Introduction. Flow-mediated dilation (FMD), low flow-mediated constriction (L-FMC), and reactive hyperemia-related changes in carotid-to-radial pulse wave velocity (ΔPWVcr%) could offer complementary information about both “recruitability” and “resting” endothelial function (EF). Carotid-to-femoral pulse wave velocity (PWVcf) and pulse wave analysis-derived parameters  are the gold standard methods for noninvasive evaluation of aortic stiffness and central hemodynamics. If healthy pregnancy is associated with both changes in resting and recruitable EF, as well as in several arterial parameters, it remains unknown and/or controversial. Objectives. To simultaneously and noninvasively assess in healthy pregnant (HP) and nonpregnant (NP) women central parameters in conjunction with “basal and recruitable” EF, employing new complementary approaches. Methods. HP  and age- and cardiovascular risk factors-matched NP (n = 22) were included. Aortic blood pressure (BP), AIx@75, PWVcf, common carotid stiffness, and intima-media thickness, as well as FMD, L-FMC, and ΔPWVcr %, were measured. Results. Aortic BP, stiffness, and AIx@75 were reduced in HP. ΔPWVcr% and FMD were enhanced in HP in comparison to NP. No differences were found in L-FMC between groups. Conclusion. HP is associated with reduced aortic stiffness, central BP, wave reflections, and enhanced recruitable, but not resting, EF. Finally, PWVcf was automatically calculated as the quotient between C-F Δx and Δt3  was measured to analyze aortic regional stiffness. To this end, carotid and femoral artery waveforms were consecutively obtained with a high-fidelity applanation tonometer from the carotid and femoral regions simultaneously with continuous ECG monitoring  . Then, clsewhere . Straighand Δt3 . The repAIx@75, adjusted to a rate of 75 beats/minute), and amplification ratio (pPP/cPP) were determined with the integrated software.Pulse wave analysis (PWA) was used to assess central hemodynamics as well as systemic arterial stiffness and wave reflections. For this porpoise, mean radial artery waveform was obtained (through the acquisition of many cycles) with the applanation tonometer from the wrist, and a corresponding mean ascending aortic pressure waveform was generated with a validated generalized transfer function using the same mentioned customized software  . The radZ]), applied to each digitized image . A region 1.0 cm proximal to the carotid bulb was identified, and the far wall CIMT was determined as the distance between the lumen-intima and the media-adventitia interfaces  was calculated relating these measures with central blood pressure as follows ) to brachial mean diameter (Dm) according to the following equations:In addition, Doppler signals were performed to acquire blood flow velocity in baseline conditions and at specific moments during the RH period. Doppler signals were used to obtain the brachial shear stress without accounting for blood viscosity [SR is an estimate ofiscosity  and was x) and the time delay (Δt) between the carotid and radial waveforms onset  by placing them on the skin over the carotid and radial sites (left hemibody). PWVcr was determined taking into account the given distance between these arterial sites  was quantified as follows:P < 0.05 indicates significant statistical differences. Comparisons between pregnant and non-pregnant women were performed using two-tailed unpaired Student t-test. Differences in prevalence were analyzed using χ2 Test with or without Yates's correction if appropriate. Differences in percentage of change of variables determined before and after the VRT  were evaluated using two-tailed paired Student t-test. Linear regression analyses were used to assess relationships between variables.The statistical analyses were performed using the Statistical Package for Social Sciences (version 19.0). All data were expressed as mean value (MV) ± standard deviation (SD) and a P < 0.05).Recordings were successfully obtained from all women and all studies were included in the analysis. The mean duration of the studies was one hour approximately and they were all well tolerated (without symptoms and/or complications). The mean gestational age at examination in HP women was 34.2 ± 3.3 weeks. Demographic, anthropometric, and clinical data are shown in P < 0.05). No pSBP differences were found between the groups. However, in addition to differences in cDBP, significantly higher values in cSBP were evidenced in NP women.Baseline cardiovascular characteristics are given and compared in P = 0.019), whereas amplification ratio was significantly reduced  and PWVcr values were higher in NP compared with HP (P = 0.003). Elastic arteries such as aorta and CCAs were also analyzed by both regional and local arterial stiffness parameters (EP) of both right and left CCA did not reach statistical differences among groups, despite the lower mean values that were found in HP.When analyzing geometrical and biomechanical characteristics of muscular peripheral arteries important differences were found between groups. In concrete, basal brachial SD and DD were significantly increased in HP versus NP (rameters . MeaningP = 0.044).None of the groups presented atherosclerotic plaques. Structural differences were only noticed on the right CCA, where CIMT was significantly reduced in HP with respect to NP women (P < 0.001) . Nevertheless, after cuff deflation, peak SR and ΔSR% were not different between groups , ensuring a similar hyperemic stimulus  evaluated by changes in SR before and after cuff deflation (< 0.001) . Pregnanstimulus . As was P < 0.05) (P = 0.005) and NP . The mean absolute change of the study groups was similar; however PWVcr response in % differed comparing HP women with NP women  (P < 0.001). However, even though maximal vasoconstriction of the brachial artery  was observed in HP women  in comparison to NP , the magnitude of the reduction of arterial diameters was not statistically different between the groups  , despite < 0.05) . One min < 0.05) . L-FMC oe groups .R = 0.54, P = 0.038) and ΔPWVcr% , whereas no significant correlation was evidenced between ΔPWVcr% and L-FMC . A positive correlation between L-FMC (negative number) and basal SR (positive number) was found across the whole studied population .Finally, there were no significant correlations between endothelial function parameters  and AIx@75, PWVcf, or central blood pressure (data not shown). However, FMD correlated with L-FMC  reduced aortic and “upper limb” arterial stiffness levels, in coherence with the higher basal brachial artery diameters that were found in this group; (2) reduced central (aortic), but not peripheral, systolic blood pressure, determined by a reduced contribution of reflected waves to central aortic pressure waveform (lower AIx@75); (3) an enhanced recruitable (FMD), but not resting (L-FMC), endothelial function, despite higher basal brachial diameters.Ep) related with pregnancy were not statistically significant, despite lower mean levels in HP. This finding supports Kärkkäinen et al. report, since these authors evidenced that carotid arterial distensibility (inverse of EP) decreased towards the end of the pregnancy reaching the lowest values in the third trimester [Regarding the hemodynamic parameters, we found that HP women showed, in comparison to controls, increased HR and reduced pDBP and MBP in basal state. These findings are in consonance with an expected pregnancy-induced decrease in peripheral vascular resistance and increased cardiac output at rest. However, pregnancy-related changes were also notable when central hemodynamics is analyzed. Central (aortic) systolic blood pressure and PWVcf (aortic stiffness) were lower in HP comparing to controls, independently of brachial systolic blood pressure levels. In addition, AIx@75, a composite parameter of systemic arterial stiffness and wave reflection amplitude, was different between HP and NP. This suggests that healthy pregnancy is associated with reduced wave reflection contribution to the central aortic pressure waveform and central arterial (aortic) stiffness. However, changes in CCA stiffness (rimester . NeverthP < 0.05). It is noteworthy that both groups showed a similar “endothelial stimulus,” since peak SR and ΔSR% were similar between them. In addition, even though starting  levels of brachial diameter and PWVcr  in HP were higher and lower, respectively, these values were not correlated with the vascular response . When examining the relationship between FMD and PWVcr the analysis should take into account the Moens and Korteweg equation. In that sense, PWV is determined by both arterial diameter and the elastic modulus, among other factors [Among the methods that allow for measurement of endothelial function in the clinical setting, FMD has rapidly gained popularity because of its simplicity, reproducibility, and noninvasiveness , 28. How factors . In a pr factors . In lighTaking into account “resting” endothelial tone, our results show that, during the cuff inflation, L-FMC occurred in the brachial artery independently of the physiological status. However, mean L-FMC was not different between the groups. Although L-FMC was firstly described at the radial artery as a specific phenomenon , in the We found a significant correlation between FMD and L-FMC, FMD and ΔPWVcr%, but not between L-FMC and ΔPWVcr%. Our results indicate that brachial artery responses to inflation and deflation of the cuff related with endothelial dynamics could share some vascular mechanism. However, there are confusing results around the FMD and L-FMC correlation, with variable results depending on the analyzed artery  and type of physiological or pathophysiological circumstance –10, 34. The important additional information brought by the introduction of changes in PWVcr and L-FMC, together with the information of central and peripheral hemodynamics, is that these variables provide information concerning different aspects of vascular reactivity and endothelial function, therefore complementing (and not overlapping) the information provided by FMD. An enhanced response and/or increased vasodilator reserve to changes in blood flow in a concrete vascular ledge  implicates an elevated capability of the arterial system to accomplish an appropriate vascular adjustment against hemodynamic changes in the long term  and even in the short term . In addition, these could be associated with cardiovascular benefits reported by other authors like reduced left ventricle afterload and improve diastolic function and reduced myocardial oxygen demand in the maternal circulation –44. Prevn = 28) of the total sample size (the sum of the sizes of comparison groups) would be required to detect a statistically significant effect of the pregnancy status with at least 80% of power [The sample size of our study was relatively small. However, our findings were statistically significant and, by definition, this indicates that the study was adequately statistically powered. Our technical approaches including the use of both multiple types of automated and semiautomated edge-detection/point software in ultrasound image and pressure wave assessment are largely operator independent and also empower our findings . Given tof power . SecondlThis vascular approach may provide a more comprehensive assessment of vascular state and endothelial function in normal pregnancy. Future studies will have to determine if accounting of this information, particularly during the early stages of pregnancy , in conjunction with recognized important clinical, obstetric, laboratory variables, will be able to improve early detection of pathophysiological circumstances like pregnancy-induced hypertension.With respect to nonpregnant women matched by age, anthropometric features and cardiovascular risk factors, pregnant women showed (1) reduced aortic and “upper limb” arterial stiffness levels, in coherence with the higher basal brachial artery diameters that were found in this group; (2) reduced central (aortic), but not peripheral, systolic blood pressure, determined by a reduced contribution of reflected waves to central aortic pressure waveform; and (3) an enhanced recruitable, but not resting, endothelial function, despite higher basal brachial diameters.


To study the relation between adiponectin level with glycemic control and complication of diabetes.The study included 40 female adolescent type 1 diabetic patients and 40 healthy volunteers of the same age and sex. Blood sample was taken for assessment of glycosylated hemoglobin, lipid profile and adiponectine. Urine sample was taken for assessment of albumin/creatinine ratio.Diabetic patients had a significantly higher diastolic blood pressure, triglyceride, total cholesterol, LDL and adiponectin than controls. Patients with diabetes complication had a significant lower BMI and HDL. On the other hand, they had higher disease duration, total cholesterol, HbA1, albumin/creatinine ratio and adiponectin. Patients with microalbuminuria had a lower BMI, higher disease duration, diastolic blood pressure and adiponectin. Patients with diabetic retinopathy had higher disease duration, insulin dose, HbA1, microalbuminuria and adiponectin. Adiponectin in diabetic patients had a significant negative correlation with BMI and positive correlation with systolic blood pressure and microlabuminuria.Serum adiponectin level is high in adolescent type 1 diabetic girls. It can be used as a predictor of diabetes complications rather than a sensitive biochemical marker for glycemic control. Adiponectin is a member of a group of adipose secreted proteins, sometimes described as adipocytokines. Adiponectin is a plasma protein that has been discovered few years ago. It is produced exclusively and abundantly in adipose tissue and circulates at relatively high concentration . AdiponeThe circulating concentrations of adipocytokines are abnormal in type 1 diabetic children. The direction of change differs according to cytokine, pubertal development; in addition to insulin therapy and glycemic control . The relWe are aiming to determine the influence of adolescent girls with type 1 DM on circulating levels of adiponectin and to study the relation between adiponectin level with glycemic control and complication of diabetes.It is a cross-sectional observational study done after obtaining approval from the ethical committee of the National Research Centre, Cairo, Egypt. It conforms to the provisions of the Declaration of Helsinki (as revised in Edinburgh 2000). Written informed consent was obtained from all patients, their parents and controls after full discussion about the aim of the study.The study included 40 female adolescents with type 1 diabetes mellitus attending the Pediatric Endocrinology Out-patient Clinic, National Research Center, Cairo, Egypt. Patients with type 1 diabetes were defined according to the criteria of American Diabetes Association . AnotherInclusion criteria are type 1 diabetic females on insulin therapy with age between 9-18 years. Exclusion criteria are adolescent girls with other chronic diseases.All included cases were subjected to full medical history taking.2 and plotted on age and sex matched Egyptian standard BMI percentiles [Assessment of anthropometric measures including weight in kilograms (kg), height in centimeters (cm) and body mass index (BMI) was measured as kg/mcentiles .th percentile for age and sex. Blood pressure measurement was repeated twice for the validity of the reading [Measurement of blood pressure (mmHg) was obtained after a 5-minute rest in the seated position using mercury sphygmomanometer. Blood pressure values were considered as hypertension if mean values (systole/diastol) were greater than 90 reading .Clinical examination include: chest, cardiac, abdomen and neurological examination. Neurological examination: Clinical neuropathy was diagnosed in patients with two or more of the following four measures: the presence of one or more symptoms of diabetic neuropathy , the absence of two or more reflexes of the ankle or knee tendons, a vibration perception threshold was abnormal for the patient’s age, and abnormal autonomic function  .Reviewing the records of routine annual fundus was examined by indirect ophthalmoscope through dilated pupils for assessment of diabetic retinopathy. Patient was defined as having diabetic retinopathy if the following diabetic retinal changes were present; micro-aneurysms, capillary leakage, micro-infarcts, macular edema, traction detachment of the macula or vitrous hemorrhage .All patients and controls underwent the following tests: For cholesterol measurements, venous blood was sampled after a 12-h fast. Serum total cholesterol was determined by a commercial kit  . High-deAssessment of glycosylated hemoglobin % (HbA1 %); peripheral blood samples were collected on ethelene diamine tetra-acetic acid (EDTA) (1.2 ng/ml) for assay of HbA1 % using D-10  and reviewing two previous readings to calculate the mean value of HbA1 % in the last year prior to the study . ReviewiStatistical analysis was conducted using Statistical Package for Social Science (SPSS) program version 15.0 . t -test for independent variables was done. Pearson correlation was also done.The study included 40 type 1 diabetic patients, their mean age was 14.4 ± 2.5, mean duration of diabetes was 10.1 ± 2.8 and mean insulin dose was 1.4 ± 0.5 U/kg. Diabetic patients had a significantly higher diastolic blood pressure, triglyceride, total cholesterol, LDL and adiponectin than controls . PatientPatients with microalbuminuria had a lower BMI, higher disease duration, diastolic blood pressure and adiponectin .Patients with diabetic retinopathy had higher disease duration, insulin dose, HbA1, microalbuminuria and adiponectin .Adiponectin in diabetic patients had a significant negative correlation with BMI and positive correlation with systolic blood pressure and microlabuminuria . Six patIn the present study, diastolic blood pressure, cholesterol, triglyceride, LDL-c and adiponectin were significantly higher in diabetic patients than controls. On the other hand CRP as a marker of infection revealed no significant difference in diabetics and controls. Similar other studies have shown that, the absolute concentrations of total adiponectin and all subforms were higher in type 1 DM patients than healthy controls . This inSeveral studies showed that, circulating concentrations of adiponectin are higher in type 1 diabetic patients than in controls, while in type 2 diabetic patients, adiponectin levels are lower than controls , 20. It In the current study, adiponectin had a significant negative correlation with body weight and body mass index (BMI). In the contrary a longitudinal study from Germany showed that children and adolescents with type 1 diabetes have BMI-dependent elevated serum adiponectin compared with healthy children . Other sIn the current study, there was no significant correlation between any of lipid parameters and serum adiponectin level. A study done by Patel et al.,  showed n1 % in type 1 diabetics, so it can be used as a good marker for metabolic state among these patients [1% [In the present study, no significant correlation was found between serum adiponectin and HbA1. Similar finding was demonstrated by a recent study . On the patients . Also otents [1% , 24. A sents [1%  put an eIn the present study, 45 % of our diabetic patients had one or more of diabetic complications . Patients with diabetic complications had a significant lower body weight, BMI and serum HDL. On the other hand, they had a significant higher insulin dose, disease duration, total cholesterol, HbA1, urinary albumin/creatinine ratio and serum adiponectin. This is in agreement with Morales et al., , Galler Patients with microalbuminuria had a significant longer disease duration and higher serum adiponectin level compared to normoalbuminuric patients. This in accordance with Hovind et al.,  who mentIn the current study, 11 patients (27.5%) had diabetic retinopathy. Patients with diabetic retinopathy had a significant higher insulin dose, disease duration, HbA1, urinary albumin/creatinine ratio and serum adiponectin. Chronic hyperglycemia is thought to be the primary cause of diabetic retinopathy, this hypothesis was supported by diabetes Control and Complications Trial (DCCT), which found that intensive insulin therapy, achieving a mean HbA1 % of 7.9 %, reduce the incidence of retinopathy by as much as 76% compared with conventional therapy. The reduction was directly related to the degree of glycemic control as estimated by HbA1 % .Habeeb et al,  and ZietNagaoka et al.,  reportedFinally, serum adiponectin was found to have highly statistically significant negative correlations with weight and BMI in female adolescent with type 1 diabetes. This is in agreement with Kishida et al.  who founWe conclude that serum adiponectin level is high in adolescent type 1 diabetic girls. It can be used as a predictor of diabetic complications rather than a sensitive biochemical marker for glycemic control.


Arterial stiffness of patients with coronary artery disease (CAD), which is expected to be increased due to a generalized atherosclerotic process of human body, may be more evident after the acute increase of blood pressure (BP) or peripheral vascular resistance. Isometric handgrip exercise is a simple and easily applicable method to achieve this goal. We investigated the changes of hemodynamic parameters and arterial stiffness indexes after handgrip exercise in patients with CAD.Forty-two subjects, who underwent coronary angiography (CAG), were enrolled. After CAG, baseline arterial waveforms were traced at the aortic root and external iliac artery using right coronary catheters. Arterial waveforms were recorded at 1, 2, and 3 min in the aortic root and at 3 min in the external iliac artery after isometric handgrip exercise at 30% ~ 40% of the maximal handgrip power. Augmentation pressure (AP) and augmentation index (AIx) were measured at aortic pressure waveforms. Pulse wave velocity (PWV) was calculated using the ECG-gated time difference of the upstroke of arterial waveforms and the distance between the aortic root and the external iliac artery.p < 0.001). PWV also increased significantly after exercise only in patients with CAD .Thirty patients had CAD (CAD group), and others showed no significant coronary stenosis (non-CAD group). Baseline hemodynamic parameters including AIx and PWV were not different between both groups. After isometric handgrip exercise, central systolic blood pressure (BP), central diastolic BP, central pulse pressure, peripheral systolic BP, and peripheral pulse pressure were increased in all patients. AIx inclined significantly from 1 min after exercise only in patients with CAD (before 17.7% ± 9.7% vs. 3 min after exercise 22.3% ± 10.7%, Arterial stiffness indexes at rest were not different between patients with and without CAD. After isometric handgrip exercise, increased arterial stiffness became evident only in patients with CAD. Vascular aging is characterized by the functional and structural changes of the arterial wall, resulting in the increased arterial stiffness. Increased arterial stiffness is associated with the increased systolic blood pressure (BP) but decreased diastolic BP, which causes the widened pulse pressure and the decreased coronary perfusion. Arterial stiffness is known to be a useful marker for predicting the future cardiovascular events, such as myocardial infarction or stroke -4.Arterial stiffness can be invasively or non-invasively evaluated. One commonly used method is measuring pulse wave velocity (PWV) between the aortic root or carotid artery and femoral artery, and increased PWV means stiff arteries . A numbeAnother method to assess the arterial stiffness is the analysis of pulse waveforms of the central arteries. The backward reflected wave from the peripheral arteries as well as the forward wave generated by the left ventricular contraction contributes to the central aortic pressure. As the arterial stiffness increases, the velocities of both forward and backward arterial waves increase, resulting in the earlier arrival of the reflected wave and the augmentation of the aortic systolic BP. This augmentation is expressed as augmentation pressure (AP) or augmentation index (AIx) which is a percentage of AP on pulse pressure . The earIsometric handgrip exercise is an easily applicable maneuver to increase the cardiac afterload ,16. The Patients who underwent the coronary angiography (CAG) for the diagnosis of CAD or follow up after percutaneous coronary intervention (PCI) and agreed to participate in the study were included. CAD was defined as ≥70% stenosis in at least one major epicardial coronary artery or a history of PCI or coronary artery bypass graft. Patients with acute coronary syndrome, left main or three-vessel CAD, or valvular heart disease were excluded. The study protocol was approved by the institutional review board of Jeju National University Hospital. We enrolled 42 patients: 30 patients with CAD (CAD group) and 12 patients without CAD (non-CAD group), and they all signed the informed consents.Before CAG, the maximal voluntary forearm contraction power was measured with a JAMAR dynamometer , and a submaximal target at 30% ~ 40% of maximal handgrip power was used for 3-min isometric handgrip exercise.After routine CAG, baseline arterial pressure waveforms were traced at the aortic root and external iliac artery using a right coronary catheter and a fluid-filled pressure transducer system, and central and peripheral BP were measured from those waveforms. Arterial waveforms were recorded at 1, 2, and 3 min in the aortic root and at 3 min in the external iliac artery after isometric handgrip exercise .Values are expressed as mean ±1 SD. Mean values between two groups were compared by Student’s The mean age of patients of this study was 63.0 ± 9.3 years range: 41–82 years). Age, sex, height, and body mass index were not different between patients with and without CAD  and AIx  were statistically significant. In patients without CAD, AP increased from 1 min after exercise, but AIx did not increase significantly at 1 and 3 min after exercise. At 3 min, AP  and AIx  of patients without CAD had not changed significantly.Maximal handgrip power was not different. Handgrip power at exercise was about 38% of maximal power in both groups and also not different. During isometric handgrip exercise, heart rate, central systolic and diastolic BP, pulse pressure, and forward pressure were increased progressively from 1 min after exercise and reached the maximal level at 2 min in both groups (Table p < 0.001), but PWV of patients without CAD had not changed after isometric handgrip exercise   isometric handgrip exercise is a simple, easily applicable, and safe maneuver to increase the central aortic BP and pulse pressure; (2) PWV and AIx measured at rest may not be useful markers for CAD presence, especially in old aged group; and (3) the acute increase of systolic BP after isometric handgrip exercise may uncover a subtle change of PWV and AIx in patients with CAD.Atherosclerosis is a generalized process of the arterial system, resulting in intimal hyperplasia, plaque formation, narrowing of the internal diameter, obstruction, or decreased compliance. Atherosclerotic change of large arteries such as aorta makes them stiffer. One of the most commonly used methods to evaluate the arterial stiffness is measuring aortic PWV. Aortic PWV is regarded a useful marker for the prediction of future CAD or stroke. One community-based study showed that subjects with the third tertile of aortic PWV had increased risk for CAD with hazard ratio (HR) 2.45 and stroke with HR 2.28 . In the AIx is another useful marker for increased arterial stiffness. In CAD, AIx was also increased, especially in younger patients ,12, and Pinteraction <0.001) [In this study, no differences were found in age, height, smoking, prevalence of hypertension, diabetes mellitus or chronic kidney disease, and medications which may influence PWV and AIx. BP of hypertensive patients was adequately controlled. However, all central and peripheral hemodynamic parameters at rest, including PWV and AIx, were not different between patients with and without CAD Table . Arteria <0.001) . AIx was <0.001) ,12, and  <0.001) ,20.Isometric handgrip exercise is a simple, easily applicable, and safe stress test. During sustained isometric handgrip exercise, heart rate, systolic and diastolic BP, left ventricular systolic and end-diastolic pressure, and cardiac output were increased ,17,21. IThis study has several limitations. First, instead of a catheter with a high-fidelity micromanometer, a fluid-filled catheter was used to record the pressure waveforms. Accurate pressure recording may be blunted in a fluid-filled transducer system. Definite inflection points were not identified in aortic pressure waveforms of four patients (9.5%) in this study, and they were excluded from pulse wave analysis. Second, most of the patients were taking medications with a vasodilating property. These medications might be a cause of no difference in AIx or PWV at rest between patients with and without CAD. It might also influence the response of PWV or AIx during isometric handgrip exercise, but such medications were similarly taken in both groups. Third, poor patient cooperation during isometric handgrip exercise may result in insufficient hemodynamic stress, but all patients had finished 3-min exercise at 30%–40% of maximal handgrip power. Fourth, the number of patients was too small, especially in non-CAD group, and this may result in the similar baseline AIx and PWV. Although statistically not significant, baseline central and peripheral BP was lower in patients with CAD. Because BP is one of the most important determinants of AIx and PWV, this finding may be another cause of no difference in baseline AIx and PWV between two groups.All hemodynamic parameters were invasively measured after CAG. Feasibility of this invasive method in the usual clinical practice is very limited. A future study of measuring central hemodynamic parameters with an applanation tonometry during isometric handgrip exercise may solve this problem.Isometric handgrip exercise is a simple, easily applicable, and safe maneuver to increase the central aortic BP and pulse pressure. Arterial stiffness index such as PWV or AIx at rest was not different between patients with and without CAD, suggesting that PWV and AIx measured at rest may not be useful markers for CAD presence, especially in old age group. After isometric handgrip exercise, increased arterial stiffness became evident only in patients with CAD.


To identify prevalence of previous blood pressure measurement and analyze some associated factors in adolescents. This cross-sectional study included 6,077 adolescents aged 14 to 19 years. Demographic characteristics included  status, history of blood pressure measurement within last 12 months, local of blood pressure measurement, and reading obtained. To assess associations between previous blood pressure measurement with demographic characteristics and high blood pressure we used descriptive statistics and logistic regression analysis. Out of the adolescents, 56.8% reported no blood pressure measurement within the last 12 months. The health centers and the physician’s office were most mentioned places for blood pressure measurement . Boys (odds ratio of 1.64 95%CI: 1.46-1.84) aged 14 to 16 years , whose economic status was unfavorable  were significantly associated with no blood pressure measurement. Working was a protective factor for was not blood pressure measurement . Most of adolescents did not have their blood pressure measured within the last 12 months. Boys aged 14 to 16 years and those with unfavorable economic status had higher chance of not having their blood pressure measured. In this sense, we consider mandatory begin annual blood pressure measurement at 3 years of age, or even before, when the child present early neonatal morbid. The measurement should follow technique and classification parameters adequate to this population age range.8 Other recommendation is routine measurement of blood pressure within school environment.8 However, whether this latter has been put into practice is still unclear.The VI Brazilian Guidelines on Hypertension recommends the early diagnosis,9 illustrated a low frequency of blood pressure measurement (28.6%) among children and adolescents aged 7 to 17 years old. However, because the study was conducted only in the capital of the State, its result cannot be extrapolated for other regions, especially for rural area where differences are seen in access to health services. Other factors associated with blood pressure measurement in adolescents remain unknown, although their identification may help to implement preventive programs for this age range.A previous Brazilian studyTo determine prevalence of previous blood pressure measurement in the last year and analyze some associated factors with this measurement in adolescents.This cross-sectional epidemiological study was part of the project entitled “The practice of physical activities and health-related risk behaviors of high-school students living in the State of Pernambuco: a temporal trend study (2006-2011)”.Universidade de Pernambuco CAAE: 0158.0.097.000-10. The adolescents aged between 18 and 19 years signed the Consent Form, but those under 18 years the signature of Consent Form was requested from a parent or guardian.The study was approved by the Ethics Committee on Research with Human Subjects of the Pernambuco. The State of Pernambuco can be geographically divided into five regions: metropolitan region, Zona da Mata (forest zone), the agreste (arid zone), the sertão (backland) and São Francisco region. These five regions have 658 public high schools administered by the State Government. We used the following criteria to calculate the sample size: estimated population 338,698 (according to data of Pernambuco State Department of Education), confidence interval 95%, maximum error tolerance of 2, effect of sample type of 2, and because it covered the multiple analyses of behavioral the estimated prevalence was defined in 50%. In addition, we included a percentage of 20 for possible losses and/or inappropriate complete of the questionnaire that represented a minimal sample of 5,683 individuals.We included adolescents aged between 14 and 19 years of both sexes who were attending public high school in the State of We used a two-stage conglomerate sampling to guarantee a representative sample of the target population. In the first stage the sample unit was the school, stratified by its size , and then by geographic region. In the second stage, groups were drawn based on shift distribution (morning/evening) and grade. Schools were drawn using random numbers generated in the Statistical Package for Social Sciences (SPSS), version 20.0 .1012 The questionnaire was applied to in the classroom. Members of the study were trained to read questions out loud to participants in order to standardize collection procedures. A copy of the manual was made available to each team to clarify possible doubts.Data was collected between May and December 2011 using the translated and adapted version of the do Global School-Based Student Health Survey proposed by World Health Organization in order to evaluate lifestyle and health risk behaviors in adolescents available at www.who.int/chp/gshs/en. This questionnaire has been widely used by epidemiological studies.Each participant blood pressure measurement (dependent variable) was obtained using the question: “Have you had your blood pressure checked at least once within the last 12 months?”; responses were dichotomous.Associated factors analyzed were local of measurement of blood pressure, high blood pressure and demographic characteristics such as: sex, age, region of residence , work and issues related with economic status.Local of the measurement of blood pressure was obtained using the question: “Where did you have your blood pressure checked?”. This question had the following response options: (1) physician’s office; (2) health unit; (3) school; (4) pharmacy; (5) gym; (6) other place or occasion”.13 and previously calibrated. Before blood pressure measurement we requested participants to avoid vigorous exercise, tobacco use, drink alcohol and caffeinated beverages. During measurement the student should remain in silence, have an empty bladder, be comfortably seated with back supported, and legs uncrossed legs. Cuff size was approved according to arm circumferences of the adolescent; it was placed in right arm, 2 to 3cm above the cubital fossa, at the heart level and palm of the hand turned upward. We performed three readings at intervals of at least 1 minute. The average of last two readings was used to represent the student’s blood pressure.Adolescents were considered hypertensive if their systolic and/or diastolic blood pressure readings were at or above the 95th percentile for the age, sex and height. Blood pressure was measured using digital monitors with automatic deflation (Omron HEM-742), validated by adolescents,14 favorable and unfavorable economic status and high blood pressure.For economical classification, we elaborated a score based on interviewees’ responses. Scores were attributed to housing condition, mother’s formal education level and real and personal property. We considered values 1 or 2; 1 for variables with low impact in economic and health status such as to have a TV, a computer, access to the internet, and 2 points for variables considered basic such as to have a toilet at home, a refrigerator, piped water and mother with more than 8 years of formal education. Based on this score the sample was stratified by medianTabulation of data was performed using the Epi Data 3.1. To detect errors, data were double tabulated and compared through the tool “validate double entry of data” to obtain information about typing errors. All errors were corrected based on the questionnaire.2 test. These analyses investigated possible confusing factors and identified statistical adjustment needed for multiple analyses.The SPSS, version 20.0, was used for analyses and also descriptive statistics procedures (frequency distribution) and association measures (binary logistic regression). The frequency of previous measures with demographic variables and high blood pressure were compared by χWe used binary logistic regression, which was characterized by odds ratio values, to evaluate associations between previous measures of blood pressure, demographic variables  and high blood pressure. All demographic variables with p<0.20 in crude analyses were tested in adjusted model, and remained in the same level regardless of the significance level that was established in 5%.In 2011, 11,849 adolescents were enrolled in 84 schools selected in our study. However, 2,455 of them abandoned the school, 1,866 were absent in the day of data collection, and 333 refused to participate in the study (317 students and 16 parents/guardians). In addition, we excluded participants younger than 14 years old and older than 19 years old (931 adolescents), those who did not follow the recommendation for blood pressure collection or measurement and those who left the questionnaire incomplete (n=187). The final sample included 6,077 adolescents. Their demographic characteristics are shown in Boys from urban area whose economic status was favorable reported to have their blood pressure measured at a physician’s office (p<0.05). On the other hand, older girls from rural area whose economic status was unfavorable often reported to have their blood pressure measured at a health unit (p<0.05).Local where blood pressures were measured according to characteristics of adolescents are shown in In crude analysis, we observed a significant association between no blood pressure measurement and sex, and between work and economic status (p<0.05). However, no significant association was observed among no blood pressure measurement, age range, skin color, region of residence, high blood pressure (p<0.20) and period of study (p>0.20).Adjusted associations among previous measure of blood pressure, demographic variables and presence of high blood pressure are presented in The main results of this study were: (i) more than half of adolescent did not have their blood measured within the last 12 months; (ii) factors associated to high chance of no blood pressure measurement were boys, aged 14 and 16 years, who did not work and had unfavorable economic status; (iii) in 34.7% of reports, blood pressure was not measured by health professionals who could identify hypertension; and (iv) local where the blood pressure was measured seemed to be related with sex, region of residence and economic status.Positive aspects of this research were inclusion of students from both morning and evening periods and rural and urban areas; these facts were presented as limitations in previous studies. Our sample was also representative and included schools throughout the State. This approach enabled not only to be aware about the status of specific region, but also about the status of the State of Pernambuco as a whole.15 including 1,005 adolescents aged 6 to 18 years who had their blood pressure measured within the last year as recommended by health organizations.8 This finding can be explained by inclusion of younger individuals, particularly because blood pressure measurement seems to be significantly associated with age. Other study carried out in the city of Maceió (AL) Northeast Brazil,9 including children and adolescents observed that students who reported to have had previous blood pressure measurement were at an older age range 49%. Additionally, another study16 observed that frequency of blood pressure measurement increased with age and can be related with early appearance of organic disorders because of unhealthy life habits that may also increase the demand for health services among individuals.17 Inclusion of adolescent at an older age range in the job market may also influence the increase of demand for health services because current Brazilian Labor Law encourages periodic health evaluation for employees . Perhaps, this fact explain the reason why adolescents who work are more likely to have had their blood pressured measured.18Results of not measured blood pressured was higher in our study than those reported in a previous investigation conducted in Belo Horizonte (MG) Southeast Brazil,7Other contributing factor for non-incorporation of the blood pressure measurement in the healthcare delivered to younger adolescents is that some procedures are need to guarantee the accuracy of the measurement, such as: choose proper cuff size for the child/adolescent’s arm, use of growth curves to identify height percentile according to age and sex, and percentile identification. These procedures require adequate devices and more time than adult blood pressure reading.Instituto Brasileiro de Geografia e Estatística) including adolescents observed that women mentioned to use health services more frequently than men, regardless of their age.19 This finding can be explained by the number of consultations offered related with maternity or preventive actions for women in healthcare services.Boys had less chance to have their blood pressure measured at least once than girls. A study performed by the Brazilian Institute of Geography and Statistics  compared with users of private health system has 3.8 times less physicians available, and, for this reason, those who can afford private care have more access to medical consultation,21 so that justifying the economic profile of boys who had more access to appropriate healthcare. The high number of boys seeking for medical consultation can be related with health evaluations required for those who work, considering that job positions in Brazil, regardless of the age, are often fulfilled by men.22Boys living at urban area and with favorable economic status mentioned more frequently the physician’s office as the place where they had their blood pressure measured. This finding can be explained by the concentration of physicians’ offices and healthcare professionals in less developed areas.18 based on data from IBGE, that illustrated that services funded by SUS, such as health units, are commonly located outside urban area in order to assist the more underserved population. In our study, as described above, a high demand for preventive health service was observed among women older than 15 years.Older girls living in rural areas and with unfavorable economic status mentioned more frequently the health unit as the place where they had their blood pressure measured. This finding agrees with a previous study,26 In addition, early identification of systemic blood hypertension enables intervention to reduce deleterious effect of hypertension.27Higher levels of blood pressure were not associated with previous blood pressure measurement, therefore, suggesting that adolescents who need more health care attention might not have access to preventive actions such as blood pressure measurement. This is a worrying finding because cardiovascular disease commonly appears early in life.Limitations of this study were the lack of adolescents who were not students and students from private schools. For this reason, a selection biased should not be disregarded, because this lack can be under or overestimated our findings. The use of self-reported information regarding previous blood pressure measurement can also give space for inaccurate information. Another significant factor not included in our study was participants’ medication and medical history, however these two factors may cause confusion in the analysis.Results indicated that most of adolescents did not have their blood pressure measured in the last year before our study. Boys aged 14 and 16 years who were not working, and had unfavorable economic status were more likely to not have blood pressured measured at least once. Higher levels of blood pressure were not significant associated with frequency of blood pressure measurement, and, perhaps is explained for the lack of diagnosis. 1 Além disso, a pressão arterial elevada é o principal fator de risco para doença da artéria coronária e cerebrovasculares.2 No Brasil, a prevalência da hipertensão arterial sistêmica varia de 15,1 a 24,9%,3 e alcança mais de 60% daqueles com idade acima de 60 anos.4No mundo, a pressão arterial elevada é responsável por 7,5 milhões de mortes, o que representa 12,8% do total das mortes anuais.5 Estudos de revisão demonstraram que a prevalência de pressão arterial elevada apresenta grande variação, alçando até 30% em crianças e adolescentes.6 Por isso, o diagnóstico precoce é recomendado pelas VI Diretrizes Brasileiras de Hipertensão,7 por meio da incorporação da medida da pressão arterial como importante componente da rotina pediátrica. Nesse sentido, considera-se obrigatória a medida da pressão arterial a partir dos 3 anos de idade, anualmente, ou antes, quando a criança apresenta antecedentes mórbidos neonatais, utilizando-se técnicas e parâmetros de classificação adequados para essa faixa etária.8 Há ainda a recomendação de realização rotineira da medida da pressão arterial em ambiente escolar.8 Todavia, o quanto essas recomendações têm sido realizadas na prática ainda permanece pouco conhecido.Embora a maior parte dos diagnósticos de hipertensão arterial sistêmica seja firmada na idade adulta, sabe-se que essa doença pode ter início na infância e na adolescência.9 foi observada baixa frequência de medida da pressão arterial  em crianças e adolescentes com idade entre 7 e 17 anos. No entanto, por se tratar de um estudo realizado apenas na capital, não é possível extrapolar os resultados para outras regiões, principalmente do interior, onde geralmente há diferenças em relação ao acesso aos serviços de saúde. Ademais, ainda não se conhecem os fatores associados à medição da pressão arterial nos adolescentes, embora a identificação deles possa fornecer subsídios para a implantação de programas preventivos nesse grupo etário.Em estudo realizado anteriormente,Identificar a prevalência de medida prévia da pressão arterial no último ano e analisar alguns fatores associados a essa medida em adolescentes.Trata-se de um levantamento epidemiológico transversal de base escolar e abrangência estadual, que fez parte de um projeto intitulado “Prática de atividades físicas e comportamentos de risco à saúde em adolescentes do ensino médio no Estado de Pernambuco: estudo de tendência temporal (2006-2011)”.Este estudo foi aprovado pelo Comitê de Ética em Pesquisa com Seres Humanos da Universidade de Pernambuco, CAAE: 0158.0.097.000-10. Os adolescentes com idade entre 18 e 19 anos assinaram o Termo de Consentimento Livre Esclarecido para participar do estudo, enquanto para os menores de 18 anos foi fornecido o Termo de Consentimento Livre Esclarecido para os pais ou responsáveis.A população alvo foi constituída por adolescentes com idades entre 14 e 19 anos, de ambos os sexos, matriculados em escolas da rede pública de Ensino Médio do Estado de Pernambuco. O Estado de Pernambuco pode ser dividido geograficamente em cinco regiões: região metropolitana, Zona da Mata, agreste, sertão e a região do São Francisco. Nas cinco regiões, existem 658 escolas públicas de Ensino Médio pertencentes à rede estadual. Para o cálculo do tamanho amostral, foram utilizados os seguintes critérios: população estimada em 338.698 (segundo dados da Secretaria de Educação do Estado de Pernambuco); intervalo de confiança de 95%; erro máximo tolerável de 2 pontos percentuais; efeito de delineamento amostral de 2; e, por abranger a análise de múltiplos comportamentos, definiu-se a prevalência estimada em 50%. Além disso, foram acrescidos 20% na amostra para possíveis perdas e/ou preenchimento inadequado do questionário, representando uma amostra mínima de 5.683 sujeitos.Statistical Package for Social Sciences (SPSS), versão 20.0 .Para garantir que a amostra selecionada representasse a população alvo, a seleção da amostra foi realizada por meio de conglomerados em dois estágios. No primeiro, a unidade amostral foi a escola, estratificada por porte  e região geográfica; no segundo, foram sorteadas turmas, considerando a distribuição por turno (diurno/noturno) e série. O sorteio das escolas foi realizado por meio de números aleatórios gerados no Global School-Based Student Health Survey proposto pela Organização Mundial da Saúde com o intuito de avaliar o estilo de vida e os comportamentos de risco à saúde em adolescentes, que está disponível www.who.int/chp/gshs/en. Tal questionário já é amplamente utilizado por estudos epidemiológicos.12 Os dados foram coletados entre maio e dezembro de 2011. A aplicação do questionário foi realizada na sala de aula dentro da escola. Todas as questões do questionário foram lidas pelos membros da equipe, os quais foram previamente treinados, visando à padronização dos procedimentos da coleta. Além disso, um manual ficou disponível para cada equipe para eventuais dúvidas.Para a coleta de dados, foi utilizada uma versão traduzida e adaptada do A medida da pressão arterial no último ano (variável dependente) foi obtida por meio da pergunta: “Durante os últimos 12 meses, sua pressão arterial foi aferida (medida) pelo menos uma vez?”, sendo a resposta dicotômica.Os fatores associados analisados foram o local da medida da pressão arterial, pressão arterial elevada e as características demográficas, como: sexo, idade, região de residência , trabalho e questões referentes à condição econômica.O local da medida da pressão arterial foi obtido pela pergunta: “Em que local a pressão arterial foi aferida (medida)?”. Nessa questão, foram dadas como opção de resposta: “(1) consulta médica; (2) posto de saúde; (3) escola; (4) farmácia; (5) academia de ginástica; (6) em algum outro local ou ocasião”.13 previamente calibrados. Para a realização da medida, foi requerido que os adolescentes evitassem a prática de exercício físico vigoroso, fumo e ingestão de bebidas alcoólicas e cafeína. Durante a coleta, era solicitado que os alunos não estivessem com a bexiga cheia, sentassem com o dorso encostado na cadeira, em silêncio e com as pernas descruzadas. O tamanho do manguito foi apropriado de acordo com a circunferência do braço do adolescente, posicionado no braço direito, 2 a 3cm acima da fossa cubital, na altura do coração, com a palma da mão voltada para cima. Foram efetuadas três medidas, com o intervalo mínimo de 1 minuto entre elas, sendo utilizada como a medida da pressão arterial a média das duas últimas medidas.A pressão arterial elevada foi definida como pressão arterial sistólica e/ou diastólica maior ou igual ao percentil 95 para idade, sexo e estatura. A medida da pressão arterial foi realizada por meio de monitores digitais com deflação automática (Omron HEM-742), validados para adolescentes,internet, e 2 pontos para varáveis consideradas de necessidade básica e mais importantes, como possuir, na residência, vaso sanitário, geladeira, água encanada e escolaridade da mãe maior que 8 anos de estudo. Com base nesse escore, foi possível estratificar a amostra pela mediana:14 situação econômica favorável e desfavorável, e a pressão arterial elevada.Para a classificação econômica, foi elaborado, com base nas respostas dos entrevistados, um escore pelos pesquisadores, no qual foram atribuídas pontuações de acordo com as condições de moradia, escolaridade da mãe e posse de bens. Foram atribuídos valores de 1 ou 2, sendo 1 ponto atribuído para variáveis consideradas de pouco impacto na situação econômica e de saúde, como a posse de televisão, computador e A tabulação dos dados foi efetuada no programa Epi Data 3.1. Para detectar erros, os dados foram inseridos por tabulação dupla e foi comparado por meio da ferramenta “validar dupla digitação” do programa, gerando informações sobre os erros de digitação. Todos os erros foram corrigidos com base no questionário.2 foi utilizado para comparar a frequência da medida prévia às variáveis demográficas e a pressão arterial elevada. Essas análises foram realizadas a fim de explorar possíveis fatores de confusão e para identificar a necessidade de ajustamento estatístico das análises múltiplas.As análises dos dados foram efetuadas no programa no SPSS, versão 20.0. Foram utilizados procedimentos de estatística descritiva (distribuição de frequência) e medidas de associação (regressão logística binária). O teste χodds ratio, foi utilizada para avaliar as associações entre a medida prévia da pressão arterial e as variáveis demográficas  e pressão arterial elevada. Todas as variáveis demográficas com p<0,20 nas análises brutas foram testadas no modelo ajustado, permanecendo no mesmo independentemente do nível de significância, que foi estabelecido em 5%.A regressão logística binária, representada pelos valores de No ano de 2011, 11.849 adolescentes estavam matriculados nas 84 escolas selecionadas sorteadas do estudo. No entanto, 2.455 adolescentes abandonaram a escola e 1.866 não estavam presentes no dia da coleta de dados, sendo elegíveis 7.528 adolescentes. Destes, 333 recusaram-se a participar do estudo ; assim, 7.195 adolescentes foram avaliados. Após a exclusão dos respondentes com idade menor que 14 anos e maior que 19 anos (931 adolescentes), dos que não seguiram as recomendações para a coleta da pressão arterial ou não mediram, e os questionários incompletos (n=187), a amostra final foi composta por 6.077 adolescentes. Na A consulta médica foi o local de realização da medida da pressão arterial mais apontado por rapazes, residentes da área urbana e que possuíam situação econômica favorável . Já o posto de saúde foi apontado com mais frequência pelas mulheres, mais velhas, da região rural e com situação econômica desfavorável .Na Na análise bruta, foi observada associação significante entre a não medição da pressão arterial com o sexo, o trabalho e a situação econômica dos adolescentes . Por outro lado, não houve associação significante entre a não medição da pressão arterial com faixa etária, cor da pele, região de residência, pressão arterial elevada  e turno de estudo .Na Os principais resultados deste estudo foram: (i) mais da metade dos adolescentes não foram submetidos à medida da pressão arterial nos últimos 12 meses; (ii) os fatores associados a maior chance de não medir a pressão arterial foram: rapazes, com idade entre 14 e 16 anos, que não trabalhavam e com situação econômica desfavorável; (iii) em 34,7% dos relatos, o local da medida da pressão arterial não ocorreu por profissionais que possibilitassem a detecção da hipertensão arterial sistêmica; e (iv) os locais onde foi realizada a medida da pressão arterial pareceram estar relacionados a sexo, região de residência e situação econômica.Os aspectos positivos desta pesquisa estão no fato de a avaliação ter sido realizada nos períodos diurno e noturno, assim como na região rural e urbana, o que se apresentou como limitações em outros estudos. Além disso, a pesquisa contou com amostra representativa e de abrangência estadual, possibilitando uma visão não só de regiões específicas, mas de todo o cenário do Estado de Pernambuco.15 realizado com 1.005 adolescentes de 6 a 18 anos de Belo Horizonte (MG) na Região Sudeste do Brasil, no qual foi visto que 26,3% dos adolescentes tiveram a pressão arterial aferida no último ano, como recomendado pelas entidades de saúde.8 Isso pode ser explicado pela inclusão de indivíduos mais jovens, visto que a medição da pressão arterial parece estar positivamente associada com a idade. De fato, em estudo realizado na cidade de Maceió (AL), no Nordeste brasileiro,9 com crianças e adolescentes, foi observado que, dos alunos que referiram ter tido a pressão arterial medida previamente, 49% possuíam faixa etária mais elevada. Estudo anterior16 constatou que a frequência de medida da pressão arterial aumenta à medida que aumenta a idade, o que pode estar relacionado com o surgimento precoce de distúrbios orgânicos, advindos de hábitos de vida pouco saudáveis, fazendo com que esses indivíduos aumentem a procura pelos serviços de saúde.17 A inserção do adolescente de maior faixa etária no mercado de trabalho também pode influenciar na procura pelo serviço de saúde, uma vez que as leis trabalhistas atuais incentivam avaliações de saúde periódicas para os trabalhadores (anuais para menores de 18 anos), o que parece explicar o motivo pelo qual os adolescentes que trabalham têm maior chance de medir a pressão arterial.18Os resultados referentes a não medição da pressão arterial no presente estudo foi superior aos achados observados em estudo anterior,7Outro fato que pode ter contribuído para a não incorporação da medida da pressão arterial no atendimento de adolescentes mais jovens é que, para a realização da medida da pressão arterial, são necessários alguns procedimentos para garantir a fidedignidade da medida, como a escolha de manguitos adequados ao braço da criança/adolescente, a utilização de curvas de crescimento para identificação do percentil de altura segundo a idade e o sexo, e a identificação do percentil, o que demanda equipamentos adequados e mais tempo do que a realização da medida em adultos.19 Este fato pode ser explicado pelas consultas relacionadas à maternidade ou a ações preventivas direcionadas a mulher nos serviços de saúde.Foi observado, ainda, que rapazes apresentavam menos chance de medida da pressão arterial comparados às moças. Em pesquisa realizada pelo Instituto Brasileiro de Geografia e Estatística (IBGE), incluindo adolescentes, foi observado que mulheres referem utilizar com mais frequência os serviços de saúde comparadas aos homens, independente da faixa etária.20 com a finalidade de realizar atenção preventiva entre os escolares e, dentre as diversas ações preventivas, a medida da pressão arterial é realizada. Tal programa poderia ser a maneira mais eficaz para as ações de saúde para crianças e adolescentes, uma vez que 95,9% dos adolescentes com idade entre 10 e 14 anos do Estado de Pernambuco estão matriculados, assim como 68,5% dos indivíduos de 15 a 19 anos.19 Todavia, os mecanismos de atenção à saúde precisam ser aperfeiçoados, pois, como pode ser observado, a realização da medida da pressão arterial neste ambiente foi apontada por apenas 3,7% dos adolescentes.Interessantemente, no presente estudo, foi verificado que 34,7% das medidas da pressão arterial não ocorreram em locais que possibilitassem a detecção da hipertensão arterial sistêmica, como em consultas médicas e postos de saúde. Isso sugere que, em sua maioria, nesses casos, o ato de medir a pressão arterial provavelmente não resultou em nenhuma ação específica de saúde, e que crianças e adolescentes ainda são carentes de intervenções preventivas dos serviços de Atenção Primária e Secundária. Recentemente, alguns programas de saúde pública têm surgido com ações direcionadas para atender crianças e adolescentes. Recentemente, foi criado o Programa Saúde na Escola21 Outro fato a ser considerado é que, comparados ao sistema de saúde privado, os usuários do Sistema Único de Saúde (SUS) têm 3,8 vezes menos médicos; com isto, os usuários de serviços privados possuem maior acesso à consulta médica,21 justificando o perfil econômico encontrado. Quanto à procura maior das consultas médicas por adolescentes do sexo masculino, esta pode estar relacionada às avaliações de saúde exigidas aos trabalhadores, uma vez que a maioria dos postos de trabalho, no Brasil, independente da faixa etária, estão preenchidos por indivíduos do sexo masculino.22A consulta médica, como local de medida da pressão arterial, foi referida com maior frequência por rapazes, residentes da área urbana e com situação econômica favorável. Este achado pode, em parte, ser decorrente da concentração de consultórios e profissionais médicos nos centros mais desenvolvidos.18 que, por meio de dados do IBGE, observou que os serviços financiados pelo SUS, como os postos de saúde, estão, em sua maioria, fora da área urbana, atendendo a população mais carente. Neste estudo, conforme já citado, é possível observar uma maior procura dos serviços de saúde por mulheres, na faixa etária maior que 15 anos, para consultas de caráter preventivo.Já o posto de saúde foi apontado com mais frequência pelas mulheres, mais velhas, da região rural e com situação econômica desfavorável. Estes dados estão em concordância com o estudo prévio,2326 Além disso, a detecção da hipertensão arterial sistêmica precocemente permite intervenções que o efeito deletério dessa doença seja minimizado.27A presença de níveis elevados de pressão arterial não foi associada com a medida prévia da pressão arterial, sugerindo que adolescentes que necessitam de maior atenção à saúde podem não ter tido acesso a condutas preventivas, como a medida da pressão arterial. Este achado é preocupante, uma vez que a maioria das doenças cardiovasculares surge justamente nas fases iniciais da vida.O presente estudo apresentou limitações. Não foram incluídos adolescentes que estavam fora da escola e nem aqueles que estudavam em escolas privadas. Assim, não se pode descartar a possibilidade de ter ocorrido um viés de seleção, que pode ter subestimado ou superestimado os valores encontrados. A utilização de informações autorreferidas relacionadas à medida prévia pode ter possibilitado a ocorrência de viés de informação. Também não foi questionado o histórico de consultas médicas e nem o uso de medicações, o que poderia representar fator de confusão nas análises.Os resultados apresentados neste trabalho indicaram que a maioria dos adolescentes não realizou medida da pressão arterial no último ano. Além disso, rapazes, com idade entre 14 e 16 anos, que não trabalhavam e com situação econômica desfavorável apresentaram maior chance de não medir a pressão arterial. Outro achado deste estudo foi que a presença da pressão arterial elevada não representou associação significante com a frequência da medida da pressão arterial; assim, é provável que não tenham tido a possibilidade de diagnóstico.


Remote Ischemic Preconditioning (RIPC) is emerging as a new noninvasive intervention that has the potential to protect a number of organs against ischemia–reperfusion (IR) injury. The standard protocols normally used to deliver RIPC involve a number of cycles of inflation of a blood pressure (BP) cuff on the arm and/or leg to an inflation pressure of 200 mmHg followed by cuff deflation for a short period of time. There is little evidence to support what limb (upper or lower) or cuff inflation pressures are most effective to deliver this intervention without causing undue discomfort/pain in nonanesthetized humans. In this preliminary study, a dose–response assessment was performed using a range of cuff inflation pressures  to induce limb ischemia in upper and lower limbs. Physiological changes in the occluded limb and any pain/discomfort associated with RIPC with each cuff inflation pressure were determined. Results showed that ischemia can be induced in the upper limb at much lower cuff inflation pressures compared with the standard 200 mmHg pressure generally used for RIPC, provided the cuff inflation pressure is ~30 mmHg higher than the resting systolic BP. In the lower limb, a higher inflation pressure, (~55 mmHg > resting systolic BP), is required to induce ischemia. Cyclical changes in capillary blood O2, CO2, and lactate levels during the RIPC stimulus were observed. RIPC at higher cuff inflation pressures of 160 and 180 mmHg was better tolerated in the upper limb. In summary, limb ischemia for RIPC can be more easily induced at lower pressures and is much better tolerated in the upper limb in young healthy individuals. However, whether benefits of RIPC can also be derived with protocols delivered to the upper limb using lower cuff inflation pressures and with lesser discomfort compared to the lower limb, remains to be investigated. Remote Ischemic Preconditioning (RIPC) is emerging as a new noninvasive intervention that has the potential to protect a number of organs against ischemia‐reperfusion (IR) injury. Currently, there is little evidence to support what limb (upper or lower) or cuff inflation pressures are most effective to deliver this intervention without causing undue discomfort/pain in nonanesthetized humans. In this study we have demonstrated that limb ischemia for RIPC can be more easily induced at lower pressures and is much better tolerated in the upper limb compared with the lower limb, in young healthy individuals. Remote ischemic preconditioning (RIPC) refers to the ability of episode/s of sublethal ischemia–reperfusion (IR) in an organ/muscle to confer protection against subsequent lethal IR injury in another or distal organ  were made ischemic for a short period of time by vascular occlusion through inflating and deflating a blood pressure cuff on the limb(s). Typically, 3–4 cycles of cuff inflation/deflation have been used, (involving 5 min of inflation–deflation) using a cuff inflation pressure of 200 mmHg .Six healthy male volunteers  with no known medical problems participated in this study after signing an informed consent. None of the volunteers were on any regular medications. The study was a randomized controlled crossover design.Upon entry to the lab, subjects were asked to rest in a supine position for 10 min before measuring resting blood pressure. Blood pressure (BP) was measured on the right arm using an automatic BP monitor . Three readings were obtained and the average values were used for statistical analysis. Additional BP measures were also taken at the end of the study protocol and 10 min post each RIPC protocol  was used for upper limb RIPC while an automated rapid cuff inflator  with an 8‐inch‐wide cuff was used to induce lower limb RIPC.The study utilized a randomized controlled, crossover design. RIPC was administered to the right upper limb or the right lower limb using cuff inflation pressures of 140, 160, or 180 mmHg, respectively. RIPC comprised of three cycles of cuff inflation each lasting 5 min in duration followed by 5‐min period of cuff deflation. A manual BP cuff (HEINE Gamma XXL LFμL of capillary blood was drawn in heparinized capillary tubes) at the time points shown in the protocol  and CO2 (pCO2), bicarbonate , base excess (BE), oxygen saturation (sO2), and blood lactate levels using a handheld blood chemistry analyzer .Mixed capillary blood was obtained via finger prick (for the upper limbs protocols) and via toe prick (for the lower limbs protocols) prior to RIPC . Subjective pain scores reported by volunteers were also assessed by using a standard (0–10) numerical rating scale (NRS)  was carried out to assess significance of changes in various blood gas parameters as well as in the severity of pain reported by volunteers with RIPC in the upper and lower limb using various cuff inflation pressures. All the statistical analyses were performed with Graphpad Prism 6 . Alpha was set at 0.05 level. All values are expressed as Mean ± Standard Error, unless specified.2. Mean arm circumference was 31.6 ± 1.2 cm, whereas the mean mid‐thigh circumference was 51.8 ± 1.3 cm. This difference in the mean circumference between thigh and arm was statistically significant (P < 0.01).The mean height of the volunteers was 177.4+1.6 cm, the mean weight was 77.6 ± 4.3 kg and the mean BMI was 24.6 ± 1.3 kg/mThe mean blood pressures recorded at baseline, at the end of RIPC and at 10 min into recovery post RIPC are summarized in Cuff inflation pressure of 140 mmHg (Upper limb), caused a cessation of pulsatile arterial blood flow in three of six volunteers during all three RIPC cycles. This was identified through the loss of Doppler signal in the radial artery in the corresponding limb, distal to the site of cuff inflation. At 160 mmHg cuff inflation pressure (Upper Limb), arterial blood flow was successfully occluded during all occlusions in five of six volunteers. At an inflation pressure of 180 mmHg in the upper limb, arterial blood flow was occluded in all three cuff inflations and in all individuals Fig. .In the upper limb complete cessation of blood flow in all of the chosen RIPC cuff inflations was reliably achieved when the occlusion pressure was 30 mm of Hg or more higher than the subjects mean resting systolic pressure.In the lower limb, a cuff inflation pressure of 140 mmHg did not occlude arterial flow in any of the volunteers. Presence or absence of pulsatile flow was assessed in the posterior tibial artery in the lower limb. At 160 mmHg, arterial flow was occluded during all three cuff inflations in only one out of six volunteers. At 180 mmHg cuff inflation pressure, all cuff inflations led to cessation of arterial flow in the limb Fig. .In the lower limb, a cuff inflation pressure approximately 50–55 mmHg higher than the resting mean systolic blood pressure was required to reliably occlude arterial flow distally in the limb.2) and oxygen saturation (sO2).Blood oxygenation was assessed from changes in partial pressure of oxygen (pO2 (%) in the upper limb with each of the three cuff inflations during all three cycles of RIPC at all the cuff inflation pressures  (P < 0.01). In the lower limb, only the highest cuff inflation pressure of 180 mmHg led to a significant reduction in the mean sO2 (%) level in the limb compared with the baseline  levels returned back to baseline after 5 min of reperfusion of the limb after the cuff was deflated. Similarly, significant reduction in the pO2 was noted with each cuff inflation during the three cycles of RIPC at each of the three cuff inflation pressures  in the upper limb (P < 0.01) . While there were comparable significant changes in sO2 and pO2 levels in both the upper and lower limbs with cuff inflation at 180 mmHg pressure, cuff inflation at lower pressures of 140 and 160 mmHg led to significant changes in the upper limb but not in the lower limb.A significant reduction was noted in the mean sObaseline ; Fig. 3. < 0.01) . In the 2 levels at all the cuff inflation pressures assessed (2 levels in the upper limb at the end of the second and the third cuff inflation only. At 160 and 180 mmHg cuff inflation pressures (UL), a significant increase in the pCO2 levels was observed in all cycles of RIPC (P < 0.01). At the end of 5 min of the cuff deflation, pCO2 levels returned back to baseline with the exception of the third cuff inflation at 180 mmHg, where 10‐min recovery time was required before pCO2 levels returned to baseline. In comparison, no significant changes were noted in the pCO2 levels at 140 and 160 mmHg cuff inflations, in the lower limb. At 180 mmHg there was a progressive rise in pCO2 levels with successive cuff inflations, values reaching significance during the second and third cuff inflation (P < 0.01). In the lower limb, the pCO2 levels recovered back to the baseline at the end of 5 min of cuff deflation. Significant effects were observed for “inflation pressure” and “limb” for pCO2 levels (P = 0.0003). In the upper limb, all three cuff inflation pressures led to significant increase in the mean pCO2 levels recorded at the end of 5 min of cuff inflation, while conversely, only the highest cuff inflation pressure was able to induce significant increase in capillary arterial levels of pCO2 in the lower limb.In the upper limb, significant increases were noted in the pCOassessed ; Fig. 4.P < 0.01). Interestingly, none of the cuff inflations in the lower limb at any of the pressures  were able to change the pH significantly from baseline. There was no significant change in the  levels (P > 0.05) or Base excess (P = 0.09) in the capillary arterial blood with cuff inflations at any of the three cuff inflation pressures assessed in either the upper or the lower limb.With regard to changes in pH, there was a significant decrease in the pH of the capillary arterial blood with each cuff inflation at each of the three cuff inflations pressures apart from the first cuff inflation in the upper limb at 140 mmHg (P < 0.01) (P < 0.01).There was a significant rise in the mean capillary arterial blood lactate levels with each of the three cuff inflations at 140, 160, and 180 mmHg cuff inflation pressures ( < 0.01) . In all  < 0.01) ; Fig. 5.P < 0.01) (P < 0.01). In the third cycle of RIPC, there was no significant difference in the pain associated with cuff inflations even at the higher 160 and 180 mmHg inflation pressures.In both the upper and lower limbs, there was a significant increase in the pain score from baseline with all three cuff inflation pressures used for RIPC ( < 0.01) ; Fig. 6.2 (%), pO2 levels and pH in the limb as well as an increase in the levels of CO2 and lactate, but without any change in the base excess or  levels at all cuff inflation pressures in the upper limb. However, in the lower limb, these changes were present to a significant level only at the highest 180 mmHg cuff inflation pressure. Even the highest cuff inflation pressure used (180 mmHg) was not sufficient to cause significant changes in pH in the lower limb. All the changes that were seen during cuff inflation reverted back to baseline with 5 min of limb reperfusion when the cuff was deflated. Therefore, ischemic changes were more easily induced at lower cuff inflation pressures in the upper limb compared with the lower limb. One obvious reason could be the vast difference in the mean limb circumference between the upper and lower limb. The mean arm circumference in our study was 31.6 ± 1.2 cm which was significantly lower than the mean lower limb circumference 51.8 ± 1.3 cm. Hence, in the upper limb the cuff occlusion was resisted by a smaller bulk of muscle/tissue compared with the lower limb.The aim of this study was to assess the dose–response relationship of an increase in the cuff inflation pressure used for RIPC with the physiological changes that occur in the upper and lower limb. In addition, the ability of various cuff inflation pressures to cease pulsatile blood flow in the upper and lower limb as well as the pain/discomfort associated with the respective cuff inflation pressures was investigated. Results showed that cessation of arterial blood flow in the upper limb was achieved in all the cases in our study when the cuff inflation pressure was ~30 mmHg higher than the resting systolic blood pressure. In comparison, in the lower limb arterial flow was only reliably occluded during all RIPC cuff inflations at 180 mmHg which was ~55 mmHg higher than the mean resting systolic pressure. Thus a higher cuff inflation pressure was required to terminate pulsatile blood flow in the lower limb compared with the upper limb. Analysis of physiological changes in the limb during ischemia demonstrated a reduction in sORIPC was better tolerated in the upper limb compared with the lower limb at higher cuff inflation pressures. At the lowest cuff inflation pressure studied (140 mmHg), there was no significant difference in the pain scores reported by the volunteers during any of the three cycles. However, in the first two cycles of RIPC at the higher 160 and 180 mmHg cuff inflation pressures, pain/discomfort associated with RIPC was significantly higher in the lower limb compared with RIPC in the upper limb. Interestingly, in the third cycles of RIPC at these cuff inflations pressures, there was no longer a significant difference in the pain associated with RIPC as there was a progressive reduction in the pain/discomfort perceived by the volunteers with consecutive cycles of RIPC in the lower limb. This is an intriguing finding, though the mechanisms underlying this gradual reduction in the pain/discomfort associated with RIPC in nonanesthetized subjects remains to be investigated. Overall, the present results suggest that limb ischemia for RIPC can be induced in the upper limb at lower pressures compared with the lower limb and that this is better tolerated. However, whether protection against IR injury in the target organs or improvement in athletic performance can also be induced at lower cuff inflation pressures in the upper limb compared with the lower limb remains to be studied. This would be important to study as clearly cuff inflations were better tolerated in the upper limb compared with the lower limb, apart from the extremely low cuff inflation pressure of 140 mmHg which was equally well tolerated in the upper and lower limb.However, these results do highlight that the physiological responses and tolerability of RIPC vary according to the limb and the blood pressure cuff inflation pressure used; thereby demonstrating a need to take these factors into account in designing future RIPC clinical trials. Clearly, further studies are required to directly compare the upper and lower limbs in their ability to deliver the benefits from RIPC. Future research into this subject in a target population using appropriate protection end‐points will help establish effective RIPC protocols that are also the most tolerated.The authors have no conflicts of interest to declare.


Staphylococcus aureus bacteremia (SAB) than patients without CHF due to insufficient cardiovascular responses during systemic infection. We investigated 90-day mortality in SAB patients with and without CHF.Patients with chronic heart failure (CHF) may experience higher mortality of Using population-based medical databases, we conducted a cohort study of all adult patients with community-acquired SAB (CA-SAB) in Northern Denmark, 2000-2011. Ninety-day mortality after SAB for patients with and without CHF was estimated by the Kaplan-Meier method. Based on Cox regression analysis, we computed hazard ratios as estimates of mortality rate ratios (MRRs) overall and stratified by CHF-related conditions , CHF severity (defined by daily dosage of loop-diuretics), and CHF duration while adjusting for potential confounders.Among 2638 SAB patients, 390 (14.8 %) had a history of CHF. Ninety-day mortality was 45 % in patients with CHF and 30 % in patients without CHF, which yielded an adjusted MRR (aMRR) of 1.24 . Compared to patients without CHF, the excess risk of death was most pronounced among patients with valvular heart disease ), patients with daily loop-diuretic dosages of 81–159 mg/day ) and ≥160 mg/day ), and among patients with <3 years of CHF duration ).CA-SAB patients with CHF experienced increased 90-day mortality compared to patients without CHF.The online version of this article (doi:10.1186/s12879-016-1570-7) contains supplementary material, which is available to authorized users. Staphylococcus aureus bacteremia (SAB) continues to be associated with considerable morbidity and a 30-day mortality of 20–40 % in developed countries [ountries , 2. Chroountries . FurtherStill, data on the prognostic impact of CHF in patients with SAB are limited and inconsistent, and to our knowledge no prior prognostic study has addressed CHF as the main exposure in this clinical setting. Previous studies have been restricted by a limited number of SAB patients (N < 400) –9, oftenThis cohort study was conducted using routinely recorded data from population-based medical registries in Northern Denmark between 1 January 2000 and 31 December 2011 (catchment population ~ 1.8 million inhabitants). Tax-supported, unfettered healthcare is provided for the entire Danish population through a national health insurance program , 11. NorS.aureus as the sole isolate . Because recurrence of SAB may affect prognosis [Using the databases of the departments of clinical microbiology within the area, we identified all patients hospitalized with CA-SAB from 1995 onwards. We included patients ≥15 years with ≥1 positive blood cultures with rognosis , we limiCA-SAB was defined as SAB in patients, in whom one or more positive blood cultures had been obtained within the first two days of admission. Patients with a first blood cultured obtained >2 days after admission were excluded, because we consider these infections to be hospital-acquired. Patients with CA-SAB and healthcare contacts recently preceding the current admission were sub-classified as healthcare-associated SAB (HCA-SAB) if one or more of the following criteria were met: ≥1 hospital admission, ≥1 contacts to hospital outpatient surgical clinics (including minor surgery), or ≥1 contacts to clinics of hematology, oncology or nephrology, all within a 30-day window of the current admission.Data on recent health care contacts were retrieved using the Danish National Patient Registry (DNPR) . This rePatients diagnosed with CHF at any time before the current admission were identified from the DNPR . We defiSeverity of CHF is not included in the diagnostic codes in the DNPR. Thus, as a proxy for CHF severity, patients were categorized according to daily dosage of redeemed prescriptions of loop-diuretics: non-users (no loop-diuretics), low dose (≤40 mg/day), medium dose (41–80 mg/day), high dose 81–159 mg/day), and very high dose ≥160 mg/day). We computed mean loop-diuretic dosages by dividing the number of dispensed tablets by a dispensing time interval of 180 days, as described previously , 15. Loo9 mg/day,0 mg/day.Data on sex, age, and marital status was retrieved from the Danish Civil Registration System, which is updated electronically on a daily basis and keeps track of demographic data and changes in vital status and migration for all Danish residents since 1968 , 11. We All patients were followed from the date the first positive blood culture was drawn until death, emigration or 90 days, whichever came first. Patient characteristics  were tabulated according to CHF status. We computed the 90-day mortality risk using the Kaplan-Meier method  and graphically displayed 90-day mortality for patients with and without CHF. Ninety-day mortality rates for patients with vs. without CHF were compared using a Cox proportional hazards model estimating hazard ratios as a measure of mortality rate ratios (MMRs) with corresponding 95 % confidence intervals (CIs). CHF exposure was further subcategorized according to CHF-related conditions, CHF severity and CHF duration. To examine whether mortality differed among subsets of CHF patients, we stratified the analyses by sex, age category , and m-CCI level . All MRRs were adjusted for age, sex, conditions included in the m-CCI, hypertension, alcohol related conditions, marital status (as a marker of socioeconomic status) and preadmission use of antibiotic therapy (within 30 days). The assumption of proportional hazards in the Cox models was assessed graphically and found appropriate. We conducted all statistical analyses using Stata 11.2 for Windows .S.aureus (MRSA) was rarely observed . Patients with CHF had considerably more hospital-diagnosed comorbidity than patients without CHF, including diabetes (31.0 % vs. 12.8 %), chronic pulmonary disease (30.8 % vs. 10.8 %), renal disease (33.3 % vs. 13.6 %), and hypertension (49.5 % vs. 20.4 %). Compared to patients without CHF, patients with CHF were more likely to have filled prescriptions for angiotensin-converting-enzyme inhibitors, beta blockers, acetylsalicylic acid, and statins.During the study period 2638 patients aged ≥15 years were hospitalized with incident CA-SAB, of which 390 (14.8 %) had CHF ) and ≥160 mg/day ), whereas no association was noted among patients with daily intakes of loop-diuretics ≤80 mg/day Table .Table 3NIn this large cohort study of 2638 patients with incident SAB, we observed a 24 % increase in 90-day all-cause mortality associated with CHF. Compared to patients without CHF, the excess risk of death within 90 days was most pronounced among CHF patients with concomitant valvular disease, patients with CHF of less than 3 years duration, and patients with a daily loop-diuretic dosage above 80 mg/day.Our results are in line with the limited existing knowledge on the impact of CHF on mortality in SAB patients –9. In a Several mechanisms may underlie our observations. Myocardial dysfunction is a well-known complication of sepsis , 21. CarOur study has several strengths including its size, population-based design and adjustment for relevant confounders facilitated by our access to medical databases ensuring a complete prescription and hospitalization history. All data was collected prospectively and independently of the study hypothesis, thus reducing the risk of selection and information biases, and follow-up was virtually complete. However, some important limitations should be addressed in the interpretation of our results. Identification of patients with CHF from medical databases may be hampered by inaccurate coding, which would bias our results towards unity. Yet, two recent Danish validation studies reported positive predictive values for chronic heart failure in the DNPR of 81 %  and 100 We used loop-diuretic dosage as a proxy for CHF severity, since we did not have access to data on ejection fraction or New York Heart Association Functional Class among patients with CHF. If some patients used loop-diuretics for other reasons than CHF  this may have led us to underestimate any differences between less severe and severe CHF, although we do not expect this to alter our overall conclusions. Finally, the medical databases did not contain data on smoking and obesity, still these potential confounders may be partly accounted for by adjustment for lifestyle-associated comorbidities included in our statistical models.Due to the low prevalence of MRSA in our study area , these dIn summary, patients with CA-SAB and CHF experienced higher 90-day mortality than patients without CHF, which was most apparent among CHF patients with valvular heart disease, patients with a short history of CHF, and patients with high daily dosages of loop-diuretics. SAB patients with CHF may benefit from the collaborated care of infectious diseases specialists and cardiologists ensuring increased adherence to evidence-based guidelines, optimized post-discharge follow-up and possibly improved clinical outcomes.Staphylococcus aureus bacteremia; CHF, chronic heart failure; CI, confidence interval; DNPR, danish national patient registry; HCA-SAB, healthcare-associated Staphylococcus aureus bacteremia; IQR, interquartile range; m-CCI, modified Charlson comorbidity index; MRR, mortality rate ratio; MRSA, methicillin-resistant Staphylococcus aureus; OR, odds ratio; SAB, Staphylococcus aureus bacteremia.ATC codes, anatomical therapeutic chemical classification system codes; AUPD, Aarhus University prescription database; CA-SAB, community-acquired