The right atrium pressure load is increased in pulmonary stenosis (PS) that is a congenital anomaly and this changes the electrophysiological characteristics of the atria. However, there is not enough data on the issue of P wave dispersion (PWD) in PS.Forty- two patients diagnosed as having valvular PS with echocardiography  and 33 completely healthy individuals as the control group were included in the study. P wave duration, p wave maximum (p max) and p minimum (p min) were calculated from resting electrocariography (ECG) obtained at the rate of 50 mm/sec. P wave dispersion was derived by subtracting p min from p max. The mean pressure gradient (MPG) at the pulmonary valve, structure of the valve and diameters of the right and left atria were measured with echocardiography.  The data from two groups were compared with the Mann-Whitney U test and correlation analysis was performed with the Pearson correlation technique.There wasn’t any statistically significance in the comparison of age, left atrial diameter and p min between two groups.  While the MPG at the pulmonary valve was 43.11 ± 18.8 mmHg in PS patients, it was 8.4 ± 4.5 mmHg in the control group. While p max was 107.1 ± 11.5 in PS group, it was 98.2 ± 5.1 in control group (p=0.01), PWD was 40.4 ± 1.2 in PS group, and 27.2 ± 9.3 in the control group (p=0.01)Moreover, while the diameter of the right atrium in PS group was greater than that of the control group, . We detected a correlation between PWD and pressure gradient in regression analysis.P wave dispersion and p max are increased in PS. While PWD was correlated with the pressure gradient that is the degree of narrowing, it was not correlated with the diameters of the right and left atria. P wave dispersion (PWD) indicates the spreading of the sinus stimulus in the atria. geneity in the depolarisation of the atria and thus causes atrial fibrillation. Stretching of the atria due to pressure and/or volume load, electrolyte imbalance or increase in sympathetic activity are the main causes that increase PWD.  It is recognised that PWD and hence the probability of atrial fibrillation are increased in pathological conditions that increase the left atrial pressure such as mitral stenosis, aortic stenosis and systemic hypertension -3 or in In atrial septal defect or COPD, the right atrial pressure increases, and the right atrium stretches and becomes more enlarged. Thus, the depolarisation duration of the right atrium is prolonged and this causes an increase in PWD. Valvular pulmonary stenosis (PS) results from the fusion of pulmonary cusps in the intrauterine period and constitutes 7% of congenital heart diseases. Pulmonary stenosis which is a relatively rare congenital heart disease causes concentric hyperthrophy of the right ventricle, increase in end-diastolic pressure and increase in right atrial pressure.  This condition can be expected to lead an inrease in PWD. P wave dispersion in PS patients was not defined previously. In this study, we  have investigated PWD in patients with valvular PS.A total of 42 patients with valvular PS diagnosed by echocardiography performed after cardiac examination were admitted into the study. 33 apparently healthy age-matched subjects were included to the study as the control group. Healthy status was documented using physical examination, ECG, chest X-ray and echocardiography. Patients with any acquired or congenital heart disease, valvular disease, pericardial disease, bronchial asthma, COPD or any systemic disease were excluded from the study. All patients provided written consent and the study was  approved by the local Ethics Committee.The left and right ventricles and their valvular structures were assessed in detail using the standart left lateral decubitus position Vingmed system FiVe with 2.5 MHz probe . In the apical four chamber image, the diameter of the right atrium (RAD) and the diameter of the left atrium (LAD) were measured at the level of the annulus of mitral and tricuspid valves in millimeters (mm), respectively defined as the distance from the lateral wall of the right atrium to the interatrial septum, and from the lateral wall of the left atrium to the interatrial septum. The pulmonary valve was structurally assessed in the parasternal short axis image. Then, the mean and peak pressure gradients over the pulmonary valve were obtained using CW Doppler. Valvular pulmonary stenosis was defined as a dysplastic or dismorphic pulmonary valve with a peak systolic pressure gradient (PG) more than 20 mm Hg and a mean pressure gradient more than 10 mm Hg.Twelve-lead surface ECG was obtained from all patients and controls at a paper of 50 mm /s with 1 mV/cm   standardization after resting 5 minutes.  Subjects were allowed to breathe freely but not to speak or cough during recording.  The P wave duration was manually measured by a cardiologist blind to the study, using a magnifying lens. The onset of the P wave was defined as the junction between isoelectric line at the beginning of the P wave deflection and the offset of the P wave and the isoelectric line. The leads with the onset or offset of the P wave not clearly determined were excluded from the analysis. 2 patients whose ECGs not clear enough were also excluded from the study. This method was used in previous studies by different investigators ,9. P maxThe data from the patient and control groups were compared with each other using SPSS 11.0 statistical software package  program. PWD, Pressure gradient, right and left atrium diameters were compared with the Mann-Whitney U test, and the correlation between PWD and the other variables was seeked using the Pearson correlation co-efficient. The data were expressed as mean ± SD. P values under 0.05 were considered  statistically significant.Forty two patients with valvar PS were included in the study; 35 were males, 7 were females  and the mean age was 22.1 ± 4.2 years. The control group was comprised of 33 subjects; 23 were men, 10 were women and the mean age was 23.8 ± 3.1 years. In the PS group, only 5 patients complained of  palpitations, but rare atrial premature beats were detected,  and atrial fibrillation was not observed in any patient. There was not any statistical significance between groups as to the mean ages or heart rate . While the mean pressure gradient at the pulmonary valve was 43.1 ± 18.8   mmHg in the PS group, it was 8.4 ± 4.5 mmHg in the control group (p=0.01). The average right atrium diameter was 38.7 ± 3.9 mm in PS group while it was 30.2 ± 2.5 mm in control group (p=0.02). However, the average left atrium diameter was 32.2 ± 4.1 mm in PS group and 30.2 ± 2.8 mm in control group, and there was no significant difference (p=0.64). According to this, while the right atrium was significantly larger in PS patients, the left atrium diameter was not different from that of the control group .While p max was 107.1 ± 11.5 ms in patients with PS, it was 98.2 ± 5.1 ms in the contol group (p=0.01), and while PWD was 40.4 ± 1.2 ms in PS group, it was 27.2 ± 9.3 ms in the control group (p=0.01). Both p max and PWD values were significantly greater in the PS group. However, p min was similar in both groups (66.1±1.2 ms vs 71.2 ±4.3 msn p>0.05) .In the pulmonary stenosis group, PWD, p max and mean pressure gradient and the right atrium diameter were significantly greater than control group. A correlation analysis of PWD with pressure gradient and right and left atria diameters was performed; while PWD was correlated with pressure gradient , there was no correlation between PWD and the right and left atrium diameters .The main findings of our study are as follows: 1. PWD is increased in pulmonary stenosis. 2. PWD shows correlation with the pressure gradient. 3. PWD is not greatly affected by the right atrial diameter in PS patients. The low AF incidence in PS patients may be attributed to the intervention in this patient group before PWD is further increased.Increased PWD is an electrocardiographic marker that has been associated with the inhomogeneous and discontinuous propagation of sinus impulses. It can be defined as the difference between maximum and minimum p-wave duration. Prolongation of intra-atrial and interatrial conduction time and inhomogenous prolongation of sinus impulses are known electrophsiologic characteristics of atria prone to fibrillation ,10. MoreIt is known that atrial conduction is impaired and PWD is prolonged in haemodialysis patients as a result of intravascular volume load and electrolyte imbalance .  ReductOn the other hand, PWD and the duration of p max are increased also in aortic stenosis and mitral stenosis in which the pressure load in the left atrium is increased. Turhan et al , showed It is observed that p max is prolonged in both the mentioned studies and our study. This is interpreted as an indicator of interatrial conduction impairment independent of the atrium diameter . LikewisGuray et al. showed  that p max and PWD were prolonged in patients with ASD . In thatThe only study related to the right atrium and right cardiac pressure loading is the study by Tukek et al.  on PWD iMorover, PS is relatively rare congenital heart disease, there is not enough information on PWD in PS. That these patients are detected and treated at a young age may be the reason for this lack of information. Considered from this perspective, our study might be interesting also because it is the first of its kind.P wave dispersion and p max are increased in PS which is a congenital heart disease. There is a correlation between the pressure gradient that is the degree of narrowing and PWD. On the other hand, there is no correlation with the right and left atrium diameters. However, we think that studies involving larger patient populations are warranted.


Even patients with well-controlled asthma reported an average of 6 worsenings/year. The mean period from the onset to the peak symptoms of a worsening was 5.1 days. Although most patients recognised the early signs of worsenings, the most common response was to increase short-acting β2-agonist use; inhaled corticosteroids were increased to a lesser extent at the peak of a worsening.Despite being prescribed regular maintenance therapy, 74% of patients used short-acting βPrevious studies of this nature have also reported considerable patient morbidity, but in those studies approximately three-quarters of patients were not receiving regular maintenance therapy and not all had a physician-confirmed diagnosis of asthma. This study shows that patients with asthma receiving regular maintenance therapy still have high levels of inadequately controlled asthma. The study also shows that patients recognise deteriorating asthma control and adjust their medication during episodes of worsening. However, they often adjust treatment in an inappropriate manner, which represents a window of missed opportunity. Even paPatients' own perceptions of how good their level of asthma control was during the week preceding the interview contrasted with the ACQ findings. Of those patients with asthma that was not well controlled according to the ACQ, 87% classed their asthma control during the week preceding the interview as "relatively good"; furthermore, 55% of patients classified as having uncontrolled asthma rated their asthma as being "relatively good".The majority of patients (84%) recognised that they had experienced variation in their asthma during the past year. When asked whether they perceived any signs or warnings that they were about to experience a worsening of asthma, 68% of patients said that they were able to identify such signs. When described, these signs or warnings were found to correspond to asthma symptoms, the most common being "shortness of breath/getting breathless". Of the patients who reported recognising signs of an impending worsening, the mean length of time from the appearance of the first signs to the peak symptoms of the worsening was 5.1 days (range: ≤ 30 minutes to > 2 weeks). The mean length of time from peak symptoms to recovery was 6.2 days.Patients responded to the signs of an impending worsening by increasing their medication. Regardless of the type of maintenance therapy they were prescribed, patients reported using their SABA at the onset of symptoms, with the ICS being increased later and to a lesser extent when symptoms were at their worst Figures  and 3b. Although only 29% of patients stated that their physician had instructed them to step up their maintenance medication in response to worsening asthma, 52% of patients stated that they increased the dose regardless of what they had been advised. Fewer patients underused their maintenance medication when they experienced worsening asthma compared with when they felt well Figure .A total of 2992 patients (88%) stated that they were very or quite confident that they could self-manage their asthma worsenings without physician visits. Many patients (n = 1858 [54%]) were concerned about taking too much medication when they felt well or during periods with no symptoms  survey indicated that only a small proportion of patients achieve guideline targets for asthma control ; howeverAsthma was shown to impact on all aspects of patients' lives. In particular, patients referred to the panic or fear they have when their symptoms increase, emphasising the significant emotional burden of asthma. Asthma's interference with daily activities was reported by most patients to be the worst part of having the disease. These restrictions imposed by asthma demonstrate the extent to which poor control affects patients' health-related quality of life.There was a discrepancy between the level of asthma control demonstrated by the ACQ questionnaire and patients' perceived level of control. These data show that even patients prescribed maintenance medication and with recent physician contact tend to underestimate their asthma symptoms and tolerate suboptimal control. This situation may reflect a lack of information from PCPs and nurses and a lack of regular contact with medical professionals . AlternaMost patients reported experiencing early warning signs – symptoms such as breathlessness – before periods of worsening asthma. The mean period from the occurrence of these early signs to the peak of a worsening was approximately 5 days and was followed by a recovery period of similar length. This time period from the onset of initial symptoms to an exacerbation, or worsening, is in line with observations from the FACET study. Tattersfield and co-workers  showed tOur data demonstrate that patients try to intervene early in response to signs of an impending worsening by increasing their intake of medication, and fewer patients underused their maintenance medication during such periods. However, the current study highlights a missed opportunity, as patients tended to adjust their therapy in a suboptimal manner – increasing their intake of SABA when symptoms first appear, but only increasing their ICS dose when symptoms had continued to worsen, at the peak of an asthma attack. Despite controversy regarding the benefit of increasing the dose of ICS when asthma deteriorates ,19, an eDuring periods of worsening asthma, treatment regimens whereby patients increase their ICS/LABA maintenance dose in line with a self-management plan have been demonstrated to improve asthma control compared with fixed-dose combination therapy plus SABA ,26. A suThe study recruited patients who had recently visited their physician's clinic, either for consultation or to receive a prescription. This inclusion criterion potentially excluded patients with poor access to medical care – often associated with lower socioeconomic status and increased disease morbidity . As a reThe majority of patients with asthma receiving maintenance therapy who had had recent contact with their physician were found to have poor asthma control. Regardless of the availability of effective medication, patients' asthma continues to have a large impact on their health and health-related quality of life. This study has shown that patients recognise deteriorating asthma control and are willing to self-treat episodes of worsening. However, patients often adjust their medication in an inappropriate manner, which represents a window of missed opportunity. These findings demonstrate the need for a patient-centred approach to asthma management in which patients are educated to adjust their medication in a more appropriate manner. This approach, combined with a written personal action plan, has the potential to improve asthma control.MRP has received honoraria for lectures, educational activities and ad hoc consultancies from AstraZeneca, Vitaris, GSK and Novartis and research funding from the AstraZeneca Foundation. TvdM has received research grants from AstraZeneca, GSK and Altana, speakers' fees from AstraZeneca, GSK, Altana and MSD, and has participated in advisory boards for Altana, AstraZeneca and Boehringer Ingelheim. SEM received funding for travel to the 2005 European Respiratory Society congress, and honoraria from AstraZeneca for participating in a steering committee and for speaking at a press conference. WWB has received research funds from AstraZeneca, Dynavax, GlaxoSmithKline, Merck and sanofi-aventis. WWB has served on advisory boards for AstraZeneca, Merck, Pfizer and sanofi-aventis, has been a consultant to Dynavax, Schering, Merck and Wyeth, and a member of a steering committee for GlaxoSmithKline.All authors formed the INSPIRE steering committee and were involved in developing the questionnaire. M. R. Partridge contributed to the conception and design of the study, the analysis and interpretation of the data, and the drafting of the paper. T. van der Molen, S.E. Myrseth and W. W. Busse contributed to the design of the study and to revising the paper critically. All authors made final decisions on all aspects of the article and hence are in agreement with, and approve, the final version of the submitted article.The pre-publication history for this paper can be accessed here:


The aim of this study was to determine if hypertensive type 2 diabetic patients, when compared to patients with essential hypertension have an increased left ventricular mass index (LVMI) and a worse diastolic function, and if this fact would be related to 24-h pressoric levels changes.Ninety-one hypertensive patients with type 2 diabetes mellitus (DM) (group-1 [G1]), 59 essential hypertensive patients (group-2 [G2]) and 26 healthy controls (group-3 [G3]) were submitted to 24-h Ambulatory Blood Pressure Monitoring (ABPM) and echocardiography (ECHO) with Doppler. We calculated an average of fasting blood glucose (AFBG) values of G1 from the previous 4.2 years and a glycemic control index (GCI) .2; P < 0.05, respectively). In G1, LVMI correlated with NSBP  and GCI  while NSBP correlated with GCI  and AFBG . When G1 was divided in tertiles according to NSBP, the subgroup with NSBP≥140 mmHg showed a higher risk of LVH. Diabetics with NSBP≥140 mmHg and AFBG>165 mg/dl showed an additional risk of LVH . In multivariate regression, both GCI and NSBP were independent predictors of LVMI in G1.G1 and G2 did not differ on average of diurnal systolic and diastolic BP. However, G1 presented worse diastolic function and a higher average of nocturnal systolic BP (NSBP) and LVMI (NSBP = 132 ± 18 vs 124 ± 14 mmHg; P < 0.05 and LVMI = 103 ± 27 vs 89 ± 17 g/mThis study suggests that hyperglycemia and higher NSBP levels should be responsible for an increased prevalence of LVH in hypertensive patients with Type 2 DM. Clinical, epidemiologic and pathological data support the occurrence of a specific cardiomyopathy related to diabetes mellitus (DM) -3. HowevIn 1992, Grossman et al , showed The purpose of this study was to determine if hypertensive type 2 diabetic patients, when compared to patients with essential hypertension have an increased LVMI and a worse diastolic function, and if this fact would be related to 24-h pressoric levels changes.A total of 176 subjects recruited from our Hypertension Clinic during one year period were enrolled in this study. The 91 (64 women and 27 men) hypertensive patients with type 2 DM (group-1 [G1]), the 59 (46 women and 13 men) nondiabetic hypertensive patients (group-2 [G2]) and the 26 healthy control subjects (group-3 [G3]) were submitted to 24-h ABPM and to ECHO with Doppler to evaluate LVMI and diastolic function. ABPM was done after a 15 days washout of all antihypertensive drugs in order to evaluate patient's real blood pressure and minimize the effect of BP variations during the long period of cardiac hypertrophy development. Ten patients of G1 couldn't have their LVMI measured because of technical problems (narrow window: obesity); the other 81 remainders were divided in 3 subgroups (tertiles) based on their NSBP to stablish the prevalence of LVH. G1 had the following parameters calculated: the average of fasting blood glucose (AFBG) values and the glycemic control index (GCI).All patients had normal levels of serum creatinine and only two had abnormal 24-h urinary protein excretion (>150 mg/24h). Patients with clinical or echocardiographic evidence of ischemic or valvular heart disease were not included in this study, nor were those with congestive heart failure, alcoholism or secondary or severe hypertension. Criteria for established hypertension were systolic and diastolic blood pressure≥140/90 mmHg on repeated measurements . Diabete2 in men and ≥110 g/m2 in women [M-mode, two-dimensional echocardiographic and cardiac Doppler studies were performed using a commercially available echo-Doppler unit  equipped with a 2.5-MHz mechanical transducer. It was performed with patients in the partial left lateral supine position. M-mode measurements were performed acording to the recommendations of the American Society of Echocardiography . Left vein women ,14. All in women ,16. All The 24-hour ABPM recording was performed using a SpaceLabs – 90207 automatic cuff-oscillometric device  after 15 days washout of all antihypertensive drugs. Patients should keep their habitual routine and present a report with the activities done. Systolic and diastolic BP and heart rate were recorded at 15-minutes intervals during daytime and nighttime periods. Daytime period included all activities done from 8am to 8pm and the 8pm to 8am period was considered nighttime. After this, the average of systolic and diastolic BP was calculated for each hour, for daytime, nighttime and for the 24-hour period. The exam was considered reliable when at least 75% of the measurements were successfully executed. Moreover, it was calculated the nocturnal BP decrease . It was considered normal values of nocturnal BP decrease greater than 10% (dippers) and patients that showed BP decrease lower than this value were called "nondippers". We used the absolute values of NSBP instead of nocturnal BP fall to divide the subgroups in tertiles because the first variable has a minor coefficient of variation (data not published).To create a measure of the previous long-term glycemic control, the average of all fasting blood glucose (AFBG) values available before the study was calculated . A total of 1014 FBG were evaluated. If several FBG were recorded during a month, only the first value of the month was used. These FBG values were also used to calculate the glycemic control index (GCI) .t test was used for comparison between two groups. Fisher's exact or chi-squared tests for trend have been used to compare categorical data. For correlation analysis, correlation coefficients (Pearson or Spearman) were calculated. For regression analysis (forward stepwise regression), in a first model, the LVMI was used as a dependent variable and age, sex, body mass index (BMI), NSBP, GCI and diabetes and hypertension duration were used as independent variables. A second model of regression analysis was used with NSBP as dependent variable and age, BMI, AFBG and DM and hypertension duration as independent variables. A P value (two-tailed) less than 0.05 was considered statistically significant. All calculations were made with a commercially available program, SigmaStat 1.0 .All normally distributed values were given as mean ± SD and all other values were given as median (range). In comparisons of the nonnormally distributed variables, the Kruskal-Wallis test on variance was used to test the differences between the three groups. If differences were found, the Mann-Whitney test was used for comparisons between two groups. For all normally distributed variables, analysis of variance was performed to test the differences among the three groups. If differences were found, the Student's Clinical characteristics of the three groups are in table G1 and G2 did not differ in age, BMI, sex, duration of hypertension and average of diurnal systolic and diastolic BP, however healthy control subjects (G3) differed in diurnal BP levels when compared to G1 and G2  and GCI , while NSBP correlated to GCI  and AFBG .When G1 was divided in tertiles according to NSBP table , the sub2 = 0.11; P < 0.01 and r2 = 0.08; P < 0.01, respectively). In the second model, only hypertension duration was an independent predictor of NSBP .In G1, the first model of multivariate regression showed both GCI and NSBP as independent predictors of LVMI   that couPatients with type 2 DM are more stable in blood glucose control than patients with type 1 DM  and FBG It has also been suggested that a poor glycemic control could be responsible for the increase of NSBP levels . In factAutonomic neuropathy (AN) could be a via through hyperglycemia would elevate NSBP levels. Some studies have related AN to an increase of LVM  and to tIt has been described a correlation between hyperglycemia and LVMI in diabetic patients ,7 and soThe coexistence of LVH and possible ischemic heart disease is a well-known phenomenon in general population and it has been suggested that ischemic heart disease is a consequence rather than a cause of LVH . In addiIt has been suggested that abnormalities in lipid metabolism could be involved in the pathogenesis of diabetic cardiomyopathy . NeverthAlmost all of our diabetic patients were using anti-hypertensive drugs for more than one year before the study. Most of them were in use of ACE-inhibitors and calcium antagonists, which are recognized efficients at LVH regression in hypertensive patients . Hence, Salmasi et al  describeAepfelbacher et al  have desA BP overload, detectable by ambulatory recording and not by clinic measurements, may be a major determinant of left ventricular diastolic dysfunction and left ventricular mass increase . Our stuThe author(s) declare that they have no competing interests.JF conceived of the study, participated in its design and coordination and performed the statistical analysis. JP, SF, FP and OK participated in the sequence alignment. VM carried out the echocardiography. AR and MZ participated in the design of the study. All authors read and approved the final manuscript.


We examined independent influences of contextual variables on cardiovascular risk factors in Shilin county, Yunnan province, South-west China.Three villages were selected from each of the ten townships based on probability proportional to size. In each selected village, 200 individuals aged ≥ 45 years were chosen based on simple random sampling method. From 6006 individuals, information on demographic characteristics, smoking and drinking status was obtained by interview. Blood pressure, height, weight, and waist and hip girth were measured. Fasting blood sugar was measured in a 10-percent subsample. Contextual data were from official reports. Multi-level regression modelling with adjustment for individual and contextual variables was used.Contextual variables associated with CVD risk factors included: remoteness of village with higher blood pressure and fasting blood sugar, high proportion of Yi minority with drinking, high literacy rate with a lower rate of smoking and a lower mean waist-hip ratio, and high average income with lower systolic blood pressure and body mass index (BMI) but higher FBS.While contextual SES is associated with a few CVD risk factors, villages with high level of income are worse off in fasting blood sugar. Strategies of economic development should be reviewed to avoid adverse effects on health. Cardiovascular diseases (CVD) are a major public health concern in the world, accounting for half of all non-communicable disease deaths worldwide . SimilarTraditionally, epidemiological studies have focused on identifying individual-level risk factors for diseases. Recently in epidemiology, there is increasing interest in exploring the effect of population or group  variables on disease risks. People residing in the same community or context would share the same contextual or environmental exposure and statistical assumption of independence is usually not true. Without proper adjustment, simplistic analysis of contextual independent variables as if they vary independently across individual subjects would bias the result toward overestimation of association. Multilevel modelling  providesDiscrimination of effects of contextual from individual independent variables is also important for public health. A good example of contextual concept is externality. While individual socioeconomic status (SES) variables such as income, unemployment and educational level -16 have Yunnan province of China is a multi-ethnic area and has 52 ethnic groups. The terrain is mainly mountainous with high variability in level of socioeconomic development and ratio of ethnicities among communities. The risk for CVD among the population is high and also varies by geography . Under sThis was a cross-sectional community survey combined with investigation of contextual variables from existing official data sources.Shi Lin County, a rural area of Kunming, the capital of Yunnan province (one of the poorest provinces in south-west China), was chosen as the study community. In 2004, it had a population of 205,186 and contained 10 townships, 90 villages and 65,135 families. The county was a typical minority rural county in Kunming, predominated by Yi ethnic group, and is one of the poor counties in Kunming, with a per capita income among peasants of US$313  in 2004.Socioeconomic characteristics of villages with regard to population size, adult literacy rate, proportion of Yi ethnic minority and distance from city were based on the 2000 census in China obtained from the local statistics office. Individual characteristics, village average income and CVD risk factor parameters were obtained from a cross-sectional community survey.In order to obtain information on each township for subsequent spatial study, reported separately, standard cluster sampling technique  was modiIn each selected village, from a name list of individuals aged ≥ 45 years obtained from the village committee, 200 subjects were chosen based on simple random sampling method.The questionnaire was adapted from that used by Inter-ASIA collaborative group . The insIn the morning of data collection, each participant was given full explanation of the research purpose, invited to participate and sign informed consent, and interviewed by one of the interviewers. Information on demographic characteristics, status of current cigarette smoking and alcohol drinking, blood pressure and fasting blood sugar test was obtained. Anthropometric measurements included height, weight, and waist and hip girth. Data collection was started in May 2005 and completed within 45 days.Three blood pressure (BP) measurements were made according to the American Heart Association recommendations . After aWeight was measured using a balance beam scale. The measurement of height and weight was done with the participants standing on the scale wearing indoor clothes and barefoot. To ensure sufficient precision, height was measured to the nearest 0.2 centimeter, and weight was measured to the nearest 0.2 kilogram. Body mass index (BMI) was calculated as weight in kg divided by height in meters squared .Waist girth was measured around the narrowest point between ribs and hips when viewed from the front after exhaling. Hip girth was measured at the point where the buttocks extended the maximum when viewed from the side. Waist-hip ratio was subsequently calculated.A random 10% of participants were selected from each village for fasting blood sugar study. The subjects were instructed to fast overnight for at least 10 hours. A small drop of fingerprick blood was obtained and put onto a special strip of paper, which was then inserted into the blood glucose monitor machine . The monitor measured and displayed the result within 15 seconds. This strip glucose technique had been validated against a standard test in Kunming Hospital, and found to give a 10% lower value. Values obtained from the participants' blood stick test were therefore adjusted upward as appropriate.This study was approved by the Ethics Committee of Faculty of Medicine, Prince of Songkla University, before carrying out the research.2 or greater [Cigarette smokers were defined as persons who had smoked at least 100 cigarettes in their lifetime, and those who smoked tobacco products during the survey time were classified as current smokers. Current drinkers were defined as persons who drank alcohol regularly during the previous 12 months (i.e. on 12 or more different days during the year). Hypertension was defined as a mean systolic blood pressure ≥ 140 mm Hg, diastolic blood pressure ≥ 90 mm Hg, and/or use of antihypertensive medications. Overweight was defined as a BMI of 25 kg/m greater . Diabete greater  or the u2), waist-hip ratio, current smoker and current drinker.The outcome variables included systolic blood pressure (mmHg), diastolic blood pressure (mmHg), fasting blood sugar (mmol/l), BMI . Among the participants, 611 randomly selected people received fasting blood sugar test. Their demographic characteristics are summarized in Table Individual mean values of height, weight, waist girth, hip girth, BMI, waist-hip ratio, blood pressure and fasting blood sugar by sex are demonstrated in Table Table Table From results of multi-level analysis are shown in Table From this study, several geographical and socio-economic contextual variables were shown to exert an independent influence on CVD risk factors.While a previous study found high prevalence of CVD risk factors in poor rural villagers who were rarely exposed to the modern world , our finWhile an inverse relationship between individual educational level and CVD risk factors has been reported in a number of studies -33, onlyYi ethnic minority has increased risk for alcohol drinking in this study. Alcohol drinking is an integral part of Chinese culture. Distilled spirit is the primary beverage of choice for men, accounting for more than one-third of all drinks consumed . A surveWhile western studies have demonstrated that deprivation in low income communities increases the level of various CVD risk factors such as SBP , overweiThe strength of our study lies in the large sample size and high response rate fulfilling the requirement for multilevel modelling . The limThe study area shares the global trend of increased CVD risk factors, which are contributed to by contextual setting in addition to the known personal lifestyles. Unlike findings from the western countries, where most unfavourable outcome are more common among the low SES, local directions of association are inconsistent. While contextual SES development is associated with a few CVD risk factors, villages with high level of income are worse off in fasting blood sugar. Strategies of economic development should be reviewed to avoid their adverse effects on health.The authors declare that they have no competing interests.Cai Le carried out the study and drafted and revised the manuscript. Virasakdi Chongsuvivatwong conceptualized the research idea, participated in the design of the study, laid out the framework for data analysis, interpreted the results and helped to draft the manuscript and revised the discussion. Alan Geater participated in the design of the study and helped to draft and revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Despite widespread availability of a large body of evidence in the area of hypertension, the translation of that evidence into viable recommendations aimed at improving the quality of health care is very difficult, sometimes to the point of questionable acceptability and overall credibility of the guidelines advocating those recommendations.The scientific community world-wide and especially professionals interested in the topic of hypertension are witnessing currently an unprecedented debate over the issue of appropriateness of using different drugs/drug classes for the treatment of hypertension. An endless supply of recent and less recent "drug-news", some in support of, others against the current guidelines, justifying the use of selected types of drug treatment or criticising other, are coming out in the scientific literature on an almost weekly basis. The latest of such debate (at the time of writing this paper) pertains the safety profile of ARBs vs ACE inhibitors.To great extent, the factual situation has been fuelled by the new hypertension guidelines  through, apparently small inconsistencies and conflicting messages, that might have generated substantial and perpetuating confusion among both prescribing physicians and their patients, regardless of their country of origin.The overwhelming message conveyed by most guidelines and opinion leaders is the widespread use of diuretics as first-line agents in all patients with blood pressure above a certain cut-off level and the increasingly aggressive approach towards diagnosis and treatment of hypertension. This, apparently well-justified, logical and easily comprehensible message is unfortunately miss-obeyed by most physicians, on both parts of the Atlantic.Amazingly, the message assumes a universal simplicity of both diagnosis and treatment of hypertension, while ignoring several hypertension-specific variables, commonly known to have high level of complexity, such as:- accuracy of recorded blood pressure and the great inter-observer variability,- diversity in the competency and training of diagnosing physician,- individual patient/disease profile with highly subjective preferences,- difficulty in reaching consensus among opinion leaders,- pharmaceutical industry's influence, and, nonetheless,- the large variability in the efficacy and safety of the antihypertensive drugs.The present 2-series article attempts to identify and review possible causes that might have, at least in part, generated the current healthcare anachronism (I); to highlight the current trend to account for the uncertainties related to the fixed blood pressure cut-off point and the possible solutions to improve accuracy of diagnosis and treatment of hypertension (II). Recent changes in definition and classification of blood pressure levels make hypertension, by far, the most commonly diagnosed condition in primary and secondary healthcare systems and projects the entity on the first place in terms of work load and prescribing cost."People with normal blood pressure by their 50 years of age are considered to run a 90% life-time risk for developing hypertension later during their lives".This statement puts in perspective the epidemic nature of hypertension and the growing concern of all societies in dealing with this outstanding public health problem, in developed as well as in developing countries.There is little doubt that the American , the EurThe National Health and Nutritional Health Survey (NHANES)  data froThese disappointing figures are in sharp contradiction with the hypertension-related successes over several years before the survey.Even worse, the recently published results of an epidemiologic inquiry to assess the hypertension burden and overall prevalence for the same period (1999 to 2000) in US  showed tprehypertension category in the JNC VII-hypertension classification ,-49,46-49A 24-hour ambulatory blood pressure curve see Fig.  fully ilThe great uncertainty that lies in casual blood pressure measurements, reflecting the biologic variations of this parameter, has been emphasized through Bayesian analysis  and a prThe total range of variation observed for 24-hour mean in healthy pregnant women is even larger; 28 and 26 mmHg for SBP and DBP, respectively. This range of blood pressure variability is approximately three times larger when computed on the basis of individual blood pressure measurements instead of the 24-hour mean .It has been estimated that use of a single blood pressure measurement to assist in diagnostic decision making would overdiagnose hypertension in 20–30% of cases and miss a third of those who truly have the disease ,57.white coat effect, defined as an office blood pressure exceeding mean daytime ambulatory pressure by at least 20 mmHg systolic and/or 10 mmHg diastolic has been found in as many as 73% of treated hypertensive subjects. It may occur more frequently in women than in men [The n in men  and it in in men .White-coat hypertension  is reported in as many as 20 to 35% of patients in whom hypertension is diagnosed [iagnosed ,61 and iiagnosed . ABPM iniagnosed . Likewisper se, comes from a study comparing the long-term, office blood pressure measurements with 24-hour ambulatory blood pressure measurement in treated hypertensive patients [Newer insights in this area, further emphasizing the tremendous complexity of hypertension patients .The study by Clement et al.  showed tAmong several valuable findings of this study, the most notable is that patients whose mean 24-hour systolic pressure was 135 mmHg or higher, when they were receiving treatment, were nearly twice as likely to have a cardiovascular event as patients with a mean 24-hour systolic pressure of less than 135 mmHg, regardless of their office blood pressure values.sine qua non condition for accurate diagnosis in cases with hypertension recently termed reversed or masked hypertension [The use of 24-hour ambulatory blood pressure measurement seems to be a rtension ,66, in wrtension . The new1). Patients with high office pressure but with low ambulatory pressure (no more likely than normotensive persons to have a cardiovascular event); intensive treatment of these patients, exclusively on the basis of office blood pressure measurement and/or their labelling as having "resistant hypertension" (in absence of associated risk factors or established organ damage), is likely to be deleterious and, it may even lead to adverse drug events;2). Patients with low office blood pressure but high ambulatory blood pressure (who are in the opposite extreme of the hypertension spectrum); apparently, these patients are "well controlled", however, in need of intensified treatment as they seem to be running a worse long-term prognosis.The multiple sources of errors that may be encountered in the office blood pressure measurement emphasize the great degree of non-accurate, misleading results generated by such assessments in daily clinical practice. Two examples bellow highlight the consequences of only minimal biased assessments .An overestimating systematic error of 5 mmHg would misclassify some 27 million people as being hypertensive rather than having normal-high blood pressure, i.e., prehypertension . The indFurther, a systematic error of underestimating true blood pressure by 5 mmHg would mean that 21 million people would go untreated as their real hypertension would be labelled as normal-high blood pressure . In thisBoth these scenarios may occur with rather high probability in clinical practice given the current, widespread model of healthcare based on a dichotomous paradigm of "yes/no" decision making as to establishing an initial diagnosis, as to the need to investigate or not investigate or, to treat or not to treat, currently arbitrarily fixed for hypertension at 140/90 mmHg.risk/no risk circumstances [Amazingly, the scientific community seems to accept the particular outlook reflected by this dichotomous reasoning despite widespread awareness that the risk associated with increasing blood pressure is graded and continuous. It begins as low as at 115/75 mmHg [mstances .the lower the blood pressure, the better" – treatment philosophy, applicable to the general population and advocated as such by the majority of current guidelines.The lack of such a threshold combined with the information derived from a multitude of clinical trials, convincingly demonstrating the benefits of treatment across all levels of blood pressure in Western populations (not only in hypertension) -71, havegoal/target for pharmacologically treated hypertensives. These targets are supposed to be pursued aggressively with even three or four drugs if needed, in order to achieve "optimal" or "normal" BP in young, middle-aged, or diabetic subjects (below 130/80 mmHg), and at least "high-normal" BP in elderly patients  [The <140/90 mmHg cut-off point (respectively <130/80 mmHg for those with compelling indications) have been chosen as treatment 90 mmHg) ,73.Unfortunately, current evidence indicates that most patients fail to achieve systolic blood pressure below 140 mmHg -76. AccoMancia and Grassi  pointed Additionally, common sense suggests that there may be a level at which the benefits of treatment are outweighed by its side effects . LikewisThe aforementioned major problems with accurately measuring blood pressure in day-to-day clinical practice for the purpose of diagnosis and treatment of hypertension, highlight the magnitude of the uncertainty range around the current blood pressure cut-off point (140/90 mmHg), consisting of huge number of people being misdiagnosed of having or not having hypertension.Failure in both directions are regrettable but, in the context of currently increasing aggressive approach to hypertension mandated by most guidelines, overdiagnosis exposes people unnecessarily to considerable risk for adverse drug reactions (ADR).lowest effective dose (of whatever agent had been used) at initiation of therapy, with the aim to maximize the likelihood of successful early treatment and improve the long-term compliance rate.Patients' low compliance rate with the prescribed medication is a widely acknowledged problem in hypertension treatment. Up to 50% of the patients quit the treatment they were given within the first year -92. Advelowest effective dose principle is, however not easy, as the labeling information at hand is often not enough informative for confident decision making. This is the case even when the doctors carefully take into account the known individual variations in drug response due to differences in age, weight, sex, ethnic background, state of health, concomitant medication use, and genetic polymorphism in drug metabolism.The task of the prescribing physician when attempting to stick to the The all too high dosage of a particular drug at launch seems to be inherent in the current drug development paradigm. Namely, high doses are selected during the early clinical trials phases with the purpose of assessing the agent's efficacy and less so its safety profile. Maximizing efficacy by preferential selection of higher doses may, obviously, be deleterious from safety point of view, particularly when such doses selected in early trials are used to prove efficacy in later phase trials and eventually are brought to the market once the drug is granted marketing authorization. Several studies have highlighted deviations in the post-licensing dose administration levels ,96. One The problem above is further compounded by the initial drug dosage guidance available for physicians in US  – the JNThe well-intended use by many physicians of a "half-dose" of a particular drug at initiation of treatment is hampered by the impossibility of dividing capsules, coated tablets and drugs with irregular format.The "start low, go slow" principle, promoted constantly during the past decades as a stepwise approach to treating patients with hypertension, allows patients time to adjust psychologically to the fact that they have hypertension. A meta-analysis of 354 trials involving 56,000 participants showed that blood pressure reductions produced by the major classes of drugs at standard dose are similar, and that half the standard dose reduces efficacy by only 20% while more than halving side-effects -105.passing the threshold to "real" hypertension (>140/90 mmHg). The distress about having hypertension and possibly requiring life-long drug therapy may lead to development of anxiety symptoms that may be mistaken for ADR, which may lead to skipping doses or quitting treatment.Given the current prehypertension category, most "new hypertensive" patients are counselled as to lifestyle changes that either may fail or simply are not enough to prevent Worse than that is the case of those patients who, through the nature of their hypertension , are candidates for combination treatment from the start. Indeed, for these patients, or those whose blood pressure levels increase to these levels, the current guidelines recommend that consideration should be given to initiating (first-line) therapy with two drugs, either as separate prescriptions or in fixed low-dose combination. The main logic of these recommendations is simplicity of use of such combinations and their potential to considerably improve the blood pressure response rate while minimizing the incidence of adverse effects.sustained hypertension diagnosed by ABPM but, it might be a high-risk approach in cases with white coat hypertension, not recognized by conventional office blood pressure measurement.This might be a best evidence approach in patients with Proper diagnosis of hypertension is of paramount importance for successful implementation in the clinical practice of current treatment guidelines. Consequently, failure to do so by the prescribing physician community suggests that there might be difficulties with accurately diagnosing hypertension, a fact, ultimately resulting in poor control of hypertension.As control of hypertension, defined as BP < 140/90 mm Hg had been conferred status of quality indicator in the Health Employer Data Information Set by the National Committee for Quality Assurance in US , the potth world conference of Hypertension League Council held in Montreal in 1997 adopted the 140/90 mmHg cut-off point for hypertension diagnosis while the remaining 13 societies stayed with 160/95 mmHg [Fourteen out of 27 national hypertension societies represented at the 17/95 mmHg .Not surprisingly, a questionnaire survey among primary care physicians in US indicated that a significant proportion of them were reluctant to seek treatment goal below 140/90 mmHg while, in the same time, being pretty tolerant with mildly elevated SBP in older patients. These findings led the authors of the article  to make The situation is very similar in UK where an editorial by Campbell entitled: "Patients decide how low they go, not targets" , generatAnother issue of discontent among practicing physicians is the way results of clinical trials are presented, a fact that seems to impact the prescribing propensity of physicians and the patients' willingness to accept treatment .The apparently small range between the two thresholds under debate (140/90 – 160/95 mmHg), encompasses the great majority of individuals with hypertension in whom most of the hypertension-related morbidity and mortality is recorded ,113. OveGiven that most of older hypertensive patients in general practices have a clustering of risk factors , there iObviously, it is difficult to find an all-fit formula for all these uncertainties; however, an emerging trend is to incorporate into the treatment management decision making the values and preferences of patients, clinicians and the general public -121. ThiPhilipps et al.  emphasizclinical inertia – recognition of the problem but failure to act on it"."Despite advances......, health care providers often do not initiate or intensify therapy appropriately during visits of patients with these problems. We define such behavior "........achieving standard-of-care goals in only limited numbers of treated patients must be attributed either to therapeutic ineffectiveness or to clinical inertia. The attainment of treatment targets in clinical trials shows the effectiveness of present therapies for hypertension, elevated LDL cholesterol levels, and diabetes – leaving clinical inertia as the presumptive basis for treatment failure in many patients with these disorders".The content of the first quote seems to ignore most of the sensitive aspects that normally occur in the patient-physician relationship and in the mutual decision making process of the two parts involved. Likewise, the second quote assumes generalization of the mean global estimates of clinical trials to the particular individual as a universal task to be fulfilled by all practicing physicians.Indeed, epidemiologic data indicate that the long-term average BP is the best predictor for risk , howeverBut, "physician behavior" and failure of clinicians to monitor blood pressure aggressively and institute pharmacotherapy when indicated were invoked as causes for poor control of hypertension already by the NHANES III, in 1997 . From thMost recently they could find out that they might be about to loose entirely what was left of their credibility in terms of diagnosing and treating hypertension.In an article by Graves and Sheps in the American Journal of Hypertension , the autThis might certainly be true, and I also agree that something should be done, however, extreme solutions like: "It is clear from evidence trails that current practice of BP measurement is inadequate. Thus, the question is not whether physicians should or should not measure BP in the hypertensive patients; rather, it is how are we to replace the physician measurement with a higher quality BP measurement", might be too long far fetched.The authors answer the hypothetical question and suggest that "trained observers" or validated automated devices should be used. They acknowledge, however, that observer-dependent errors seen in "trained observers" (commonly nurses) are similar in type and magnitude to those seen in physicians .The most recent AHA Scientific Statement  makes thEligibility to become "Observer" is dependent on a number of physical and cognitive competencies required to perform, assess and report the blood pressure measurement. The physical requirement includes vision, hearing and eye/hand/ear coordination see .Furthermore, observers are supposed to undergo careful evaluation as to their ability to assess "different types of bias, general technique, and the interpretation of the measurements including an understanding of the normal variability of blood pressure by time of day, exercise, timing of antihypertensive medications, etc. The observers should know how and when to communicate blood pressure readings gathered at home or other settings to the health care professional responsible for the care of the patient and management of hypertension".A comprehensive model of retraining of all observers is suggested, whereby: "a central master trainer trains the site master trainers, and they in turn train the observers at each site. This model could be replicated within hospitals, ambulatory care settings, and community agencies".The AHA document gives insight in the area of home/self-monitoring of blood pressure as a methodology that has the potential to "improve both therapeutic compliance and blood pressure control", according to two studies from mid 80s ,131.Despite the benefits of home blood pressure measurements – being more reliable than those recorded in the clinic setting – the Working Group on Blood Pressure Monitoring of the ESH neither recommend extensive use of the model, nor empowers patients to take action on the basis of the results . Even wiFurthermore, the main advantage of the home blood pressure monitoring – accurate readings – is not a guarantee of accurate reporting to the physician. This fact is highlighted in two studies employing measurement devices with memory. Patients using them were supposed to carefully record their blood pressure and to report the results to their physicians. More than half the subjects omitted or fabricated readings ,135. SupESC advocates the home blood pressure monitoring for detecting white coat hypertension among patients with persistently raised clinic blood pressure, however, it emphasizes that a diagnosis requires confirmation with ambulatory monitoring.A widespread awareness seems to emerge as to the doubtful clinical relevance of the most used investigation in clinical practice – the blood pressure measurement.As mentioned in this paper, a great number of factors are contributing to the more than 100-year old method being carefully scrutinized, primarily because of the biological, random fluctuations of the blood pressure variable and the white coat effect.These two latter aspects, as well as many others , have forged a big quantum leap in our understanding of hypertension and seem to bring about the need for radical change, a real paradigm shift in the way we see and deal with blood pressure and with hypertension.Sadly enough, the realization that the classically office-based BP can, on no account, be relied upon for diagnosis and treatment purposes, has generated a wave of mistrust with the practicing physicians, commonly involved in the management of patients with hypertension.At closer scrutiny, however, most of the reproaches directed toward physicians are exaggerated and many of the "solutions" suggested extreme. Moreover, the peculiar "physician behavior" might be a deliberate acting to account for the uncertainties related to the much debated BP range of 140/90 – 160/95 mmHg and for the failure of the current health care systems to generalize implementation of ABPM in clinical practice, at least for all "first diagnosis" and treatment decision making.The second part of this paper will attempt to elaborate on these latter issues.The author(s) declare that they have no competing interests.Guidelines for blood pressure measurement. .Click here for fileFactors that can interfere with accuracy of BP measurement (after McAlistar and Strauss).Click here for fileEffects of routine activities on BP .Click here for fileIndications for ABPM (JNC VI).Click here for filePhysical and cognitive competencies required in "observers" certified to measure blood pressure .Click here for file


The paradigmatic shift to evidence-based dentistry (EBD) that relates to occlusal therapy, selective occlusal adjustment (OA) and stabilization splints therapy (SS) for TMDs has had an unfavourable impact on the teaching of many of the important aspects of occlusion needed in dental practice. The teaching of OA systematically in dental schools has been nearly abandoned because of the belief that OA is an irreversible procedure and gives the impression that it is without merit elsewhere in the management of occlusion. However, a particular dose of knowledge and practice of occlusion that is necessary for all aspects of dental care should be taught systematically in dental schools. The uses and misuses of OA and SS and their limitations should be emphasized because of their importance to bring clinical reality into the dental curriculum. Thus, and irrespective of EBD induced contradictions, OA and SS should still have a significant place in systematically teaching of occlusal therapy. However, there are many more aspects of the management of occlusion that should to be considered. Hopefully, because of their importance, other aspects of the management of occlusion will once again become a significant part of the dental curriculum. Quintilian, a Latin rhetorician of the first century, proposed the following advice: Write not so you can be understood but so that you cannot be misunderstood." Hopefully, the following is written so that it is not only understood but also not misunderstood. The following thoughts on occlusal adjustment and the use of stabilization occlusal bite plane splints relate to some of the aspects of occlusal therapy that should be taught systematically in the dental curriculum. The term systematic refers to structured courses with goal oriented outcomes.The paradigmatic trends in academic dental health sciences reflect attempts to provide a knowledge nexus between the biological and mechanical, or the art and the science aspects of dentistry using probabilistic scientific data. However, the paradigmatic shift to evidence-based dentistry that relates to occlusal therapy, selective occlusal adjustment (OA) and stabilization splints therapy (SS) for TMDs has had an unfavorable impact on the teaching of many of the important aspects of occlusion needed in dental practice. The term selective means the studied amount of occlusal adjustment needed to fulfil the goals of the treatment plan, e.g. from the removal of an iatrogenic occlusal interference to a comprehensive occlusal adjustment for restorative purposes. In the face of the uncertainly of time-dependent and seemingly inconclusive recommendations in qualitative systematic reviews, and the absence of an acknowledged successful therapy for refractory cases of TMD, a clinician may be faced with the studied unfortunate option of redefining evidence-based dentistry (EBD) , e.g., iIrrespective of the position of those in academia relative to the role of occlusal therapy in the treatment of TMDs, -4 the boMany of the publications dealing with OA and SS assume that every OA relates to same goal; and that SSs need only one adjustment, the one at the time of delivery. There is too often the assumption that the sample size used in research will be large enough to take into account all such variations.The teaching of OA systematically in dental schools has been nearly abandoned because of the belief that OA is an irreversible procedure and gives the impression that it is without merit elsewhere in the management of occlusion. There is no question that the initial therapy for most cases of TMD should be conservative, non-invasive therapy. Occlusal therapy and OA as the only treatment modality is not usually recommended for TMDs; however, it appears to have merit when used with other forms of therapy such as counseling, splints, and physiotherapy.  This essOn boards and in clinical examinations it is found altogether too often that a mere occlusal contact on the non-working  in mediotrusive position is called an occlusal interference. Such contact is not an occlusal interference. In order to be called a mediotrusive (non-working side) interference, the occlusal contact relation has to cause an interference with functional contact relations elsewhere, e.g., interfere with laterotrusive (working side) contacts. Some limitation of this example should be considered: a mediotrusive contact on a gold crown may become an interference problem because of the different wear rates of gold and normal enamel on the laterotrusive (working) side, especially with bruxism. To cover all the systematic teaching about occlusion that should be a part of the dental curriculum is well beyond the space that is allowed here.The teaching of selective occlusal adjustment should include all the following, including clinical experience, but not limited to just the following: ,10.1. Systematic  correction of occlusal contact relations that:• interfere with function• prevent closure into the intercuspal position• cause excessive loading of implants• are needed for endodontic treatment• is needed for proper restorative treatment• involve cracked teeth• cause or contribute to periodontal trauma• prevent appropriate design of splints• enhance occlusal stability2. Iatrogenic restorations that:• aggravate bruxing or clenching• immediately precede TMD-like symptoms3. Proper emphasis on patient-centered criteria of what is perceived to be important by each patient, including shared decision-making, informed consent, and dealing with the difficult patient, e.g., phantom bite.None of the above aspects of teaching selected occlusal adjustment is controversial; the impact of their studied absence from systematic courses in occlusion both in the literature and in the clinic has become obvious.Some systematic and other research review papers seem to suggest that it is possible to do an occlusal adjustment in the presence of temporomandibular joint and/or muscle dysfunction. However, in order to do an occlusal adjustment how often is it possible to obtain a point of reference  in order to do an occlusal adjustment in the presence of significant and painful temporomandibular joint and/or muscles disorders? Without a goal and some reference position of the mandible, grinding on the teeth is not an acceptable occlusal adjustment. It is interesting that at least three textbooks on occlusion teach occlusal adjustment but where does one find it being taught systematically?The systematic teaching of the use of occlusal bite plane stabilization splints should include, but not necessarily be limited to the following: .1. Diagnostic proceduresa. Diagnostic procedures required for determining the basis for use of the stabilization splint, as well as the occlusal factors that determine the design of the splint, e.g., curve of Spee, vertical overlap, extruded teeth, Angle class of malocclusion, location of TMJ clicking (opening and closing), determination of type of TMD. Shim stock should be used to determine the presence or absence of all supporting cusp contacts.b. Patient evaluation: avoid forgetting that symptoms are the sine qua non of diagnosis; consider the patient's potential for compliance; determine if there are any problems other than "TMJ" that are of greater significance to the patient.2. Uses of stabilization splintsa. Primary dental treatment for controlling the effects of parafunction , and for protection against cheek and lip biting , for limiting periodontal trauma from occlusion, for control of occlusal forces on implants, and for fractured teeth as secondary treatment for bruxism in cases of coexisting comormid disorders  where bruxism occurs.b. Adjunctive treatment for secondary otalgia (earache) associated with clenching; subjective hearing disorder ("stuffiness") associated with some TMDs.c. Selective treatment for symptoms of TMJ disk derangement, TMJ clicking and episodic locking, TMJ arthralgia and arthritis, myalgia, adjunctive treatment for tension-type headaches, chronic daily headache and some types of migraine .3. Design of several types of stabilization splintsa. Flat plane splint that utilizes bilateral balanced occlusion to the extent possible, and incisal guidance is a constant feature.b. Flat plane splint with canine rise but no incisal guidance. Splint designed to provide for freedom in splint centric. Canine rise varies in pitch to prevent mediotrusive contacts, laterotrusive contacts, and protrusive contacts away from splint centricc. Generally a splint should be about 2 mm in thickness; however, the actual possible thickness may related to prevention of a closing click, sharpness of the curve of Spee, canine rise, and vertical overlap.d. Splints should be made of heat processed acrylic.e. Most stabilization splints utilize the maxillary arch.4. Adjustment of stabilization splinta. The splint should be stable with all contact movements. Retention may be obtained by undercuts  or clasps (not often needed).b. On mandibular closing all supporting cusps should make simultaneous contact in tap centric, swallowing, yawning, muscular closure and operator guided closure.c. Adjustment of the splint takes place over a period of time consistent with mandibular repositioning due to changes in muscles and joints, as well as behavioral modificationsEvery interocclusal device by whatever name it is called requires oversight adjustments to meet the individual needs of every patient. There is no occlusion or patient so "standard" that adjustment and maintenance of a splint is not needed as long as the splint is worn. It is assumed incorrectly that jaw reference positions  used in constructing splints are possible to determine accurately in most instances in the presence of pain and muscular dysfunction. Another assumption is that a single design, a single splint adjustment, and/or a single time period for use of a stabilization splint will "work" for all TMDs. It is possible to deduce such metamorphic thinking of "one size fits all" from many of the studies in the literature.Only two of the many aspect of the management of occlusion that need to be included more systematically in the dental curriculum have been addressed, OA and SS therapy However, there are many more that should to be considered. Hopefully, because of their importance, other aspects of the management of occlusion will once again become a significant part of the dental curriculum.The author(s) declare that they have no competing interests.


Peak heart rate and use of pharmacologic stress affect the interpretation of lung thallium uptake. The current study was performed to determine whether 99mTc-sestamibi sLHR measurements are affected by stress-related variables, and whether this in turn affects prognostic utility.Increased 99mTc-sestamibi SPECT stress imaging. sLHR was assessed in relation to demographics, hemodynamic variables and outcomes (mean follow up 5.6 ± 1.1 years).sLHR was determined in 718 patients undergoing Mean sLHR was slightly greater in males than in females (P < 0.01) and also showed a weak negative correlation with age (P < 0.01) and systolic blood pressure (P < 0.01), but was unrelated to stress method or heart rate at the time of injection. In patients undergoing treadmill exercise, sLHR was also positively correlated with peak workload (P < 0.05) but inversely with double product (P < 0.05). The combined explanatory effect of sex, age and hemodynamic variables on sLHR was less than 10%. The risk of acute myocardial infarction (AMI) or death increased by a factor of 1.7–1.8 for each SD increase in unadjusted sLHR, and was unaffected by adjustment for sex, age and hemodynamic variables (hazard ratios 1.6–1.7). The area under the ROC curve for the unadjusted sLHR was 0.65  and was unchanged for the adjusted sLHR .Stress-related variables have only a weak effect on measured sLHR. Unadjusted and adjusted sLHR provide equivalent prognostic information for prediction of AMI or death. Whenever possible, beta blockers and calcium-channel antagonists are withheld for 24–48 hours prior to the stress procedure, and nitrates are avoided for at least six hours. Symptom-limited treadmill exercise is performed with tracer injection at peak exercise followed by 1–3 minutes of exercise post-injection. For individuals unable to achieve a satisfactory exercise workload, pharmacologic stress with dipyridamole 0.56 mg/kg is administered intravenously over 4 minutes with tracer injection 4 1/2 minutes later. Low-level (supplementary) exercise is performed following dipyridamole infusion for those patients without a left bundle branch block whenever possible. Supine, non-gated SPECT imaging is commenced 30–60 minutes post-stress and 45–75 minutes following the resting tracer injections.normal, equivocal, abnormal with fixed defects, abnormal with fully reversible defects, or abnormal with partially reversible defects. For analytic purposes, these categories were recoded using two variables as follows: normal scan  versus abnormal scan ; no reversibility  versus reversibility . The image data was subsequently reprocessed using commercially available software  [An initial visual interpretation of the scan data was performed without image quantification by a pair of nuclear medicine specialists with extensive experience in cardiac nuclear medicine. Images were categorized as tas, CA) -13. Lefttas, CA) ,15. The tas, CA) ,16. An atas, CA) . Visual 99mTc-sestamibi was calculated as a stress lung-to-heart ratio (sLHR) using an automated technique previously validated by Bacher-Stier et al [Lung uptake of er et al . The algCohort follow up was performed through the Manitoba Population Health Research Data Repository which contains anonymized encounter-based records of individuals' interactions with the provincial health care system, including physician services and hospitalizations for all residents of the province of Manitoba . These aThe primary outcome of this study was death or AMI. The date of death was established from the Vital Statistics database. AMI was defined from hospital discharge diagnosis (ICD-9-CM 410.xx). Clinical and stress variables were primarily obtained from chart review. The data repository was used to identify individuals with diabetes or previous hospitalization with AMI using validated definitions ,23.Statistical analysis was performed with a commercial software package . Continuous variables are reported as mean ± SD and P < 0.05 is considered to represent a statistically significant difference. Group comparisons were performed using ANOVA (continuous variables) or a Chi-square test . Logistic regression was used to identify the independent correlates of an elevated sLHR . Cox proportional hazards model was used to estimate relative event rates from sLHR before and after adjustment for stress-related correlates. Receiver operating curve (ROC) analysis was used to assess overall risk stratification for single multi-level variables .The selection criteria identified 1,027 potentially eligible cases. Exclusion criteria were present in 309 of these leaving a final study population of 718 patients. Excluded patients were similar to the final study cohort in terms of age, gender, stress procedure and frequency of abnormal scans. The mean age of the cohort was 60 ± 11 years. Of the 718 patients included in the analysis, 380 (53%) were male, 186 (26%) had a history of MI, 112 (16%) had undergone prior coronary bypass surgery or coronary angioplasty, 90 (13%) were diabetic, and 556 (77%) had treadmill exercise as the only stress method. As expected, heart rate at the time of tracer injection was greater with exercise stress alone (131 ± 21 BPM) than for dipyridamole alone (87 ± 20 BPM) or dipyridamole combined with supplemental exercise (103 ± 19 BPM) (P < 0.0001). Similarly, systolic blood pressure varied according to stress method .sLHR was positively correlated with SSS , though SSS explained less than 15% of the variance in sLHR. Of the 718 patients, 69 (10%) had sLHR values that exceeded the normal range (≤ 0.39). Factors that were associated with elevated sLHR are summarized in Table Clinical and hemodynamic variables that might affect interpretation of lung uptake measurements were assessed in the 334 event-free patients with normal perfusion  Table . Of thesIn the 284 event-free patients with normal perfusion undergoing treadmill exercise only, sLHR was again unrelated to peak heart rate  but was positively correlated with peak workload  and inversely related to systolic blood pressure  and double product . Peak double product was used in the multivariable regression model since it explained slightly more of the variance in sLHR than systolic blood pressure. Peak workload was no longer a significant variable after adjustment for the other variables.The mean period of follow up was 5.6 ± 1.1 years. During this time, 114 (16%) from the cohort experienced a primary outcome event. There were 81 deaths and 62 acute myocardial infarctions, including 29 patients recorded as having AMI followed by death. For the latter, time to AMI was used in the survival analysis. The hazard ratio (HR) for an adverse event increased by a factor of 1.7 (95% CI 1.4–1.9) for each SD increase in unadjusted sLHR. This was no different than for sLHR after adjustment for sex, age and systolic blood pressure . ROC analysis confirmed a significant association between adverse outcomes over the range of sLHR measurements . The relative hazard for an adverse event increased by a factor of 1.8 (95% CI 1.5–2.1) for each SD increase in unadjusted sLHR, similar to the adjusted sLHR .99mTc-sestamibi stress lung uptake and together these variables explain less than 10% of variation in the sLHR. The risk of acute myocardial infarction (AMI) or death increased by a factor of 1.7–1.8 for each SD increase in unadjusted sLHR, and this was similar after adjustment for sex, age and hemodynamic variables (hazard ratios 1.6–1.7). The area under the ROC curve for the unadjusted sLHR was also similar to the adjusted sLHR. It has previously been shown that the sLHR gives incremental predictive information when added to a model containing clinical, stress, perfusion and left ventricular volume information [This report shows that sex, age and hemodynamic variables have only a very weak effect on Thallium lung uptake has been shown to be affected by hemodynamic variables and imaging time. In 59 normal patients, lower peak heart rate during exercise and propranolol peak heart rate during exercise and propranolol usage were both associated with higher lung uptake  and thisWe found slightly higher sLHR in males with normal perfusion scans than in females and this has also been reported by others . This geA limitation of our study is the absence of the additional functional information that comes from gated SPECT imaging. Gated SPECT is performed in most nuclear cardiology laboratories and provides an assessment of regional and global left ventricular function. Left ventricular ejection fraction derived from gated SPECT myocardial perfusion imaging contributes independent prognostic information .sLHR appears to be another adjunctive prognostic measure in patients with known or suspected coronary artery disease. Age, gender and stress variables show only weak correlations with sLHR, and adjustment for these factors does not appear to be necessary for interpreting sLHR measurements. These and other variables, such as regional perfusion and systolic function, remain important prognostic variables which must be considered in patient risk stratification.The author(s) declare that they have no competing interests.WDL developed the study protocol, performed the data analysis and drafted the manuscriptMSY performed the data linkage and outcomes data extractionLMW restored the archived scan data, performed the QPS re-analysis and assembled the clinical datasetsKAN contributed to the study protocol and data interpretationCJM obtained approvals from Manitoba Health and the Manitoba Centre for Health Policy, and coordinated anonymization of the clinical informationAll authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


To determine the prevalence of ischemic heart disease and the associated risk factors among the urban population of Siliguri.A cross-sectional survey of a random sample of the population aged ≥40 years old in the Municipal Corporation area of Siliguri. Study variables were age, sex, occupation, addiction, food habit, physical activity, body mass index, blood pressure, and electrocardiogram change.Out of 250 individuals who took part in this study, 29 (11.6%) had ischemic heart disease (IHD) and 118 (47.2%) had hypertension. Males had a higher (13.5%) prevalence of IHD than females (9.4%). About 5% of the patients had asymptomatic IHD. IHD among the study population is significantly associated with hypertension and smoking. Cardiovascular disease, one of the non-communicable diseases, has become a major public health problem in many developing countries. About two-thirds of the global estimated 14.3 million annual cardiovascular disease deaths occur in the developing world. By the year 2015, cardiovascular diseases could be the most important cause of mortality in India. The prevalence of coronary artery disease in India increased from 1% in 1960 to 9.7% in 1995 in urban populations, and in rural populations it has almost doubled in the last decade. of Siliguri was conducted. The sampThere are 47 wards in the Siliguri Municipal Corporation area. Ward number 23 (Dabgram) and 47 (Pati colony) were selected from the 47 wards of Siliguri. The total population of two selected wards was 14,568. From the updated voter list of this ward, all the members who were permanent residents aged ≥ 40 years old were selected. By using the systematic random sampling method, a list of 271 members aged ≥ 40 years old was prepared with names and addresses. They were given a pre-tested, semi-structured questionnaire (the Rose questionnaire from the cardiovascular survey methods of WHO-1982). were also calculated. Hypertension was diagnosed when the systolic blood pressure was 140 mmHg or more and the diastolic blood pressure was 90 mmHg or more, as per the guidelines of the British Hypertension Society. a history of angina or infarction and previously diagnosed disease, (b) an affirmative response to the Rose questionnaire, and (c) electrocardiographic findings, namely Minnesota codes 1-1, 4-1, 5-9, 5-2 or 9-2. The presQuantitative data was entered into EPIINFO software, Version 3.2 and then exported to SPSS software, Version 10.0 for analysis. Data was analyzed and tabulated using frequency distribution tables and proportion. Association between the prevalence of IHD and risk factors were examined using the Chi-square test. EPIINFO software, Version 3.2 was used to calculate Chi-square for the linear trend of change in IHD. Binary logistic regression analysis was done between the predictor variable and dichotomous outcomes (ischemic heart disease or not).P<0.01). The highest prevalence of IHD was found in the ≥ 80 years old group (40.0%) and the lowest prevalence was found in the 40–49 year old group (5.4%). The prevalence of symptomatic IHD was 6.4% and that of asymptomatic IHD was 5.2% [P>0.05).Of the 271 individuals age ≥40 years old enrolled in the study, 250 took part in the study. The mean age of the study population was 52.8 years old (+ 12.6). The mean age of males was 54 years old and the mean age of females was 51.5 years old. Among 250 study subjects, 29 (11.6%) had IHD. The prevalence of IHD significantly increased with an increase in age  was higher than Grade 1 (14.4%). Grade 3 hypertension was 6%, Grade 1 isolated systolic hypertension was 5.6%, and Grade 2 isolated systolic hypertension was 2.8% .P<0.01) [P<0.01). The highest prevalence of IHD was found among the severe hypertensive population (26.7%) and the lowest prevalence was found in those patients with normal blood pressure (3.3%). The prevalence of IHD increased with higher BMI (P<0.05). The prevalence was 25% among patients with BMI ≥ 30 and 6.8% among patients with BMI 18.5-23.5.The prevalence of IHD among smokers was higher than among non-smokers (P<0.01) . PrevaleBinary logistic regression analysis shows that 88% of IHD can be explained by predictor variables. Diastolic blood pressure, systolic blood pressure, and smoking habits were significantly associated with IHD, whereas no significant relation was found between age, sex, physical activity, body mass index, or diet habit .This study shows that the prevalence of coronary artery disease was 11.6% in the urban populations, which is lower than the Trivandrum study 13.9%) and the Tirupati study (12.63%). Lower prevalence was reported in Chennai (11%).18 Sex-sp5% and theIn the Jaipur study, a 3.2% prevalence of symptomatic CAD (known coronary artery disease plus Rose-positive angina) was similar to the Delhi survey (3.2%) but higher prevalence (6.4%) was noted in the present study. The SeveThe findings of this study indicate that the prevalence of coronary artery disease and coronary risk factors is high in this urban population in India. Further research is required to document the impact of increased physical activity, change in dietary habit to more quantities of fruits and vegetables and reduced use of poly unsaturated fatty acid, no smoking, and controlling blood pressure and cholesterol as is recommended in the third joint task force guidelines of European and other societies on cardiovascular disease prevention in clinical practice.


Elevated intra-abdominal pressure can cause significant impairment of cardiac, pulmonary, renal, gastrointestinal, hepatic, and central nervous system function. The significant prognostic value of elevated intra-abdominal pressure has prompted many intensive care units to adopt measurement of this physiologic parameter as a routine vital sign in patients at risk. A thorough understanding of the pathophysiologic implications of elevated intra-abdominal pressure is fundamental to 1) recognizing the presence of intra-abdominal hypertension and abdominal compartment syndrome, 2) effectively resuscitating patients afflicted by these potentially life-threatening diseases, and 3) preventing the development of intra-abdominal pressure-induced end-organ dysfunction and failure. The currently accepted consensus definitions surrounding the diagnosis and treatment of intra-abdominal hypertension and abdominal compartment syndrome are presented. Although initially recognized over 150 years ago, the pathophysiologic implications of elevated intra-abdominal pressure (IAP) have essentially been rediscovered only within the past two decades . An explRecently, evidence-based consensus definitions and recommendations for the resuscitation and rehabilitation of patients with IAH and ACS have been published ,20. Cent2O significantly impaired diaphragmatic excursion leading to elevated intrathoracic pressure, respiratory failure, and death [The impact of elevated IAP upon respiratory function was first documented by Marey in 1863 and subsequently by Burt in 1870 . In 1890nd death . The thend death . The detnd death -33. Overnd death . He postnd death . The expnd death -39. Grosnd death .Although surrogate measurement of IAP via measurement of intravesicular, intragastric, and intracolonic pressure in animal models was commonplace in the 1920's and 1930's, it was Söderberg who, in 1970, first described the strong correlation between IAP and intravesicular pressure during laparoscopy in humans . The lanAn increasing body of literature has identified the significant physiologic derangements that occur as a result of elevated IAP. The effects of IAH are not limited just to the intra-abdominal organs, but rather have an impact either directly or indirectly on every organ system in the body. As a result, patients with prolonged, untreated IAH commonly manifest significant malperfusion and subsequent organ failure. Pre-existing comorbidities, such as chronic renal failure, pulmonary disease, or cardiomyopathy, play an important role in aggravating the effects of elevated IAP and may reduce the threshold of IAH that causes the clinical manifestations of ACS. The etiology for the patient's IAH is similarly of vital importance and may be determined as being either intra-abdominal, as occurs in surgical or trauma patients following damage control laparotomy, or extra-abdominal, as occurs in medical patients with sepsis or burn patients who require aggressive fluid resuscitation ,7,43-46.As originally described over 80 years ago by Emerson, rising IAP increases intrathoracic pressure through cephalad deviation of the diaphragm . IncreasParadoxically, intracardiac filling pressures such as pulmonary artery occlusion ("wedge") pressure (PAOP) and central venous pressure (CVP) typically increase with rising IAP despite the reduced venous return and cardiac output ,57,59-64IAH also reduces venous return from the lower extremities functionally obstructing inferior vena caval blood flow by two mechanisms. First, inferior vena caval pressure increases significantly in the presence of IAH and has been demonstrated to parallel changes in IAP ,33,53,56The pulmonary effects of elevated IAP have been recognized for many years ,68,72-74IAH-induced reductions in renal blood flow and function have been demonstrated in both animal and human models ,42,51,77Several mechanisms have been proposed as the etiology for IAH-induced renal dysfunction and failure. Harman et al. negated direct ureteral compression as a cause through studies utilizing ureteral stents . Other aIAH decreases glomerular filtration rate causing a rise in both blood urea nitrogen and serum creatinine and a reduction in creatinine clearance ,48,51,79Of all the organ systems, the gut appears to be one of the most sensitive to elevations in IAP. Such reductions in mesenteric blood flow may appear with an IAP of only 10 mmHg . CaldwelIn addition to reducing arterial blood flow, IAP compresses thin walled mesenteric veins promoting venous hypertension and intestinal edema. Visceral swelling further increases IAP initiating a vicious cycle which results in worsening malperfusion, bowel ischemia, decreased intramucosal pH, feeding intolerance, systemic metabolic acidosis, and significantly increased patient mortality ,50,86,87Hepatic artery, hepatic vein, and portal vein blood flow are all reduced by the presence of IAH ,54,77,912 , and decreased cerebral venous outflow [Cerebral perfusion and function are also directly affected by the presence of IAH. According to the Monroe-Kellie doctrine, the brain consists of four discrete compartments: parenchymal, vascular, osseous, and cerebrospinal fluid. An increase in the pressure within one compartment results in a reciprocal increase in the pressure within each of the other non-osseous compartments. Whereas chronic, slowly developing increases in intracranial pressure (ICP) may allow time for compensation, the acute increases in ICP characteristic of both traumatic injury and acute illness commonly result in rapidly escalating intracranial pressures. Elevations in intra-abdominal and intrathoracic pressure may also directly impact the pressures within the cranium. Coughing, defecating, emesis, and other common causes of increased intra-abdominal and intrathoracic pressure are well known to transiently increase ICP ,93,94. I outflow ,94,97,98 outflow ,97. This outflow . Intrace outflow ,98. Suge outflow . Decreas outflow ,95. Hypo outflow ,95.Although commonly overlooked, the abdominal wall is also subject to the effects of elevated IAP. Visceral edema, abdominal packs, and free intraperitoneal fluid all distend the abdomen and reduce abdominal wall compliance ,100. Abd consisting of European, Australasian, and North American surgical, trauma, and medical critical care specialists. Recognizing the lack of accepted definitions, and the resulting confusion and difficulty in comparing studies published in this area, the WSACS tasked these specialists to create evidence-based definitions for IAH and ACS. After extensively reviewing the existing literature, the authors suggested a conceptual framework for standardizing the definitions of IAH and ACS as well as a general technique for IAP monitoring based upon the current understanding of the pathophysiology of these two syndromes [In 2004, a consensus conference was convened by the World Society of the Abdominal Compartment Syndrome (WSACS) yndromes . A briefThe abdomen may be considered as a closed box with walls that are either rigid  or flexible . The compliance of these walls and the volume of the organs contained within determine the pressure within the abdomen at any given time -104 IAP Analogous to the widely utilized concept of cerebral perfusion pressure, abdominal perfusion pressure (APP), defined as MAP minus IAP, has been demonstrated to be an accurate predictor of visceral perfusion and an endpoint for resuscitation ,105,106.As described above, oliguria is one of the first visible signs of IAH. Inadequate renal perfusion pressure and renal filtration gradient (FG) have been proposed as key factors in the development of IAP-induced renal failure ,108. The2O while subsequent studies using electronic pressure transducers reported IAP in mmHg (1 mmHg = 1.36 cm H2O). This led to confusion and difficulty in comparing studies. A point of further confusion has been the appropriate zero reference point for the abdomen. Changes in body position  can have a significant impact upon the measured IAP. While head of bed elevation is now commonly performed to reduce the incidence of ventilator-associated pneumonia, the clinical studies that determined the threshold IAP values that lead to organ dysfunction were determined in the supine position. Further, the presence of both abdominal and bladder detrusor muscle contractions have been demonstrated to impact the accuracy of IAP measurements. Perhaps the greatest point of contention has been the proper priming-volume to be instilled into the bladder to ensure a conductive fluid column between bladder wall and transducer. Large instillation volumes, as commonly utilized in years past, have been demonstrated to result in artificial increases in IAP that could lead to inappropriate therapy. In an attempt to address these issues and ensure both the accuracy and reproducibility of IAP measurements, the WSACS has recommended that IAP be expressed in mmHg and measured at end-expiration in the complete supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the mid-axillary line [The sensitivity of both clinical judgement and physical examination have been demonstrated to be very poor in predicting a patient's IAP ,110. Earary line . Furtherary line .Normal IAP ranges from sub-atmospheric to zero mmHg ,113,116.2O) as follows: Grade I, 7.5–11 mmHg (10–15 cm H20); Grade II, 11–18 mmHg (15–25 cm H20); Grade III, 18–25 mmHg (25–35 cm H20); and Grade IV, > 25 mmHg (> 35 cm H20) [Pathological IAP is a continuum ranging from mild IAP elevations without clinically significant adverse effects to substantial increases in IAP with grave consequences to virtually all organ systems in the body. The exact IAP that defines IAH has long been debated. Burch et al. defined an early grading system for IAH (in cm H cm H20) . Burch s cm H20) ,118-124. cm H20) ,20. In tAmong the majority of patients, critical IAP appears to be 10–15 mmHg. It is at this pressure that reductions in microcirculatory blood flow occur and the initial signs of organ dysfunction and failure are witnessed. ACS is the natural progression of these pressure-induced end-organ changes and develops if IAH is not recognized and treated in a timely manner. Failure to recognize and appropriately treat ACS is commonly fatal while prevention and/or timely intervention is associated with marked improvements in organ function and patient survival ,125-127.In contrast to IAH, ACS is not graded, but rather considered an "all or nothing" phenomenon. The WSACS defines ACS as a sustained IAP > 20 mmHg (with or without an APP < 60 mmHg) that is associated with new organ dysfunction or failure (Appendix 1) ,20. ACS Elevated IAP commonly causes marked deficits in both regional and global perfusion that, when unrecognized, result in significant organ failure and patient morbidity and mortality. Significant progress has been made over the past decade with regard to understanding the etiology of IAH and ACS as well as implementing appropriate resuscitative therapy. Routine measurement of IAP in patients at risk is essential to both recognizing the presence of IAH/ACS and guiding effective treatment. Adoption of the proposed consensus definitions and recommendations has been demonstrated to significantly improve patient survival from IAH/ACS and will facilitate future investigation in this area.2: fraction of inspired oxygen; PEEP: positive end-expiratory pressure; ICP: intracranial pressure; PAOP: pulmonary artery occlusion pressure; CVP: central venous pressure.IAP: intra-abdominal pressure; IAH: intra-abdominal hypertension; ACS: abdominal compartment syndrome; MAP: mean arterial pressure; APP: abdominal perfusion pressure; FG: filtration gradient; GFP: glomerular filtration pressure; PTP: proximal tubular pressure; PIP: peak inspiratory pressure; FiOFinancial competing interests• Dr. Cheatham has served as a consultant for Kinetic Concepts, Inc., Wolfe-Tory Medical, Inc., and Bard Medical, Inc.Non-financial competing interests• Dr. Cheatham is a member of the World Society of the Abdominal Compartment Syndrome Executive Committee.MLC is the sole contributor to this manuscript.Abdominal distentionElevated IAPOliguria refractory to volume administrationElevated PIPHypercarbiaHypoxemia refractory to increasing FiO2 and PEEPRefractory metabolic acidosisElevated ICPLegend: These represent the most common organ dysfunctions associated with the development of severe intra-abdominal hypertension and a diagnosis of abdominal compartment syndrome.