Phenotyping asthma according to airway inflammation allows identification of responders to targeted therapy. Induced sputum is technically demanding. We aimed to identify predictors of sputum inflammatory phenotypes according to easily available clinical characteristics.This retrospective study was conducted in 508 asthmatics with successful sputum induction recruited from the University Asthma Clinic of Liege. Receiver-operating characteristic (ROC) curve and multiple logistic regression analysis were used to assess the relationship between sputum eosinophil or neutrophil count and a set of covariates. Equations predicting sputum eosinophils and neutrophils were then validated in an independent group of asthmatics.NO and IgE level and low FEV1/FVC. The derived equation was validated with a Cohen’s kappa coefficient of 0.59 (p < 0.0001). ROC curves showed a cut-off value of 220/mm3  or 3%  for blood eosinophils to identify sputum eosinophilia ≥3%. Independent predictors of sputum neutrophilia were advanced age and high FRC but not blood neutrophil count.Eosinophilic (≥3%) and neutrophilic (≥76%) airway inflammation were observed in 46% and 18% of patients respectively. Predictors of sputum eosinophilia ≥3% were high blood eosinophils, FEEosinophilic and paucigranulocytic asthma are the dominant inflammatory phenotypes. Blood eosinophils provide a practical alternative to predict sputum eosinophilia but sputum neutrophil count is poorly related to blood neutrophils. NO) has already been identified [Asthma is a heterogeneous disease of the airways. The traditional guidelines for asthma diagnosis include suggestive clinical symptoms and the demonstration of airflow variability. However, symptoms and lung function are insensitive in reflecting the underlying airway inflammation. There is increasing evidence that phenotyping asthma according to airway inflammation can allow the identification of subgroups of patients who are more likely to respond to targeted therapy. In particular, important studies have confirmed that eosinophilic airway inflammation most reliably predicts the response to anti-inflammatory treatment such as inhaled corticosteroid ,2 and anentified ,10 as a The purpose of this study was twofold. In a large asthmatic population encompassing the all disease severity spectrum, we first sought to assess the proportion of asthmatic patients displaying eosinophilic vs neutrophilic vs paucigranulocytic phenotypes based on sputum cell analysis. Secondly we aimed at determining factors associated with eosinophilic and neutrophilic phenotypes.NO measurement at a flow rate of 50 ml/s according to the ERS/ATS recommendations . FENO was first measured and followed by spirometry with bronchodilation, sputum induction and blood sampling. All tests were performed on the same day. Asthma was diagnosed based on the presence of chronic respiratory symptoms such as cough, breathlessness or dyspnoea together with the demonstration of airflow variability. The latter was defined by airway hyper-responsiveness shown by one or more of the following: increase in Forced expiratory volume in 1 s (FEV1) of >12% and 200 ml following inhalation of 400 μg salbutamol or inhaled concentration of methacholine provoking a 20% fall in FEV1 of <16 mg/ml. Methacholine challenge was performed according to a standardised methodology as previously described [We conducted a retrospective study on a series of 508 patients with asthma recruited from the University Asthma Clinic of Liege between 1 October 2005 and 27 June 2011 and who had a successful sputum induction. Their demographic and functional characteristics are summarised in Table escribed . Sputum escribed  and was escribed . When deescribed , most of1%, FEV1/FVC, TLC, FRC, KCO, PC20M, Reversibility, Fibrinogen, CRP, FENO, ACQ, AQLQ, ICS therapy). The results were considered to be significant at the 5% critical level (p < 0.05). The ability of the equation to predict sputum eosinophilia or neutrophilia was tested in an independent population of 178 asthmatics recruited between July 2011 and May 2012. The demographic, functional and inflammatory characteristics of the validation population were similar to those of the study population.The results were expressed as mean ± SD for continuous variables; median and interquartile ranges (IQR) were preferred for skewed distributions. For categorical variables, the number of observations and percentages were given in each category. Comparisons between different subgroups were performed with a Kruskal-Wallis test. The Spearman correlation coefficient was used to measure the association between clinical parameters. The receiver-operating characteristic (ROC) curve was constructed to determine the concentration of blood eosinophils or neutrophils which best identified a sputum eosinophil count ≥3% or a sputum neutrophil count ≥76% respectively. Logistic regression analysis was used to assess the relationship between the binary outcome (sputum eosinophil count ≥3% or sputum neutrophil count ≥76%) and a set of covariates, individually or in combination .This study was conducted with the approval of the ethics committee of CHU Liege B70720096732, reference Liege 2009/161.The demographic and functional characteristic of the patients are given in Table NO levels and lower asthma control compared to paucigranulocytic. Mixed granulocytic phenotype had higher levels of fibrinogen, the lowest lung function and the highest degree of bronchial hyperresponsiveness to methacholine  had eosinophilic inflammation (≥3% eosinophils), 80 (16%) neutrophilic inflammation (≥76% neutrophils), 14 (3%) mixed granulocytic and 203 (40%) paucigranulocytic (sputum eosinophil count <3% and sputum neutrophil count <76%) inflammation (Tables 2% had eo3 yielded 77% sensitivity and 70% specificity (Area under the curve (AUC) = 0.79, p < 0.0001, Figure NO  for identification of sputum eosinophilia ≥3%. The comparison of the AUC for both tests failed to demonstrate a significant difference (p = 0.77).For the whole group there was a significant positive relationship between blood eosinophil count, either expressed as percentage or absolute value, and percentage of sputum eosinophil count , FENO , and IgE  were independent factors associated with the presence of sputum eosinophilic inflammation , FEVπ: probability of sputum eosinophil count ≥ 3%.Blood eos%: Blood eosinophil count in %.NO50, spirometry, sputum induction and gave a blood sample. The agreement between predicted and observed value of sputum eosinophil counts gave a Cohen Kappa’s coefficient of 0.59 . The specificity and sensitivity were 62.7% and 93.7% respectively while the PPV was 67% and the NPV was 93%.To test the ability of the equation to predict sputum eosinophilia, we recruited a validation population of 138 asthmatics that underwent FE3 and 66% respectively giving a sensitivity of 49% and 37%, a specificity of 70% and 90%, p = 0.03 and p = 0.003, AUC = 0.59 and AUC = 0.63 respectively.As far as the sputum neutrophilic phenotype is concerned, there was a weak correlation between sputum and blood neutrophil count taken in percentage  but not in absolute value . Using the ROC curve method, we found a cut-off of 4960/mmHowever, when combining all variables into the logistic model, age (p = 0.006) and Functional residual capacity  were independent factors associated with sputum neutrophilia while blood neutrophils were not significant in this case. The formula to predict the presence of a sputum neutrophil count ≥ 76% was:π: probability of sputum neutrophil count ≥ 76%.. Patients receiving moderate to high dose ICS had higher sputum neutrophil count (47.3%) than patients receiving low dose ICS . Smokers did not have significantly higher proportion of neutrophils in their sputum (Median 48.9%) than ex-smokers  or never smokers . However, neither smoking status nor the dose of inhaled corticosteroids was able to predict elevated sputum neutrophil count.To test the ability of the equation to predict sputum neutrophilia, we recruited a validation population of 178 asthmatics that underwent spirometry and sputum induction. The agreement between predicted and observed value of sputum neutrophil counts gave a Cohen Kappa’s coefficient of 0.24 . The specificity and sensitivity were 21% and 97% respectively1/FVC, high FENO and IgE levels. A cut-off value of 220/mm3 or 3% for blood eosinophils performed equally to FENO50 to identify the presence of a sputum eosinophil count ≥3%. Independent predictors of sputum neutrophilia were advanced age and high FRC while blood neutrophil count was not.In a large cohort of asthmatics encompassing all disease severity spectrum, eosinophilic and pauci-granulocytic were the most frequent phenotypes while neutrophilic asthma represented less than one fifth of the inflammatory patterns. Independent predictors of sputum eosinophil count ≥3% were the percentage of blood eosinophils, low FEVThe proportion of asthmatics with raised sputum eosinophil counts was 46% in our series. Gibson et al. found that 41% of non-smoking asthmatics had a sputum eosinophil counts >2.5% . The proNO levels, higher proportion of males and atopic patients, higher bronchial hyperresponsiveness and lower asthma control. Those results are in accordance with previous studies [1 and increased risk of Chronic Obstructive Pulmonary Disease (COPD) in a population study [Lung function was less altered in those patients with paucigranulocytic phenotype while eosinophilic phenotype exhibited higher FE studies ,21-24. L studies , we idenon study . As for 3 as the best compromise for predicting sputum eosinophil count ≥2% [3 and 3% and these thresholds being as effective as FENO at predicting uncontrolled airway eosinophilic inflammation. Our findings are in keeping with those recently reported by McGrath et al. [NO has however the advantage of giving immediate results and its measurement is more comfortable to the patient. In this study the performance  of FENO to identify sputum eosinophil count is very similar to the one we reported previously [NO and blood eosinophil counts came out as independent predictors of sputum eosinophilia in the multiple logistic regression suggests that these two markers reflect different mechanisms promoting the recruitment of eosinophils into the airways.Among the factors shown to contribute to airway eosinophilia, blood eosinophils came first when performing a multiple logistic regression. There are few studies assessing the ability of blood eosinophils to identify airway eosinophilic inflammation. Previous studies showed that peripheral blood eosinophil count was correlated with bronchoalveolar lavage eosinophil count  and sputount ≥2% . Anotherh et al. . Compareeviously . The fac1/FVC and total serum IgE level. Previous studies have shown that FEV1/FVC, an index of airway narrowing, was correlated to sputum eosinophilia [Other independent factors to be shown associated with prominent sputum eosinophilia are FEVnophilia  and eosinophilia . In our nophilia . From thnophilia . In thisnophilia  and COPDnophilia .The same approach as for eosinophils was used to predict the presence of sputum neutrophils. Despite statistically significant correlation between sputum and percentage blood neutrophils, the strength of the relationship was rather poor. As opposed to what we found with eosinophils, multiple logistic regression analysis demonstrated the inability of blood neutrophils to predict uncontrolled sputum neutrophilic inflammation. The accumulation of airway neutrophils has been reported to be directly associated with the activation state of circulating neutrophils in response to the chemokine Interleukin 8 ,36. BainFrom a multiple logistic regression two factors came out as being independently associated with sputum neutrophilia. In keeping to what was found by Thomas et al. in healthy subjects  and WoodNO, blood eosinophil counts may provide a practical alternative to predict sputum eosinophilia ≥3%. In contrast, sputum neutrophilia is only poorly related to blood neutrophil count.This study shows that eosinophilic and pauci-granulocytic are the most frequent asthma phenotypes in a large unselected asthmatic population. Like FEThe authors declare that they have no competing interests.Conception and design of the study: FS, RL; Data collection: FS, MM, JS, MH, RL; Analysis and interpretation: FS, RL, LS; Drafting the manuscript for important intellectual content: FS, RL, LS. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2466/13/11/prepub


Hypertension, a worldwide public health problem, is a major risk factor for cardiovascular and kidney disease, and the medical and economic burden of hypertension is increasing. Auricular acupuncture has been used to treat various diseases, including hypertension. Several studies have shown that auricular acupuncture treatment decreases blood pressure in patients with hypertension; however, the scientific evidence is still insufficient. Therefore, we aimed to perform a randomised controlled clinical trial in patients with prehypertension and stage 1 hypertension to evaluate the effect and safety of auricular acupuncture.This on-going study is a two parallel arm, assessor-blinded, randomised controlled trial. Sixty participants with prehypertension and stage 1 hypertension will be recruited and randomly allocated into two groups in a 1:1 ratio. Participants in the auricular acupuncture group will receive auricular acupuncture treatment two times per week for 4 weeks. Participants in the usual care group will not receive any acupuncture treatment during the study period. All participants in both groups will be provided with verbal and written educational materials regarding the dietary and physical activity habits for controlling high blood pressure, and they will self-manage their lifestyle, including diet and exercise, during the study. The primary outcome is the 24-h average systolic and diastolic blood pressure, as measured with an ambulatory monitor. The secondary outcomes are the mean change in the average systolic and diastolic blood pressure during day- and night-time, the circadian rhythm of blood pressure, the mean arterial pressure, the change in blood pressure before and after auricular acupuncture treatment, the EuroQOL-5D (EQ-5D), heart rate variability (HRV), body mass index (BMI) and laboratory examination, including lipid profile and high sensitivity C-reactive protein (hs-CRP). Safety will be assessed at every visit.This pilot multicentre randomised controlled trial will explore the feasibility of further auricular acupuncture research and provide important clinical evidence for the effect and safety of auricular acupuncture on blood pressure in patients with prehypertension and stage 1 hypertension compared with usual care.KCT0000169Clinical Research Information Service:  Hypertension, a worldwide public health problem, is a major risk factor for cardiovascular and kidney disease. The prevalence and global burden of the disease are increasing . Stage 1The current treatments for hypertension include several classes of antihypertensive drugs and strategies to modify the effect of adverse lifestyles on blood pressure. Non-pharmacological interventions, including weight loss, reduced sodium intake, regular physical activity, smoking cessation, and the moderation of alcohol intake, are recommended ,3. AntihAcupuncture has been widely used to treat various conditions, including cardiovascular disease and hypertension . The mecIn the present study, we aimed to perform a randomised controlled clinical trial in patients with prehypertension and stage 1 hypertension to evaluate the effect and safety of auricular acupuncture compared with usual care. The 24-h ambulatory blood pressure will be used as the primary endpoint. The results derived from this study will also be used to explore the feasibility of auricular acupuncture treatment and calculate the appropriate sample size for a future large clinical trial.This study is a two parallel arm, assessor-blinded, randomised controlled trial. The trial will be performed at two clinical research centres in Korea in accordance with the Declaration of Helsinki and the Guidelines for Good Clinical Practice: the Korea Institute of Oriental Medicine  and Dongguk University Ilsan Oriental Hospital. This protocol was registered with the ‘Clinical Research Information Service’, Republic of Korea, which is a registry in the WHO Registry Network. Eligible participants will be stratified by centre, age, and sex and randomly allocated into one of the two groups  at a 1:1 allocation ratio and receive treatment for 4 weeks, with 2 months of follow-up  or stage 1 hypertension (SBP of 140–159 mmHg or DBP of 90–99 mmHg) according to JNC 7 criteria; and signed written informed consent. After providing consent, the blood pressure of potential subjects will be measured three times. Patients will be eligible for inclusion in the study if the average of three systolic or diastolic pressure measurements is within the specified intervals.Participants will be excluded if they are experiencing or have a history of the following: currently taking antihypertensive prescription or OTC medication or herb/supplements for controlling blood pressure; secondary hypertension; cerebrovascular or cardiovascular disease history; malignant cancer history; diabetes mellitus requiring medication or insulin injection; disease history, including renal diseases, hepatic diseases, thyroid diseases, active tuberculosis, and other infectious diseases; haemorrhagic diseases or taking anticoagulants; T-needle allergy; local infection at the ear; systemic steroid therapy or immune depressants; medications that may affect blood pressure, such as oral contraceptives, central nervous system depressants or stimulants; pregnant or breast-feeding women or women who plan to become pregnant; the use of traditional Korean medicinal treatment during the last 1 month; or inappropriate for this trial for other reasons, including unwillingness to comply with this study protocol or inability to complete the study-related questionnaires by themselves or with assistance, as decided by researchers.Study participants who meet the eligibility criteria will be randomly assigned to two groups  at the second visit through central randomisation in a 1:1 ratio. Randomisation will be conducted using a computer-generated random allocation sequence through the stratified block randomisation method of the SAS package  by a statistician with no clinical involvement in this trial, and the patients will be stratified by centre, age  and sex.Allocation concealment will be ensured, as the randomisation code will be released after the participants are recruited into the trial and all baseline measures are taken. The subjects and practitioners will be aware of the allocation arm according to the routine care setting. However, the outcome assessors and the statistician performing the data analyses will be masked to the treatment allocation .shen men point (TF4), the superior triangular fossa point (TF1), the heart point (CO15), and the groove of the posterior surface point (PS). Attached T-needles should be maintained for 3–4 days and then removed. In addition, T-needles will be attached on one ear in the first session and the opposite ear in the next session, alternating thereafter.Patients in the auricular acupuncture group will receive auricular acupuncture treatment twice a week for 4 weeks. Auricular acupuncture, which is attached to the skin, will be used for this trial, and Haeng Rim T-needles  will be adopted for intervention. The acupuncture points were selected by an expert committee composed of professors and researchers who specialise in traditional Korean medicine on the basis of a literature review ,22 and aThe auricular acupuncture treatment will be conducted by doctors of Korean medicine who are certified by the Korean Ministry of Health and Welfare with at least 4 years of clinical experience and who have received more than 6 years of oriental medicine college education. They will take a 1-day training course for this trial, and the techniques for auricular acupuncture treatment will be standardised between practitioners. In addition, all study protocols and details, including the recording method for the clinical record form, outcome assessment methods, and monitoring process, will be standardised between the two centres through workshops before the beginning of the study. Additional treatment, including antihypertensive drugs and treatment with traditional Korean medicine, will not be allowed during the trial.Subjects randomised to the usual care group will not be given auricular acupuncture treatment. However, participants in both groups will be provided with verbal and written educational materials regarding dietary and physical activity habits for controlling high blood pressure and self-manage their lifestyle, including diet and exercise, during the study. Additional treatment, including antihypertensive drugs and treatment with traditional Korean medicine, will be prohibited, and any violations will be recorded.The primary outcome measure is the 24-h mean systolic and diastolic blood pressure. The subjects will undergo 24-h ambulatory blood pressure monitoring , and the monitor will be programmed to record blood pressure measurements twice per hour during daytime (7 a.m. to 10 p.m.) and once per hour during night-time (10 p.m. to 7 a.m.). The mean systolic and diastolic blood pressure during the entire 24-h monitoring period will be used in the data analysis.We will assess the mean change in the mean systolic and diastolic blood pressure during daytime and night-time. The participants will be instructed to fill out a diary to record the time of sleeping and rising, and the readings will be divided into daytime and night-time values according to individual wake times and bedtimes. In addition to the mean systolic and diastolic blood pressure, the circadian rhythm of blood pressure and the mean arterial pressure will also be evaluated.The change in blood pressure before and after auricular acupuncture treatment will be assessed. Blood pressure will be observed and recorded at every visit. At every visit, the brachial blood pressure will be measured three times in at least 1-min intervals using an automatic blood pressure monitor  with the subjects resting for at least 5 min in a quiet and temperature-controlled room with their upper arm at heart level. Subjects will be instructed not to drink caffeinated drinks such as coffee or tea and not to exercise, smoke, or eat 2 h before the blood pressure test . The meaThe EuroQOL-5D (EQ-5D) will be used to evaluate health-related quality of life (HRQOL). The EQ-5D questionnaire is the most widely used instrument to measure health status, and it assesses scores across five dimensions of health: mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. Each dimension is divided into three categories: no problems, some problems, and extreme problems. The Korean version of the EQ-5D has been developed, and its validity and reliability have been demonstrated .Heart rate variability (HRV) is a useful non-invasive tool to investigate the sympathetic and parasympathetic function of the autonomic nervous system and cardiac autonomic dysregulation in hypertension. An SA-6000  will be used for studying HRV. The results, including the standard deviation of all of the normal-to-normal intervals (SDNN), the square root of the mean squared differences of successive normal-to-normal intervals (RMSSD), the percentage of successive normal interbeat intervals greater than 50 ms (pNN50), the very low frequency (VLF), low frequency (LF), high frequency (HF), total power (TP), LF/HF ratio, heart rate, and HRV index, will be analysed at baseline and 5 and 13 weeks after baseline. This test will be performed at DongGuk University Ilsan Oriental Hospital only.BMI (body mass index) is the most commonly used indicator of obesity and is determined from height and weight. In this trial, BMI will be assessed at baseline and 5 and 13 weeks after baseline.Laboratory examination will be performed for the lipid profile, hs-CRP, fasting blood glucose, and uric acid. The lipid profile measures total cholesterol, HDL cholesterol, LDL cholesterol, and triglyceride levels. Blood samples will be collected after overnight fasting at baseline and at weeks 5 and 13. An overview of the outcome measurement time points is presented in Table There is a growing body of research evaluating the effect of acupuncture for various diseases, including hypertension. However, there is still a lack of studies evaluating the effect of auricular acupuncture on prehypertension or stage 1 hypertension. There is no previous study on which to base the sample size calculation. The current study is designed as a pilot study to determine initial data for the primary outcome measure to perform a sample size calculation for a large-scale randomised controlled trial. Each group will include 30 participants, which is the minimum sample size for evaluating the effect of auricular acupuncture. More than 80% of all eligible patients can be recruited, and more than 80% of all randomised patients have to complete the scheduled treatments, assessments, and follow-up -31.All analyses will be performed with SAS  by a statistician blinded to the allocation of groups. Statistical analysis will be undertaken on the intent-to-treat (ITT) basis with a 95% confidence interval using multiple imputations. The ITT analysis will include all patients who are randomised , and theAnalysis of covariance (ANCOVA) with the baseline score as a covariate for the whole subject pool will be used to assess differences in treatment outcomes between the two groups at each of these time points as a main analysis. The results for the applicable stratified groups with centre, age, and sex as stratified variables will be assessed as additional analyses. The repeated measures analysis of variance will be performed for the different time point assessments.Any expected or unexpected adverse events will be reported by the participants and practitioners at every visit and followed up to completion. The adverse events known to be related to auricular acupuncture treatment include local bleeding or pain at the needle insertion points, local redness, itching, and dizziness during treatment and the follow-up period . If any This research protocol has been reviewed and approved by the institutional review boards of each trial centre . Written informed consent will be obtained from all study participants prior to enrolment into the study.The initial management of hypertension begins with a diagnosis based on several blood pressure measurements made in the clinic. Ambulatory blood pressure (ABP) is a more accurate measure of BP compared with clinical BP and shows better correlation with cardiovascular outcomes and target organ damage -36. SomeBlood pressure is a surrogate end point, and the relationship between blood pressure and the risk of morbid cardiovascular events is well established ,40. The In addition to appropriate outcome measures, the use of an appropriate control group is a critical issue in designing a high-quality clinical trial. In prehypertension and mild hypertension, lifestyle modification is the first line and an essential step for lowering blood pressure before starting lifelong antihypertensive medication ,4. The pIn conclusion, this pilot multicentre randomised controlled trial will provide important clinical evidence for the effect of auricular acupuncture on blood pressure in patients with prehypertension and stage 1 hypertension compared with usual care.The trial is currently in the recruitment phase, and 54 patients were recruited.SBP: Systolic blood pressure; DBP: Diastolic blood pressure; JNC7: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure; BP: Blood pressure; OTC: Over-the-counter; ABPM: Ambulatory blood pressure monitoring; BMI: Body mass index; EQ-5D: EuroQOL-5D; HRV: Heart rate variability; SDNN: Standard deviation of all of the normal-to-normal intervals; RMSSD: Square root of the mean squared differences of successive normal-to-normal intervals; pNN50: Percentage of successive normal interbeat intervals greater than 50 ms; VLF: Very low frequency; LF: Low frequency; HF: High frequency; TP: Total power; hs-CRP: High-sensitivity C-reactive protein; HDL: High-density lipoprotein; LDL: Low-density lipoprotein; ITT: Intent-to-treat; PP: Per-protocol; ANCOVA: Analysis of covariance; ABP: Ambulatory blood pressure.The authors declare that they have no competing interests.JHK drafted this manuscript. HJJ and THK made a substantial contribution to designing the study protocol. JEK and SL participated in the critical revision of the manuscript. KWK participated in the design of the statistical analysis. SYJ, ARK, HJP, KMS, HJJ and MSS participated in the design of the outcome measurements and assessing the outcomes. SDL and KEH helped to draft the manuscript. SMC had final responsibility for the decision to submit for publication. All of the authors read and approved the final manuscript.


Type 1 diabetes mellitus is a generally accepted atherogenic risk factor. The aim of this prospective longitudinal study was to evaluate changes in carotid intima media thickness (cIMT) in children and adolescents with type 1 diabetes mellitus (T1DM) using standardized methods.We re-evaluated cIMT in 70 (38 f) of initial 150 (80 f) patients with T1DM after 4 years. At re-evaluation, mean (± SD) age was 16.45 ± 2.59 y, mean diabetes duration was 9.2 ± 3.24 y and patients had a mean HbA1c of 8.14 ± 1.06%.Mean cIMT z-scores increased significantly during 4 years  as well as BMI-z-score , systolic blood pressure  and HbA1c . In a linear regression model systolic blood pressure z-score at first measurement  was a significant predictor for the mean effect on cIMT z-score. In a logistic regression model significant risk factors for an increase in IMT of ≥1.5 z-scores were BMI z-scores , diabetes duration  and systolic blood pressure  at first measurement each.Longitudinal cIMT measurements revealed progression in subclinical atherosclerosis during a four year period in diabetic children and adolescents. Systolic blood pressure and BMI were related to cIMT increment. Control of these risk factors by lifestyle and medical intervention may prevent progression of cIMT in diabetic children. Cardiovascular disease as a result of macrovascular atherosclerotic changes is the major cause for mortality among patients with diabetes mellitus . Even ifCommon carotid artery intima-media thickness (cIMT) as measurable by high resolution B-mode ultrasonography is a non-invasive marker of subclinical atherosclerosis . An incrIn the past a cross sectional study in 150 pediatric diabetic patients in our center revealed significantly increased cIMT values . Age at Now we present the results of the 4-years prospective longitudinal cIMT assessment in the entire patient cohort and compared them with data on classical atherogenic risk factors available for the complete study period. We hypothesized that with age and diabetes duration cIMT progression take place.From a total of 150 eligible children and adolescents with type 1 diabetes mellitus included in the first cross sectional study, 70 patients could be enrolled for follow up. The majority of patients not included in this study was now cared for in the adult clinic and invited to take part in the study, but did not show up. To exclude a selection bias we compared the previous group of 150 patients with the remaining 70 patients with special attention to anthropometric and metabolic parameters. Patients enrolled only in the first measurement  had a significantly longer diabetes duration , higher HbA1c  and a lower cIMT z-score .As reported in the first study, the diagnosis of diabetes mellitus was based on the current criteria of the American Diabetes Association. All patients were recruited consecutively during their regular 3-months visits as outpatients at our tertiary health care center . None of the patients had evidence of retinopathy (as determined by dilated fundoscopy), clinical neuropathy or overt nephropathy. Medical records were available for all patients  for the entire follow up period. Pubertal stage was defined according to the criteria published by Tanner et al. . Waist-tst and 2nd cIMT measurement, we calculated an intraobserver variability of 2.5% and 2.1%, respectively. The coefficient of variation between the single measurements was 2.6%. In the 1st measurement, we investigated also a control group (n = 58) to assess the quality of our measurement results and found no significant differences to normal values from the literature. For the calculation of z-scores of cIMT, the sex- and height-dependent normative values from the literature were adopted [As reported previously, the ultrasonographic study was performed with the patient supine for at least 10 minutes in a quiet room at 22 degrees centigrade. For data acquisition, a Philips IE33 was used equipped with a linear 11.0 MHz transducer . All studies were done according to a standardized scanning protocol for the right and left common carotid arteries. The common carotid artery bulb was identified and the segments of the common carotid arteries 1 to 2 cm proximal to the bulb region were scanned. The image was focussed on the posterior - the far - wall. Two angles were used at each side for scanning the common carotid artery IMT: lateral and anterior-oblique [Blood pressure measurement during the regular 3-months-follow-up visits was performed in a quiet room. Blood pressure was obtained using a conventional oscillatory measurement system positioned at the right upper arm . Measurements of blood pressure were performed for each clinic visit (3.2 ± 0.4 visits per year) and averaged for one year. Z-scores were calculated adopting normative values from the literature .Fasting blood samples were taken during the patients` follow up visit. Total cholesterol, high density (HDL) and low density cholesterol (LDL) were measured by standard laboratory methods. Each sample was processed immediately following the patient's visit with a maximum delay of one hour. Serum leptin levels were measured in duplicate by RIA using commercial kits . The limit of sensitivity was 0.5 μg/L, the intraassay CV was 8.2%, and interassay CV was 6.5%. Adiponectin was measured by ELISA . The limit of sensitivity was <0.6 μg/L, the intraassay and interassay CV was < 8.5% and < 5.4%, respectively. The HbA1c level was measured by DCA 2000 ™, based on specific inhibition of latex immunoagglutination . Normal values of HbA1c as established in our laboratory range from 4.0% to 6.0%. Moreover, an average HbA1c was calculated for each patient taking the mean of measurements (3.2 ± 0.4 visits per year) during the previous 12 months before each cIMT measurement.http://cran.r-project.org). Differences within the patient group and at different time points were examined by the non-parametric Mann-Whitney U-test. Statistical significance was defined as p < 0.05, 2-sided. Spearman's rank correlation was used to determine r values. We performed a linear regression analysis to evaluate the associations between mean cIMT z-scores differences between the two measurements (dependent variable) and BMI z-scores, mean HbA1c, diabetes duration, insulin dose, LDL cholesterol, HDL cholesterol and systolic blood pressure (independent variables) at first and second measurement (in separate models). We further performed a logistic regression analysis to identify predictor variables for an increase ≥ 1.5 SD in cIMT of over time. Regression analyses were performed in observations with complete information on the dependent and all independent variables at each measurement (n = 61). In each model, backward variable selection was applied using the Akaike Information Criterion (AIC) (13).Calculations were performed using the statistical package SPSS for Windows  and R 2.12.1  patients could be analyzed. The characteristics of the study group at first cIMT measurement and 4 years later are reported in Table At first cIMT measurement 28 (17 m) patients were prepubertal, 42 (15 m) patients in early puberty corresponding to Tanner stage 2 and 3. Patients proceeded with pubertal development, at second measurement 28 (16 m) patients were in early or mid puberty (Tanner stage 2 or 3), whereas 42 (16 m) patients were late or postpubertal (Tanner stage 4 or 5 ).During the follow up period patients had a significant increase in mean BMI z-score  and mean systolic blood pressure z-score . Regarding the metabolic profile, there was a significant increase in mean HbA1c levels , whereas HDL-cholesterol  and LDL-cholesterol remained stable .nd measurement  . At second measurement, cIMT correlated with the level at 1st measurement: the higher cIMT z-score at first measurement, the higher cIMT-z-score at 2Looking for traditional cardiovascular risk factors we compared normal weight (n = 44) and overweight diabetic patients  at 2nd measurement and found no difference in age, sex distribution, systolic blood pressure or cIMT-z-score. In the group of patients with adiposity  there were more smokers  and a significant difference in terms of systolic blood pressure z-scores  and its increase over time  as well as the number of patients on ACE inhibitor treatment (5/13 vs.5/57). The increase in BMI-z-score in the whole group of patients had no significant influence on cIMT development, but was associated with a higher increase in systolic blood pressure z-score . Leptin and adiponectin had no influence on cIMT development. At second measurement 16 patients (23%) were hypertensive. Within this group 60% were male and 27% were smokers, whereas in the normotensive group were 10% smoker. Patients with hypertension had a significantly higher cIMT z-score .In a multivariable linear regression model for the mean effect on cIMT z-score change HbA1c  and systolic blood pressure z-score at first measurement  remained as significant predictors after backward selection. With respect to variables from second measurement, the only remaining significant predictor for mean cIMT z-score change was systolic blood pressure z-score  (data not shown). In logistic regression models significant risk factors for an increase in cIMT of ≥ 1.5 z-scores were at first measurement BMI z-scores, diabetes duration and systolic blood pressure, while at second measurement only systolic blood pressure was borderline significant (Table In the present study on longitudinal evolution of carotid intima-media-thickness in children and adolescents with type 1 diabetes mellitus over 4 years we observed a significant progression in carotid IMT z-scores. We assume a promoting and accelerating effect of known cardiovascular risk factors on cIMT.Macrovascular disease leading to cardiovascular complications remains the endpoint of type 1 diabetes mellitus in adulthood . In diabIn a previous cross sectional study in children and adolescents with type 1 diabetes, we were able to show that cIMT is elevated in comparison to a healthy control group and to normative data. We proposed longitudinal cIMT measurements to elucidate more details on the individual cardiovascular risk based on the cIMT evolution . SubsequWithin the patient group, we observed an individual increase of cIMT z-scores over 4 years. Thus, not only vascular health, but also vascular aging seems to be affected in diabetic children . In concThe association between cIMT and diabetes duration and age at manifestation was found by us and by other research groups ,21. ConvWithin the study group, patients developed higher BMI z-scores. This is in accordance with other studies on weight and BMI development in children and adolescents with diabetes type 1 . The BMIThe majority of patients showed a cIMT z-score increment during pubertal development. This is in accordance with Wiegman et al. who found a significant deviation in cIMT at the age of 12 years in children with familial hypercholesterolemia compared to unaffected siblings . AdolescSome limitations of our study have to be addressed. An observational study cannot establish causality. Our measurement method differs from some other research groups; but according to the actual recommendations semi automated border detection software is the best solution for cIMT measurement up to date. Also, the normative data adopted were obtained by the same method and protocol . FurtherConcluding, the results of our study indicate that children and adolescents with type 1 diabetes mellitus show increased cIMT values also after a period of 4 years. Patients with increased cIMT at baseline show a further acceleration in cIMT increment indicating that vascular changes continue to evolve throughout puberty and adolescence. In a multivariate logistic regression model systolic blood pressure, diabetes duration and BMI were associated with major cIMT increment. So, we propose to optimize blood pressure levels and BMI development as early as possible in diabetic children to prevent long-term vascular damage. Further studies addressing the effect of interventional programmes on the cIMT are warranted.The authors declare that they have no competing interests.RDP contributed in research design, performance, calculations and writing. AB contributed in research calculations and writing. CT contributed in research performance. CW contributed in research performance. HN contributed in research design and results interpretation. HS contributed in research design and reults interpretation. SB contributed in research design, performance, calculations, results interpretations and writing. All authors read and approved the final version of this manuscript.


The Quality and Outcomes Framework (QOF), a major pay-for-performance programme, was introduced into United Kingdom primary care in April 2004. The impact of this programme on disparities in health care remains unclear. This study examines the following questions: has this pay for performance programme improved the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has this programme reduced disparities in the quality of care between these ethnic groups? Did general practices with different baseline performance respond differently to this programme?Retrospective cohort study of patients registered with family practices in Wandsworth, London during 2007. Segmented regression analysis of interrupted time series was used to take into account the previous time trend. Primary outcome measures were mean systolic and diastolic blood pressure, and cholesterol levels. Our findings suggest that the implementation of QOF resulted in significant short term improvements in blood pressure control. The magnitude of benefit varied between ethnic groups with a statistically significant short term reduction in systolic BP in white and black but not in south Asian patients with hypertension. Disparities in risk factor control were attenuated only on few measures and largely remained intact at the end of the study period.Pay for performance programmes such as the QOF in the UK should set challenging but achievable targets. Specific targets aimed at reducing ethnic disparities in health care may also be needed. The Quality and Outcomes Framework (QOF), a major pay for performance programme, was introduced into United Kingdom (UK) primary care as part of a new General Practitioner (GP) contract in April 2004. The Framework accounts for approximately one-quarter of a general practice's income The QOF aims to improve and standardise the quality of primary care and places considerable emphasis on the secondary prevention of cardiovascular disease. As a result, QOF is also considered to have an impact on health care disparities Previous literature suggests that physicians may respond to financial incentives but there are also other relevant issues such as their intrinsic motivation Data used in this study were extracted from a longitudinal primary care record of 220,743 patients registered with 29 family practices in Wandsworth, south London during 2007. The population of Wandsworth is younger than that of England as a whole, with 74% aged<45 years . Approximately one in five Wandsworth residents (22%) belong to a minority ethnic group. Of these, 8.8% are black (African or Caribbean) and 4.4% are south Asian . Wandsworth also has a higher than average level of income disparity.For the purpose of this study, we examined quality of care in all adult patients (≥18 years) diagnosed with stroke, coronary heart disease or hypertension. Patients registered with practices in 2007 with these conditions were identified using an established method which involves searching both diagnostic and management Read and OXMIS codes This study was approved by the Wandsworth Local Research Ethics Committee. The committee gave approval for the data to be extracted and analysed without individual patient consent because no patient identifiers were included in the dataset and as such it was anonymised.See The primary outcome measures were mean systolic and diastolic blood pressure and total cholesterol. Each indicator was based on last recorded measurement each year in the electronic record. Our main explanatory variable was ethnicity. Information on ethnic background in primary care is collected from patients during registration, or during the consultation process, using the 2001 UK census classification. Due to small numbers in some of the ethnic groups, we grouped patients into three main categories: white, black, and south Asian. Covariates in the analysis included age, gender, socio-economic status and number of comorbid medical conditions. We assigned socioeconomic status to individual patients based on the postcode of their practice using the Index of Multiple Deprivation 2004. The index of Multiple Deprivation is the most commonly used method of measuring neighbourhood socioeconomic status in the UK and is compiled from a variety of sources, including the 2001 UK census, unemployment, and social security benefit records. We identified additional co-morbid conditions using Read codes in the medical record: asthma, diabetes, depression, heart failure, hypertension, atrial fibrillation, chronic obstructive pulmonary disease, adrenal disease.As previous literature suggests some aspects of patients' health care were already improving before the implementation of pay for performance in UK primary care Taking into account the multilevel nature of the data , a mixed effect multilevel model with two random intercepts was adopted. The model Specification is the following:We examined whether the differential effect of QOF for general practices with different baseline performance prior to the implementation of the policy. As some studies have suggested that the differential effect of QOF by practices' with different baseline performance, particularly the worst performers improved at the fastest rate after QOF This study also investigates whether this pay for performance program reduced disparities among patients in different ethnic groups. We compare differences in blood pressure and cholesterol control between ethnic groups before  and after  using analysis of covariance (ANOCOVA). For this model, a linear model was adopted which adjusted for age, gender, deprivation, duration of illness, number of co-morbidities and clustering at practice level.The dataset consists of the historical records (2000–2007) of patients registered with practices in 2007. Some patients might not have complete records throughout each year and we did not capture information on patients with cardiovascular conditions registered with practices during the study period who moved away or died prior to 2007. For example, 71.1% of CHD patients, 61.1% of stroke patients, and 63.8% of hypertension patients have complete record from throughout the study period). To compensate for this, we conducted sensitivity analysis using imputation method and Heckman sample selection model , but not in black and south Asian patients, with CHD before the introduction of QOF. Diastolic blood pressure was decreasing in all three groups before the introduction of QOF. There was no significant level change in systolic or diastolic blood pressure suggesting that the introduction of QOF did not have an immediate beneficial impact on mean blood pressure control. The trend change for systolic blood pressure suggested a significant reduction during the post-QOF period which exceeded the pre-QOF period among south Asian (1.8 mm Hg per year) but not white or black patients. The trend change for diastolic blood pressure suggested a significant increase during the post-QOF period which exceeded the pre-QOF period among south Asian (0.9 mm Hg per year). There was no significant change in white or black patients.The baseline trend suggests that systolic blood pressure was not decreasing in any group before the introduction of QOF. Conversely, diastolic blood pressure was decreasing significantly in all three groups during this period. There was no significant initial level change in systolic blood pressure in any group. The results for initial level change in diastolic blood pressure suggested that south Asian patients experienced a significant immediate increase (4.2 mm Hg) after the introduction of QOF but there no significant changes among white or black patients. The trend change for systolic blood pressure suggested a significant reduction among white patients (1.1 mm Hg per year) but no change in black or south Asian patients. The trend change for diastolic blood pressure suggested a significant increase among south Asian patients (2.0 mm Hg per year) but no change in black or white patients.The baseline trend suggests that systolic blood pressure was decreasing significantly in white (0.9 mm Hg per year) and south Asian (0.6 mm Hg per year) patients but not black patients prior to the introduction of QOF. Diastolic blood pressure was decreasing in all three groups during this period. The level change suggested a significant reduction in systolic and diastolic blood pressure in white and black patients, but not south Asian patients, associated with the introduction of QOF. The trend change suggested that there were sustained reductions in systolic blood pressure in all three ethnic groups in the post-QOF period when compared to the pre-QOF period. The trend change for diastolic blood pressure suggested a significant increase among south Asian patients (0.7 mm Hg per year) but no change in black or white patients.The baseline trend suggests that total cholesterol was decreasing significantly in all ethnic groups before the introduction of QOF. The results for level changes in each ethnic group did not reach statistical significance. The trend change for total cholesterol suggested a significant decrease among black patients (0.1 mmol/L per year) but no change in south Asian or white patients during the post-QOF period.The baseline trend suggests that total cholesterol was decreasing significantly in white patients but not in black or south Asian patients prior to the introduction of QOF. There were no statistically significant reductions in the level or trend change in any ethnic group.Trends in mean blood pressure and cholesterol over the study period in are presented in The results for the effect of QOF on practices with different baseline performance  suggest Disparities in blood pressure and cholesterol control between ethnic groups before QOF (2003) and at the end of the study period (2007) for the three conditions is shown in To address the potential attrition bias of the dataset, we have applied two methods (LOCF and Heckman sample selection model) in the sensitivity analysis. The results in sensitivity analysis are similar to those from our main analysis and suggest that they are robust see  and S2.By using interrupted time series, we were able to take into account the previous time trends in quality improvement and to identify the impact of QOF on disparities in intermediate health outcomes. Previous research has examined the overall effect of QOF The impact of pay for performance on disparities in care is an important concern for designers of these programmes and policy makers Our study has several strengths and limitations. The key strength of this study is that it utilises patient level longitudinal data with near complete coverage of patients in the study area. In addition, this study is also able to adjust for important patient characteristics covariates and look at the effect of QOF on disparities in intermediate health outcomes among different ethnic groups. One of the limitations of the dataset is that it only includes patients registered with practices in 2007 and we lack information on those who died or moved away before this which may cause attrition bias. To address this, we conducted sensitivity analysis under the assumption of both missing at random as well as not at random. These were results are consistent with those from the main analysis which suggests that they are robust.Another limitation of this study is relatively small sample size, particularly for CHD and stroke, meant that some of our results did not achieve statistical significance due to lack of power. The ITS method relies on the assumption of linearity of the time trend. Based on the descriptive statistics and year by year analysis for the outcome measures, it appears that most of the improvement in risk factor control occurs early in the study period which means that our analysis may have underestimated the effect of QOF.Our model did not take autocorrelation in the patient-level into account, instead we adopted a mixed effect model  to adjust to correlation of the error term within practices. Previous studies have highlighted the importance of taking into account of the correlation in the error term within the same practice Previous literature suggests that QOF has had an effect on quality improvement for physicians in general; although there may be little or no effect on physicians already achieving the target before the implementation of the policy. Hence, some general practices can achieve the targets without making any additional efforts in improving quality. Rosenthal et al (2005) Previous studies on the impacts of QOF have generally either used a cross-sectional analysis or used practice level datasets The results of the study suggest there is a significant positive relationship between the implementation of QOF and risk factor control in people with cardiovascular disease in primary care. However, this effect is mainly attributed to the practices with a worse baseline performance subsequently achieving QOF targets. We found some attenuation of disparities but this was not true across all outcome measures and ethnicities studied. Our findings suggest that pay for performance programmes such as the QOF in the UK should set challenging but achievable targets. Specific targets aimed at reducing ethnic disparities in health may also be needed.Appendix Table S1Sensitivity Analysis, results from last observation carried forward method.(DOCX)Click here for additional data file.Appendix Table S2Sensitivity Analysis, results from the Heckman sample selection model.(DOCX)Click here for additional data file.Appendix S1(DOCX)Click here for additional data file.


Variability in blood pressure predicts cardiovascular disease in young- and middle-aged subjects, but relevant data for older individuals are sparse. We analysed data from the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) study of 5804 participants aged 70–82 years with a history of, or risk factors for cardiovascular disease. Visit-to-visit variability in blood pressure (standard deviation) was determined using a minimum of five measurements over 1 year; an inception cohort of 4819 subjects had subsequent in-trial 3 years follow-up; longer-term follow-up (mean 7.1 years) was available for 1808 subjects. Higher systolic blood pressure variability independently predicted long-term follow-up vascular and total mortality . Variability in diastolic blood pressure associated with increased risk for coronary events , heart failure hospitalisation  and vascular  and total mortality , all in long-term follow-up. Pulse pressure variability was associated with increased stroke risk , vascular mortality  and total mortality , all in long-term follow-up. All associations were independent of respective mean blood pressure levels, age, gender, in-trial treatment group (pravastatin or placebo) and prior vascular disease and cardiovascular disease risk factors. Our observations suggest variability in diastolic blood pressure is more strongly associated with vascular or total mortality than is systolic pressure variability in older high-risk subjects. This follow-up was considered ‘short-term’.All in-trial endpoints were assessed by the PROSPER Endpoints Committee, which was blinded to study medication. For this study the in-trial outcomes occurring over a maximum of 3 years (mean 2.3 years), following National Health Service Scotland. The data obtained included the Scottish Morbidity Records (SMR) - SMR00 outpatient attendances; SMR01 general acute inpatient and day case discharges; SMR04 psychiatric admissions, residents and discharges; SMR06 cancer registrations, and General Register Office for Scotland death registrations. The outcomes for the Scottish sub-group were followed up over a maximum of 9.3 years (mean 7.1), following two years of blood pressure observations (with nine blood pressure measurements). This was considered the ‘long-term follow-up’.Routine health data on morbidity and mortality for the Scottish sub-group  were obtained from the Information Services Division, a division of National Services Scotland, part of Baseline summary characteristics are reported as means with standard deviations (SD) for continuous variables and as numbers with percentage (%) for categorical variables. Variability of blood pressure was quantified using the standard deviation (SD) and the coefficient of variation . The results for SD and CV were qualitatively the same; therefore the results for SD are presented. F-tests were used to test the difference in blood pressure variability between participants receiving pravastatin and those receiving placebo. The association of visit-to-visit variability in blood pressure in relation to the different endpoints was assessed separately for short- and long-term follow-up, the latter restricted to the Scottish sub-cohort. For short-term follow-up blood pressure variability was calculated from measurements made at visits 1 to 5 (0–12 months). In the Scottish sub-cohort which, in addition, has longer-term follow-up, blood pressure variability was calculated from measurements made from visit 1 to 9 (0–24 months). Participants who had a CVD event during the blood pressure variability measurement period (0–12 months for short-term follow-up and 0–24 months for long-term follow-up) were excluded from relevant analysis. Participants with one or more missing blood pressure measurements, including those who died during the blood pressure variability measurement period, were excluded from the analyses. The agreement in blood pressure variability was assessed for the short-term inception cohort by analysing the Spearman Rank Correlation between the first three blood pressure measurements and the last two measurements. For the long-term Scottish sub-cohort, agreement in blood pressure variability was assessed by analysing the Spearman Rank Correlation between the first five blood pressure measurements and the last four measurements.The associations between measures of blood pressure variability and time to occurrence of clinical outcomes were assessed using Cox proportional hazards models. Measures of blood pressure variability used were standard deviations and these were split into quarters of their distributions and hazard ratios (HRs) and corresponding 95% confidence intervals were calculated in relation to the lowest quarter of SD (referent); homogeneity across the quartiles was assessed using a general test of heterogeneity.Analyses were adjusted for country , randomized treatment group (pravastatin or placebo) and the respective mean blood pressure measure during the period blood pressure variability was assessed  (Model 1). A second model (Model 2) included additional adjustment for age, gender, smoking status, and prior histories of diabetes, hypertension, cardiovascular disease, cerebrovascular disease or peripheral vascular disease, as well as body mass index (BMI), high density lipoprotein cholesterol (HDL) and low density lipoprotein cholesterol (LDL). The results for Models 1 and 2 were qualitatively the same; therefore the results for Model 2 are presented in the main tables.We performed a number of sensitivity analyses, including using continuous values of the blood pressure variability measurements to evaluate the influence of the splitting the blood pressure variability measurements by quartiles. In this case continuous measures of variability of blood pressure were reported as HRs per 5 mmHg increase in SD of systolic and diastolic blood pressure and pulse pressure. HRs for one SD difference in baseline blood pressure, mean blood pressure and blood pressure variability, for systolic and diastolic blood pressure and pulse pressure were calculated. Further subgroup analyses were conducted for gender, the use of antihypertensive medication at baseline, baseline blood pressure above and below the median and for patients with/without a history of a stroke or transient ischaemic attack.Of the initial cohort of 5804 PROSPER participants, 5054 were alive and had a full blood pressure profile up to 12 months (five measurements); 235 of these participants were excluded from analyses as having had a CVD event during this period, giving 4819 participants as an inception cohort to be included in the short-term  follow-up analyses Figure 1We initially examined whether there was a difference in variability in blood pressure between participants receiving pravastatin and those receiving placebo. There was no significant difference for short-term and long-term follow up, systolic and diastolic blood pressure and pulse pressure ; therefore, data from both groups were combined; however all subsequent analyses were adjusted for randomized treatment group because of the effect of the pravastatin on CVD outcomes.Blood pressure variability was reproducible for short-term and long-term follow up, for systolic and diastolic blood pressure and pulse pressure . The Spearman Rank Correlation was higher when more blood pressure measurements were added in the model.Across the first five blood pressure measurements in the short-term follow-up cohort the mean SD for variability of systolic blood pressure was 13.6 mmHg. The mean SD for variability of systolic blood pressure across the first nine blood pressure measurements in the long-term follow-up cohort was 14.1 mmHg. Across the first five measurements in the whole cohort the mean SD of diastolic blood pressure was 7.3 mmHg. The mean SD of diastolic blood pressure across the first nine measurements in the Scottish sub-cohort was 7.4 mmHg. Variability in diastolic blood pressure was more predictive for coronary events in male participants (p for interaction = 0.008) and for vascular mortality in male participants and participants with systolic blood pressure below median  in long-term follow-up.Across the first five measurements in the whole cohort the mean SD of pulse pressure was 12.2 mmHg. Across the first nine measurements in the Scottish sub-cohort the mean SD of pulse pressure was 12.6 mmHg.One SD difference in variability in systolic and diastolic blood pressure predicted an increased risk of vascular and total mortality, but was not associated with an increased risk of stroke.In the analyses with one SD difference in baseline, mean and variability in blood pressure in the short-term follow-up cohort, one SD difference in variability in diastolic blood pressure predicted an increased risk in coronary events and heart failure hospitalisation , no other associations were found (data not shown).This study shows that in older subjects visit-to-visit variability in systolic blood pressure, diastolic blood pressure and pulse pressure are associated with an increased long-term risk for cardiovascular and total mortality. In addition variability in diastolic blood pressure was predictive of coronary events and heart failure hospitalisation; variability in systolic blood pressure was predictive of heart failure hospitalisations. Variability in pulse pressure (but not diastolic blood pressure or systolic blood pressure) was somewhat associated with long-term stroke risk. These associations were independent of respective mean blood pressure values, the use of antihypertensive medication and other risk factors.The association of intra-individual variability in blood pressure measurements with adverse clinical outcomes was first recognised in the early 1990s The reliability of blood pressure variability increased with the number of measurements included, this is in line with previous research in younger age groups The association between visit-to-visit variability in systolic blood pressure and increased total mortality found in older persons in this present study is generally in line with previous research in younger age-groups et al.In our cohort, variability in pulse pressure was the only measure that was associated with an increased risk of stroke, albeit modestly so; systolic blood pressure variability may be a more powerful predictor of stroke in younger cohorts; Rothwell In previous research, in predominantly younger populations compared to the present study, no associations were present between visit-to-visit variability in diastolic blood pressure and all-cause mortality and CVD The present study reveals some differences in the association between variability in the different blood pressure measurement and outcomes and shows some differences with previous research. One of the major differences between the present study and previous research is the age of the participants. Although the present study was not aimed to investigate etiological mechanisms behind the observed associations, it is tempting to hypothesize that the mechanisms involved in the association between variability in blood pressure and stroke are different in younger and older persons. In previous studies, greater variability in blood pressure was related to older age and pulse pressure This study has a number of strengths. Blood pressure was not part of the inclusion or exclusion criteria for the PROSPER trial. Therefore, people with the full range of baseline blood pressure and variability in blood pressure were included. The estimation of visit-to-visit variability should be reasonably reliable because of the frequency of measurements. The large sample size allowed us to conduct several subgroup analyses and investigating different outcomes. However a limitation of this study is that long-term follow-up was not assessed in the total PROSPER trial population and it was only available for the Scottish sub-cohort. Another potential limitation is that the participants were randomized to an intervention (pravastatin vs. placebo), however, we found no difference in variability in blood pressure between randomized groups and all analyses were adjusted for the randomized treatment. Third, we had no data on the use of antihypertensive medications during the follow-up after the randomized control trial ended. PROSPER was not designed to assess the effect of blood pressure on outcomes and the accuracy of measurement of blood pressure was reduced. By not having the perfect blood pressure measurement we may have underestimated the true effect of variability in blood pressure on clinical outcomes.The present study aimed only to establish whether there is an association between of visit-to-visit variability in blood pressure and adverse CVD outcomes in older patients; however if these associations are causal the results may have implications in the management and treatment of blood pressure in the older population. Besides the aim of lowering the usual level of blood pressure in hypertensive patients, it is possible that additional benefit might be obtained from reducing variability in blood pressure. In a recent meta-analysis it was suggested that the use of calcium channel blockers and non-loop diuretics results in less systolic blood pressure variability than the use of ACE inhibitors and angiotensin 2 receptor antagonists. Calcium channel blockers have shown to reduce visit-to-visit variability compared with placebo In conclusion, in older subjects at risk of CVD events variability in systolic blood pressure is predictive for the risk of heart failure hospitalisations and cardiovascular and total mortality; variability in diastolic blood pressure is predictive for the risk of coronary events, and vascular and total mortality; variability in pulse pressure is predictive of stroke.


Angiotensin receptor blockers (ARBs) are reported to provide direct protection to many organs by controlling inflammation and decreasing oxidant stress in patients without arteriosclerosis. This study aimed to evaluate (1) whether an ARB (candesartan) decreases values for inflammatory parameters in hypertensive patients with type 2 diabetes mellitus of long duration accompanied by arteriosclerosis and (2) whether there any predictors of which patients would receive the benefits of organ protection by candesartan.We administered candesartan therapy (12 mg daily) for 6 months and evaluated whether there was improvement in serum inflammatory parameters high molecular weight adiponectin (HMW-ADN), plasminogen activator inhibitor-1 (PAI-1), highly sensitive C-reactive protein (Hs-CRP), vascular cell adhesion molecule-1 (VCAM-1) in serum and urinary-8-hydroxydeoxyguanosine (U-8-OHdG). We then analyzed the relationship between the degree of lowering of blood pressure and inflammatory factors and the relationship between pulse pressure and inflammatory factors. Finally, we analyzed predictive factors in patients who received the protective benefit of candesartan.After 6 months of treatment, significant improvements from baseline values were observed in all patients in HMW-ADN and PAI-1 but not in Hs-CRP, VCAM-1 and U-8-OHdG. Multilinear regression analysis was performed to determine which factors could best predict changes in HMW-ADN and PAI-1. Changes in blood pressure were not significant predictors of changes in metabolic factors in all patients. We found that the group with baseline pulse pressure <60 mmHg had improved HMW-ADN and PAI-1 values compared with the group with baseline pulse pressure ≥ 60 mmHg. These results suggest that pulse pressure at baseline could be predictive of changes in HMW-ADN and PAI-1.Candesartan improved inflammatory parameters (HMW-ADN and PAI-1) in hypertensive patients with type 2 diabetes mellitus of long duration independent of blood pressure changes. Patients with pulse pressure <60 mmHg might receive protective benefits by candesartan.UMIN000007921 Almost half of type 2 diabetic patients are reported to have hypertension during their lifetime , and theAngiotensin receptor blockers (ARBs) are regarded as first line therapy for hypertensive patients with type 2 diabetes mellitus ,7. In adIn this study, we administered an ARB (candesartan: only sartan which can use for chronic heart failure patients in Japan) to hypertensive patients with type 2 diabetes mellitus and evaluated whether there was improvement in the following inflammatory parameters: high molecular weight adiponectin (HMW-ADN), plasminogen activator inhibitor-1 (PAI-1), highly sensitive C-reactive protein (Hs-CRP), vascular cell adhesion molecule-1 (VCAM-1) and urinary 8-hydroxydeoxyguanosine (U-8-OHdG). We then analyzed the relationship between the degree of lowered blood pressure and values for inflammatory factors and the relationship between pulse pressure and pulse wave velocity (PWV), which are index parameters of arteriosclerosis. Finally, we analyzed predictors of patients who would receive benefit from candesartan by protecting their organs.This was a prospective study. Patients were targeted for enrollment among hypertensive patients with type 2 diabetes mellitus who regularly attended the Jikei University School of Medicine affiliated hospital for treatment. We enrolled 56 patients  who had hypertension  or were taking antihypertensive medicine , SBP, DBP, PWV, HbA1c, fasting plasma glucose (FPG), HMW-ADN, PAI-1, Hs-CRP, VCAM-1 and U-8-OHdG.Before starting the study, all patients underwent an initial screening assessment that included a medical history and physical examination. We evaluated patients at the start of the study to establish baseline values, then again after the 6To evaluate tolerability to candesartan, all adverse events were recorded. All plasmatic parameters were measured after a 12-h overnight fast. In all cases, venous blood samples were taken between 800 and 900 h. We used plasma obtained by the addition of Na2-EDTA (1mgml_1) and centrifuged at 3000 g for 15 min at 4°C. All measurements were performed in a central laboratory.BMI was calculated as weight (kg) divided by the square of height (m). Height and weight were determined using a standard scale . Aortic PWV measurements using the right carotid and right femoral arteries were performed with the patient in a supine position after resting at least 5 min. A Vasera VS-1500A System  device was used at each site. All personnel were trained and certified to take blood pressure measurements from the right arm with a Tyco aneroid sphygmomanometer using American Heart Association standards and to perform the aortic PWV measurements. Blood pressure measurements were obtained from the patients’ right arm while they were in a seated position, using a standard sphygmomanometer  (Korotkoff I and V) with an appropriately sized cuff. Furthermore, the same investigator measured patients’ blood pressure at each visit, always in the morning and after the patient had rested for at least 10 min in a quiet room. Three successive blood pressure readings were obtained at 1-min intervals, and the mean of the three readings was calculated. HbA1c level was measured by a high-performance liquid chromatography method , with intra- and inter-assay coefficients of variation (CsV) of 1%. Plasma glucose was assayed by the glucose-oxidase method  with intra- and inter-assay CsV of 0.8%.Plasma HMW-ADN level was determined using an CLEIA . Plasma VCAM-1 level  was determined using an ELISA . Plasma PAI-1level  were determined using a LPIA . The U-8-OHdG level  was measured using HPLC . Plasma hs-CRP level  was measured using the latex agglutination nephelometry method .Statistical analysis of data was performed using the Statistical Package for Social Sciences software, version 19.0 . The data are presented as the mean±s.e. For all statistical analyses, P<0.05 was considered statistically significant.Fifty-six patients were enrolled in the study and of these 46 completed the study. The reason for premature withdrawal was lost-to-follow-up. The characteristics of the patient population upon entering the study and the antidiabetic agents taken before and during the study are shown in Table Patient data at baseline prior to and after the 6 months of the study Table Significant improvements from baseline values were observed in both SBP and DBP after 6 months  and the urokinase type activator (uPA), often leading to fibrin accumulation in basement membranes and interstitial tissues. Elevated plasma PAI-1 has been demonstrated in various subgroups as an important feature of type 2 diabetes and metabolic syndrome . Plasma Although the mean duration of diabetes mellitus in our study was over 15 years, HMW-ADN and PAI-1 values were reduced after patients received 12 mg candesartan o.d. for 6 months. This result might partially explain the protective effect of candesartan therapy against cardiovascular disease in hypertensive patients with type 2 diabetes mellitus.On the other hand, there is evidence that pulse pressure is an index parameter of arteriosclerosis. Pulse pressure is a marker of arteriosclerosis that can be measured simply. It is correlated with IMT and PWV, and an increase in pulse pressure has been reported to be associated with risk of onset of coronary artery disease ,26. It iWe therefore focused attention on the relationship between changes in inflammatory parameters and changes in pulse pressure. Prior to the study, we divided patients into 2 groups, group A with high pulse pressure (66.0 mmHg ± 0.8) and group B with low pulse pressure (52.0 mmHg ± 0.8), and examined the rates of improvement in blood pressure, HMW-ADN, and PAI-1. In the total patient population, the median pulse pressure was 60.0 mmHg±1.4.Interestingly, a significant improvement in HMW-ADN and PAI-1 was observed in the group with pulse pressure ≧60 mmHg (group A) compared with the group with pulse pressure <60 (group B). Findings were as follows: ⊿SBP: average =−9.20, P value=0.048; ⊿DBP: average =−6.61, P value=0.08; ⊿AND: average = group A 2.3 and group B 0.052 μg/ml, P value=0.005; PAI-1: average =group A −10.1 and group B −0.48 ng/ml, P value =0.012. These results suggest that diabetic patients with comparatively low pulse pressure indicating less advanced arteriosclerosis may receive benefits of improvement in inflammatory parameters such as HMW-ADN and PAI-1 by taking candesartan.Hs-CRP, VCAM-1 and U-8-OHdG values did not change during this study. Also, there were no relationships between blood pressure and pulse pressure changes and Hs-CRP, VCAM-1 and U-8-OHdG.In this study, no improvement in Hs-CRP was observed because of the following reasons. It has been reported that Hs-CRP levels are increased in patients with arteriosclerosis and other diseases that cause blood flow disturbance, and that Hs-CRP can be used as a predictor of cardiovascular events. On the other hand, it has also been reported that Hs-CRP is increased in patients with obesity and diabetes, and could be decreased by certain antidiabetic drugs. The subjects of this study had a long history of diabetes, and drugs were used in most subjects. Indeed, the Hs-CRP levels were likely below detection level in almost half of the subjects before the commencement of the study, and this might contribute to the lack of improvement of Hs-CRP. The reason might be that VACM-1 reflects early vascular endothelial dysfunction, so it increases from the onset of hypertension or diabetes mellitus . The hisAlternatively, candesartan might be less effective in patients with advanced arteriosclerosis with regard to Hs-CRP, VACM-1 and U-8-OHdG. This may be why the ACCRD BP study did not find positive data for type 2 diabetic patients with hypertension from the point of view of inflammatory parameters.It has been reported that ARB could increase adiponectin levels to a greater degree compared with calcium channel blockers and β blockers. By contrast, it has also been reported that ARB would have greater effects on VACM-1, U-8-OHdG, and PAI-1, while protecting organs, compared with calcium channel blockers in preclinical studies of diabetes. However, no difference in usefulness has been shown between the drugs in clinical studies, especially for patients with diabetes.This study has limitations as single group pre-post study, small population, the unbalance between men and women. The results of larger clinical trials evaluating the cardiovascular protective effects including other ARBs are awaited.Candesartan improved plasma HMW-ADN and PAI-1 values but not those of plasma Hs-CRP, VACM-1 and U-8-OHdG in hypertensive patients with type 2 diabetes mellitus of long duration independently of blood pressure changes. Patients whose pulse pressure is under 60 mmHg may receive the benefits of improvement of inflammatory parameters such as HMW-ADN and PAI-1 by administration of candesartan.HMW-ADN: High molecular weight adiponectin; PAI-1: Plasminogen activator inhibitor-1; Hs-CRP: Highly sensitive C-reactive protein; VCAM-1: Vascular cell adhesion molecule-1; U-8-OHdG: Urinary 8-hydroxydeoxyguanosine; ELISA: Enzyme-linked immunosorbent assay; PWV: Pulse pressure and pulse wave velocity; BMI: Body mass index; SBP: Systolic blood pressure; DPB: Diastolic blood pressure; FPG: Fasting plasma glucose; HbA1c: Glycated hemoglobin A1c.The authors declare that they have no competing interests.MS and HS conceptualized the research hypothesis and analyses, researched the data, performed all of the statistical analyses and wrote the manuscript. TH, HI, NS and YK reviewed and edited the manuscript. KT and KU assisted in conceptualizing the research question and reviewed and edited the manuscript. All authors read and approved the final manuscript.


Background. Numbers of drugs are required to manage patients with chronic kidney disease (CKD). Drug adherence is relatively poor in this population. Methods. In 36 CKD patients with hypertension and dyslipidemia, who were prescribing amlodipine 5 mg and atorvastatin 10 mg daily, the influences of exchanging to a combination drug containing equivalent doses of amlodipine and atorvastatin were observed for 6 months. Results. At the baseline, flow-mediateddilation (FMD) was reduced (2.4 ± 0.3%), and proteinuria was significantly contributed to decrements of FMD , and  P < 0.01). Six months later from exchanging to combination drug, total cholesterol  and triglycerides  were decreased, but high density lipoprotein cholesterol  was increased. FMD was slightly albeit significantly improved to 2.7 ± 0.3% (P < 0.05). No serious adverse effects were seen by the combination drug. Subanalysis for the patients with considerable reductions of TC demonstrated that the combination drug decreased proteinuria and high sensitive CRP (P < 0.05 for both). Conclusion. Our data indicate that proteinuria constitutes a determinant of a reduced FMD. The present results implicate that combination drug is useful to improve adherence and suggest that atorvastatin refines endothelium function as well as lipid profiles in CKD patients. Patients with chronic kidney diseases (CKD) are at high cardiovascular risk . AccelerCKD patients frequently manifest dyslipidemia, such as hypercholesterolemia, as well as hypertension. Proteinuria could be linked to an increase in cholesterol, as evident in nephrotic syndrome . To contEndothelial function can be examined by various methods –12, inclThis is a retrospective cohort-based study that utilized medical records from April 2011 to March 2012 on patients who visited our outpatient facility for management of CKD. All patients had consented for use of their clinical data for research purposes. Subjects were 36 CKD patients with hypertension and dyslipidemia who were taking amlodipine 5 mg and atorvastatin 10 mg daily in the morning. From their clinical data, we determined the effects of changing the administration of these two drugs to a combination drug (Caduet) containing equivalent doses of amlodipine and atorvastatin after a 6-month period. In these patients, central blood pressure was estimated by radial artery tonometry, and FMD was measured using echography on the brachial artery. At the time of entry, some patients were also taking other antihypertensives including angiotensin receptor blockers, angiotensin converting enzyme inhibitors, direct renin inhibitor, beta-blockers, alpha-blockers, diuretics, and drugs acting on central nervous system (CNS). We did not exclude such patients, but dosages of the other medications were not changed during observation periods .All of the subjects had switched their once-daily amlodipine and atorvastatin to a combination drug. No washout period was set due to ethical considerations. The office systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured after the patient had rested for at least 5 min between 9 and 11 AM using a mercury sphygmomanometer . Two measurements were done after the patient had been in the sitting position for 5 and 10 min, respectively, and the average of the 2 values was defined as the blood pressure for efficacy analysis. The target blood pressure was ≤130/80 mmHg. Amlodipine was taken once in the morning. If BP was not controlled, the dose of amlodipine would have been titrated, but this was not required. Patients were requested to continue their usual diet and daily activities during the study period. We had only analyzed data for 6 months because a longer study period might have obscured the effects of drug exchange by the alteration of other factors such as diet and daily activities .Exclusion criteria were as follows: a history of recent (<6 months) myocardial infarction, unstable angina, heart failure, and cerebrovascular events; severe hepatic disease; CKD stage 5; and a history of malignancy. The criteria for discontinuing the study were uncontrolled hypertension (>170/110 mmHg), persistent hypotension (SBP < 110 mmHg), doubling of serum creatinine, and the requirement for renal replacement therapy. The study was conducted according to Good Clinical Practice and the Declaration of Helsinki .At the time of exchange, as well as 6 months later, FMD, central and brachial blood pressures, laboratory data including urinary protein, serum creatinine and high sensitive C-reactive protein (CRP) were measured while fasting. The estimated GFR (eGFR) was calculated by using the MDRD equation modified for Japan . Radial t-test was employed for comparisons. Simple or multiple regression analysis was also applied. Statistical significance was defined as  P < 0.05. All analyses were performed with SPSS software .Results are expressed as the mean ± SEM. Student's  Patient data are shown in P < 0.2  in univariate regression as independent variables. Among three blood pressure parameters, SBP was used to reduce multicollinearity with SBP2. As shown in R2 = 0.38,  F = 3.7, df , and P < 0.01).Firstly, univariate regression analysis of FMD was performed using as independent variables various patient data for which we had information in order to explore the factors that contributed to a reduction in FMD . Serum cP < 0.05) increased at 6 months from the change to a combination drug (P < 0.01) and triglycerides  were reduced, whereas high density lipoprotein cholesterol (HDL-C) was elevated (P < 0.05). No serious adverse effects such as rhabdomyolysis or liver dysfunction were observed in those using the combination drug. Indeed, neither high sensitive CRP (to 1.1 ± 0.1 mg/L) nor creatine kinase (149 ± 16 to 152 ± 17 U/L) was altered by the switch in medication.Both systolic and diastolic blood pressures (to 135 ± 2/74 ± 1 mmHg), including central blood pressure (to 122 ± 3 mmHg), and pulse rate (to 74 ± 2 bpm) did not alter during the observation period. Proteinuria (to 0.96 ± 0.11 g/gCr) and serum creatinine (to 1.44 ± 0.08 mg/dL) remained unchanged. However, FMD was slightly, albeit significantly, . Surprisingly, there was a significant correlation between changes in FMD and those of proteinuria , and  P < 0.0001).Since FMD as well as lipids was altered by the use of the combination drug, univariate regression was performed for changes in FMD using changes in lipid parameters as the independent variable. Changes in three lipid parameters correlated with that of FMD . Changesteinuria . Next, mteinuria . The anaP < 0.05) and high sensitive CRP , in addition to the trends similar to the mother data .A subanalysis was performed on 11 patients whose TC was decreased more than 10 mg/dL by the switch to the combination drug because these patients seemed not to adhere to the original medications and because a separate analysis would better characterize the effects of the combination drug. The subanalysis revealed that the switch to a combination drug decreased proteinuria (1.25 ± 0.28 to 1.12 ± 0.24 g/gCr, Clinical trials have demonstrated that antihypertensive drugs improve cardiovascular and renal prognosis in hypertensive and CKD patients , 20. HowChang et al. reported that adherence to both antihypertensive drugs and statins decreased to 50% in the subsequent 3 years in CKD patients . In contThe present data indicated that FMD was prone to be reduced in the CKD patients, suggesting that endothelial NO synthesis is decreased in this population. Prolonged hypertension in CKD elicits endothelial cell damage . There aPrevious findings indicated that atorvastatin reduced proteinuria in nondiabetic CKD patients and that it improved renal function and podocyte injury in diabetic nephropathy , 27. SubAs stated, CKD is characterized by excessive oxidative stress, which induces arterial contraction and remodeling , 16, 25.The present study had several limitations. Because this retrospective study examined data on patients from a single center in one country, there is a potential bias regarding patient selection. Although statistical significance was attained, the sample size was relatively small especially for the subanalysis. Only the active treatment group was examined. Larger randomized controlled studies across a number of countries will be required to draw final conclusions. In addition, oxidized LDL-C was shown to correlate with total LDL-C . ChangesIn summary, the present data provided evidence that the combination drug is safe and effective for CKD patients to improve adherence and lipid profiles. In addition, our results indicate that proteinuria is involved in the reduced endothelial function in CKD. Finally, the present findings suggest that pleotropic actions of atorvastatin including decreasing proteinuria and high sensitive CRP participate in an improvement of FMD by a combination drug in CKD patients.