recommendations for the management (and control) of high blood pressure really result in improved cardiovascular (CV) outcomes. Adherence to the recommendations by the Canadian Hypertension Education Program did significantly improve all the aspects  of hypertension, as well as mortality and hospitalization due to strokes, heart failure, and myocardial infarction. The authors suggest that application of similar recommendations for the management and control of hypertension in other regions of the world may be helpful. An interesting paper by C. Sierra reviewed that presence of cerebral white matter lesions  were more severe and appeared early in patients with high blood pressure. There was an association between blood pressure parameters obtained by ambulatory blood pressure monitoring (ABPM) and presence of white matter lesions, suggesting that data obtained from ABPM may be helpful in identifying asymptomatic hypertensive patients with brain damage. R. Fagugli and C. Taglioni discuss that aldosteronism , which was thought to be rare (affecting 1% of the hypertensive population), occurs at a much higher incidence (5–20%) in patients with type 2 diabetics and resistant hypertension and is associated with a high incidence of cardiovascular (CV), cerebrovascular, and kidney complications. The variation in the estimates of prevalence may be due to methodology and definitions. M. Roy et al. determined that among African Americans with type 1 diabetes mellitus, without elevated blood pressure, 29% develop hypertension in the course of 6 years. The risk factors associated with the development of hypertension include age, duration of diabetes, family history of hypertension, higher baseline arterial pressure, overt proteinuria, presence of retinopathy or peripheral neuropathy, smoking, and psychological factors, such as perceived hostility. An interesting paper by M. Yamori et al. investigated the association of hypertension with periodontitis and/or tooth loss  in a group of nonsmoking, nondrinking middle-aged African women. Their studies show that the severity of periodontal disease was significantly associated with increased systolic and diastolic blood pressure. In addition, low dietary intake of potassium and fiber was directly associated with higher blood pressure and periodontal inflammation. On the other hand, higher dietary intake of potassium, fruits, and vegetables decreased inflammation of the gums. The authors suggest that increased dietary intake of potassium, fruits, and vegetables may decrease the incidence of periodontitis. Q. Nguyen and coworkers analyzed cardiovascular risk factors in a large cross-sectional survey in Vietnam. The prevalence of the clustering of metabolic (such as in the metabolic syndrome) and behavioral risk factors was more prevalent in men than in women, and there was a 4-fold higher overall 10-year CV risk in men than in women. Targeting only a single risk factor would not decrease the overall risk. A pharmacological means of correcting endothelial dysfunction was proposed by M. Pokrovskiy et al., by the use of inhibitors of arginase , thus increasing the production of the vasodilating nitric oxide, thereby protecting the endothelium. In their studies in rats, R. Peroni and coworkers observed that phytoestrogens produced an estrogen receptor-dependent enhancement of anandamide-induced reduction of contractility (of mesenteric bed) caused by noradrenaline by modulation of calcitonin gene-related peptide. The in vivo suppression of adrenergic hyperactivity (which precedes the onset of hypertension) by anandamide  was observed in female but not in male rats or ovariectomized female rats.Manuel VelscoManuel VelscoZafar IsrailiZafar Israili


Posterior reversible leukoencephalopathy syndrome refers to a constellation of neurologic symptoms related to temporary white matter changes. The disease typically presents in the context of an abrupt and drastic elevation in blood pressure (>180/110 mmHg). We report an unusual case of posterior reversible leukoencephalopathy syndrome in a post-operative setting, with a blood pressure parameter generally tolerated by most patients.We report the case of a 22-year-old Caucasian man who suffered acute onset visual acuity loss four days after an ileocecal anastomosis. A head magnetic resonance imaging scan revealed findings typically associated with posterior reversible leukoencephalopathy syndrome. His symptoms developed in the context of blood pressure parameters that are typically well tolerated in a post-operative setting (150-160/80-90 mmHg). He did not have a history of renal failure or immunosuppression. His symptoms resolved with aggressive blood pressure management.Posterior reversible leukoencephalopathy syndrome can occur in a post-operative setting with blood pressure parameters typically well-tolerated in most post-surgical patients. Timely diagnosis and treatment will minimize the risk of permanent neurologic injury. Posterior reversible leukoencephalopathy syndrome (PRES) refers to a constellation of neurologic symptoms related to temporary white matter changes . ClinicaWhile extreme cases of PRES may progress to infarction and hemorrhage despite appropriate blood pressure control , the neuWe report a case of PRES in a man with mild hypertension (150-160/80-90 mmHg) following the repair of an ileocecal anastomosis breakdown. This case is of interest because PRES occurred in the context of blood pressure parameters that are generally well tolerated in post-operative patients, and our patient harbored no other risk factors for PRES. Through our case report and a review of the literature, we hope to heighten an awareness of this syndrome, particularly in a post-operative setting.We report the case of a 22-year-old Caucasian man with a 10-year history of Crohn's disease. He had recently undergone a small bowel resection and ileocecal anastomosis. On his fourth post-operative day, he experienced a breakdown of his anastomosis and underwent surgical repair. He had no other medical co-morbidities and was not being treated with immunosuppressive agents. On post-operative day three, he developed symptoms of lightheadedness, headache, and blurred vision that progressed to visual loss. An emergent ophthalmology evaluation revealed poor visual acuity  but no fundoscopic or ocular abnormality. His neurologic examination was otherwise unremarkable. Shortly thereafter, he developed a tonic-clonic seizure that abated spontaneously after approximately one minute. His blood pressure throughout the episode was 150-160/80-90 mmHg, up from a baseline of 100-130/70-80 mmHg. His serial electrolytes , arterial blood gas, cardiac enzymes, urine analysis, and electrocardiogram were within normal limits. A head computed tomography (CT) scan demonstrated subtle, ill-defined regions of low attenuation involving his bilateral posterior temporo-occipital lobes . Such transient, benign hypertension is frequently seen in a post-operative setting and generally resolves spontaneously. Recognition of the possibility that PRES can occur in this setting is critical for a timely diagnosis and treatment.Given the complexity of the post-operative state and the limitations of a case report, it is difficult to identify the pathogenesis in our case report. The pathophysiologic mechanism of PRES is unknown, although it is thought that PRES results from dysfunction of the cerebrovascular auto-regulatory mechanism secondary to hypertension or pharmacologic agents. It is thought that cerebral vasculature constricts in response to hypertension to prevent cerebral over-perfusion. This vasoconstriction is mediated by an increased sympathetic tone. Dysfunction in this process predisposes patients to cerebral over-perfusion and consequently, PRES. It is hypothesized that the vulnerability of the posterior cerebral parenchyma is related to the paucity of sympathetic innervation in the posterior cerebral vasculature . It is cThrough our case report and a review of the literature, we wish to highlight the fact that PRES can occur in a post-operative setting with blood pressure parameters usually well tolerated in most post-surgical patients. An awareness of this observation is crucial for a timely diagnosis and treatment, in order to minimize the risk of permanent neurologic deficits.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing or financial interests.This study was conducted according to HIPAA/IRB guidelines by the Harvard Medical School, MGH, and Beth Israel Deaconess Medical Center.POZ, RRC, EMK, CCC wrote the manuscript. All authors read and approved the final manuscript.


Background. Hypertension management is of a paramount importance in diabetic patients for cardiovascular risk reduction. Aim. To evaluate prescribing pattern of antihypertensive in T2DM (type 2 diabetes) patients and compare with existing recent guidelines. Methods. A cross-sectional study involving evaluation of all T2DM patients referred to endocrinology unit at tertiary care centre for hypertension, comorbid complications, and recording prescription. Utilization of 5 different antihypertensive drug classes was compared for all patients receiving 1, 2, 3, 4, or more drugs. Logistical regression was used to assess likelihood of prescription of drugs and/or therapy for specific conditions mentioned in the guidelines. Results. Out of 1358, T2DM enrolled patients 1186 (87%) had hypertension . The median duration (IQ) of hypertension diabetics was 4 (1–10) years. A total of 25% patients had controlled BP and 75% with uncontrolled blood pressure . Overall, ACE inhibitors (ACEIs) were prescribed the highest (59%) followed by angiotensin receptor blockers (ARBs) (52%), calcium channel blockers (CCBs) (29%), diuretics (27%), and beta-blockers (14%). Overall, 55% of T2DM patients were on polytherapy, 41% on monotherapy, and 4% had no antihypertensive treatment. Polytherapy was more predominant with age, duration of diabetes, duration of hypertension, and comorbid complications. Conclusion. Although prescribing pattern of antihypertensive showed adherence to existing evidence-based guidelines, higher proportion of uncontrolled hypertensive patients was found. Diabetes and hypertension are the major burden of global Health. The World Health Organization projected that 300 million people will suffer from diabetes and 1.5 billion . AccordiHypertension has been identified as a major risk factor not only for the development of diabetes but also for the development of micro and macro vascular complications, that is, neuropathy, nephropathy, retinopathy, coronary artery disease (CAD), stroke, peripheral vascular disease (PVD) in diabetic patients. It has been evident from Framingham heart study, UKPDS (United Kingdom Prospective Study-39), Hypertension Optimal Treatment (HOT), Systolic Hypertension in the Elderly Programme (SHEP), Systolic hypertension in Europe (SYST-Eur), Hypertension in the Very Elderly Trial (HYVET-Pilot) that reduction in either isolated systolic or systolic-diastolic hypertension significantly reduces the risk of micro and macro vascular complications and cardiovascular (CV) death or diabetes-related death –11. LoweGiven the importance of the blood pressure control in diabetic patients, there has been much needed data on achievement of target control in real world diabetic hypertensive patients; however, the data on prescribing pattern as well as blood pressure control is scare especially in Asian-Indian subcontinent. Thus, this study was conducted to assess blood pressure control and the prescribing patterns of antihypertensive in hypertensive diabetic patients in real world clinical settings. Further, the study also assessed adherence of prescribing pattern with existing guidelines.This cross-sectional study was carried out from June 2008 to May 2009 at the Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh. Patients were confirmed by physician diagnosed T2DM patients, were further examined consecutively for social, demographical, and clinical variables. Informed and written consent was obtained from all the participants after full explanation of the procedure. The study protocol was approved by the Institute's Ethics Committee.2) was calculated by dividing weight (in kilograms) by the square of height (in meters), as a measure of total adiposity. Percent body fat (%BF) was evaluated by impedance plethysmography ). Standing body height (to the nearest 0.5 cm) was measured with a commercial stadiometer. A digital scale, with an accuracy of ±100 g, was used to measure body weight (BW). The waist circumference (WC) was measured in a horizontal plane, midway between the inferior margin of the ribs and the superior border of the iliac crest. Hip circumference (HC) was measured at the fullest point around the buttocks with a metallic tape. The measurements were taken thrice and the mean was taken in all cases. WC (cm) was divided by HC (cm) to calculate waist to hip ratio (WHR). Body mass index (BMI) (kg/mSystolic and diastolic blood pressure (SBP & DBP) were measured twice at an interval of 3 min in the sitting position after a 15 min rest, and the mean was taken. Further, hypertension conformation was based on any of following criteria: at least two outpatient visit diagnosis of hypertension; at least 1 prescription of antihypertensive drug plus at least 1 outpatient diagnosis of hypertension; At least 2 elevated BP measurements plus one outpatients diagnosis of hypertension; at least two elevated blood pressure measurement. According to JNC-7 report , elevated blood pressure was defined as higher than or equal to 130/80 mmHg.Blood samples (3 mL) were drawn after 8–12 h overnight fasting for the measurement of lipid profile  cholesterol, and triglycerides) and fasting plasma glucose levels. Plasma glucose was measured using the glucose oxidaseperoxidase method , serum tμg/mg. Clinical nephropathy was evaluated by the estimation of 24 hr urine protein, and it was present if urine proteins were more than 500 mg/total volume of urine. Ophthalmologist diagnosed retinopathy by detailed fundus examination and was classified according to Diabetic Retinopathy Study (DRS) and Early Treatment Diabetic Retinopathy Study (ETDRS) . As individual drug class, ACEIs were utilized highest 627 (59%), followed by ARBs 620 (52%), CCBs 340(29%) diuretics 315 (27%) and BB 167 (14%) either as mono or combination therapy see . HoweverIn two drugs combination therapy, ACEIs plus ARBs were prescribed highest 89 (21%), followed by ARBs plus diuretics 76 (18%), ACEIs plus CCBs 72 (17%), and ARB plus CCBs 67 (16%). In three drug combinations, combination of ACEI plus ARB plus diuretics were highest with 58 (30%) followed by ARB plus CCB plus diuretics 41 (21%). In 4 or more drug combinations of ARB, ACEI, CCBS plus diuretics were commonly prescribed [13 (35%)] see . A totalA1c, neuropathy, nephropathy, retinopathy, CAD, and DF foot complications were taken as independent variable. Patients with >55 years were more likely to receive diuretics compared to patients with ≤55 years. . Prescription of any hypertensive drugs were not associated with gender or duration of diabetes, however polytherapy was more predominant in elderly (P < 0.05) and was positively associated with duration of diabetes  and duration of hypertension . ARBs, calcium channel blocker, and diuretics were more likely to be prescribed when considered as mono or combination therapy . Prescription pattern of any antihypertensive drugs did not significantly associate with neuropathy. The prevalence of nephropathy was 480 (41%). The significant difference was observed in patients with mono and poly therapy with nephropathy (P < 0.05). ARBs and ACEIs were the drug of choice for nephropathy. ARB and diuretics were more likely to be prescribed in nephropathy . In addition patients with elevated serum creatinin level (>1.2 mg/dL) ACE were less likely to be prescribed . P < 0.05). Patients with CAD were likely to get ACEI/ARB with diuretics . Beta-blockers were more likely to prescribe both in mono and polytherapy . The prevalence of CAD was found to be 13% (159). Patients with CAD were more likely to be prescribed polytherapy  collaborations meta analysed evidence of clinical trials on treatment of hypertension, which showed significant benefits from a more intense blood pressure reduction in stroke and major cardiovascular events. Aggressive antihypertensive treatment, although difficult to achieve, resulted in substantial reductions of left ventricular mass (LVM) index and arterial stiffness in relatively uncomplicated hypertensive T2DM patients , 19. The choice of antihypertensive drug should be determined by the drug's capacity to lower pressure, to protect the diabetic patient's kidney from ongoing injury and cardiovascular complications. Antihypertensive and lipid-lowering teatment to prevent heart attack trial (ALLHAT) compared metabolic, cardiovascular, and renal outcomes in individuals assigned to initial hypertension treatment with a thiazide-like diuretic , a calcium channel blocker , or an ACE inhibitor (lisinopril) in nondiabetic individuals with or without metabolic syndrome. It showed despite a less favorable metabolic profile, thiazide-like diuretic initial therapy for hypertension offers similar, and in some instances possibly superior, CVD outcomes in older hypertensive adults with metabolic syndrome, as compared with treatment with CCBs and ACE inhibitors strategies based on renin-angiotensin system inhibitors were not clearly superior to conventional  strategies . FurtherACEIs have shown a specifically beneficial effect in microvascular disease in kidney. It is mainly due to decreasing capillary perfusion, reducing transcapillary leakage of albumin, and in long run decrease damage to both capillaries and arteries . It has The UKPDS showed the beneficial effects of the ACE inhibitor captopril on diabetes-related mortality and microvascular and cardiovascular complications in patients with type 2 diabetes , ACE inhEuropean guidelines utilized cost-effective treatment of antihypertensive treatments based on sound economic model ling. Guidelines suggested that strategy based CCBs are the most cost effective and BB were least cost effective –31. In pESH suggests ARBs should be a regular component of combination treatment and preferred one when monotherapy alone in diabetics . In addiIn the present study with the prescription of antihypertensive medication was consistent with guidelines as significantly high use of ACEI with low dose of diuretics in high risk groups for cardiovascular events. Initial choice of monotherapy was mostly ACEIs or ARBs (76%). Use of multiple drugs in combinations is being increasingly recognized as critical to control hypertension in patients with diabetes. Several large clinical trials demonstrated that most patients with hypertension could achieve and sustain adequate blood pressure control only with the use of multiple antihypertensive drugs , 36. A lDual blockade of the reninangiotensin system using ARBs and ACEIs  found that the combination of both agents reduced blood pressure and urinary albumin levels to a greater extent than either medication alone .In diabetic patients >65 years of age with isolated systolic hypertension , pharmacological treatment should be initiated. Earlier recommendations to treat a systolic blood pressure <160 mmHg have been reduced based on the increased cardiovascular risk of these patients and the results of the SHEP study, in which a systolic blood pressure of 144 mmHg was achieved. Combinations of agents are often required . When drDiuretics were more utilized in combinations with other antihypertensive drugs in elderly compare to nonelderly patients A meta analysis has suggested that in elderly, diuretics have more pronounced preventing effects on cardiovascular mortality. In trials of isolated systolic hypertension first line comprised diuretics or calcium channel blocker , 38, 39.It has been shown that ACEIs as well as conventional antihypertensive delays progression of nephropathy . AvailabIn present study, among 219 overt nephropathy patients 120 were on ARBs  and 116 on ACEIs . A meta analysis has shown ACEIs to be effective for the primary prevention of kidney disease in diabetes and with ACEIs, a RR reduction of 42% has been demonstrated (95% CI 16% to 60%). ACEIs alone or with low dose of diuretics delay end stage renal disease or prevent microalbunuria or proteinuria . ADA gui ACE and ARB were found to be major category for two-drug combination use. Recent studies found that combination of ACE and ARB compared with ACE inhibitors alone, was associated with significant increases in renal dysfunction and hyperkalemia, poorly tolerated, patients less adhere to combination therapy due to adverse effect . The curIn patients with CHF, ARBs were superior to calcium channel blocker for reducing heart failure , 45, henTreatment with beta blocker has a protective effect on cardiovascular mortality after myocardial infraction, as this is a major cause of disease. So, prophylaxis of BBs are advisable with high risk patients. In present study, it was significantly higher proportion were on beta blocker with coronary artery disease .The rate of successful blood pressure control was 26% compared higher hypertensive patients receiving treatment, and despite the inadequacy of monotherapy to control blood pressure, many of the patients received this treatment regimen. We found overall BP control (<130/85) to be 32%. Obviously, BP control is multifactorial, with factors such as age, comorbidity, and patient adherence to medication regimens affecting this outcome, and our study does not attempt to examine all other parameters like adherence to the method.We found that however prescribing patterns was consistent with the evidence-based guideline, only one fourth of diabetic patient had blood pressure within the target. However, the result is encouraging as it is better compared to previous report from the same hospital which suggested only 11% T2DM patient have hypertension under control.


The prevalence of chronic kidney disease, currently estimated to vary between 8 and 12 % in the general population, is steadily rising due to aging and to the ongoing epidemic of hypertension and type 2 diabetes. Even in its early stages, chronic kidney disease entails a greater risk for cardiovascular mortality, and its prevention and treatment is rapidly becoming a key medical issue for many health care systems worldwide. Adequate blood pressure control and reduction of urine protein excretion, preferably obtained by the use of renin-angiotensin-aldosterone system inhibitors, have traditionally been considered the mainstay of therapeutic strategies in patients with renal disease. Given the pivotal role of renin-angiotensin-aldosterone system activity in the pathogenesis and progression of renal and cardiovascular damage, a more profound inhibition of the system, either by the use of multiple agents or by a single agent at high dosage has recently been advocated, especially in the presence of proteinuria. Recent trials, however have failed to confirm the usefulness of this therapeutic approach, at least in unselected patients. This article will critically review the current literature and will discuss the clinical implications of targeting the renin-angiotensin-aldosterone system in order to provide the greatest renal protection. Chronic kidney disease (CKD) is currently estimated to affect between 8 and 12 % of the general population, and its prevalence may be as high as 20–30 % in subgroups at increased risk such as patients with diabetes, hypertension and the elderly –6. In faThe magnitude of systolic blood pressure reduction as well as the degree of proteinuria reduction has been related to renal outcome in patients with non diabetic CKD, with greater renal protection being obtained when these two variables are lowered to a range of 110–130 mmHg and below 1.5 g/day, respectively –18. FurtExtensive experimental and clinical evidence, accrued over more than three decades, document the deleterious effects of increased RAAS activity at the vascular and tissue level, especially within the kidney . An exceAt the beginning of this century, the then new class of angiotensin II type I receptor blockers (ARBs) was tested (again vs placebo) on the subgroup of patients that were rapidly becoming the most prevalent in renal practice everywhere, i.e. those with type 2 diabetes. In two similar landmark trials , 34, losAfter the initial enthusiasm over the results of trials conducted with ACE-Is and ARBs, investigators realized that in the presence of proteinuria, a disappointingly large fraction of CKD patients, with or without diabetes, tend to progress toward ESRD over a few years, despite optimal antihypertensive treatment and RAAS-inhibition. In the meantime, new experimental data uncovered several biochemical mechanisms, such as non ACE-dependent Angiotensin II formation pathways  or countPreliminary results of several small studies and three meta-analyses –42 suggeThe development of aliskiren  the firsMore recently, however the strategy of combining aliskiren with an ACE-I or an ARB in diabetic patients at high cardiorenal risk was shown to entail potentially unfavorable effects. The ALTITUDE study, which was conducted on 8,500 patients, had to be prematurely stopped due to what turned out to be a lack of benefit, possibly associated with a greater risk of complications . Thus, iBased on experimental studies indicating different degrees of RAAS activity and drug effectiveness at the circulating and tissue level –54, withSeveral relatively small and short term studies have shown that both spironolactone and eplerenone can produce further reductions in albuminuria/proteinuria when added to optimal treatment with an ACE-I or an ARB . These fThe high CV and renal residual risk observed in patients with overt CKD despite multifactorial intensive treatment has prompted many to advocate prevention of renal damage in the subgroups of patients at risk as a way to more effectively fight the current epidemic of ESRD and associated CV diseases. Again, even in the field of primary prevention it has sometimes been difficult to distinguish the effect of blood pressure lowering from that of RAAS inhibition per se.The BENEDICT study, carried out on patients with type 2 diabetes and hypertension, investigated the effectiveness of the ACE-inhibitor trandolapril as compared to the non-dihydropyridine calcium channel blocker verapamil given alone or in combination, over a mean 3.6 year follow-up period . TreatmeFinally, in the ROADMAP study, treatment with olmesartan was more effective than placebo in delaying the onset of microalbuminuria in a large cohort of type 2 diabetics, but again in the context of a slightly greater blood pressure lowering effect as compared to placebo .Taken together, these data suggest a mildly favorable role for RAAS inhibitors in the prevention of renal damage in patients with diabetes, especially in the context of hypertension. This renal protective effect however, seems at least in part due to the blood pressure lowering effect of these agents.Achieving optimal blood pressure values through effective pharmacological treatment is associated with a reduction in proteinuria and a slower rate of renal deterioration over time in patients with CKD. RAAS-Is represent the antihypertensive drugs of choice and have been shown to provide greater antiproteinuric effects at comparable blood pressure regimens. Although only a few trials have directly compared ACE-Is to ARBs, these two classes of antihypertensives appear to have similar renal protective effectiveness. The latter however, are characterized by undisputed greater tolerability. Dual RAAS inhibition with an ACE-I/ARB combination does not provide additional CV benefits and might have serious side effects in the renal patient. Whether these risks are worth taking in selected cases, and if the slightly greater proteinuria reduction reported with this combination will actually translate into long term benefits on hard renal end point remains to be seen. There are currently insufficient data to recommend other RAAS combinations (with ARA or DRI) and high dose monotherapy with ACE-I or ARB in order to achieve greater renal protection. This is certainly an area that warrants further clinical investigation.In the presence of CKD, achieving blood pressure targets almost invariably requires the association of several drugs , not rar


We used proportional hazards regression to evaluate this score in quintiles (Q) and each food group making up the score relative to incident HNBP or hypertension over nine years in the Atherosclerosis Risk of Communities (ARIC) study of 9913 African-American and Caucasian adults aged 45–64 years and free of HNBP or hypertension at baseline. Incidence of HNBP varied from 42.5% in white women to 44.1% in black women; and incident hypertension from 26.1% in white women to 40.8% in black women. Adjusting for demographics and CVD risk factors, the “a priori” food score was inversely associated with incident hypertension; but not HNBP. Compared to Q1, the relative hazards of hypertension for the food score Q2–Q5 were 0.97 (0.87–1.09), 0.91 (0.81–1.02), 0.91 (0.80–1.03), and 0.86 (0.75–0.98); ptrend = 0.01. This inverse relation was largely attributable to greater intake of dairy products and nuts, and less meat. These findings support the 2010 Dietary Guidelines to consume more dairy products and nuts, but suggest a reduction in meat intake.Dietary intake among other lifestyle factors influence blood pressure. We examined the associations of an “ Diet plays an important role in the modulation of blood pressure in hypertensive and normotensive adults ,10,11,12A posteriori” derived dietary patterns, including the Western and Prudent patterns, are data driven and created through factor or cluster analysis [A priori” diet patterns or scores, such as the Healthy Eating Index (HEI) and Diet Diversity Score (DDS) [In observational studies, dietary pattern analysis has been useful in predicting diet-disease associations because a diet pattern captures total dietary intake instead of individual nutrient or food intakes . Howeveranalysis . “A priore (DDS) ,22, havere (DDS) ,23, whilre (DDS) . Given ta priori” healthy diet pattern [We propose to examine the associations of an “ pattern  that is n = 3972), Washington County (n = 3975) and Forsyth County (n = 3531), but none in Jackson; while African Americans were recruited predominantly from Jackson (n = 3728) and some from Forsyth County (n = 483), Minneapolis (n = 22), and Washington County (n = 33). The total number of participants enrolled at the baseline exam (1987–1989) was 15,792 adults aged 45–64 years. Investigators reported less than 5% bias in prevalence estimates related to nonresponse for most of the measured characteristics [n = 48), had hypertension at baseline (n = 5495), had missing data (n = 80), or had implausible energy intake  (n = 256), resulting in 9913 participants for this analysis.The Atherosclerosis Risk in Communities (ARIC) study is a community-based prospective study investigating the etiology and natural history of atherosclerosis in middle age US adults . Particieristics . Return Baseline information about demographic characteristics and lifestyle habits, including smoking and physical activity, were collected by trained interviewers. Height was measured without shoes to the nearest 1 cm and weight measured in light clothing to the nearest 0.1 kg on a beam balance scale. Body mass index (BMI) was calculated by weight in kilograms divided by height in meters squared. Smoking status was categorized as current smoker, former smoker, and never smoker. A modified Baecke physical activity questionnaire assessed leisure time physical activity . A sporti.e., butter, margarine, vegetable oil, vegetable shortening, lard, bacon grease). Study participants were also asked to report other foods not queried and these were coded. Nine frequency categories from almost never to over six times a day were asked by the FFQ, and standard portion sizes and food models were provided to evaluate the amount of consumption. Use of salt added in cooking and at the table as well as brand name of usual cold breakfast cereal consumption were also obtained. The ARIC study used a modified 66-item interviewer-administered food-frequency questionnaire (FFQ) to assess dietary intake at baseline and Exam 3 . Modificet al. [The Healthy Food Score (HFscore), adapted from Steffen et al.  was baseet al. ,11,12,19et al. . Daily cet al. . For alcet al. . The average of the second and third sitting blood pressure readings as measured by random-zero sphygmomanometer (RZ) was used in Exams 1–3, while the mean blood pressure as measured by the RZ in Exam 4 included the only two blood pressure measurements obtained. High normal blood pressure was defined as systolic blood pressure greater than or equal to 120 mmHg and less than 140 mmHg and/or diastolic blood pressure greater than 80 mmHg and less than 90 mmHg and no use of antihypertensive medication. Hypertension was defined as greater than or equal to 140 mmHg systolic, 90 mmHg diastolic, or use of antihypertensive medication. Follow-up time was terminated for participants who developed incident high-normal blood pressure (yes/no) or incident hypertension (yes/no). Because actual time to diagnosis is unknown, the time to blood pressure events was interval censored by the follow-up visit schedule . Follow-n = 5260). However, participants with normal or high normal blood pressure at baseline who developed hypertension were included in the hypertension outcome only (n = 9913).High normal blood pressure and hypertension were defined as independent endpoints. Participants with normal blood pressure at baseline who developed high normal blood pressure, but not hypertension, were included in the analysis of the high normal blood pressure outcome . Baseline characteristics are described as mean ± SD or frequencies. Cumulative average diet, which has been shown to increase the precision of dietary data, was used to create food groups and the HFscore . Specifin = 5260) and hypertension (n = 9913), the mean ± SD age at baseline was 54.0 ± 5.7 years in men and 53.0 ± 5.6 years in women. The mean ± SD systolic and diastolic blood pressures at baseline for the total population were 114 ± 12 mmHg and 70 ± 9 mmHg, respectively  were more likely to be younger, African American, current smokers, physically inactive, and have less education than those in Quintile 5 . Intakesptrend = 0.63) (ptrend = 0.01). After adjusting this model for BMI and diabetes at baseline and change in BMI, the relation was slightly attenuated .There was no relation for the risk of developing high normal blood pressure across quintiles of HFscore ( = 0.63) , Model 2ptrend = 0.90); however, compared to Quintile 1 intake, consuming one or less daily serving of meat, more than two daily servings of dairy products, and about one quarter serving of nuts per day (Quintile 5 intake) was independently related to lower risk of developing hypertension. Adjusting the model for calcium and vitamin D enhanced the inverse association for dairy (data not shown). Race or gender did not modify the relations between the HFscore and incident high normal blood pressure or hypertension.To determine which food groups in the HFscore that contributed most to the risk of developing hypertension, we examined individual food groups relative to incident hypertension . GreaterThe HFscore was inversely related to the risk of developing hypertension, but not HNBP, in middle-aged African American and white men and women. Moreover, in studying the components of the diet pattern, the inverse relation with hypertension was largely attributable to greater intakes of dairy products and nuts, and lower intake of meat. Specifically, study participants with the lowest risk of developing hypertension consumed more than two daily servings of dairy products, at least one serving of nuts per week, and one or fewer daily servings of meat, in addition to the combination of greater intakes of fruit, vegetables, whole grains, legumes, and fish and lower intake of sugar sweetened beverages.Our findings were consistent with those observed in the CARDIA study of young African American and white men and women, the study from which the HFscore used in ARIC was adapted . Even thOur findings demonstrate a lower risk of hypertension with higher intake of dairy products and nuts, but lower intake of meat, after adjusting for the rest of the diet pattern and other confounding factors. Inconsistent results have been reported for studies about dairy products, whether total dairy, high-fat or lowfat dairy, relative to elevated blood pressure (defined as SBP ≥130 mmHg and/or DBP ≥85 mmHg)  and highGenerally, greater meat consumption has been associated with higher risk of developing elevated or high blood pressure among a variety of populations ,19,51,52Finally, our study adds to the accumulating evidence that nut consumption has a blood pressure lowering effect . Nuts arThere are a few limitations to our study. Because blood pressure fluctuates during the day and over time, we captured blood pressure at only one sitting during each exam; however, participants had the opportunity for four blood pressure measurements between 1987–1989 and 1996–1998. Second, even though the FFQ used to assess dietary intake included only 66-items, which may misclassify food intake somewhat, study participants had the opportunity to report other foods not queried, which were coded and included in analysis. Nevertheless, daily nutrient intake may be underestimated; however, food intake is most likely correctly ranked. While acknowledging these limitations, the FFQ has been previously tested for validity and reliability of diet patterns yielding correlations ranging from 0.45 to 0.74 between food records and two FFQs . FinallyThe strengths of this study include its prospective study design, high participation rate, and the standardized procedure for measuring blood pressure at four clinic exams. Further, dietary intake was measured on two occasions . In addiThese findings are consistent with the 2010 U.S. Dietary Guidelines for Americans , and sug


Prehypertension remains an important public health challenge all over the world and appropriate treatments should be adopted to prehypertensive group in different degree effectively. This review aimed to assess the prevalence of Prehypertension and provide effective evidence of the benefits of treating prehypertensive patients. The reasonable evaluation and appropriate intervention of prehypertensive remain need further study. Prehypertension was defined as a systolic blood pressure of 120–139 mmHg and/or a diastolic blood pressure of 80–89 mmHg. The concept of prehypertension was introduced as the new guideline for the management of blood pressure by the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JnC-7) . PatientThe National Health and Nutrition Examination Survey (NHANES) 1999-2000 reported that the overall prevalence of prehypertension was 31% all over the world, which was higher in men than in women . A stati2 was the strongest determinant of prehypertension [ Prehypertension is correlated with the recognized traditional cardiovascular risk factors such as obesity, diabetes mellitus, and dyslipidemia. NHANES II 1999-2000 data showed that 64% of individuals with prehypertension had at least another cardiovascular risk factor; persons with Prehypertension were 1.65 times more likely to have at least another adverse risk factor than those with normotension and the percentage increased to 94% in those aged 60 years or older . Anotherrtension .Other nontraditional cardiovascular risk factors had also been relevant to the development of prehypertension. The prevalence of metabolic syndrome in the prehypertension group was higher than in the normal BP group. Larger waist circumference and body mass index, higher levels of triglycerides, fasting blood glucose, uric acid and ferritin, and lower levels of high-density lipoprotein-cholesterol were more common in subjects with prehypertension than in those with normal BP . Compare Individuals with prehypertensive levels of blood pressure had an increased risk of developing cardiovascular disease relative to those with optimal levels. The association was pronounced among individuals with diabetes mellitus, and among those with high BMI . It was The relationship between prehypertension and cardiovascular disease aroused widespread concern, and it became an important subject to prevent and intervene. JNC-7 suggested the individuals of prehypertension adopted a healthy lifestyle in order to lower blood pressure and prevent progression to hypertension, with associated reductions in target organ damage and cardiovascular events. 2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension emphasized that cardiovascular complications of patients should immediately take drug therapy to reduce the risk of cardiovascular events even in the scope of prehypertensive .2. (2) Adopt DASH eating plan, consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat. (3) Adopt dietary sodium reduction and reduce dietary sodium intake no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). (4) Promote physical activity. (5) Attempt moderation of alcohol.Prehypertensive blood pressure levels identify individuals with elevated risk of developing hypertension. Prehypertensive patients are not the usual candidates for antihypertensive drug therapy, and prehypertensive individuals should primarily be advised to modify their lifestyle to lower their blood pressure to normal values (systolic/diastolic blood pressure <120/80 mmHg) to reduce the risk of developing hypertension. Lifestyle modifications were the main treatment recommended by JNC-7 guidelines for the prehypertension patients. The lifestyle modifications included (1) Lose weight, maintain normal body weight, keep body mass index between 18.5 and 24.9 kg/mIt is known that obesity, sodium intake, and alcohol consumption factors influence blood pressure. The DASH diet is recommended by physicians for people with hypertension (high blood pressure) or prehypertension. The DASH diet eating plan has been proven to lower blood pressure in studies sponsored by the National Institutes of Health (Dietary Approaches to Stop Hypertension). In addition to being a low-salt (or low-sodium) plan, the DASH diet provides additional benefits to reduce blood pressure. It is based on an eating plan rich in fruits and vegetables, and low-fat or nonfat dairy. DASH dietary pattern is rich in potassium (from fruits and vegetables) and calcium (from dairy), low in total and saturated fat, and contains limited amounts of meats and sweets . CompareIncreased body weight is a strong risk factor for prehypertension and weight loss is important for the prevention and treatment of prehypertension and hypertension. A lot of clinical trial data document the significant BP-lowering effect of weight loss. A meta-analysis of randomized controlled trials included twenty-five randomized, controlled trials (comprising 34 strata) published between 1966 and 2002 with a total of 4874 participants was performed to estimate the effect of weight reduction on blood pressure overall and in population subgroups in 2003. Blood pressure reductions were −1.05 mmHg  systolic and −0.92 mmHg  diastolic when expressed per kilogram of weight loss in this study. It was found that physical exercise with weight reduction reduced blood pressure, decreased cardiovascular risks, and improved abnormal left ventricular relaxation recently .Many surveys reveal the consistent correlation between sodium intake and BP. Numerous trials show that the limit of sodium intake leads to reductions in BP , 33. A l The correlation between habitual physical activity and the development of hypertension have been found in numerous studies. A meta-analysis demonstrated the studies published and indexed between January 1966 and December 1998 concluded that progressive resistance exercise was efficacious for reducing resting systolic and diastolic blood pressure in adults . AnotherThe recommendation of JNC-7 suggested that the limit consumption to no more than 2 drinks  per day in most men and to no more than 1 drink per day in women and lighter weight persons. The regular consumption of alcohol elevates blood pressure and the global estimates showed that the attributable risk for hypertensive disease from alcohol was 16%. The increase of blood pressure is approximately 1 mmHg for each 10 g alcohol consumed and is largely reversible within 2–4 weeks of abstinence or a substantial reduction in alcohol intake, and this increase of blood pressure occurs irrespective of the type of alcoholic beverage. Maximum cardiovascular benefit occurs at relatively low levels of consumption  and up to one a day in women ). In hypertensive subjects, consumption beyond these levels would be unwise .The reduction of blood pressure is always the comprehensive effect of the lifestyle interventions in the management of prehypertension. The main 6-month results from the PREMIER trial showed that comprehensive behavioral intervention programs improved blood pressure .Whether people without diabetes or chronic kidney disease (CKD) should be given pharmacological treatments or not is still on discussion . The phaThe category of “prehypertension” increases the awareness of the high risk group of hypertension. Individuals with Prehypertension have an increased risk of full-blown hypertension, target organ damage, and cardiovascular-related morbidity and mortality . Despite


Coronary Artery Disease (CAD) is the most important cause of mortality in the world. About half of cardiovascular risk factors have not been completely understood. Oxidation of LDL by oxidants such as iron plays a central role in atherogenesis. As a result, evaluation of the iron stores is important in the risk evaluation of the atherosclerotic disease.This cross sectional study was performed on 337 patients with chronic stable angina hospitalized in Sari heart center, Mazandaran University of Medical Sciences from February 2010 to July 2012. Coronary angiography was performed and the angiograms were evaluated by two cardiologists. Moreover, blood samples were collected after a 14-hour fast immediately before the coronary angiography in order to measure the total cholesterol, HDL- cholesterol, and glucose. The patients were divided into four groups to evaluate the severity of Coronary Artery Disease (CAD) according to Syntax scoring system.The study results revealed a significant difference among the four study groups regarding the iron serum level. It was significantly higher in the sever atherosclerosis group compared to the normal (P=0.0122), mild (P=0.023), and moderate CAD groups (P<0.001).The findings indicated that the serum level of iron was higher in the atherosclerotic patients and increased with the severity of CAD. Therefore, a basic relationship probably exists between the serum iron level and CAD. Further prospective and experimental studies are needed to confirm the association between the iron status and atherosclerosis. Cardiovascular disease is epidemic at present and by 2020, it will be the single most important disease in the world in the terms of mortality, morbidity, disability, and economic loss. This chronic disease has also an enormous impact on the quality of life . CardiovFor the first time, Sullivan  suggesteAlthough the vast majority of basic and animal researches have been largely supportive of the role of iron status in atherosclerosis, human studies have been equivocal . MoreoveThus, the present study aims to investigate the relationship between serum levels of iron and the severity of CAD measured by Syntax score.The present cross sectional study was performed on the patients hospitalized in Sari heart center, Mazandaran University of Medical Sciences from February 2010 to July 2012. Written informed consent was obtained from all the participants according to the criteria of the Ethical Committee of Mazandaran University of Medical Sciences.The sample consisted of 337 patients with chronic stable angina each of whom had been admitted for diagnostic coronary angiography for typical indications, such as evaluation of stable exertional angina.The patients who had a history of infectious diseases in the recent two months, collagen vascular disease, and recent cardiac events were excluded from the study.Coronary angiography was performed by the Judkins technique through femoral artery access and the angiograms were evaluated by two cardiologists who were blinded to the study plan.The study patients were divided into four groups to evaluate the severity of Coronary Artery Disease (CAD) according to Syntax scoring system.The diagnosis of CAD was based on the presence of 50% luminar diameter stenosis of the major epicardial coronary artery which was determined in a standard manner during the coronary angiograms (1.5 mm less severe lesions should not be included in the SYNTAX score). The percent diameter stenosis was not considered in the algorithm and distinction has been made only between occlusive (100% diameter stenosis) and non occlusive (50-99% diameter stenosis) disease. Besides, multiplication factors of 2 and 5 were used for non-occlusive and occlusive lesions, respectively. Furthermore, CAD was categorized into three groups of mild for 0-22 scores, moderate for 23-32 scores, and severe for 33 and higher scores .Cardiovascular risk factors, including age, sex, systolic and diastolic blood pressure, smoking status, history of dyslipidaemia, and diabetes, were assessed for each subject.Dyslipidaemia was defined as the Total Cholesterol (TC) to High Density Lipoprotein (HDL) more than 4. In addition, Hypertension (HT) was defined as a systolic blood pressure above 140mmHg, diastolic blood pressure above 90mmHg, or current use of antihypertensive medication. Besides, Diabetes Mellitus (DM) was defined as a known history of DM, fasting blood glucose of 126 mg/dl, GTT greater than 200 mg/dl, or treatment with insulin or oral hypoglycemic agents. Moreover, different categories of cigarette smoking status were defined according to World Health Organization (WHO) guidelines  technology .The study data were analyzed using the SPSS-16 software. Baseline demographic and laboratory data were presented as mean ± SD for continuous variables and as frequencies for discrete variables. Parametric and non parametric data were compared between the study groups using one-way ANOVA and chi-square tests. Besides, the mean difference of iron level was compared among the four groups using one-way ANOVA. P<0.05 was considered as statistically significant.No significant difference was found among the four groups regarding the smoking habits (P=0.682), occurrence of DM (P=0. 843) and HT (P= 0. 552), serum TC/ HDL, and blood glucose levels.The main results of the study are summarized in Moreover, the serum level of iron in the normal coronary group was 9.4±1.9 mg/L. Sheffe test results showed that the iron level was significantly higher in the severe atherosclerosis group in comparison to the normal (P= 0.0122), mild (P=0.023), and moderate CAD groups (P<0.001).CAD is a leading cause of mortality, morbidity, and disability in Iranian population. It accounts for nearly 50% of all the annual CAD-related deaths in IR Iran . CAD hasThe relationship between iron status and atherosclerosis has long been a topic of debate in the literature.Steinberg showed that reduced iron played a role in the peroxidation of lipids . In a stHowever, some studies have suggested that iron does not play a major role in development of CAD. More recent data from the National Health and Nutrition Examination Study (NHANES II) did not demonstrate a relationship between ferritin and cardiovascular mortality . On the In conclusion, the findings of the present study showed elevated serum iron concentrations to be associated with increased syntax score and athrosclerosis severity. The present data suggested that iron may play a role in the incident of atherosclerosis. In this study, iron level was measured for once and error of measurement should be considered. Thus, further studies are required to be conducted on the issue in a clinical model of early and advanced stages of atherosclerosis.


Describe informal allopathic practitioner (IAP) knowledge and practice about management of hypertension and identify gaps in IAP knowledge and practice amenable to interventions.A cross sectional descriptive survey of 642 IAPs in Kamalapur (urban) and Mirsarai  Bangladesh was conducted from March to April, 2011. Using a structured, pre-tested questionnaire sociodemographic, training, knowledge and practice data about management of hypertension was collected. Comparative statistics were preformed to show differences between urban and rural practitioners using SAS 8.0.99.4% of IAPs were male, mean age was 37.5 (12.5 SD) years. Greater than 65% correctly identified the upper limit of normal blood pressure. 50.2% underestimated lower limit of systolic hypertension. 79.8% allowed age to affect their treatment approach. As blood pressure increased, willingness to treat with medication decreased and tendency to refer increased. Sedative/sleeping pills, antidepressants, and beta blockers were the most commonly prescribed medications for prehypertension , stage I hypertension  and stage II hypertension . Rural IAPs were more likely than urban IAPs to treat (84.7% vs 77.7%), order tests (27.1% vs 6.0%) and write prescriptions (60.4% vs 18.7%).While IAPs are crucial to Bangladesh’s pluralistic healthcare system, gaps in knowledge and practice could cause unnecessary harm. To include IAPs in the public sector’s fight against the chronic disease epidemic, interventions aimed at standardizing IAPs knowledge and practice will be essential. Successfully utilizing IAPs will have beneficial implications not only for Bangladesh, but for all developing countries. The WHO recognizes primary care as a bed rock of cost effective, efficient health care. However, the developing world faces shortages of and lack of access to physicians A growing chronic disease epidemic is now making new demands of healthcare systems and providers. The steady increase of global chronic disease burden disproportionately affects low and middle income countries A recent literature review concluded that despite importance of primary care health workers in developing countries, an inappropriate knowledge and practice persisted across the spectrum of training and specialty. The review further concluded that inadequate or nonexistent national guidelines frequently played a central role in these knowledge and practice deficits IAPs are a primary source of healthcare in Bangladesh and could potentially be key actors in controlling the chronic disease epidemic. Before speculating at their potential role in the formal sector, data must be collected about their current knowledge and practice in the informal sector. This study aims to fill the gap in the literature by describing and comparing IAPs knowledge and practice in urban and rural Bangladesh.upazilla  and the urban Kamalapur surveillance site (an urban collection of 7 stratum in southeastern Dhaka). The total surveillance population in Mirsarai in 2009 was 39,025. Mirsarai’s average household income was 8,040 BDT per month (in 2008) median 6,000 BDT. Mirsarai’s disease profile is predominantly fever, digestive disturbance, and respiratory disease The study population was obtained from Health Demographic Surveillance System (HDSS) study populations at 2 sites; rural Mirsarai Cross sectional data was collected on IAPs from March to April 2011 by trained ICCDDR,B field research assistants and field research officers based out of ICDDR,B field research offices in the respective surveillance sites. ICDDR,B field offices are long established satellites of the ICDDR,B used for data collection involving ICDDR,B research projects and population surveillance activities. The study population was limited to persons over 18 years old practicing allopathic medicine within the study sites. Persons practicing mixed medicine  or allopaths with MBBS degrees were excluded. Eligible respondents claimed to hold varying levels of certifications ranging from none at all or a simple Drug License obtained in a few months, a 3–6 month Local Medical Assistant and Family Planning training (LMAF) degree, a 3–6 month Primary Medical Counselor (PMC) degree, a 3 year Diploma in Medical Faculty (DMF), a 1 year Rural Medical Practitioner (RMP) degree. However, holding a given certificate does not always reflect the quality of education or the implied length of training as there is little oversight of training institutions. A total of 733 possible respondents were approached, 731 gave informed consent for the interview, 89 were ineligible  for inclusion in this study. Final sample size was 642 respondents . The original sample size target was 390, to ensure adequately powered descriptive analysis. This target was expanded to achieve sufficient power for urban rural comparisons.A structured survey was designed to collect descriptive data on IAP hypertension knowledge and practice (See Supporting Information). Survey questions and categorical responses were based on previous studies, hypertension practice guidelines, IAP interviews and focus groups discussions (FGDs) upazilla were designated rural. Distinctions were made between urban and rural IAPs based on previous literature suggesting possible differences in practice between these two groups Surveys conducted in Kamalapur were designated urban while those conducted in Mirsarai Descriptive analyses were performed on demographic characteristics, professional training, knowledge, treatment, prescribing, and referral practices. Urban and rural differences were evaluated with chi-square tests and independent sample t-tests where appropriate. Multivariate analysis was preformed looking at age religion, experience and training that affected the likelihood of appropriately defining hypertension. SAS 8.0 was used to perform all statistical analysis.IAPs were 99.4% male with a mean age of 37.5 (12.5 SD) years. 61.3% earned more than 7,500 taka, US$ 107, (1 USD: 70 BDT) per month, however, 47.2% reported being in debt. 60.8% reported education beyond the secondary level (greater than 10 years), urban IAPs had more education and higher incomes than rural IAPs .The majority of IAPs entered their profession through formal training from a private organization (58.6%) . 17.9% of IAPs had no training certification. The most common certifications were LMAF and PMC. 99.5% of IAPs practiced from a drug shop, 65.9% also made house calls. 97.7% possessed equipment for measuring blood pressure (sphygmanometer and stethoscope). 90.4% self reported receiving hypertension training .82.7% of IAPs defined hypertension as elevated blood pressure with stress being the most common cause (61.4%). Only 22.6% of IAPs ranked salt consumption among the top 3 most common causes. 79.8% acknowledged that patient age affects their practice. When asked to identify the upper limit of normal blood pressure in patients below the age of 60, 65.3% correctly identified a systolic pressure of 120 mmHg and 67.3% correctly identified a diastolic pressure of 80 mmHg (mean 82 mmHg SD 8). For patients over the age of 60, the majority of IAPs overestimated the upper limit of normal blood pressure for systolic (120 mmHg) and diastolic (80 mmHg). For patients under the age of 60, 50.2% of IAPs underestimated the lower limit of systolic hypertension as less than 140 mmHg (mean 137 mmHg SD 12); 57.3% correctly defined the lower limit of diastolic hypertension at 90 mmHg (mean 89 mmHg SD 7). For patients over the age of 60, the majority of IAPs overestimated the lower limit of systolic (140 mmHg) and diastolic (90 mmHg) hypertension .100% of IAPs reported giving hypertension patients advice while only 81.9% of IAPs reported treating hypertension patients. Compared to urban IAPs, rural IAPs were more likely to treat (77.7% vs 84.7%), order tests (6.0% vs 27.1%) and write prescriptions (18.7% vs 60.4%) . As bloo96.1% of IAPs reported “making referrals” as part of their care for hypertensive patients. 49.9% reported referring patients often or always, while 48.4% reported referring patients sometimes. Urban IAPs indicated a higher frequency of referring often or always compared to rural IAPs (67.7% vs 38.4%). 56.7% of referrals were made to a specific MBBS/MBBS specialist, while 30.4% were to government hospitals . Most IAMultivariable analysis was preformed to account for the effect of confounders and covariates on proper identification of hypertension by IAP. No statistically significant results were identified using multivariate analysis except for a decreased probability (OR 0.48) that IAPs holding drug licenses could correctly identify hypertension in patients less than 60 years old compared to IAPs with other certifications .Many gaps in IAPs knowledge  interfered with proper hypertension management, particularly in patients over age 60. Bangladeshi and international treatment guidelines do not adjust their recommendations based on age There are several potential explanations for these knowledge and practice gaps. Previous studies suggest that low standards of education required for certification and lack of continuing education are responsible for substandard IAPs practices Early referral and reluctance to treat patients with higher blood pressures points towards “adverse to risk” behavior among IAPs. Despite direct financial incentive to medicate Urban and rural IAPs were distinguished by important sociodemographic variables  as well as practices. Overall IAPs stopped attempting treatment earlier than expected, but compared to more educated and higher paid urban IAPs, rural IAPs prescribed more medications and waited to refer patients until higher blood pressures were reached. Given their lower incomes they are at particular risk of being financially influenced in their decision making practices. Rural IAPs have financial incentive to delay referrals to MBBS, but if financial incentives were the primary driving factor, they would also be expected to prescribe medications at lower blood pressure goals than urban IAP, which they do not. Unfilled rural doctor postings, and high rates of absenteeism make MBBS a less viable health care option for many rural Bangladeshis There are several strengths to our study. First our study had a relatively large sample (639 participants), making it one of the larger studies of IAPs to date in Bangladesh and internationally. Our sample compared urban and rural IAP practices; a comparison not seen in previous studies, despite a growing body of literature indicating serious differences in urban versus rural health care There are some important limitations to this study. While not nationally representative, our study was all inclusive of IAPs in the study area and baseline characteristics reflected those in previous studies. Although self reported data has long been used as an epidemiological tool, reporting bias creates a risk of intentional or accidental omissions of actual IAP practices. Therefore the information presented in this study is a theoretical description of IAPs knowledge of “best practice” for hypertension management. Direct observation of IAPs or testing with simulated clients might capture IAP knowledge and practice more accurately, but neglects informed consent and requires the logistical and technical difficulties of imitating hypertension symptoms. Selection bias for even numbers ending in zero is a likely explanation of atypical distribution patterns in our blood pressure figures. Data was not collected on IAPs therapeutic goals, although treatment duration data provides some insights.The base line characteristics of the study population were similar in most respects to those in previous Bangladeshi IAP studies Significant gaps in IAP hypertension knowledge were an expected outcome of the study based on previous IAP and MBBS knowledge and practice studies in Bangladesh and elsewhere . Knowledge and practice gaps in our study were found among MBBS in developing and developed countries  Comparison with similar international studies among trained physicians indicate that while MBBS are less likely to have gaps in knowledge and practice, their knowledge and practice deficits are likely to be similar.The likely harm caused by current IAP knowledge and practice casts doubt on the efficacy or wisdom of immediately utilizing IAP as formal sector partners in treating hypertension. However, the adverse to risk behavior and capability to detect hypertension among poor rural Bangladeshis suggest that it may be appropriate to further encourage and formalize their attempts to screen patients for hypertension. Encouraging such practices offers a first step toward harm reduction and strengthening linkages with the formal sector. IAPs participating in a screening program with the formal sector may then be further evaluated, allowing for potential expansion of their role combating the hypertension (or chronic disease) epidemic. Further research assessing IAP skill in identifying health complications related to hypertension should pay particular attention to speed of referral to appropriate care and recognition of severity of complications.Control of chronic disease in low and middle income countries is a global issue one that relies on a primary care approach emphasizing team based care and formal linkages to communities Bangladeshi IAPs have identifiable and possibly deleterious gaps in their hypertension knowledge and treatment behaviors. Because IAPs inhabit a particularly important role within the Bangladesh health system IAPs nor the aforementioned gaps can be ignored. By describing IAPs hypertension knowledge and practice, future research can study the efficacy of interventions aimed at changing IAPs practice and patient outcomes. To include IAPs in the public sector’s fight against the chronic disease epidemic, interventions aimed at standardizing IAPs knowledge and practice will be essential. However, policy makers might choose to consider IAPs limitations before officially incorporating them into the health care delivery system. Successfully utilizing IAPs will require that their limitations be fully addressed so that the beneficial implications of their collaboration can be appreciated not only in Bangladesh, but for all developing countries.Questionnaire S1(DOC)Click here for additional data file.


Mobile phone based remote monitoring of medication adherence and physiological parameters has the potential of improving long-term graft outcomes in the recipients of kidney transplants. This technology is promising as it is relatively inexpensive, can include intuitive software and may offer the ability to conduct close patient monitoring in a non-intrusive manner. This includes the optimal management of comorbidities such as hypertension and diabetes. There is, however, a lack of data assessing the attitudes of renal transplant recipients toward this technology, especially among ethnic minorities.To assess the attitudes of renal transplant recipients toward mobile phone based remote monitoring and management of their medical regimen; and to identify demographic or clinical characteristics that impact on this attitude.After a 10 minute demonstration of a prototype mobile phone based monitoring system, a 10 item questionnaire regarding attitude toward remote monitoring and the technology was administered to the participants, along with the 10 item Perceived Stress Scale and the 7 item Morisky Medication Adherence Scale.P=.03) and held a more positive attitude toward free use of the prototype system than whites .Between February and April 2012, a total of 99 renal transplant recipients were identified and agreed to participate in the survey. The results of the survey indicate that while 90% (87/97) of respondents own a mobile phone, only 7% (7/98) had any prior knowledge of mobile phone based remote monitoring. Despite this, the majority of respondents, 79% (78/99), reported a positive attitude toward the use of a prototype system if it came at no cost to themselves. Blacks were more likely than whites to own smartphones . Additionally, the data demonstrates that most kidney transplant recipients own and are comfortable using mobile phones and that many of these patients already own and use smart mobile phones. The respondents felt that mHealth offers an opportunity for improved self-efficacy and improved provider driven medical management. Respondents were comfortable with the idea of being monitored using mobile technology and are confident that their privacy can be protected. The small subset of kidney transplant recipients who are less interested in mHealth may be less technologically adept as reflected by their lower mobile phone ownership rates. As a whole, kidney transplant recipients are receptive to the technology and believe in its utility. Nearly 400,000 people living in the United States suffer with end stage renal disease, of these; approximately 93,000 are awaiting kidney transplantation ,2. KidneRecent studies have suggested that remote monitoring via mobile health technology  is an effective and sustainable strategy for facilitating patient provider communication, improving health outcomes, increasing adherence to medical regimens and reducing costs in some chronic illnesses -30. MobiThe aims of this study were twofold. First, to assess the attitudes of a racially diverse sample of kidney transplant recipients on the use of a mHealth remote monitoring system, particularly to enhance medication adherence and blood pressure control. Second, to investigate the whether demographics, prior technology utilization, stress levels and self-reported medication adherence impact on the attitudes toward mHealth.Study participants were recruited from the Kidney Transplant Clinic at the Medical University of South Carolina (MUSC), Charleston. Eligible patients were those who had previously received a kidney transplant, were over 18 years of age and spoke English. Between February and April 2012, 103 patients were approached during their usual post-transplant clinic visit, either by their clinical coordinator, clinic nurse or physician. Patients were asked if they were willing to speak to the study coordinator regarding participating in the survey, 99 agreed to participate. Those that declined did so either for lack of time or lack of interest. The demographic and transplant related clinical characteristics of the survey participants are summarized in Patients were approached about completing a survey that included questions on their attitudes toward remote monitoring, mobile phones, electronic medication monitors and electronic home blood pressure monitors. Also evaluated were perceived levels of general stress and medication adherence . PatientThe prototype system included a smartphone (Motorola Droid X), a wireless (GSM-enabled) medication tray (Maya MedMinder) and a wireless (Bluetooth-enabled) blood pressure monitor (Fora D15b). Patients were required to use the medication tray for all medication dispensing and to measure their resting blood pressure and pulse every third day at both morning and evening. The smartphone automatically transfers the blood pressure and pulse data to computer servers for later analysis. The medication tray is fully programmable and capable of delivering reminders in the form of light, tone, text message or phone call. Adherence is tracked in real time and can trigger the delivery of motivational or positive reinforcement messages to the patient via text, email or phone. A summary of the adherence over time can be generated and delivered via email to the patient and the treating clinician. Blood pressure and pulse readings outside predetermined safe parameters could generate automated alert messages that would be sent to both patient and physician. Participants were informed that a clinical coordinator would contact them in the event that alerts were generated.Medication adherence was evaluated using a 7 item modified Morisky Medication Adherence Scale with an internal consistency of 0.82 and a sensitivity and specificity of 91% and 50% respectively . FurtherGeneralized perceived stress was measured using the Perceived Stress Scale in which each of the 10 items is answered using a 5 point Likert item ranging from ‘never’ to ‘very often’. The scale has established psychometric properties including internal consistency of 0.85 . Internath item queried their a priori awareness of health related remote monitoring technology.The respondents’ awareness of, and attitudes toward, mHealth and telemedicine based remote monitoring were evaluated using a 10 item survey , in whic2 test/Fisher exact test for categorical variables.Our sample was analyzed in two ways: by race, blacks versus whites  and by aP=.13), but there was a difference in self-reported adherence (P=.03).The results indicate that 85% (83/98) of respondents are presently using devices at home to monitor either their blood pressure or blood sugar. Nearly two thirds of the respondents, 63% (62/99), were using medication dispensing devices . Respondents reported slightly lower than average levels of perceived stress  that werNearly all respondents  indicated that they already own a mobile phone and were comfortable utilizing this technology. Over a third of the patients  reported that they own a smartphone and over half  reported that they had access to a working smartphone in the household other than their own. Most of the patients , indicated that there was someone in the household who could assist them with using a mobile phone if needed.The survey results also indicated that most respondents had a familiarity with using mobile phones for reasons other than phone calls. Amongst these, over half  used a mobile phone to send or receive text messages, 38% (38/99) to browse the web, 35% (35/99) to send or receive email and 34% (34/ 99) reported using a mobile phone to download a ringtone or a mobile application.Only 7% (7/98) of participants had any prior knowledge of mHealth remote monitoring technology before being surveyed . HoweverP=.04), more likely to report hypertension as an etiology of their renal failure (P=.05), more likely to be a first time recipient of a kidney transplant (P=.02) and more likely to live nearer to the transplant center (P<.001). While mobile phone ownership did not differ significantly between races, blacks were more likely than whites to own a smartphone (P=.03). Although it did not reach statistical significance, there was a trend toward more mobile phone based internet usage among blacks (P=.08). Perceived stress levels did not vary by race (P=.13), but there was a significant difference in medication adherence with blacks reporting slightly poorer adherence (P=.03). Blacks had a slightly more positive attitude toward mHealth than whites as gauged by their willingness to use the technology if it came at no cost to them (P=.02). There were no significant differences between blacks and whites in the level of education (P=.62), annual income (P=.16) or employment status (P=.46).As shown in P=.04), the recipient of their first transplant (P=.02), already using a medication tray at home (P=.04) and the owner of a working mobile phone (P=.04). These respondents were also more likely to own a smartphone (P=.01) and to have used a mobile phone to text (P=.02), email (P=.01), browse the internet (P=.002) or download an application or ringtone (P=.03). As can be seen in P=.01).Respondents who answered either ‘agree’ or ’strongly agree’ to the query as to whether they would use the mHealth system, as demonstrated, if it were free, were more likely to be employed  of respondents owning a mobile phone and 35% (35/99) owning a smartphone, this population of kidney transplant recipients closely mirrors the adult American population . This fiFew of the kidney transplant recipients had any knowledge of mHealth technology prior to being surveyed. Despite that, the vast majority was receptive to utilizing such technology if the devices were provided at no cost. Respondents felt that having the technology would help them follow their medical regimen and improve communication with their healthcare providers, particularly with regards to the efficiency of regulating or changing their medical regime as the need arises. These findings are consistent with other studies that have evaluated the attitudes toward mHealth technology among patients with various chronic illnesses, including essential hypertension, diabetes and congestive heart failure ,34,36.Although there was a high receptivity toward using mHealth technology, there was a cohort of respondents who indicated a less than positive attitude. That these respondents were less likely to own a mobile phone and far less likely to own a smartphone might reflect a lower level of comfort with technology. This potential barrier to use of an mHealth system could be addressed both by making the system easier to use and by providing some skilled assistance and training. The fact that these same respondents were more likely to have had a prior kidney transplant and were less likely to be using a medication tray at home, might indicate a higher comfort level with immunosuppression medications or a lower perceived importance of medication adherence. That this cohort self-reports higher adherence with medications and lower levels of perceived stress may, in part, explain their diminished interest in the technology. Unsurprisingly, this same cohort of patients was less likely to respond positively to the remaining questions regarding comfort with being monitored, comfort with mobile phone technology, privacy protection and various aspects of utility.These findings must be evaluated within the context of several limitations of the study. First, that all respondents were recruited from a single transplant center, which may call into question the generalizability of the findings. However, it should be noted that this center is the sole transplant service provider for the State of South Carolina and has a catchment population of over 4.6 million persons. Second, those that chose to participate might be predisposed to a positive attitude toward mHealth and thereby introduce a positive bias. The participation of nearly everyone who was approached however, suggests that a significant bias toward mHealth is unlikely. Third, it cannot be assumed that the respondents’ purported interest in mHealth will translate into actual use. Anecdotally, as we have begun to enroll kidney transplant recipients in a mHealth medication adherence trial, as a proof of concept research based on this work, we have experienced high participation and utilization rates.This is the first study assessing the attitudes of transplant recipients with this technology and the data demonstrates that there is a positive overall attitude towards mHealth technology. Additionally, the data demonstrates that most kidney transplant recipients already own and are comfortable using mobile phones and that many of these participants already own and use smart mobile phones. Results indicate that the participants feel that mHealth offers an opportunity for improved self-efficacy and improved provider driven medical management. Participants are also comfortable with the idea of being monitored using mobile technology and are confident that their privacy can be protected. As a whole, kidney transplant recipients are receptive to the technology and believe in its utility. Further research in this area should include patient centered evaluations of usability and usefulness as well as proof of concept trials to identify areas of concern.


Pheochromocytoma is a catecholamine-secreting tumor, which is seen rarely in children. These tumors predominantly secrete norepinephrine and epinephrine. They might be familial and associated with hereditary tumors such as Von Hippel-Lindau syndrome and multiple endocrine neoplasia type II.The child might present with a spectrum of clinical manifestation including hypertension, headache, visual disturbances, and behavioral problems. A meticulous preoperative preparation is essential for a stable intraoperative and postoperative outcomeWe described successful perioperative management of a child who underwent bilateral laparoscopic cortical sparing adrenalectomy and a repeated surgery for the residual tumor removal. Pheochromocytoma and paraganglionoma are neuroendocrine tumors arising from chromaffin cells. Pediatric pheochromocytomas, although rare, have an increased incidence of bilateral, multifocal, and familial preponderance when compared to adults . It occuA 12-year-old 25 Kg male child referred to us for bilateral cortical sparing laparoscopic adrenalectomy. He complained of pain abdomen for six months, reduced appetite, and easy fatigability. General physical examination and systemic examination findings were unremarkable except for a high blood pressure of more than 160/100 mmHg for which oral nifedipine 5 mg  twice daily was started and further evaluation was pending.On further investigations including complete blood counts, serum calcium, electrolytes, urea, and echocardiography (ECHO) results were normal. Ultrasound examination (USG) of the abdomen showed multiple heterogeneous bilateral adrenal lesions that were confirmed on computed tomography (CT) scan . Suspici2) monitors, the child was pre-oxygenated and anesthesia was induced with propofol 2 mg/Kg  and fentanyl 2 mcg/Kg . Endotracheal intubation was facilitated with vecuronium 0.1 mg/Kg . Left subclavian vein and left radial artery were cannulated for continuous invasive pressure monitoring. An 18G epidural catheter was inserted in T8-T9 interspace for analgesia. Anesthesia was maintained with isoflurane 0.5-1.5% in air-oxygen mixture. Intraoperative blood pressure surge during the tumor dissection was controlled with titrated infusion of esmolol  and sodium nitroprusside (SNP) . Estimated blood loss was about 300 mL, which was replaced by crystalloids to maintain adequate urine output throughout the procedure.The child was premedicated with midazolam 1 mg  intravenously and was transferred to the operating room on an infusion of normal saline 60 mL/hr and hydrocortisone 10 mg/hr  according to the endocrinologist’s advice. After instituting electrocardiogram (ECG), noninvasive blood pressure (NIBP), and pulse oximeter  with 2 mcg/mL of fentanyl at 5 mL/hr. The child also received supplemental doses of intravenous morphine. Persistent hypertension postoperatively required SNP infusion initially and subsequently. The child received prazosin 1 mg sixth hourly, atenolol 12.5 mg OD, and nifedipine 5 mg Bid to control hypertension. Residual or extra-adrenal tumor was suspected in view of persistent hypertension and repeated 24 hr urine normetanephrines were 3480 mcg/day. As the metaiodobenzyl guanidine (MIBG) scan was inconclusive , a wholeDuring the second surgery the child was induced with thiopentone  and endotracheal intubation was facilitated with atracurium. Right subclavian vein and left ulnar arteries were cannulated for invasive pressure monitoring. Epidural catheter was not employed since the child had refused placement. Anesthesia was maintained with isoflurane 0.5-1.5% in air-oxygen mixture. Blood pressure changes during tumor handling were controlled with titrated infusion of nitroglycerine (NTG) . Following removal of residual tumor, NTG was rapidly tapered. The child was extubated and transferred to PICU. The child remained hemodynamically stable postoperatively and analgesia was achieved with intravenous paracetomol and morphine. Post-operative blood glucose level remained normal. Serum cortisol level examined two weeks later and the result was normal (13 mcg/dL).The child had an uneventful postoperative course and was subsequently discharged. In the follow up after three months, the child had normal blood pressure and serum cortisol level.123] I-labelled MIBG scintigraphy. Presently, functional imaging study by [18F] fluorodopamine (FDA) PET is superior to MIBG in evaluation of malignant chromaffin cell tumors . Clinical presentation range from being asymptomatic to symptoms of sustained hypertension like headache, sweating, visual problems, nausea, and vomiting. It may also present with decreased school performance or behavioral problems . Measurel tumors .Surgical resection is the treatment of choice for bilateral pheochromocytoma. Both open and laparoscopic approaches have been successfully employed depending on the surgeon’s choice and skill. In case of bilateral adrenalectomy, post-operative glucocorticoid and mineralocorticoid replacement is necessary. A Cortical sparing adrenalectomy is advantageous in patients with bilateral disease to avoid long-term glucocorticoid deficiency, especially in children . PostopeConventionally, the patients are started on alpha-adrenergic blockers for ten to 14 days prior to surgery. Alpha blockade is usually achieved with noncompetitive blocker phenoxybenzamine 0.2-1 mg/Kg/day in divided doses . Calcium2 are mandatory before induction of anesthesia. Invasive arterial pressure and central venous pressure monitoring are essential and are ideally employed after anesthesia induction in a pediatric patient. Temperature and urine output should also be monitored. Transesophageal echocardiography is recommended in cases of catecholamine induced cardiomyopathy or intracardiac pheochromocytoma (Preoperative benzodiazepine and reassurance reduces anxiety and pressure fluctuations. Various anesthetic techniques have been employed successfully. Combined epidural and general anesthesia is the most preferred anesthesia technique . Standarmocytoma . Thiopenmocytoma  can be umocytoma .131I] MIBG, somatostatin analogs, and chemotherapy for symptomatic relief and tumor regression (Intraoperative hypertensive spikes during induction and tumor manipulation can be impeded by deepening anesthesia and infusions of SNP, NTG, phentolamine, esmolol, nicardipine, dexmedetomidine, or magnesium sulphate. A single drug or combination regimens might be employed depending on severity, familiarity, and availability -9. We usgression . Pediatr


The age-, gender-, and height-percentile requirements of the 'gold-standard' for the diagnosis of (pre)hypertension in adolescents make it time-consuming for clinicians and difficult-to-use by non-professionals. Simplified diagnostic tools are therefore needed. The use of blood pressure-to-height ratio (BPHR) - systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) - has been reported in Han adolescents, but it requires validation in other racial groups. The diagnostic accuracy of SBPHR and DBPHR in a population of 1,173 Nigerian adolescents aged 11-17 years, was therefore studied.Blood pressures were measured using standard procedures and (pre)hypertension were defined according to international recommendations. ROC curve analyses were used to assess the diagnostic accuracy of BPHR in defining (pre)hypertension in this population. Sex-specific threshold values for SBPHR and DBPHR were determined, and thereafter used to define (pre)hypertension. The sensitivity/specificity of this method was determined.The accuracies of SBPHR and DBPHR in diagnosing (pre)hypertension, in both sexes, was >92%. The optimal thresholds for diagnosing prehypertension were 0.72/0.46 in boys and 0.73/0.48 in girls; while for hypertension, they were 0.75/0.51 in boys and 0.77/0.50 in girls. The sensitivity and specificity of this method were >96%.The use of BPHR is valid, simple and accurate in this population. Race-specific thresholds are however needed. The tracking of hypertension from adolescence (probably from childhood) into adulthood has been fairly established in the literature -3. The pIt is therefore imperative to detect (pre)hypertension early in adolescents since that would aid cardiovascular disease management in adult life. In fact, the US National High Blood Pressure Education Working Group on High Blood Pressure in Children and Adolescents recommends, in its fourth report, the initiation of blood pressure monitoring early in life . Howeveret al. The subjects were asked to rest for an initial 10 minutes, in a seated position and in a quiet room before their blood pressures were measured. Three separate blood pressure (BP) readings were taken per subject, at two minutes intervals, using an automated digital monitor (Omron HEM-741 CINT). Appropriate cuff sizes were used for each subject. The manufacturers put the error of measurement of the device at ± 3 mmHg. The first blood pressure reading was discarded and the average of the last two readings was recorded for both SBP and DBP of each subject. The same trained personnel took all measurements. To obtain the blood pressure to height ratios, the following equations were used: SBPHR = SBP (mmHg)/height (cm); DBPHR = DBP (mmHg)/height (cm) [th percentile for gender, age and height. Prehypertension is taken as systolic and diastolic blood pressure ≥ 90th percentile, but < 95th percentile for gender, age and height or ≥ 120/80 mmHg. Hypertension is taken as systolic and diastolic blood pressure ≥ 95th percentile for gender, age and height [Normal blood pressure is taken as systolic and diastolic blood pressure that is < 90Ethical approval was obtained from the Boards of the Departments of Biochemistry, Kogi State University, Anyigba, and Michael Okpara University of Agriculture, Umudike, Abia State. Further approvals were sought and obtained from the principals of participating schools.post hoc multiple comparison tests. Numerical variables are presented as means ± standard deviations. The Pearson's product moment correlation coefficients were calculated and used to assess the relationship between SBPHR and DBPHR (each) and the other relevant variables. A significant threshold of P < 0.05 was employed for all analyses.Means and standard deviations were calculated and differences between means separated by One-Way ANOVA, followed by The receiver-operating characteristic (ROC) analysis was used to show the discriminatory ability/diagnostic accuracy of SBPHR and DBPHR (separately) with respect to separating subjects into normotensive, prehypertensive and hypertensive phenotypes defined by the age-, gender-and height-specific reference standards as presented in the 2004 Working Group charts . The ROCAll data analyses were done using the statistical software package SPSS for windows version 17.0 .The means of the measured and calculated variables were found to be statistically similar (p > 0.05) between data from the two locations (within the respective ages and sexes) so the data were pooled and treated as one.The clinical characteristics of the subjects are presented in Table The correlation coefficients Table  show thaThe AUC values for the accuracy of both SBPHR and DBPHR in diagnosing both prehypertension and hypertension in both sexes ranged from 0.925 to 1.000 Table . The accThe optimal thresholds for diagnosing systolic prehypertension were 0.72 in boys and 0.73 in girls; while values for diastolic prehypertension were 0.46 for boys and 0.48 for girls. The optimal thresholds for diagnosing systolic hypertension were 0.75 in boys and 0.77 in girls; while values for diastolic hypertension were 0.51 for boys and 0.50 for girls. The sensitivities and specificities in each case were >82%  both take the height of the adolescent subject into consideration. The finding of an insignificant correlation between both SBPHR and DBPHR on the one hand, and age on the other hand, despite the significant positive correlation between SBP, DBP and age is consistent with the report of Lu et al  and implet al . The invet al .et al [et al report [The area under the ROC curves found in this study show that SBPHR and DBPHR have robust discriminatory capacities with respect to diagnosing hypertension (in this population). Applying the determined thresholds of 0.72/0.46 and 0.73/0.48 in defining prehypertension in boys and girls respectively, and 0.75/0.51 and 0.77/0.50 in defining hypertension in boys and girls respectively, discriminated effectively between the blood pressure phenotypes with sensitivities and specificities exceeding 96%. Lu l report  or diffel report . It is hThis study may be limited by some factors. First, the not-too-large sample size for this study may imply a debatably reduced statistical power of the entire analyses. It was necessitated by cultural practices/belief systems that make people feel that subjecting themselves to a "new" test may predispose them to the disease in question, which is pervasive in the studied populations, thereby affecting the number of participants especially when no honoraria was paid for lack of funding. The subjects were naïve to blood pressure measurement . Though et al [The use of sex-specific SBPHR and DBPHR proposed by Lu et al  is validThe author declares that he has no competing interests.CECCE solely designed the study, analyzed and interpreted the data and wrote the manuscript.