There is consensus on the importance of early detection and treatment of high blood pressure. Dental care is one of few medical services to which a considerable proportion of the general population comes for regular check-ups. We tested the effects of blood pressure screening in dental care centres with subsequent work-up of subjects screening positive in primary health care (PHCC).® automatic blood pressure reading device. Subjects with systolic blood pressure readings above 160 mmHg or diastolic above 90 mmHg were referred to their PHCC for a check up. Outcome data were obtained by scrutiny of PHCC and hospital patient records for hypertension diagnoses during the three years following screening.Altogether 1,149 subjects 40-65 years old or 20-39 years old with body mass index >25, and with no previously known hypertension, who came for a dental examination had their blood pressure measured with an Omron M4237 (20.6%) subjects screened positive. Of these, 230 (97.1%) came to their PHCC within the 3-year follow-up period, as compared with 695 (76.2%) of those who screened negative (p < 0.0001). Of those who screened positive, 76 (32.1%) received a diagnosis of hypertension, as compared with 26 (2.9%) of those who screened negative. Sensitivity was 79.1%, specificity 84.8% and positive predictive value 30.1%. The number of subjects needed to screen to find one case of hypertension was 18.Co-operation between dental and primary care for blood pressure screening and work-up appears to be an effective way of detecting previously unknown hypertension. Hypertension is a global health problem. It has been estimated that approximately 1.8 million 27%) adults in Sweden may have high blood pressure, according to the World Health Organization criteria [7% adultsen passant when patients seek care for other conditions, a kind of non-systematic opportunistic screening.Many subjects with hypertension are unaware of their condition. Most incidents of hypertension are detected at primary health care, usually In industrialised countries, dental care is usually the only public health care organisation to which healthy people come for regular checkups, usually at least once every second year ,4. PatieThe aim of this cooperative project between the dental and primary healthcare service was to test the efficacy of blood pressure screening in the dental service with subsequent workup in primary care.The overwhelming part of Swedish medical care is run by the counties, which have a similar legislative position as the US states. They are responsible for health care within their area, either by County council operated health care units (at the time of the study the vast majority) or by subcontracted private units. Regarding dental health care the situation is similar, except that approximately half of the units are County council operated and the remaining are private units, subcontracted by the central government. However, all units, whether County council operated or private subcontractor, follow the same regulations.The blood pressure screening study was performed at two County council operated dental clinics located in a small municipality  in the northern part of Gävleborg County, Sweden , approximately 250 kilometres north of Stockholm. The two primary health care centres (PHCC) in the municipality, both County council operated, were partners in the project and were responsible for calibration of the blood pressure reading device used and for blood pressure checkups for patients screening positive.At the two dental clinics, all consecutive patients aged 20-65 scheduled for a regular check up from 15 May 2003 to 20 December 2005 and living within the municipality were invited by letter to participate in the study. The screening procedure was performed at the dental appointment before the dental examination. Participants were asked to state their height and weight and whether they had a known hypertension. Patients who had no known hypertension and who were in the age range 20-39 with a body mass index (BMI) >25 or in the age range 40-65 regardless of BMI were eligible for screening. Of the 1,791 eligible subjects 1,149 (64%) agreed to have their blood pressure measured. The agreement rate was highly age dependent as shown in Figure ®). If the systolic blood pressure reading was above 160 mmHg or the diastolic above 90 mmHg a second reading was taken after the dental examination and the lowest recorded value was used as the screening blood pressure. Data measured at the dental clinics were registered in pre-prepared protocols and entered into the study database. Subjects with screening systolic blood pressure >160 or a diastolic blood pressure >90 were asked for a referral permission . A copy of the dental service protocol was sent as referral document for work up to the subject's PHCC, where an appointment was arranged.Blood pressure was measured in a sitting position, in the left arm, after 5 minutes' rest, with an automatic blood pressure reading device , and for GP and hypertension nurse appointments, diagnoses. The latter were coded according to the International Classification of Diseases  and wereThree outcomes were used in this study. The first was whether the referred subjects actually came to the PHCC for follow up, the second whether blood pressure was measured, and the third whether a hypertension diagnosis was established during the first three years after screening. The presence of a hypertension diagnosis during the three years preceding screening was also sought for an additional check of hypertension status at the time of screening.All participants gave their written informed consent. The study was performed in accordance with the Helsinki Declaration and was approved several times during the data collection process by the Research Ethics Committee at Uppsala University and later by the Regional Research Ethics Board.Data was analysed using the SAS software, version 9.1 . SummaryThe cumulative distribution of first PHCC post-screening follow-up appointment was analysed using Cox's proportional hazards regression, with the first appointment as outcome (dependent) variable and the group variable (screened positive or negative), age and sex as the independent variables. Follow-up time was computed as the number of days from screening until outcome or end of follow up. The subjects were censored at time of death or at end of follow up, whichever came first.The cumulative distribution of receiving a hypertension diagnosis based on PHCC and hospital records among subjects with no such diagnosis at screening was analysed accordingly, with first hypertension diagnosis as outcome and the group variable (screening positively or negatively), age, sex, and screening systolic and diastolic blood pressure as independent variables.The numbers needed to screen (NNS) to find a new case of hypertension, a parallel to numbers needed to treat (NNT) in randomised clinical drug trials, was computed in a similar way to NNT, as the reciprocal of the proportion of new cases found by screening, over and above those who would have been detected in any case . The numSome characteristics of the study population are given in Table The distribution of the screening systolic and diastolic blood pressure is shown in Figure Out of the 1,149 subjects, 115 (10.1%) had screening systolic blood pressure >160 mmHg, and 221 (19.2%) had diastolic blood pressure >90 mmHg, Table During the three years following screening 230 (97.1%) of the 237 subjects referred saw a district nurse or their GP, and had their blood pressure measured. The corresponding numbers among the non-referred was 695 (76.2%), p for difference < 0.0001.Of the referred subjects 84 (35.4%) did not receive diagnosis of hypertension, 77 (32.5%) were subjected to a hypertension work-up but received no hypertension diagnosis, and 76 (32.1%) received a hypertension diagnosis. The corresponding numbers for those not referred were 872 (95.6%), 14 (1.5%), and 26 (2.9%). The difference in work-up result between referred and non-referred subjects was highly significant (p < 0.0001).Of the 76 subjects who received a hypertension diagnosis during follow up, 66 (86.8%) had no previous history of hypertension, two (2.6%) had a previous work up performed but no diagnosis, and eight (10.5%) had a previous diagnosis of hypertension.In Figure The cumulative proportion of subjects who received a diagnosis of hypertension among those who had no diagnosis at screening is shown in Figure Of the 86 previously unknown cases of hypertension found during follow up, 68 screened positive, yielding a sensitivity of 79.1%, Table Among subjects who screened negative, 18 out of 897 (2.0%) received a hypertension diagnosis during follow up, Table In this co-operative study between the dental and primary health care services every fifth patient who came for a regular dental examination and an opportunistic blood pressure screening had systolic blood pressure >160 mmHg or diastolic blood pressure >90 mmHg. Of those who screened positive almost all saw their GP for a blood pressure follow up, and one third received a diagnosis of hypertension within three years of screening. Screening sensitivity was 79%, specificity 85%, positive predictive value 30%, and NNS was 18.® device has been tested against manual blood pressure readings. The variability of the readings appears to be comparable to that for manual readings performed by different observers [The conditions during the blood pressure screening performed in this study were basically the same as in blood pressure screening performed by medical care practitioners. The blood pressure measurement procedure was standardized, with all measurements in the left arm after at least five minutes' rest. It has previously been shown that the blood pressure level falls during the first few minutes of rest but has attained a stable level within five minutes, irrespective of blood pressure level ,9. The Observers .The strengths of this study include the fact that the study was performed as opportunistic screening at the dental care service, the only medical service that sees a considerable proportion of the general public annually or biannually, yielding a large study population at low cost. The co-operation with the primary care services was a prerequisite for a successful work-up of subjects who screened positive. Other strengths include the close monitoring of outcome, i.e., a diagnosis of hypertension in subjects screened during follow up, with an almost 100% complete information.The limitations include scanty clinical information from the GP appointments, such as the hypertension diagnosis criteria. However, we have reason to believe that the GPs were following the national guidelines for diagnosing high blood pressure, based on World Health Organization (WHO) recommendations, or used somewhat higher hypertension criteria . This meIt is well known that screening blood pressures tend to be higher than pressure readings at clinics, which in turn are higher than blood pressures measured at home ,13. ThisIn this case, 70% of subjects who screened positive were false positives in the sense that they did not receive a hypertension diagnosis during the three-year follow up. Using a higher cut-off blood pressure level would have yielded fewer false positives and higher specificity but lower sensitivity. In this study we chose a cut-off level that turned out to be close to the optimum one, as determined in the ROC curve based analysis.The risks associated with high blood pressure in terms of developing various forms of cardiovascular disease are well known and have been summarized in the Fourth Joint European Societies Recommendation on Prevention of Coronary Heart Disease in Clinical Practice guidelines . The genTraditionally blood pressure screening, especially in connection with scientific studies, has been performed by special organisations. However, the participation rate is a moderate 60%-67% and the cost of screening is high . The altThe results of screening carried out at other types of facilities, such as supermarkets ,18 and pEven though the study was performed in Sweden, the results appear to be applicable to all geographical areas with a similar structure of medical and dental services, for instance the Nordic countries and the United Kingdom.In this co-operative project between dental and primary care services the blood pressure screening procedure was efficient. One fifth screened positive, the overwhelming majority of those who screened positive came for follow up, and one third of those who screened positive received a diagnosis of hypertension during the three-year follow up. On average, for every 18 subjects screened one case of hypertension was found. The procedure therefore appears to be an effective way of detecting unknown hypertension.The authors declare that they have no competing interests.SE and KS designed the study. SE was responsible for and supervised the data collection. SE and KS performed the data analyses, and drafted the manuscript. All authors participated in the discussions of the results, provision of reference literature and in the manuscript revisions. All authors have seen and approved the final manuscript version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/194/prepub


An interarm systolic blood pressure (SBP) difference of 10 mmHg or more have been associated with peripheral artery disease and adverse cardiovascular outcomes. We investigated whether an association exists between this difference and ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), and echocardiographic parameters. A total of 1120 patients were included in the study. The bilateral arm blood pressures were measured simultaneously by an ABI-form device. The values of ABI and baPWV were also obtained from the same device. Clinical data, ABI<0.9, baPWV, echocariographic parameters, and an interarm SBP difference ≥10 mmHg were compared and analyzed. We performed two multivariate forward analyses for determining the factors associated with an interarm SBP difference ≥10 mmHg . The ABI<0.9 and high baPWV in model 1 and high LVMI in model 2 were independently associated with an interarm SBP difference ≥10 mmHg. Female, hypertension, and high body mass index were also associated with an interarm SBP difference ≥10 mmHg. Our study demonstrated that ABI<0.9, high baPWV, and high LVMI were independently associated with an interarm SBP difference of 10 mmHg or more. Detection of an interarm SBP difference may provide a simple method of detecting patients at increased risk of atherosclerosis and left ventricular hypertrophy. A blood pressure difference between arms is frequently encountered in various general populations Recently, several studies have reported that a difference in systolic blood pressure (SBP) of 10 mmHg or more was strongly associated with subclavian stenosis , peripheral vascular disease , and pre-existing coronary artery disease  The ABI is a simple, non-invasive, and reliable diagnostic tool for peripheral artery occlusive disease and an ABI<0.9 has been used to identify this condition in both clinical practice and epidemiologic studies Study subjects were randomly included from a group of patients who arranged for echocardiographic examinations at Kaohsiung Municipal Hsiao-Kang Hospital. Patients with significant aortic or mitral valve disease, atrial fibrillation, or inadequate image visualization were excluded. We did not include all patients consecutively because baPWV, ABI, and blood pressures must be measured within 5 min after the completion of an echocardiographic examination. A total of 1120 patients  were included.The study protocol was approved by the institutional review board of the Kaohsiung Medical University Hospital (KMUH-IRB-20120096). Informed consents have been obtained in written form from patients and all clinical investigation was conducted according to the principles expressed in the Declaration of Helsinki. The patients gave consent for the publication of the clinical details.3 – LVIDd3] – 13.6 g 2 in men and more than 110 g/m2 in women, with LVRWT more than 0.45; eccentric LVH was defined as LVMI more than 125 g/m2 in men and more than 110 g/m2 in women, with LVRWT less than 0.45. The left atrial volume was measured by the biplane area–length method The echocardiographic examination was performed by one experienced cardiologist with a VIVID 7 , with the participant respiring quietly in the left decubitus position. The cardiologist was blind to the other data. Two-dimensional and two-dimensionally guided M-mode images were recorded from the standardized views. The Doppler sample volume was placed at the tips of the mitral leaflets to obtain the left ventricular inflow waveforms from the apical 4-chamber view. All sample volumes were positioned with ultrasonic beam alignment to flow. Pulsed tissue Doppler imaging was obtained with the sample volume placed at the lateral corner of the mitral annulus from the apical 4-chamber view. The wall filter settings were adjusted to exclude high-frequency signals and the gain was minimized. The echocardiographic measurements included left ventricular internal diameter in diastole (LVIDd), left ventricular posterior wall thickness in diastole (LVPWTd), interventricular septal wall thickness in diastole (IVSTd), E-wave deceleration time, transmitral E wave velocity (E), transmitral A wave velocity, and early diastolic mitral velocity (Ea). Left ventricular systolic function was assessed by left ventricular ejection fraction (LVEF). Left ventricular mass was calculated using Devereux-modified method, i.e. left ventricular mass = 1.04×[(IVSTd+LVIDd+LVPWTd)The values of ABI and baPWV were measured by using an ABI-form device , which automatically and simultaneously measures blood pressures in both arms and ankles using an oscillometric method To prevent overestimation and observer bias, interarm difference of blood pressure should be assessed simultaneously at both arms with one or two automated devices Demographic and medical data including age, gender, smoking history, and comorbid conditions were obtained from medical records or interviews with patients. Study subjects were defined as having hypertension if their SBP was ≥140 mmHg or DBP ≥90 mmHg, or antihypertensive medications were prescribed irrespective of blood pressure. The body mass index (BMI) was calculated as the ratio of weight in kilograms divided by square of height in meters. Laboratory data were measured from fasting blood samples using an autoanalyzer . Serum creatinine was measured by the compensated Jaffé  method in a Roche/Integra 400 Analyzer  using a calibrator traceable to isotope-dilution mass spectrometry th–75th percentile) for interarm SBP difference and triglyceride. The differences between groups were checked by Chi-square test for categorical variables or by independent t-test for continuous variables. Multiple logistic regression analysis was used to identify the factors associated with an interarm SBP difference ≥10 mmHg. Significant variables in univariate analysis were selected for multivariate analysis. A difference was considered significant if the P value was less than 0.05.Statistical analysis was performed using SPSS 15.0 for windows . Data are expressed as percentages, mean ± standard deviation or median (25P = 0.001), higher baPWV (P = 0.044), higher LVMI (P = 0.032), lower prevalence of non-LVH (P = 0.012), and higher prevalence of concentric LVH (P = 0.018). The mean age of the 1120 patients was 60.8±13.7 years. The prevalence of interarm SBP difference ≥10 mmHg was 7.1%. The differences between patients with and without an interarm SBP difference ≥10 mmHg were shown in Compared to men, women were found to have an older age, less smoking history, lower prevalence of coronary artery disease, lower triglyceride, higher total cholesterol, lower hematocrit, lower baseline eGFR and lower uric acid.P<0.001) and high baPWV  were independently associated with an interarm SBP difference ≥10 mmHg. In the second multivariate analysis , female, hypertension, high BMI, and high LVMI  were independent factors of interarm SBP difference ≥10 mmHg.In the present study, we evaluated the association of ABI<0.9, baPWV, and LVMI with an interarm SBP difference of 10 mmHg or more. We found that ABI<0.9, high baPWV, and high LVMI were independently associated with an interarm SBP difference of 10 mmHg or more. Other factors, such as female, hypertension, and obesity were also associated with an interarm difference in SBP of 10 mmHg or more.In our study, the bilateral arm blood pressure measurements were done simultaneously using an automatic device, which might likely reflect the real interarm SBP difference, since previous studies have been based on non-simultaneous blood pressure measurement by a number of different observers using varied sphygmomanometers A lower ABI is associated with generalized atherosclerosis. There was a significant correlation between ABI and common carotid artery intima-media thickness and the degree of stenosis in the intracranial internal carotid artery and middle cerebral artery One important finding of our study was that there was a significant association between high LVMI and the interarm SBP difference of 10 mmHg or more. This finding implies that LVH may be a possible mechanism contributing to the association between an interarm SBP difference of 10 mmHg or more and adverse cardiovascular outcomes. Besides, our study also showed ABI<0.9 and high baPWV were significantly associated with an interarm SBP difference of 10 mmHg or more. These results suggested that an ABI<0.9 and high baPWV might be related to LVH. Previous studies had reported that a low ABI might be related to the interarm SBP difference and LVH Cardiovascular dysfunction progresses with arterial-cardiac interactions, but the progression of dysfunction differs in speed between the heart and the vessels. In patients with vascular disease, some patients have combined cardiac disease but other patients have only relative pure vascular disease. Hence, patients with vascular disease may not have a higher prevalence of cardiac disease. Left ventricular systolic and diastolic function was mainly determined by cardiac disease such as ischemic heart disease and cardiomyopathy, not mainly by vascular disease. Patients with vascular disease frequently have an increased LVMI Kimura A et al.'s study had shown that the interarm SBP difference was associated with risk factors for atherosclerosis, such as old age, hypertension, hypercholesterolemia, obesity, and low ABI The majority of our patients were treated chronically with antihypertensive medications. For ethical reasons, we did not withdraw these medications. Hence, we could not exclude the influence of antihypertensive agents on our findings. Moreover, the beat-to-beat variation of blood pressures, ABI, and baPWV during atrial fibrillation is very high. Therefore, we excluded patients with atrial fibrillation. Hence, our results could not be applied in atrial fibrillation. In addition, our patients' blood pressures were not measured using a direct intra-arterial method but through an indirect cuff-oscillometric method, and the readings were made in a supine position rather than in the more standard seated position. Finally, since the subjects of this study are already being evaluated for heart disease, it is susceptible to selection bias and making findings potentially less generalized.Previous studies reported a relationship between an interarm SBP difference of 10 mmHg or more and cardiovascular events or death


The aim of this meta-analysis is to compare the changes in hemodynamic parameters among patients with septic shock who have received either of the two agents in their management and try to deduce the superiority of one over the other.A total of 880 articles were identified by a computerized search using MEDLINE, OVID and the Cochrane Central Register of Controlled Trials, of which six randomised controlled studies were included in the study. Observational data, retrospective studies or animal-based studies were excluded. Main outcome measures evaluated were the changes from the baseline in heart rate, mean arterial pressure, oxygen delivery index, oxygen extraction, systemic vascular resistance index (SVRI), cardiac index (CI), central venous pressure, blood lactate levels, urine output, mean pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure, right ventricular ejection fraction (RVEF), arrhythmias and 28-day mortality rates. The statistical analysis was performed using Comprehensive Meta-Analysis software.P = 0.115). In the norpinephrine group, heart rate was significantly lower in comparison with baseline  and so also was the occurrence of arrhythmias . The SVRI, however, was significantly higher in this group . Patients who were on dopamine had significantly better RVEF%  and a lower lactate level . Urine output, oxygen delivery, MPAP and oxygen consumption were not significantly different between the two groups.No significant difference was found in mortality between the two groups (RR = 1.067, CI = 0.984 to 1.157, Patients who received dopamine had a better right ventricular ejection fraction, lower lactate levels, lower systemic vascular resistance index and a trend towards a better cardiac index. However, this group was noted to have more arrhythmias and a higher baseline heart rate versus the norepinephrine group. Overall, there was no difference in the 28-day mortality between the two groups. Although there are certain hemodynamic advantages, we were unable to deduce the superiority of one pressor. The results support the current practice of individualizing the choice of an initial vasopressor based on patient profile.


This study investigated the association between SCORE and the 2007 ESH-ESC blood pressure categories and explored achievements of blood pressure goals considering global risk. In 2001–2005, a random sample of inhabitants aged 30–74 years in southwestern Sweden was invited to a survey of cardiovascular risk factors. The study enrolled 2816 participants (participation rate 76%). Blood pressure was categorized according to the 2007 ESH-ESC guidelines. Global risk of 10-year CVD death was estimated using the Swedish SCORE chart also accounting for additional risk from diabetes (SCORE-DM). SCORE-DM increased in both sexes from optimal blood pressure to manifest hypertension but did not differ between the normal blood pressure categories. However, SCORE-DM became significantly higher among those with temporarily high blood pressure (men 3.3 SD (1.7), women 1.1 (1.8)) and hypertension (3.6 (2.0), 2.0 (2.0)), compared to optimal blood pressure (1.6 (2.9), 0.6 (1.9)). In the presence of both hypertension and diabetes, high-risk subjects dominated , and correspondingly a major proportion of patients with known hypertension were at high risk at a blood pressure ≥160/100 mm Hg. These findings have strong implications on blood pressure evaluation in clinical practice and support the use of SCORE to evaluate global risk. Population studies in Sweden and many other countries show that hypertension is a common condition , which sRecent studies in Skaraborg, Sweden, show a prevalence of manifest hypertension at 20% among both men and women aged 30–75 , 9.The aim was to study the association between SCORE and blood pressure levels according to current European expert guidelines in this Swedish population . In a seThe Vara-Skövde Cohort (VSC) was collected 2001–2005 as a random sample of subjects aged 30–74 years residing in these two small municipalities in southwestern Sweden. Of a total 2816 subjects 1400 were men and 1416 women and the participation rate 76% as described in detail before . −2) was calculated as body weight (kg) divided by body height2 (m2). Fasting venous blood samples were drawn in the morning after an overnight 10 h fast, and a standard oral glucose tolerance test (OGTT) was conducted according to WHO [The participants provided detailed information on medical history and ongoing medication and filled in a validated questionnaire regarding life styles. A standard blood pressure  to the nearest 2 mm Hg was measured twice in a supine position, with one minute in between. The arm was placed in heart level by the support of a special pillow, and the cuff was automatically adjusted to the circumferences of the upper arm using a special device . The meag to WHO . Untreated subjects with a blood pressure of at least at 140/90 mm Hg were seen again at a second visit within 2 weeks, and if still ≥140 and/or 90 mm Hg, they were seen a third time again within 2 weeks. Those with a high blood pressure at the first study visit who had a normal blood pressure  at the second or third visit were considered normotensive. However, for this paper, they were considered to have an unstable blood pressure. Normal blood pressure was defined in accordance with the 2007 ESH-ESC Guidelines  and furtA diagnosis of hypertension was considered when three consecutive high readings with two-week intervals (≥140 systolic and/or ≥90 mm Hg diastolic) were registered , or whenThe score chart of Sweden was used to estimate the 10-year risk of cardiovascular death, accounting for risks based on sex, age, systolic blood pressure, total serum cholesterol, and on current smoking , 5. BaseP < 0.05.SPSS Base System for Windows 19.0 was used for data analyses. All proportions of the study population were age-standardized by five-year age groups using the whole Skövde-Vara population 30–75 years as standard, while means were adjusted for differences in age using general linear model (GLM). GLM was used to compare means between groups in continuous variables, and results were given as differences with 95% confidence intervals (95% CI). Logistic regression was used to estimate associations between categorical variables, and results were presented as odds ratio (OR) with 95% confidence intervals (CI). Confounding was accounted for by multivariate analyses and by stratification. All tests were 2 sided, and statistical significance was assumed if ines is shown in The distribution of blood pressure categories according to the 2007 European guidelCharacteristics of high and low risk subjects, based on SCORE-DM-HIGH, are shown in Traditional CVD risk factors increased in both men and women the higher the blood pressure category. The accumulation of risk factors among subjects with manifest hypertension and unstable blood pressure was confirmed by the global risk score that significantly separated hypertension and unstable blood pressure from all the normal blood pressure categories according the 2007 European guidelines. This pattern was even more pronounced when risk score also accounted for diabetes. Most subjects with manifest hypertension had an estimated 10-year CVD mortality risk <5% and should thus not by routine be prescribed pharmacological treatment.Blood pressure levels that are recommended for therapy by expert guidelines are according to this study accurately decided based on SCORE. However, global risk estimation by SCORE did not identify all subjects with a diagnosis of hypertension and/or diabetes as being at a high risk. Many study subjects with hypertension, especially women, did not reach a SCORE that indicates the need of drug treatment. Instead this study showed that a substantial proportion of men having high SCORE had neither hypertension nor diabetes. The high SCORE risk was mainly attributed to old age if hypertension or diabetes were not present . When boA major strength of this study was the high participation rate, which gives the results a high trustworthiness. It is still likely that individuals with chronic diseases or health problems prior to the study would be more reluctant to participate than healthy people, as often seen in other surveys . NeverthOriginally SCORE did not consider risk from diabetes, but a modified algorithm has been proposed by multiplying the score value by two in men and by four in women, which we accordingly did , 6. ThisWe have found that a large proportion of patients with hypertension had a low risk according to SCORE. This contradicts previous reports suggesting that SCORE overestimates cardiovascular risk . This inThe present findings imply that cardiovascular risk estimation using SCORE is parallel with risk increase according to 2007 ESH-ESC blood pressure categories and general expert treatment guidelines. Our findings may have strong implications on blood pressure evaluation in clinical practice and emphasize the need of nonpharmacological interventions among subjects with high normal blood pressure and low risk hypertension –19. Thes


Introduction. Although alcohol abuse is associated with hypertension in whites and nonwhites, it has been scarcely investigated in HIV-infected patients. Objective. To investigate whether the association of alcohol abuse with hypertension is influenced by skin color in HIV-infected individuals. Methods. Cross-sectional study in HIV-infected individuals aged 18 years or older. Demographic characteristics, lifestyle, and HIV infection were investigated. Alcohol abuse was defined as ≥15 (women) and ≥30 g/alcohol/day (men), and binge drinking by the intake of ≥5 drinks on a single occasion. Hypertension was defined by blood pressure ≥140/90 mmHg or use of blood pressure-lowering agents. Results. We studied 1,240 individuals, with 39.1 ± 10 years, 51% males and 57% whites. Age and body mass index were associated with blood pressure, and there was an independent association of alcohol abuse with hypertension in whites  and nonwhites . Among nonwhite individuals who were alcohol abusers, systolic  and diastolic blood pressures  were higher than in nonabusers. Conclusion. Alcohol abuse is a risk factor for hypertension in white and nonwhite HIV-infected individuals. The association of ethanol consumption with blood pressure is not explained by AIDS-related conditions. Hypertension is a major cardiovascular risk factor worldwide. Projections are that, by the year of 2025, 75.0% (or 1.17 billion people) of the people with hypertension in the world will be living in emerging nations , regardlRisk factors for cardiovascular diseases, including hypertension and dyslipidemia, are determinants of reduced life expectancy in HIV-infected patients . HyperteThe relationship between alcohol consumption and hypertension may be influenced by some characteristics, such as skin color , 22. SkiWe conducted a cross-sectional study including HIV-infected individuals who were being followed up at the Outpatient Clinic of the Care and Therapy Service (SAT), Hospital Sanatório Partenon, State Department of Health of Rio Grande do Sul, Brazil. This clinic and all public health care centers provide medical care, antiretroviral therapy (ART), antihypertensives, and other medications free of charge for HIV-infected patients. We consecutively enrolled female and male patients, aged 18 or older, who were seen between June 2006 and December 2008. Pregnant women, individuals who were unable to provide written consent, or those incarcerated were excluded. Participants who were under the influence of alcohol or drugs at the time of the interview were asked to return for evaluation at another time. 3/mL), viral load (copies per mL of blood), and clinical information were confirmed by medical records. Alcohol consumption was investigated using a validated quantity-frequency questionnaire based on the kind of beverage consumed [Participants were interviewed on the day of the regular medical appointments. Since they had to consult every month, in order to get antiretroviral medication, they were seen often, which contributed to achieving high participation rate. Information was collected, using standardized questionnaires, for the following characteristics: demographic , socioeconomic , and lifestyle characteristics , as well as the use of antiretroviral therapy (ART), and time since diagnosis of HIV infection . Data related to HIV infection as CD4 lymphocyte count  was calculated as the weight (kg) divided by the square of the height (m) and classified as normal (<25.0), overweight (25–29.9), and obesity (≥30.0). Standardized measurements of blood pressure were obtained in duplicate in two visits, using a validated oscillometric device (OMRON CP-705) [Weight (Kg) and height (m) were measured twice with the participants being barefoot and wearing light clothes, using an anthropometric scale . Body mass index  . The ave normal <.0, overwCertified researchers performed the interviews and measured anthropometric parameters and blood pressure. Approximately 5% of the interviews were repeated for quality control. Data were entered twice into the database of Epinfo, version 2000. The study was approved by the Research Ethics Committee of the Hospital de Clínicas de Porto Alegre, which is accredited by the Office of Human Research Protections. All participants signed an informed consent form. Sample Size Calculation and Statistical Analysis. Sample size calculation was based on the estimated prevalence of hypertension between white and nonwhite participants with abusive alcohol consumption  and abstemious drinking (18%), with 80% of power and a significance level of 0.05 (two-tailed). A sample size of 738 white and 398 nonwhite participants with a 1 : 5 ratio for exposed and unexposed participants to excessive alcohol consumption would be required to detect a hazard ratio of at least 1.7. The estimates were based on previous studies [ studies , 29.P values lower than or equal to 0.2 in unadjusted analysis. Age, sex, educational attainment, smoking, physical activity, body mass index, time since HIV infection, and lifetime HAART use were considered confounding factors used in the multivariate models for whites and nonwhites. Partially adjusted models of alcohol consumption with systolic or diastolic blood pressure, including age, sex, and educational attainment, were run in order to better understand the associations and to interpret the risk ratios. A trend for association was determined by P values between 0.05 and 0.1.Characteristics of the sample were expressed as mean and standard deviation. We used Pearson's chi-square test for the analysis of categorical variables and analysis of variance (continuous variables) to assess the association between these factors and the different outcomes. Confounding factors were controlled using the modified Poisson regression (robust variance estimates)  and analOf the 1,295 HIV-infected patients screened, 1,255 were eligible and 1,240 were included. Thus, forty patients had not confirmed eligibility due to age under 18 years, incarceration, or pregnancy; fifteen refused to participate, and two patients were included in a second attempt due to alcohol intoxication at the first visit. Characteristics of the overall sample are presented in Risk factors for hypertension among whites and nonwhites are shown in Systolic and diastolic blood pressure was higher exclusively in nonwhite participants who abused alcohol, independently of confounding factors . SystoliIn this study, we found that the consumption of large amounts of alcohol was independently associated with hypertension in white and nonwhite HIV-infected individuals. Blood pressure, on the other hand, was higher exclusively in nonwhite abusers of ethanol, demonstrated after adjustment for confounding factors. However, even partially adjusted models showed the presence of negative confounding factors. Among, whites there was an association of blood pressure with the frequency of consumption. Taken together, these findings suggest that among nonwhite participants quantity is more important than the pattern of consumption, while for whites the frequency of drinking is more relevant.The association between alcohol abuse and hypertension identified in our study is in agreement with findings from other populations . The assOur study adds a piece of mind in the investigation of the influence of HIV-related characteristics and higher incidence of cardiovascular disease. It has been suggested that the use of HAART may be associated with increasing blood pressure , 35, 36.Some limitations of our study deserve to be mentioned. The cross-sectional design does not allow inferring causality. Data on alcohol consumption were obtained from a standardized questionnaire containing detailed information, but it relies on memory, and because it was applied in the context of medical care, this might have led individuals to underreport consumption. Another aspect to be considered is the fact that blood pressure measurements were performed at the medical consultation, and therefore the possibility of a white coat effect cannot be discarded. Even underreporting alcohol consumption or the white coat effect, the association of alcohol abuse with hypertension has been confirmed by ambulatory monitoring of blood pressure . The proIn conclusion, alcohol abuse is associated with increased risk of hypertension in white and nonwhite HIV-infected individuals. Blood pressure is higher only in nonwhite individuals who abuse alcoholic beverages and in whites who drink weekly. The association of ethanol consumption with blood pressure is not explained by AIDS-related conditions.


This did not approach significance for FEF25-75%, exhaled nitric oxide, lung volumes or airway reactivity. No demographic, asthma control measures, or lung function variables predicted loss of control. Pediatric patients with moderate-to-severe persistent asthma who discontinue LABA therapy have a 37% chance of losing asthma control resulting in augmented maintenance therapies. Recent recommendations of discontinuing LABA therapy as soon as control is achieved should be evaluated in a prospective long-term study.Recent asthma recommendations advocate the use of long-acting beta-agonists (LABAs) in uncontrolled asthma, but also stress the importance of stepping down this therapy once asthma control has been achieved. The objective of this study was to evaluate downtitration of LABA therapy in pediatric patients who are well-controlled on combination-inhaled corticosteroid (ICS)/LABA therapy. Clinical and physiologic outcomes were studied in children with moderate-to-severe persistent asthma after switching from combination (ICS/LABA) to monotherapy with ICS. Of the 54 patients, 34 (63%) were determined to have stable asthma after the switch, with a mean followup of 10.7 weeks. Twenty (37%) had loss of asthma control leading to addition of leukotriene receptor antagonists, increased ICS, or restarting LABA. There were 2 exacerbations requiring treatment with systemic steroids. In patients with loss of control, there was a statistically significant decline in FEV Reportsoutcomes . Despiteoutcomes .While there are data showing that for both pediatric and adult patients whose asthma is not well controlled, the addition of LABA therapy is clinically superior to doubling the inhaled corticosteroid dose or the addition of a leukotriene receptor antagonist , 8; therThis investigator-initiated study was designed to evaluate short-term clinical outcome after the discontinuation of LABA therapy in a population of well-controlled children with asthma.This study included patients with moderate-to-severe persistent asthma on the basis of the criteria recommended by the National Asthma Education and Prevention Program , and an in vitro quantitative assay, use of immunotherapy, or physician-diagnosed allergic rhinosinusitis.Patients were reevaluated after 8 weeks of therapy. Information recorded included symptom control , use of rescue medications including oral steroids, spirometry, lung volumes, exhaled nitric oxide, and ACT scoring. Throughout the study, patients using MDI had to use it with a spacer device with inspiratory flow signal . All patients received education by a respiratory therapist before the start of the study on device technique. Standard spacer technique included slow inhalation with 10 sec breath hold before exhalation and 4–6 regular tidal breaths/activation. All patients understood and adequately reproduced the technique. None of the patients developed hoarseness or oral candidiasis during the study. Patients were instructed to wash and clean their spacer once a week. Atopy was defined by positive allergy skin test or Immunocap Compliance was discussed with each patient on each visit. At each visit, patients were required to give the names and the daily doses of all of their asthma medications, including the inhaled steroids. Patients were also asked about their compliance with each medication, including inhaled steroids, and the information was confirmed with the parents.1 of at least 12% or FEF25–75% of 25%, or a decrease in ACT score to <20. The primary outcome was maintenance of asthma control. Secondary outcomes included the change in FEV1, FEF25–75% or ACT score, and the value of exhaled nitric oxide (eNO).Patients were considered to be uncontrolled if they met one of the following: systemic steroid use due to asthma exacerbation, drop in FEV1 was the highest of three American Thoracic Society- acceptable curves from three separate tests. The prediction equation of Polgar and Promadhat was used to determine predicted values [Lung function was assessed at each clinic visit by spirometry which was performed according to the American Thoracic Society Standardization of Spirometry Guidelines (1995) .The valud values . All evat-test if normally distributed or the Mann Whitney if not normally distributed. The institutional review board approved this retrospective review.All statistical analysis was performed with SPSS, version 19.0.0 (IBM). The Spearman correlation was utilized due to noncontinuous or not normally distributed data. The test used with continuous outcomes between groups was the A summary of select variables pertinent to our analysis is presented in Of those on fluticasone-salmeterol, 4 were started on Mometasone, 3 on Beclomethasone, and 1 on fluticasone. Of those on budesonide-formoterol: 21 were started on Mometasone, 18 on Beclomethasone, and 4 on budesonide. The remaining 3 on Ciclesonide had their formoterol discontinued, remaining on Ciclesonide alone.Patients were followed at 10.7 weeks . Thirty-four (63%) had maintained asthma control based on symptoms and spirometry in accordance with NHLBI guidelines. The remaining 20 (37%) had loss of asthma control. Of these, 8 had a decline in ACT score to <20 with associated spirometric evidence of increased airflow obstruction. Eight patients had a decrease in ACT score alone, including 2 patients that required a 5-day course of oral prednisone due to an asthma exacerbation. The remaining 8 patients had an increase in airflow obstruction without a decrease of ACT to <20. No patients required hospitalization during the followup period. All patients received bronchodilator testing at followup. Only 1 patient in the uncontrolled group had evidence of airway hyperresponsiveness.Of the patients who had uncontrolled asthma at followup, 14 were initially receiving the budesonide-formoterol combination. Of these, 8 had been switched to beclomethasone, 4 to mometasone, and 2 remained on budesonide. Of the 3 patients on fluticasone-salmeterol that were uncontrolled, they were switched to beclomethasone, mometasone and fluticasone. All three of the patients receiving ciclesonide-formoterol and switched to ciclesonide alone had uncontrolled asthma at followup.These findings prompted the restarting of LABA therapy in 18 patients. In the other 2 patients, the ICS was doubled in one due to elevated exhaled nitric oxide and LTRA was started in the other due to known underlying atopy.1/FVC, ratio and unchanged ACT. Likewise, those with a decrease in ACT had unchanged spirometric data and were felt to clinically have either a viral upper respiratory illness or allergic rhinosinusitis. Eleven patients in the controlled group and 7 in the uncontrolled group had lung function and exhaled nitric oxide evaluation at followup. There was no significant difference in exhaled nitric oxide or evidence of hyperinflation. However, the uncontrolled group did have a significantly elevated residual volume over total lung capacity ratio (RV/TLC)  indicating more air trapping in the group off LABA therapy. No group differences were present based on date of study enrollment.A summary of the between-group differences of those maintaining and losing control is provided in Asthma guidelines have advocated step-down therapy once asthma is well controlled ; howeverThis study highlights the challenges faced by clinicians on a daily basis. For patients with uncontrolled asthma, there is evidence regarding the utility of adding LABA therapy. Conversely, there are little data, specifically in pediatric patients, on the discontinuation of LABA therapy. Studies from the early 1990s were the first to illustrate the beneficial effects of adding LABA therapy for patients with uncontrolled asthma , 18. TheThe effectiveness of LABA therapy in the management of asthma has been dampened by safety concerns since the time of their FDA approval. The available data and their interpretation regarding safety implications has been ongoing, culminating in 2010 with the release of specific label changes for LABA and planning for a safety megastudy. The label change included “stop use of LABA, if possible, once asthma control is achieved and maintain use of an asthma-controller medication, such as inhaled corticosteroid” .How best to step off LABA therapy is an open question based on available data. Maintaining LABA while reducing the dose of ICS has been shown to maintain control . ExtendiThis first report of the loss of asthma control in the pediatric setting is limited by the lack of a control or comparison group, randomization, and blinding. These are inherent biases in an observational study evaluating a universal change in a clinical practice. However, each patient in effect acted as his/her own control, since their degree of control was compared to themselves before the clinical change. During this time our patient care goals were to stop LABA therapy entirely, so a comparison group of lower dose ICS/LABA combination was not considered. With the group's normal spirometry one could postulate that our patients were overtreated for their asthma. However, that strengthens the findings since control should have been maintained by the decrease in therapy. We were unable to get lung volume and exhaled nitric oxide measurements on all of the patients at followup as desired. Reasons for this included patients being seen for a sick visit, insurance coverage, or parent preference. Nor are those measurements part of our routine practice, so baseline measurements are not available. However, there was a statistically significant increase in RV/TLC ratio in the group that lost control despite the small patient number. With the dose of ICS being stable one would not expect the eNO to change significantly with the discontinuation of LABA.In a secondary analysis, there was no association of lack of control with race or ethnic group. However, this study was not powered to do so, nor did it include genetic polymorphism analysis. Studies have shown a differential response to asthma therapy based on racial demographic , 25. TheThose eight of our patients who had a significant decline in airflow despite no noticeable worsening of symptoms further reminds us of the role of spirometry in asthma management. The Expert Panel Report 3 (EPR-3) recommends the use of spirometry in the diagnosis and periodic monitoring of patients with asthma . The useThe goals of most asthma guidelines, as well as the recent FDA concerns, can be met in most patients. However, this study adds to the mounting literature of a group of asthmatics who gain better control on LABA therapy and subsequently lose control when it is discontinued. Clearly, LABA therapy is not acceptable as monotherapy, and the use of combination ICS/LABA therapy in one single device precludes this option. If achieving symptomatic and spirometric control is the goal in pediatric asthma, the availability of LABA therapy as an added option appears necessary. Future prospective trials looking at LABA and stratifying risk by race, gender, and phenotypic response will help further to clarify their role.


We examined the relationship between the intima-media thickness of the common carotid artery (CCA-IMT) and arterial stiffness, assessed by pulse wave velocity (PWV), the ambulatory arterial stiffness index (AASI) and the augmentation index (AIx) in subjects with and without type 2 diabetes.A case-series study was made in 366 patients (105 diabetics and 261-non-diabetics). Ambulatory blood pressure monitoring was performed on a day of standard activity with the SpaceLabs 90207 system. AASI was calculated as "1-slope" from the within-person regression of diastolic-on-systolic ambulatory blood pressure readings. PWV and AIx were measured with the SphygmoCor system, and a Sonosite Micromax ultrasound unit was used for automatic measurements of CCA-IMT.PWV, AASI and CCA-IMT were found to be greater in diabetic patients, while no differences in AIx were observed between the two groups. CCA-IMT was independently correlated to the three measures of arterial stiffness in both groups. We found an increase in CCA-IMT of 0.40, 0.24 and 0.36 mm in diabetics, and of 0.48, 0.17 and 0.55 mm in non-diabetics for each unit increase in AASI, AIx and PWV. The variability of CCA-IMT was explained mainly by AASI, AIx and gender in diabetic patients, and by age, gender, AASI and PWV in non-diabetic patients.CCA-IMT showed a positive correlation to PWV, AASI and AIx in subjects with and without type 2 diabetes. However, when adjusting for age, gender and heart rate, the association to PWV was lost in diabetic patients, in the same way as the association to Alx in non-diabetic patients. The present study demonstrates that the three measures taken to assess arterial stiffness in clinical practice are not interchangeable, nor do they behave equally in all subjects. The ultrasound measurement of the intima-media thickness of the common carotid artery (CCA-IMT) has been recognized as a powerful method for identifying subclinical atherosclerosis. CCA-IMT is well-known to be a strong predictor of future vascular events and a surrogate marker of atherosclerosis -3.Arterial stiffness assessed through pulse wave velocity (PWV) ,5 and thIntima-media thickness (IMT) is associated with PWV and AASI in untreated hypertensive patients . The stuThe present study examines the relationship between CCA-IMT and arterial stiffness evaluated by PWV, AASI and AIx in subjects with and without type 2 diabetes.Study design and population: A case-series study was conducted in a primary care setting. Using consecutive sampling, we included 366 patients (105 diabetics and 261 non-diabetics) from a population of 46,000 people corresponding to two primary care centers. The patients were between 30-80 years old, visited their family doctor between January 2.009 and June 2.010, and signed the informed consent to participation in the study. The latter adhered to the principles of the Declaration of Helsinki, and was approved by an independent ethics committee of Salamanca University Hospital (Spain).A detailed description of the measurement techniques can be found elsewhere . ClinicaAmbulatory blood pressure monitoring (ABPM) was performed on a day of standard activity, using a cuff suited to the size of the patient's arm. A SpaceLabs 90207 control system , validated according to the protocol of the British Hypertension Society, was used . The recAASI was calculated as 1 minus the regression slope of diastolic blood pressure (DBP) plotted against systolic blood pressure (SBP) obtained through individual 24-hour blood pressure monitoring . The stiAIx and PWV were estimated using the SphymgoCor System , currently accepted as the gold standard for measuring arterial stiffness. Using the SphygmoCor System , with the patient in the sitting position and resting the arm on a rigid surface, pulse wave analysis was performed with a sensor in the radial artery, using mathematical transformation to estimate the aortic pulse wave. From the morphology of the aortic wave, central (aortic) blood pressure, the pressure increase, and central pressure pulse were estimated. Central AIx was estimated using the following formula: increase in central pressure * 100/pulse pressure. Using the SphygmoCor System (Vx Pulse Wave Velocity), and with the patient in the supine position, the pulse wave of the carotid and femoral arteries was analyzed, estimating the delay with respect to the ECG wave and calculating the PWV. Distance measurements were taken with a measuring tape from the sternal notch to the carotid and femoral arteries at the sensor location . A measuCarotid ultrasound for assessing IMT was performed by two investigators specifically trained to the effect before starting the study. The reliability of the measurements was evaluated before the start of the study using the intraclass correlation coefficient, which showed values of 0.97 for intraobserver agreement on repeated measurements in 20 subjects, and 0.89 for interobserver agreement. A Sonosite Micromax ultrasound device coupled to a 5-10 MHz multifrequency high-resolution linear transducer with Sonocal software was used for performing automatic measurements of IMT in order to optimize reproducibility. Measurements were made of the common carotid after the examination of a 10-mm longitudinal section at a distance of 1 cm from the bifurcation, performing measurements in the anterior or proximal wall, and in the posterior or distal wall in the lateral, anterior and posterior projections, following an axis perpendicular to the artery to discriminate two lines: one for the intima-blood interface and the other to the media-adventitious interface. A total of 6 measurements were obtained of the right carotid and another 6 of the left carotid, using average values (average IMT) and maximum values (maximum IMT) calculated automatically by the software. The measurements were obtained with the subject lying down, with the head extended and slightly turned opposite to the examined carotid, following the recommendations of the Manheim Carotid Intima-Media Thickness Consensus . Mean IMContinuous variables were expressed as the mean ± standard deviation, while frequency distributions were used in application to qualitative variables. The mean difference between two categories of qualitative variables was analyzed with the Student's t-test for independent samples. Pearson's correlation coefficient was used to estimate the relationship between the quantitative variables, while the chi-square test was used to associate the qualitative variables. We performed multiple linear regression analysis by means of the enter method, using CCA-IMT as dependent variable -and parameters such as age, gender , office heart rate, AASI, AIx and PWV as independent variables. In order to obtain a homogeneous measurement scale and facilitate interpretation of the regression analysis, standardized variables were used. The data were analyzed using the SPSS version 17.0 statistical package . A value of P < 0.05 was considered statistically significant.The main clinical characteristics of the patients (105 diabetics and 261 non-diabetics) are reported in Table The existing correlations of PWV, AASI and AIx to patient age, cardiovascular risk factors and the different measures of clinical blood pressure and blood pressure are shown in Table Figure The present study provides the first systematic evaluation of the relationship between CCA-IMT and arterial stiffness in subjects with type 2 diabetes and in non-diabetics. We found that the values of AASI, PWV and CCA-IMT, but not AIx, are higher in diabetic subjects. There is a positive correlation between CCA-IMT and the parameters used to assess arterial stiffness. However, AASI would explain the variability of CCA-IMT in both groups, AIx only in diabetic patients, and PWV in non-diabetic subjects.In the same way as in patients with metabolic syndrome, where according to the CARMELA study  CCA-IMT As in other studies which compare subjects with and without type 2 diabetes , patientIn our univariate analysis AIx was not associated to PWV  in diabetic patients, or to AASI  in non-diabetic patients. Li et al.  reportedThe association between AASI and increased CCA-IMT is an ongoing finding in hypertensive patients ; in thisThe correlation between AIx and CCA-IMT reported by Westerbacka et al.  in diabeIn a recently published study among untreated hypertensive patients, Triantafyllidi  assessedIn a study carried out by Polak et al.  to analyBaumann et al. , in patiThe main limitation of this study is its case series study, which hinders longitudinal analysis between CCA-IMT and AASI, PWV and AIx. Another restriction is the selection of the study population, based on consecutive sampling with pragmatic and broad inclusion criteria. Therefore, in the analyzed population we find diabetic and non-diabetic subjects with different treatment and evolution times. These facts may limit the external validity of the study. However, it must be remembered that the study sample represents the general population seen in primary care centers.CCA-IMT showed a positive correlation to PWV, AASI and AIx in subjects with type 2 diabetes and in non-diabetics. However, on adjusting for gender, age and heart rate, the association with PWV and AIx was lost in diabetic patients and in non-diabetics, respectively. The present study demonstrated that in these patients there is poor agreement between AASI, PWV and AIx, confirming that the three measurements used to assess arterial stiffness in clinical practice are not interchangeable, nor do they behave equally in all subjects.Lastly, we consider that follow-up studies are necessary to establish the relationship between CCA-IMT and each of these three measures, and to determine whether their joint determination offers additional benefits.CCA-IMT: Intima-media thickness of the common carotid artery; PWV: Pulse wave velocity; AASI: Ambulatory arterial stiffness index; AIx: Augmentation index; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; ABPM: Ambulatory blood pressure monitoring; PP: Pulse pressure; SOD: Subclinical organ damage;The authors declare that they have no competing interests.MAGM devised the study, designed the protocol, participated in fund raising, interpretation of results, prepared the manuscript draft and corrected the final version of the manuscript. JIRR and CAC participated in the study design, data collection and manuscript review. MCPA performed all analytical methods, interpretation of results, and manuscript review. ERS, LGS and CMC participated in the study design, interpretation of results, and manuscript review. LGO participated in the protocol design, fund raising, analysis of results, and final review of the manuscript. Finally, all authors reviewed and approved the final version of the manuscript.


In group IV, a placebo was applied (laser device was turned off). The laser therapy at a wavelength of 658 nm appeared to be effective at healing pressure ulcers. The wavelengths of 808 and 940 nm did not have any effect in our study.The aim of the study was to assess the efficacy of laser therapy  for treating pressure ulcers. The primary endpoint in this trial included both the percentage reduction of the ulcer surface area and the percentage of completely healed wounds after one month of therapy . The secondary endpoint was the ulcer healing rate at the follow-up evaluation (3 months after the end of the study). In total, 72 patients with stage II and III pressure ulcers received laser therapy once daily, 5 times per week for 1 month using a (GaAlAs) diode laser with a maximum output power of 50 mW and continuous radiation emission. Three separate wavelengths were used for the laser treatment: 940 nm (group I), 808 nm (group II), and 658 nm (group III). An average dose of 4 J/cm Of the health problems specific to frail older people, pressure ulcers are a major health disorder, and the establishment and spread of an effective treatment method for pressure ulcers are a pressing issue. Pressure ulcers are a common and costly problem in nursing home settings, with prevalence estimates varying widely from 7 to 23% . Care and management can have significant economic consequences. Staff time for ongoing assessment, documentation, and dressing changes and expensive pharmaceuticals drain the available resources. Well-documented, promising, and inexpensive methods from alternative medicine are necessary. Laser therapy has been used to accelerate wound healing since the late 1960s, but its results are still controversial. The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) published an international guideline, “Treatment of pressure ulcers: quick reference guide,” in 2009 [According to the guideline , several forms of energy have been studied for healing pressure ulcers. These include acoustic, mechanical, and kinetic energy, as well as energy from the electromagnetic spectrum (EMS). Infrared  radiation and ultraviolet light (invisible light) are all part of the EMS as is electrical/electromagnetic stimulation. The recommendation for biophysical agents is supported by direct scientific evidence from properly designed and implemented clinical studies on pressure ulcers in humans (or on humans at risk for pressure ulcers), providing statistical results that consistently support the recommendation.One of the proposed physical methods  in this document is laser irradiation, but the guideline stated that there is insufficient evidence from research on pressure ulcers and other chronic types of wound to recommend the use of laser therapy for treating pressure ulcers. An international collaboration has recently been formed between the National Pressure Ulcer Advisory Panel (NPUAP), the European Pressure Ulcer Advisory Panel (EPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA), an alliance formed between the Australian Wound Management Association, New Zealand Wound Care Association, Hong Kong Enterostomal Therapy Association, and Wound Healing Society of Singapore. The intent of the collaboration is to develop a 2014 update of the international guidelines for the prevention and treatment of pressure ulcers, which was initially developed by the NPUAP and EPUAP in 2009. Complete clinical information must be received before creating an updated guideline and to discuss the effectiveness of controversial alternative therapies in wound healing.The aim of this clinical study was to assess the efficacy of laser therapy  for the treatment of pressure ulcers. The primary study endpoints were the percentage change in the ulcer surface area and in the number of completely healed wounds after one month of therapy . The secondary endpoint was the follow-up ulcer healing rates (3 months after the end of the study).The study was performed at the Limf-Med Clinic in Chorzow, Poland, from January 2012 to February 2013. Participating subjects met the following inclusion criteria: (1) presented with a lower extremity pressure ulcer and (2) provided written informed consent to participate in the study. There were no restrictions on gender, race, age, or ulcer duration. Subjects with the following conditions were not allowed to participate or were excluded from the study: (1) clinically detectable infection in the ulcer ; (2) use of drugs, such as corticosteroids, that could interfere with the wound-healing process; (3) use of special dressings, such as hydrocolloids, calcium alginate, activated carbon, or any type of therapeutic procedures different from that used routinely by all groups in the study; (4) nonattendance to the therapeutic program; (5) pregnancy; (6) ankle-brachial pressure index (ABPI) <0.8; (7) diabetes mellitus; (8) systemic sclerosis; (9) cancer diagnosis; and (10) pareses and paralysis caused by injuries to the central or peripheral nervous system. Patients whose pressure ulcers required surgical intervention were also excluded from the study . 2 indicates adipositas. The number of smokers was recorded as well. To determine whether they met the inclusion/exclusion criteria described in the protocol, the recruited participants underwent complex tests  twice within the three months prior to the experiment. The body mass index (BMI) was calculated for all patients. According to international norms, a BMI higher than 30 kg/m Participants were randomly allocated to the groups. Computer-generated random numbers were sealed in sequentially numbered envelopes, and the group allocation was independent of the time and person delivering the treatment. The physician (main coordinator) who allocated the patients to groups had 75 envelopes, each containing a piece of paper marked with either group I, II, III, or IV. The physician would select and open an envelope in the presence of a physiotherapist to see the symbol and would then direct the patient to the corresponding group. A clinical nurse collected the data and coded them into an Excel database. The “blinded” results were transferred to a Statistica version 10.0  database by a technician. The research coordinators had no contact with and could not identify the patients. Subjects from all groups received a routine treatment, including daily simple dressings with sterile gauze after wound cleaning with a 0.9% physiologic solution, use of 1% hydrophilic silver sulfadiazine cream, and an orientation about the use of adapted footwear, self-care, and the prevention of disabilities (the drug therapy was in accordance with the TIME strategy for chronic wound treatment and the EPUAP/NPUAP recommendation from the 2009 reference guide).2. The laser was wired to a cone-shaped applicator (scanner). The laser beam was scanned over the wound surface at a distance of 50 cm from the ulcer surface using a compound movement; the movement frequency was 20 Hz along the ordinate axis and 0.5 Hz along the abscissa axis. The duration of a single procedure was relative to the wound size; the therapy was adjusted to obtain an average dose of 4 J/cm2 cm2 . In group IV, the placebo group, a laser was applied in the same manner, but the device was turned off during the treatment sessions (only the applicator was turned on to scan ulcers using noncoherent red visible light). Subjects from groups I, II and III received laser therapy once daily, 5 times per week for 1 month. The equipment was a Rainbow Drops  gallium-aluminum-arsenide (GaAlAs) diode laser with an output power of 50 mW and continuous radiation emission at separate wavelengths of 940 nm (group I), 808 nm (group II), and 658 nm (group III). The spot size was 0.1 cmThe following research was a single-blind, controlled, and randomized clinical trial. The study design, methodology, and treatment doses were programmed by coordinators . Standard care, infrared camera measurements, and data collection were provided by a nurse. The laser/quasilaser therapy was performed by a physiotherapist. The final statistical analysis was performed by a technician. The ulcer area reduction and the healing rate  were evaluated in this study. The healing rate was calculated as the proportion of the number of healed wounds (number of patients) to the total number of patients in that group. The criterion for complete healing was final epithelization of the skin. The nurse and physiotherapist were jointly responsible for deciding whether ulcers were healed. μm–14 μm sensor) has a thermal sensitivity of 80 mK. The infrared camera was connected to a portable computer through a special interface. All images were stored on the computer for further analysis. Images were analyzed using Guide IrAnalyser V1.4 researcher software . Infrared thermography was used to monitor the arterial hemodynamic effects on each ulcer  infrared camera was used in this study; this uncooled long-wave detector UFPA :SI is the initial total area (cm2) and SF is the final wound total area after one month (cm2). ΔThe laser therapy  in all comparative groups lasted one month. Three months after the therapy, all patients were reviewed . During this time, the participants only received routine treatment, including daily simple dressings with sterile gauze after wound cleaning with a 0.9% physiologic solution and use of 1% hydrophilic silver sulfadiazine cream.χ2) for categorical variables were used. The nonparametric matched pair Wilcoxon test was used to compare the within-group results before and after therapy. The Kruskal-Wallis analysis of variance (post hoc Tukey's test) was used to evaluate differences in the percentage changes between the groups . Two-sided results (P < 0.05) were considered to be statistically significant.To compare the individual parameters that characterized the study groups, the nonparametric Kruskal-Wallis test for countable variables and the chi-squared test . In total, 75 individuals were qualified to participate in the treatment. One patient dropped out from the study during therapy in the placebo group . Two patients from group II (808 nm laser therapy) had complications unrelated to the treatment and were directed to other hospitals (one patient died) before the follow-up observation. One patient in the control group was excluded from the analysis . The body mass of the other participants was within the normal range. The patients were not addicted to either alcohol or drugs; 31 smoked cigarettes (22 in the laser groups and 9 in the placebo). All participants had stage II and stage III pressure ulcers on the EPUAP scale  on theirIn the first group (940 nm), four pressure ulcers occurred as a result of poorly fitting orthopedic aids (one case of wrong orthopedic footwear and three prostheses). In five patients, the ulcers developed after mechanical injuries , and in another five, temporary immobilization and forced positioning of the body due to surgical intervention (unconsciousness) or multiorgan injuries were considered the causative factors. In two patients, pressure ulcers formed beneath a cast, immobilizing splint, or traction device. Two persons had pressure ulcers because of prolonged inward pressure exerted by plates and screws used for internal bone stabilization. In the second group (808 nm), causative factors included immobilization due to postoperative positioning, multiorgan injuries, or being unconscious; poorly fitting prosthetic limbs (three patients) or footwear (one patient); mechanical injury (four); and pressure exerted by plates and screws (two patients) or pressure from a plaster cast (two) or traction device (one). In four patients, pressure ulcers appeared under postoperative dressings. In the third group (658 nm), four pressure ulcers occurred as a result of poorly fitting orthopedic aids (two cases of wrong orthopedic footwear and two prostheses). In four patients, the ulcers developed after mechanical injuries , and in another five, temporary immobilization and forced positioning of the body due to surgical intervention (unconsciousness) or multi-organ injuries were considered the causative factors. In two patients, pressure ulcers formed beneath a cast, immobilizing splint, or traction device. Two persons had pressure ulcers because of prolonged inward pressure exerted by plates and screws used for internal bone stabilization. In the fourth group (placebo), causative factors included immobilization due to postoperative positioning, multi-organ injuries or being unconscious; poorly fitting prosthetic limbs (three patients) or footwear (one patient); mechanical injury (four); and pressure exerted by plates and screws (two patients) or pressure from a plaster cast (one) or traction device (one). In five patients, pressure ulcers appeared under postoperative dressings. The observed groups were homogenous in all participant characteristics . After o The analysis of the changes of the percentage ulcer area also confirmed that laser irradiation at a wavelength of 658 nm is the most efficient for wound healing. The wavelengths of 940 and 808 nm appeared to be much less effective  and wereExamples of healed ulcers from group III are presented in Figures Laser therapy has been suggested to be a promising treatment option for sport injuries , musculon = 47); one group (n = 39) also received laser therapy, five times a week over a period of 6 weeks. The primary outcome measure was the absolute (mm2) and relative (%) wound size reduction at 6 weeks compared with baseline. Secondary outcome measures were the number of patients developing a stage IV ulcer during the study period and the median change in the Norton scores at 6 weeks compared with baseline. The data were analyzed using the intention-to-treat principle and last-observation-carried-forward analyses; the Mann-Whitney U tests showed that the differences between the two groups in terms of absolute improvement (P = 0.23) and relative improvement (P = 0.42) were not significant. During the treatment period, 11% of the patients in the control group and 8% of the patients in the laser therapy group developed a stage IV pressure ulcer (Fisher's exact test: P = 0.72). The patients' Norton scores did not change during the treatment period. For example, Lucas et al.  assessedn = 55; stage 3, n = 8; stage 4, n = 1), were randomized into treatment and control groups. The treatment group received 14 sessions of multi-wavelength light irradiation, with 46 probes of different wavelengths from a gallium-aluminum-arsenide laser source, 3 times a week. The energy used was 4.5 J/cm2. The ulcers in the control group underwent a sham treatment. There was no significant difference in the healing between the treatment and control groups. Eighteen ulcers in the treatment group and 14 in the control group healed completely (P = 0.802). The mean time for the ulcers to heal was 2.45 weeks in the treatment group and 1.78 weeks in the control group (P = 0.330).  Taly et al.  studied 2. The US/UVC regimen consisted of five treatments weekly, alternating the treatment modality daily. The pulsed US was applied at a frequency of 3 MHz and an average spatial-temporal intensity of 0.2 W/cm2 (1 : 4 pulse ratio) for 5 minutes per 5 cm2 of wound area. The UVC dosage (95% emission at 250 nm) was calculated each session according to the wound appearance. The dosage level was E1 for clean/granulating areas, E3 for purulent/slow-granulating areas, E4 for heavily infected areas, and 2E4 for wound debridement. Wounds were traced every 14 days, and surface areas were calculated using the Sigma-Scan Measurement System. The weekly percentage changes in wound area were compared. The results showed that US/UVC treatment had a greater effect on wound healing than did nursing care, either alone or combined with a laser. Using patients with spinal cord injury, Canadian researchers  comparedP = 0.039).  Some clinical reports are promising. For example, Dehlin et al.  includedIn view of the absence of randomized studies with sufficiently large sample sizes, we assessed the efficacy of lasers for treating pressure ulcers. We performed a prospective, single-blinded, and randomized clinical trial to assess the effect of laser therapy as a potential alternative to standard care. We wanted to compare a few common wavelengths in pressure ulcer therapy in a well-prepared and well-planned research program.The results of our study showed that the wavelength of the laser beam is extremely important during the wound-healing process (and perhaps this is one reason for the many controversies). In this trial, we found no evidence that justifies using laser therapy at wavelengths of 940 and 808 nm as an adjuvant to the future consensus pressure ulcer treatment. However, in our opinion the wavelength of 658 nm is interesting, and its use yielded in promising clinical results. We cannot agree with a general statement that laser therapy does not accelerate the healing process because the correct parameter settings  must still be demonstrated in the literature. Researchers still do not know all of the physical processes that occur at the cell or tissue level after laser irradiation. We believe that this study will be helpful in preparing the NPUAP/EPUAP 2014 update of the international guidelines for the prevention and treatment of pressure ulcers.At this moment, we are able to present the results from a small number of patients and a followup longer than three months . In further studies, we would like to compare the obtained results to those using other colors of lasers, especially blue, which is well known in combination with red light to be highly effective at destroying bacteria.in vitro animal and clinical studies are necessary.Laser therapy at a wavelength of 658 nm appeared to be effective for healing pressure ulcers. The wavelengths of 808 and 940 nm did not have any effect in our study. Future


It was believed that this device might improve arterial oxygenation.This prospective, randomized trial was designed to assess whether the i-gel supraglottic airway device is suitable for volume-controlled ventilation while applying positive end-expiratory pressure (PEEP) of 5 cmH2O (PEEP group) after placing an i-gel device. Volume-controlled ventilation at a tidal volume (TV) of 8 ml/kg of ideal body weight, leak volume, and arterial blood gas analysis were investigated.Forty adult patients (aged 20–60 years) scheduled for elective orthopedic surgery were enrolled in this study. Twenty patients were ventilated without external PEEP [zero positive end-expiratory pressure (ZEEP) group], and the other 20 were ventilated with PEEP 5 cmHP = 0.605), as were leak volumes. No significant PaO2 difference was observed between the two groups at 1 h after satisfactory i-gel insertion .The incidences of a significant leak were similar in the ZEEP and PEEP groups (3/20 and 1/20, respectively; 2O did not increase the incidence of a significant air leak, and a PEEP of 5 cmH2O failed to improve arterial oxygenation during controlled ventilation in healthy adult patients.The use of an i-gel during PEEP application at 5 cmH The i-gel  was introduced into clinical practice in 2007. It is made of a thermoplastic elastomer, a soft gel-like substance . This diThe gold standard for airway management remains endotracheal intubation, but in view of the fact that minimizing interruptions to chest compressions, to maximize coronary and cerebral perfusion pressure, is the most important aspect of resuscitation, supraglottic airway devices could be a good substitute for airway management during cardiopulmonary resuscitation. Furthermore, i-gel insertion has been reported to be faster than ProSeal laryngeal mask airway (LMA), tracheal tube, and classic LMA during resuscitation .2O under general anesthesia, and whether this device improves arterial oxygenation.Because most supraglottic airway devices, including i-gel, have a low airway leak pressure, moderate tidal volumes of 6–8 ml/kg have been recommended during positive pressure ventilation . AlthougThis study was approved by our institutional review board, and written informed consent was obtained from all eligible participants.Forty adult patients (aged 20–60 years) of American Society of Anesthesiologists (ASA) physical status I or II scheduled for elective orthopedic surgeries were enrolled in this study.2), a history of cerebrovascular or respiratory disease, neck or upper respiratory tract pathology, potentially difficult intubation, an increased risk of aspiration, and pregnancy. Patients were randomly allocated to one of two groups before the induction of anesthesia using computer-generated random numbers. The members of the ZEEP group were ventilated with no external PEEP application (n = 20), whereas members of the PEEP group were ventilated at a pressure of 5 cmH2O (n = 20) after placing the i-gel.The following exclusion criteria were applied: a morbidly obese status (body mass index >30 kg/m2) waveform and chest movements, as previously reported  and similar to that of the ProSeal LMA [27 ± 7 (10–40) cmH2O]  . Althoug2O under general anesthesia improved gas exchange in children when the ProSeal LMA was used with an inflatable cuff. However, improvements in functional residual capacity do not always correlate with major changes in oxygenation. For example, Futier et al. [2O improved end-expiratory lung volume 15 % but not oxygenation. Although gas exchange is often used to assess lung function during controlled ventilation, it has been reported that oxygenation does not provide a specific measure of nonaerating lung tissue [2O, functional shunt was found to be poorly correlated with the anatomical shunt compartment (r2 = 0.174), which was attributed to a large variability in apparent perfusion ratio [The use of high fraction inspired oxygen during anesthetic induction causes atelectasis to develop within minutes. However, the application of adequate PEEP can prevent atelectasis and provide a higher level of oxygenation . Goldmanr et al.  reportedg tissue , 18. In The present study has several limitations. First, leak pressure was not measured using a manometer; instead, we checked for the absence of any audible throat noise and the proper achievement of tidal volume because we wanted the study to reflect clinical usability. Also, we did not confirm the proper positioning using fiberoptic bronchoscopy. However, we ascertained that ventilation was not compromised in any patient. Second, morbidly obese patients and those with a respiratory problem, an increased risk of aspiration, or pregnant status were excluded, and thus our results cannot be directly applied to patients with reduced respiratory compliance.2O did not increase the incidence of a significant air leak. However, a PEEP of 5 cmH2O failed to improve arterial oxygenation during controlled ventilation with the i-gel device in healthy adult patients.We conclude that the use of an i-gel and the application of PEEP at 5 cmH