Increasing evidence suggests that ABPM more closely predicts target organ damage than does clinic measurement. Future guidelines may suggest ABPM as routine in the diagnosis and monitoring of hypertension. This would create difficulties as this test is expensive and often difficult to obtain. The purpose of this study is to determine the degree to which the BpTRU automatic blood pressure monitor predicts results on 24 hour ambulatory blood pressure monitoring (ABPM).A quantitative analysis comparing blood pressure measured by the BpTRU device with the mean daytime blood pressure on 24 hour ABPM. The study was conducted by the Centre for Studies in Primary Care, Queen's University, Kingston, Ontario, Canada on adult primary care patients who are enrolled in two randomized controlled trials on hypertension. The main outcomes were the mean of the blood pressures measured at the three most recent office visits, the initial measurement on the BpTRU-100, the mean of the five measurements on the BpTRU monitor, and the daytime average on 24 hour ABPM.The group mean of the three charted clinic measured blood pressures (150.8 (SD10.26) / 82.9 (SD 8.44)) was not statistically different from the group mean of the initial reading on BpTRU (150.0 (SD21.33) / 83.3 (SD12.00)). The group mean of the average of five BpTRU readings (140.0 (SD17.71) / 79.8 (SD 10.46)) was not statistically different from the 24 hour daytime mean on ABPM (141.5 (SD 13.25) / 79.7 (SD 7.79)). Within patients, BpTRU average correlated significantly better with daytime ambulatory pressure than did clinic averages . Based on assessment of sensitivity and specificity at different cut-points, it is suggested that the initial treatment target using the BpTRU be set at <135/85 mmHG, but achievement of target should be confirmed using 24 hour ABPM.The BpTRU average better predicts ABPM than does the average of the blood pressures recorded on the patient chart from the three most recent visits. The BpTRU automatic clinic blood pressure monitor should be used as an adjunct to ABPM to effectively diagnose and monitor hypertension. Hypertension is a continuous, independent, yet modifiable risk factor for cardiovascular, cerebrovascular and renal disease. It has been estimated that 62% of cerebrovascular disease and 49% of ischemic heart disease can be attributed to suboptimal blood pressure(BP) control .Since 24 hour ambulatory blood pressure monitoring (ABPM) is currently recommended as the measurement of choice in difficult cases ) -5 it is,Increasing evidence suggests that ABPM more closely predicts target organ damage than does clinic measurement. The Ohsama study found that cardiovascular mortality, but not all cause mortality, was more closely predicted by the daytime systolic blood pressure than clinic pressures . ABPM alMany patients have clinically significant WCE, making clinic measurements an unreliable indicator of true blood pressure control . Future Recently, automatic blood pressure measuring devices have been used either at home or in the clinic setting . It has The purpose of this study is to determine the possible clinical utility of the BpTRU automated blood pressure monitor in the diagnosis and monitoring of hypertension in the primary care clinic setting. Specifically, we set out i) to determine how BpTRU measurements related to ABPM measurements and ii) to determine the level of BpTRU measurement that best predicted a mean daytime blood pressure of <135 mmHG systolic and < 85 mmHG diastolic. The BpTRU monitor has been developed by VSM MedTech Ltd of Vancouver Canada specifically for the clinician's office.The data used in this study is a subset of the data collected for two ongoing RCTs being conducted at the Centre for Studies in Primary Care at Queen's University, Kingston, Ontario, Canada – the Home Monitoring of Blood Pressure Study (ISRCTN25105161) and the Intensive Scheduled Management of Hypertension Study (ISRCTN05874865) which are funded by the Heart and Stroke Foundation of Ontario. A group of 481 subjects for which all relevant data were available were used for analyses of correlations.Subjects were recruited from 51 family practices in eastern Ontario. All patients with a diagnosis of hypertension who were being treated with antihypertensive medications were identified in each practice. Each patient's chart was reviewed to abstract the blood pressures recorded on the patient's chart at the last three office visits where blood pressure was measured. Only one recording was used from any single office visit. If there was more than one recording at a given visit, the last measurement recorded for that visit was used. These visits ranged from several weeks to several months apart, depending on the practice of the physician regarding follow-up of hypertensive patients. If the mean of these three readings, taken at different visits, was ≥140/90, the patient was labeled as 'uncontrolled' by office measurement, meaning that the patient had not achieved the treatment target (≥130/80 was used for diabetics). The research nurse then contacted these uncontrolled patients and invited them to participate in the study. Subjects were excluded if they were <18 years of age, pregnant, or had a known secondary cause for their hypertension.The BpTRU device uses the oscillometric technique used by most ambulatory and home blood pressure measuring devices ,20. It iThe specific steps we used were: i) the subjects were seated for at least 5 minutes, ii) the BpTRU cuff was applied to the non-dominant arm by the research nurse, iii) the initial BpTRU blood pressure reading was taken and recorded, iv) the staff then left the room while the BpTRU device took a minimum further 5 readings at intervals of either one minute or two minutes, v) these five readings were averaged by the device and this average was recorded. The BpTRU device has passed the standards of the British Hypertension Society and the Association of Advancement of Medical Instrumentation ,21.All patients then had ABPM monitoring using oscillometric A&D Model TM2430 equipment . The ABPM equipment was applied at the same visit as the other research measurements. The cuff was fixed to the non-dominant arm and the device was set to obtain automatic readings every 15 minutes during the day 0600–2200) and every 30 minutes at night (2200–0600). This monitoring took place on working days and subjects were instructed to behave and work as usual. The A&D Model TM2430 has been clinically validated according to the British Hypertension Society protocols [00 and evOf the 481 subjects, 210 (43.6 %) were male and 271 (56.3 %) female. The average age was 64.9 (SD 11.59) with a range of 33 to 92 and average BMI was 30.6 (SD 5.22). All but 2 subjects were on antihypertensive medications. In essence, this was a population of treated known hypertensive patients.Table A large proportion of those subjects who had uncontrolled hypertension according to the mean of the three last clinic BPs had lower blood pressure on either or both of BpTRU or 24 hour monitor. In 393 (81.7%) of the 481 subjects the systolic blood pressure was less with the BpTRU than with the clinic readings and in 312 (64.8%) of the 481 subjects the systolic blood pressure was less with daytime ABPM than with the clinic readings. Diastolic pressure similarly decreased in 332 (69.0%) using the BpTRU average and 292 (60.7%) with daytime ABPM. In all, 250 of the 470 (53.2%) were found by BpTRU monitor to have achieved the accepted clinic measurement target of <140/90 mmHG. ABPM revealed that 162 subjects (33.4%) were actually normotensive with a daytime average of <135/85 mmHG.Pearson correlations Table  were calABPM is accepted as the most reliable way to determine if blood pressure targets are achieved in hypertensive patients, but using ABPM after every medication adjustment is impractical and costly. To determine which level of BpTRU blood pressure best predicted achievement of target i.e. <135/85) on ABPM, various prediction estimates  were calculated for different levels of BpTRU readings . Both of these measures, that is, the mean of the last three office blood pressures and the first, observed reading from the BpTRU, were significantly higher than multiple measurements taken when a provider is not present, that is the mean of the five BpTRU measurements and the daytime mean on ABPM. The mean of the BpTRU and the daytime mean on ABPM were not significantly different.Our data suggest that the degree of agreement between the BpTRU and 24 hour ABPM is not sufficient for clinicians to use BpTRU alone to determine if BP targets have been achieved. However, since the agreement between the BpTRU and ABPM is so much better than the usual sphygmomanometer-based, observed, clinic measures, it seems reasonable to use the BpTRU to make treatment adjustment decisions to a predetermined BpTRU level and then confirm it with a 24 hour ABPM. If one considers Table Clinicians should consider treating patients to a level of <135/85 mmHG using the BpTRU or similar automated multiple reading device, and at that point conduct a 24 hour ABPM to confirm that a daytime mean pressure of <135/85 mmHG has been achieved. If it has not been achieved, the clinician should further treat to a BpTRU level of <130/80 mmHG or <125/75 mmHG before re-assessing with 24 hour ABPM.Our data are the best currently available to provide some sense of what a BP target level should be when using the BpTRU in office practice. However there are some limitations. The BpTRU and ABPM were carried out in a research setting not a true clinical setting. All the patients had uncontrolled blood pressure according to office BP measurements, so it does not represent a full spectrum; it does not include normotensive patients or patients where the chart records suggest target has been achieved. The data was collected in the course of another study. There is a need for a study that sets out, a priori, to compared BpTRU with ABPM in the full spectrum of patients, and which follows those patients for a longer term to assess clinical outcomes.The control of hypertension is vital to decrease cardiovascular morbidity and mortality, however the current recommended BP targets are often not being met. There is also growing evidence that office measured sphygmomanometer-based blood pressures are unreliable and do not predict outcomes as well as ABPM, whereas there is increasing evidence from prospective trials that 24 hour monitoring has prognostic significance. We have shown that the BpTRU has potential to be used in the clinic setting to help overcome the difficulties caused by the WCE without the cost of having to conduct frequent 24 hour ABPMs.Although this study demonstrates that the BpTRU has a sensitivity and specificity that are not ideal when compared to the ABPM device we used, it is superior to usual office measurement and can be used by clinicians as part of their strategy for determining whether BP target has been achieved. We suggest that the BpTRU be used to adjust treatment until patient's BpTRU pressure is below 135/85 mmHg and then a 24 hour ABPM be conducted to confirm. ABPM measurement is not practical as a means of monitoring targets after each medication adjustment but in conjunction with the BpTRU can form the basis for clinical decisions that will promote more effective control of hypertension.The author(s) declare that they have no competing interests.LB abstracted the data from the larger baseline dataset from the randomized controlled trials. She analysed the data, did the initial interpretation and wrote the initial draft of the article.MG designed and is conducting the randomized controlled trials from which the data for this study was drawn. He worked with LB on the analysis and the data interpretation and helped with the substantial re-writing of the original draft of the manuscript.The pre-publication history for this paper can be accessed here:


Abstract   Hyperlipidemia  and  increased  degree  of  oxidative  stress  are  among  the  important   risk  factors  for  Atherosclerosis  in  renal  transplant  recipients  (RTR).  The  Medical   treatment of hyperlipidemia in RTR because of drugs side effects has been problematic,   therefore  alternative  methods  such  as  using  of  Garlic  as  an  effective  material  in   cholesterol lowering and inhibition of LDL Oxidation has been noted. For evaluation of   garlic effect on RTR, 50 renal transplant patients with stable renal function were selected   and divided into 2 groups. They took one clove of garlic (1 gr) by chewing or swallowing   for  two months,  after  one month wash-out  period,  they  took  garlic  by  the  other  route.   Results indicated that although lipid profile, BUN, Cr, serum levels of cyclosporine and   diastolic blood pressure did not change, Systolic blood pressure decreased from138.2 to   132.8 mmHg (p=0.001) and Malondialdehyde (MDA) decreased from 2.4 to1.7 nmol/ml   (p=0.009)  by  swallowing  route,  Cholesterol  decreased  from  205.1  to  195.3  mg/dl   (p=0.03),  triglyceride  decreased  from  195.7  to 174.8 mg/dl  (p=0.008), MDA  decreased   from 2.5 to 1.6 nmol/ml (p=0.001), systolic blood pressure decreased from 137.5 to 129.8   mmHg (p=0.001), diastolic blood pressure decreased from 84.6 to 77.6 mmHg (p=0.001)   and  Cr  decreased  from  1.51  to  1.44 mg/dl  (p=0.03)  by  chewing  route  too.   However   HDL,  LDL  and  cyclosporine  serum  levels  had  no  significant  differences  by  both  of   swallowing and chewing routes.   We conclude that undamaged garlic  had no lowering effect on lipid level of   serum. But Crushed  garlic  (chewed)  reduces  cholesterol,  triglyceride, MDA  and  blood   pressure. Additionally creatinine reduced without notable decrease in cyclosporine serum   levels may be due to cyclosporine nephrotoxicity ameliorating effect of garlic. Cardiovascular disease (CVD) is the main cause of morbidity and mortality in renal transplant recipients  and it aPathogenesis of hyperlipidemia in Renal transplant recipients (RTR) is not fully understood, but dosage of steroid, consumption of cyclosporine, anti-hypertensive medication, rising of serum creatinine, proteinuria and diabetes mellitus have been considered .There is increased degree of oxidative stress in RTR . In thesThe medical treatment of hyperlipidemia in transplant recipients is problematic . Bile biGarlic has been used for centuries as an herbal medicine in treating abscesses, cough, poisoning, parasites, worms, digestive and circulatory problems, snake bites  hemorrho50 renal transplant recipients with stable renal function (based on serum Cr<1.8 mg/dl) were selected randomly (hyperlipidemic and normolipidemic) (Table 1). Group A patients took one clove of raw aged garlic (1 gr) by swallowing and group B patients by chewing the same amount. At the start of study we checked their dietary regimen including of: intake of calorie, total fat (TF), saturated fatty acids (SFA), monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA) and cholesterol. We checked also some clinical and Para clinical parameters including of: blood pressure, weight, triglyceride (TG), cholesterol (Chol), low density lipoprotein (LDL), high density lipoprotein (HDL), serum malondialdehyde (MDA), blood urea nitrogen (BUN), creatinine (Cr) and cyclosporine serum level. Patients took garlic for 2 months then we checked above parameters again. After one month wash-out period the patients took garlic by the other route  with the same condition (as a cross over design).Lipid profiles , BUN and Cr were measured by standard enzymatic method, MDA determined by colorimetric method using thiobarbituric acid reactions  and cyclData were analyzed by paired sample t test and Non parametric 2 related sample test using SPSS11.5 program. A difference was considered statistically significant when the P value was <0.05.In this study 2 patient (group A) because of heart burn, 1 patient (group A) because of bloating, 3 patients because of change in drug regimen were excluded (group B) 44 patients continued the study (22 patients in each group).In patients who swallowed garlic, weight, intake of calorie, SFA, MUFA, PUFA had no significant differences but intake of TF and Chol were increased during the study as compared with the pre garlic period. In patients who chewed garlic, weight, intake of calorie did not change however intake of TF, SFA, MUFA, PUFA and Chol increased during the study (table 2) , triglyceride (P = 0.008) and cholesterol (P = 0.04) but not in systolic blood pressure (P = 0.187), HDL (P = 0.925), LDL (P = 0.354), MDA (P = 0.587), BUN (P = 0.657), Cr (P = 0.119) and cyclosporine serum level (P = 0.155). Other data are provided in table3  and total cholesterol were significantly lower (11.5%) with taking 900 mg garlic/day for 12 weeks in hypercholesterolemic men .Tohidi and Rahbani showed that taking 1200 mg garlic powder for 4 weeks reduced total cholesterol (9%), triglyceride (11%), LDL 15%), systolic blood pressure (3%) and diastolic blood pressure (2%) [%, systolSteiner et al with giving 7.2 gr aged garlic extract (AGE) for 4 weeks indicated reduction in cholesterol (6.1%), LDL (4%), systolic and diastolic blood pressure (5.5%) .Issacsohn et al reported that taking 900 mg garlic powder for 12 week did not change in lipid profile .Mader showed that taking 800 mg garlic powder for 4 months reduced cholesterol (9%) and triglyceride (15%) .Lash et al reported that taking garlic tablets at a dose of 680 mg two times a day for 6, 12 weeks decreased LDL (6%) and total cholesterol (4%) significantly in hypercholesterolemic renal transplant patients [Brinker mentioned that Effectiveness might be decreased by garlic's ability to induce metabolism and decrease levels of drugs like cyclosporine which are substrates of cytochrome P450 3A4. It can potentially cause transplant rejection .Blech et al showed progression of atherosclerosis is relevant with oxidative stress and indicated with measurement of MDA .MDA is important marker of lipid peroxidation  and repoIn this study after chewing of garlic, systolic and diastolic blood pressure decreased 5%, 8%, like as Steiner and Tohidi studies. Also cholesterol and triglyceride reduced 4%, 10%, according to Mader and Tohidi studies but less than these studies. Decreased Cholesterol in this study was like as Lash study however he did not report triglyceride reduction after garlic consumption. HDL did not change in all studies. Cyclosporine serum level decreased not significantly in our study and as we known it is the first study which demonstrated the effect of garlic on cyclosporine level in RTR.Ingestion of garlic by chewing (or crushed garlic) can reduce cholesterol, triglyceride, MDA, systolic and diastolic blood pressure even in the presence of increasing fat intake. But undamaged garlic  had no significant effect on serum lipids , diastolic blood pressure, and BUN, Cr and cyclosporine serum level. Our hypothesis is that it is because of inability of Alliin to convert to Allicin. So the specific garlic odor is a hallmark of releasing of Allicin.Acute cyclosporine nephrotoxicity is predominantly functional in that it produces no particular histological features. It is probably the result of renal arteriolar constriction, a feature that has been demonstrated in animals. In chronic cyclosporine nephrotoxicity the principal injury is to the small arterioles where there is vacuolation of smooth muscle and endothelial cells .Reducing creatinine without notable decrease in cyclosporine serum level by chewing of garlic may be cyclosporine nephrotoxicity protecting effect of garlic as its effect on gentamycin nephrotoxicity due to its antioxidant effect  or calciAdditional studies are necessary in order to investigate effect of garlic on cyclosporine serum levels, nephrotoxicity and serum creatinine.In conclusion we found that crushed garlic (chewed) reduced total cholesterol, triglyceride, MDA (lipid peroxidation) and blood pressure that have important role in cardiovascular disease. Therefore garlic consumption can prevent this disease.Table 1Click here for fileTable 2Click here for fileTable 3Click here for file


The European and American guidelines state the need for echocardiography in patients with syncope. 50% of older adults with syncope present with a fall. Nonetheless, up to now no data have been published addressing echocardiographic abnormalities in older fallers.In order to determine the association between echocardiographic abnormalities and falls in older adults, we performed a prospective cohort study, in which 215 new consecutive referrals  of a geriatric outpatient clinic of a Dutch university hospital were included. During the previous year, 139 had experienced a fall. At baseline, all patients underwent routine two-dimensional and Doppler echocardiography. Falls were recorded during a three-month follow-up. Multivariate adjustment for confounders was performed with a Cox proportional hazards model. 55 patients (26%) fell at least once during follow-up. The adjusted hazard ratio of a fall during follow-up was 1.35  for pulmonary hypertension, 1.66  for mitral regurgitation, 2.41  for tricuspid regurgitation and 1.76  for pulmonary regurgitation. For aortic regurgitation the risk of a fall was also increased, but non-significantly . Trend analysis of the severity of the different regurgitations showed a significant relationship for mitral, tricuspid and pulmonary valve regurgitation and pulmonary hypertension.Echo(Doppler)cardiography can be useful in order to identify risk indicators for falling. Presence of pulmonary hypertension or regurgitation of mitral, tricuspid or pulmonary valves was associated with a higher fall risk. Our study indicates that the diagnostic work-up for falls in older adults might be improved by adding an echo(Doppler)cardiogram in selected groups. Falls are a major public health hazard in countries with aging populations. Injury is the fifth leading cause of death in older adults, and most of these fatal injuries are related to falls The main cardiovascular disorders that can cause falls or syncope are orthostatic hypotension, carotid sinus hypersensitivity, vasovagal collapse, cardiac arrhythmias and structural cardiac disease All new consecutive referrals to the outpatient clinic and the Diagnostic Day Center of the Section of Geriatric Medicine at the Erasmus MC of 65 years or older, with a Mini-Mental State Examination score (MMSE) of 21 points or higher (out of 30 points) The only intervention performed during the 3 months of follow-up was withdrawal of drugs known to increase fall risk. This consisted of discontinuation or reduction to the lowest possible dose, where possible, in patients with a history of one or more falls during the previous year. The following drugs were considered for withdrawal, i.e. anxiolytics/hypnotics (benzodiazepines and others), neuroleptics (D2 agonists and serotonin dopamine receptor antagonists), antidepressants , antihypertensives , anti-arrhythmics, nitrates and other vasodilators, digoxin, beta-blocker eye drops, analgesics , anti-cholinergic drugs, antihistamines, anti-vertigo drugs, and hypoglycemics. The objectives, methods and results of this intervention have been described in detail elsewhere Functional status was measured with the Activities of Daily Living scale and the Instrumental Activities of Daily Living scale A fall was defined as coming to rest unintentionally on the ground or at a lower level with or without losing consciousness, but not if this had been induced by acute medical conditions, such as a stroke, or exogenous factors, such as a traffic accident Standard echo/Doppler transthoracic examination was performed using a commercially available ultrasound scanner . Patients were examined in left lateral recumbent position using a standard broadband S4 transducer (2–4 MHz). Echocardiography was performed according to a standard protocol by one trained operator (NV). A second investigator (WF), who was blinded to falls history reviewed all test outcomes and decided on the final scoring.et alStandard images were recorded from parasternal long axis, parasternal short axis and apical 4 chamber, apical 2 chamber and apical 3 chamber views. Systolic left ventricular function was scored both qualitatively and quantitatively. Qualitative scoring was performed visually as either good, fair, moderate or poor. For quantitative assessment, ejection fraction and fractional shortening were calculated from left parasternal long axis 2D-guided M mode measurements Baseline differences between the subgroups with and without fall incidents during follow-up were tested using an independent t-test for continuous variables, and a chi-square test for dichotomous variables.The association between falls during follow-up and cardiac abnormalities was evaluated using a Cox proportional hazards model. First, hazard ratios of events  were computed as estimates of relative risk in a binary fashion . To adjust for possible confounders, cofactors were included one-by-one in the age- and gender-adjusted multivariate model. Cofactors that changed the hazard ratio of a fall incident according to the different echocardiographic abnormalities by more than 5% or that were biologically plausible, and drug withdrawal as defined above, were maintained in the final model. In order to study the association between categories of increasing severity of the valvular regurgitation and risk of a fall, a trend analysis was performed within the Cox proportional hazards model. Thereafter, the variables were treated as categorical variables, in order to get an estimation of the risks for the separate categories of severity of the abnormality. A Kaplan-Meier analysis was performed in order to provide a figure showing the crude survival for the different valvular regurgitations. If numbers were too low in the upper categories, groups were combined in order to get more reliable results, i.e. moderately severe and severe regurgitations were combined to one category: severe. All statistical analyses were performed using SPSS software .During the study period, 350 geriatric outpatients were eligible for inclusion; 132 declined participation, mostly because of the burden of extra visits to the clinic. Patients who refused participation were on average older, used more drugs and had more comorbid diseases. We included 218 patients of whom we were not able to collect data on fall follow-up in 3 subjects: 2 subjects died during follow-up and 1 subject refused further participation during the follow-up period. The remaining 215 subjects were included in the analysis ; Fifty-five patients (26%) fell at least once during follow-up. Baseline characteristics are shown in First, the hazard ratio of fall incidents according to echocardiographic abnormalities was calculated in a binary fashion: relative risk of falls in patients with at least a mild echocardiographic abnormality  compared to patients without or with only a trivial abnormality. For the associations, the following potential cofactors were considered and tested for possible confounding: age, gender, referral for falls, cognitive function (MMSE-score), use of fall-risk-increasing drugs, withdrawal of fall-risk-increasing drugs, use of cardiovascular drugs, withdrawal of cardiovascular drugs, comorbid conditions: total number and separately arthritis, visual abnormality), use of a walking aid, ADL and IADL function, presence of abnormalities on the electrocardiogram, presence of orthostatic hypotension, carotid sinus hypersensitivity, vasovagal collapse, presence of other abnormalities on the echocardiography besides the one under consideration. Our final analysis included age, gender, MMSE-score, number of co-morbid conditions and use and withdrawal of fall-risk-increasing drugs as cofactors. This resulted in a higher risk that was statistically significant for mitral valve regurgitation, tricuspid valve regurgitation and pulmonary valve regurgitation . A statiIn our study, several echo(Doppler)cardiographic abnormalities were risk indicators for falls. First of all, risk of falls was increased if regurgitation of the mitral, tricuspid or pulmonary valve was present. The level of risk increased according to the severity of the regurgitation. Valvular disease is known to cause syncope, the main evidence being for aortic valve stenosis and mitral valve prolapse An increased fall risk was also found for high tricuspid regurgitation velocity and high pulmonary systolic pressure, which was used as a proxy for pulmonary hypertension. Our finding is therefore in line with earlier publications showing a high percentage of pulmonary hypertension in syncope patients Although further research will be needed to confirm our findings and establish the clinical usefulness of echocardiographic screening in older fallers, it is interesting to contemplate on the possible clinical consequences and effects, e.g. treatment and a possible ensuing decrease in fall risk. First of all we want to emphasize the fact that most fall incidents in older persons are of multifactorial origin and therefore treatment of valvular abnormalities will need to be part of a multifactorial intervention. Assuming that there is indeed a causal relationship between falls and valvular abnormalities, care of older fallers may be improved by implementing echocardiography in the clinical work-up for older fallers. However, further research will be needed first to determine the clinical added value of including echocardiography to the falls assessment. Furthermore, the available treatments need some consideration in order to judge the potential decrease in fall risk. Surgical repair might be feasible for a subgroup of geriatric patients. Still, it is likely that the majority will not benefit from such a drastic procedure, partly because their cardiac abnormalities are not severe enough to engage in a surgical procedure and partly because in a fair amount of geriatric patients comorbidity is significant, giving rise to an unacceptably high per-operative risk. Therefore, in most patients diligent review of possible precipitants including tailoring of drug treatments will be the intervention of choice. In case of pulmonary hypertension optimal treatment depends of course on the underlying disorder, but could consist of anticoagulants, optimizing treatment for COPD and other lung disorders including oxygen therapy, a trial period with calcium channel blockers , digoxin, or advanced therapy including prostanoids, endothelian receptor agonists and PDE5 inhibitors. For patients with mitral regurgitation and atrial fibrillation, cardioversion and antiarrhythmic drugs are recommended. Furthermore, in case of mitral regurgitation a reduction of preload with beta-blockers, calcium channel blockers or diuretics can be advantageous, in severe cases vasodilator therapy including ACE inhibitors and angiotensin II receptor blockers may be of benefit. However, data regarding the beneficial effect of long-term vasodilator therapy are conflicting. ACE inhibitors or angiotensin II receptor blockers may be of use in case of comorbity . Besides surgery, cardiac resynchronization may be of use. Reduction of systolic blood pressure is the primary goal in mitral valve prolapse and rheumatic valve disorders, using either beta-blockers, diuretics, hydrazaline or calcium channel blockers. For pulmonary regurgitation and tricuspid regurgitation evidence regarding optimal conservative treatment is limited, but consists of treatment of pulmonary hypertension if present and lowering of the afterload Well-known causes for syncope are aortic valve stenosis and left ventricular outflow-tract obstructions. Contrary to our expectations, an increased fall risk was not found for these conditions. This is most probably caused by the fact that only 20 cases of aortic valve stenosis were present in our cohort, the majority being mild (n = 17) and probably only moderate to severe aortic valve stenosis will result in deficient cardiac output in demanding situations.Our study has some potential limitations. First, in a subgroup of our cohort drugs known to increase fall risk were withdrawn. This intervention was completed after the first month and reduced fall incidence for the intervention group in the second and third month of follow-up Furthermore, we have assessed 9 predefined possible associations, giving rise to the possibility of random error due to multiple testing. However, since the associations in question were all defined a-priori on the bases of a clinical hypothesis and a significant result due to chance (random error) occurs only one in twenty times (using p<0.05) we do not think it likely that our findings were caused by chance.In conclusion, this study has shown that in our cohort of geriatric outpatients there was an increased risk of falls in patients with regurgitations or mitral, tricuspid or pulmonary valves and in patients with pulmonary hypertension. To our knowledge, this is the first study addressing the association between echocardiographic abnormalities and falls in older persons. Our study demonstrates that the incidence of cardiac abnormalities is high and that there is an association between cardiac abnormalities and fall incidents. Therefore, we think that a two-dimensional echo(Doppler)cardiogram might be useful in the diagnostic work-up of selected groups of older fallers. Echocardiographic screening of older fallers can be important for two reasons. First, it can provide a diagnosis in a fair number of cases, and second, it can help select those patients who need careful tailoring of their (drug) treatments. Since this is the first study addressing this topic, more studies will be needed to determine the need for and the yield of standard echocardiography in older fallers.


Cough variant asthma (CVA) is a cause of chronic cough and a precursor of typical asthma. We retrospectively examined the longitudinal change in bronchial responsiveness and cough reflex sensitivity in CVA patients with respect to the effect of long-term inhaled corticosteroids (ICS).Provocative concentration of methacholine causing a 20% fall in forced expiratory volume in one second (PC20-FEV1) and provocative concentration of capsaicin eliciting 5 or more coughs (C5) were measured before treatment and during a follow up period following relief of cough  years after the initial visit) in a total of 20 patients with CVA .Three of 8 patients not taking long-term ICS developed typical asthma compared to none of 12 patients taking ICS (p = 0.0171). PC20-FEV1 significantly (p < 0.0001) increased from 1.80  to 10.7  mg/ml in patients taking ICS but did not change in patients not taking ICS [2.10  compared to 2.13  mg/ml]. Cough threshold did not change in patients whether taking or not taking ICS.Long-term ICS reduces bronchial hyperresponsiveness in CVA as recognized in typical asthma. Cough reflex sensitivity is not involved in the mechanism of cough in CVA. Cough variant asthma is a well-known cause of chronic non-productive cough as well as gastroesophageal reflux-associated cough and post-nasal drip-induced cough .Pathophysiological features of cough variant asthma  appear tJohnson  reportedIn our previous study , long-teAlthough some researchers  reportedWe examined longitudinal changes in bronchial responsiveness and cough reflex sensitivity and influence of ICS on both responses in patients with cough variant asthma. Bronchial responsiveness to methacholine and cough reflex sensitivity to inhaled capsaicin were measured at least two times; at the initial visit and during the follow up period after relief of cough on treatment.Twenty patients with cough variant asthma as a single cause of chronic cough , who had undertaken spirometry, bronchial reversibility test, methacholine provocation test, capsaicin cough provocation test, measurements of peripheral blood eosinophil count, serum total IgE and specific IgE to common allergens, and induced sputum eosinophil count at presentation, were followed up with special emphasis on typical asthma onset during 6 months or more   is desirable because the long-term therapy is recommended by many asthma guidelines in typical asthma even if the disease severity is mild. Long-term treatment with ICS was accepted and taken by 12 patients but not by the other 8 patients.The diagnosis of cough variant asthma was made according to the following criteria proposed by Japanese Cough Research Society , excludi1) Isolated chronic non-productive cough lasting more than 8 weeks2) Absence of a history of wheezing or dyspnea, and no adventitious lung sounds on physical examination3) Absence of post-nasal drip to account for the cough4) Forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio within normal limits 5) Presence of bronchial hyperresponsiveness  <10 mg/mL)6) Relief of cough with bronchodilator therapy7) No abnormal findings indicative of cough aetiology on chest roentgenogramAll patients with cough variant asthma had been successfully treated with bronchodilators and/or corticosteroids, without use of other medications such as proton pump inhibitors and histamine H1-antagonists. Thus, cough variant asthma was the single cause of chronic cough in all patients studied.The efficacy of bronchodilator therapy described above was assessed according to the following criteria:1) "Excellent" when cough totally resolved2) "Good" when sleep and daytime quality of life were improved3) "Fairly good" when severity and frequency of cough were somewhat decreased4) "Poor" when cough was unchangedAn assessment of "Excellent" or "Good" was judged as effective.Pulmonary function, cough reflex sensitivity, and bronchial responsiveness were measured in that order within two weeks of the first visit Table , and theThe onset of typical asthma was defined as wheezing and/or dyspnoeic attack responding to bronchodilator therapy.2 test. Changes within group were assessed using the paired t test. PC20-FEV1 and C5 were analyzed using logarithmically transformed values. A p value of 0.05 or less was considered significant.Data excluding PC20-FEV1 and C5 were presented as mean ± standard deviation (SD). PC20-FEV1 and C5 were expressed as geometric mean value with geometric standard error of the mean. Differences between groups were determined by parametric one-way analysis of variance (ANOVA) or the χTypical asthma onset was recognized in 3 (37.5%) of 8 patients not taking long-term inhaled corticosteroids (ICS) and none of 12 patients taking ICS. The prevalence of asthma onset was significantly (p = 0.0214) different between the groups. Details of the 3 patients who developed typical asthma are shown in Fig. Clinical parameters at initial presentation are summarized in Table PC20-FEV1 significantly (p < 0.0001) increased by 5.9 GSEM, 1.40) times from 1.80 GSEM, 1.35) to 10.7  mg/ml in patients taking ICS, but did not change in patients not taking ICS [by 0.97  times from 2.13  to 2.10  mg/ml]  (Fig. Cough variant asthma was first described by Glauser . The onlNearly 30% of cough variant asthma patients eventually develop wheezing, sometimes severe enough to require continuous treatment with bronchodilators . In thisThe present study clearly showed that bronchial responsiveness did not change after relief of cough without use of ICS, and long-tem ICS attenuated bronchial responsiveness to inhaled methacholine in patients with cough variant asthma, probably resulting in prevention of development of typical asthma from cough variant asthma. There were only 3 patients developing typical asthma whose bronchial responsiveness was more increased among the patients not taking ICS and was not obviously increased after the asthma onset as shown in Fig. It has been shown that early induction of ICS within 2 years following asthma onset is beneficial to achieve both control of symptom and improvement of pulmonary function and bronchial responsiveness in asthma . AlthougAlthough other researchers have reported that cough reflex sensitivity was heightened and recovered to a normal level following successful treatments of cough variant asthma -23, it sEarly induction of ICS within 2 years following asthma onset has been shown to be beneficial in attenuating bronchial hyperresponsiveness as well as achieving both control of symptom and improvement of pulmonary function . In thismay prevent onset of typical asthma from cough variant asthma by reducing bronchial hyperresponsiveness, and that cough reflex sensitivity is not involved in mechanism of cough in cough variant asthma. Further studies including randomized placebo-controlled studies are needed to confirm the preventive effect of long-term ICS on typical asthma onset from cough variant asthma.The present retrospective study showed that bronchial hyperresponsiveness and cough reflex sensitivity did not change after relief of cough when ICS therapy was not taken in patients with cough variant asthma. A median of 2 years ICS treatment attenuated bronchial hyperresponsiveness, but not cough reflex sensitivity. Bronchial responsiveness did not further increase after onset of typical asthma in 3 patients not taking ICS. These findings suggest that long-term ICS treatment ANOVA = analysis of variance, C5 = provocative concentration of capsaicin eliciting 5 or more coughs, CVA = cough variant asthma, FEV1 = forced expiratory volume in one second, FVC = forced vital capacity, GSEM = geometric standard error of the mean, ICS = inhaled corticosteroids, PC20-FEV1 = provocative concentration of methacholine causing a 20% fall in forced expiratory volume in one second, SD = standard deviation,.


Bleeding and rupture of blood vessels has been correlated with weather conditions in the past. This is the first study in the world literature with the aim of investigating the relationship between atmospheric pressure and temperature with the presentation of aortic dissection.The dates of all emergency aortic dissection repairs from 1996–2002 in a regional cardiothoracic unit at Blackpool Victoria Hospital were obtained. Hourly temperature and pressure data from a regional weather station for this time period was supplied by the Meteorological Office. The mean and standard deviation of hourly temperature and pressure data for that month were compared to the mean and standard deviation of the data 24 and 48 hours prior to the aortic dissection.26 patients were found to have been operated on during the time period studied. There was no statistically significant correlation between temperature or atmospheric pressure readings, and the incidence of aortic dissection, using a Bonferonni-corrected significance p-value of 0.005This study is the first to examine the relationship between atmospheric pressure, temperature and dissecting thoracic aorta. No statistically significant relationship was demonstrable. Aortic dissection occurs when there is a defect in the intimal layer of the aorta. This causes blood to track through the aortic layers, creating a false lumen between the intima and the overlying adventitia, tending to obliterate the blood supply to branches along its route. The dissection may spread distally to involve the renal, spinal and iliac arteries, or proximally to involve the head and neck vessels, coronary vessels, or aortic root. Once the dissection has occurred it can rupture into the main lumen itself, in which case the patient may survive for some time, or rupture externally leading to haemorrhage and potentially a rapid death.The known risk factors for aortic dissection are male sex, hypertension, atherosclerosis, diabetes, hyperlipidemia, smoking, syphilis, Marfan's disease, and Ehlers-Danlos disease. In a large series of necropsies of acute aortic dissections more than 40% of patients with proximal dissection died immediately, the rate of death ranged between 1 and 3% per hour. Within 24 hours 70%, within 1 week 94% and within 5 weeks 100% of people with proximal aortic dissection died [The aetiology of an acute aortic dissection remains poorly understood. It is thought that the moment of dissection may be precipitated by higher than normal blood pressures, and it has been postulated that variablilty of atmospheric pressure may add to this. There is also a seasonal variation in blood pressure ,4 and itPrevious work has observed an increase in ruptured abdominal aortic aneurysms (AAA) in winter , and a cThere have been no previous studies specifically investigating the relationship between weather conditions and the incidence of thoracic aortic dissection. Considering the similarity in seasonal incidence between AAA rupture and aortic dissection, we aim to explore whether there is an association between atmospheric pressure, temperature, and the presentation of aortic dissection.Hospital records were used to identify all emergency aortic dissection repairs between 1996 and 2002 in a regional cardiothoracic unit at Blackpool Victoria Hospital. Data was available from the cardiothoracic minimum dataset, and cases were confirmed by reference to the hospital notes. Ethical approval was obtained to use this data. Temperature and pressure recordings from a nearby regional weather station were obtained for this time period from the United Kingdom Meteorological Office. Blackpool cardiothoracic unit receives referrals from northern Lancashire, and Crosby is the weather station closest to the centre of the unit's catchment area.The meteorological data used was hourly temperature measurements and hourly atmospheric pressure measurement for a full month centred on the occurrence of each aortic dissection.Using the meteorological data, the following temperature indicators were calculated Table :The following pressure indicators were also calculated Table :Indicators were then paired for comparison using each set of monthly data against the corresponding data from 48 hours, and then 24 hours before the operation. The null hypothesis was that there were no differences within each pair of indicators. These hypotheses were tested using paired t-tests and Wilcoxen signed rank tests (depending on the distribution of the data).The Bonferroni correction is a statistical adjustment to allow for multiple comparisons. A Bonferroni correction was applied by dividing the p-values by the number of outcomes being tested. In this study we have made 10 comparisons between indicators, and have therefore used α = 0.005 for hypothesis testing. The null hypothesis was therefore rejected for p values ≤ 0.005, and the probability of making a Type I error therefore 0.05.Data for 26 consecutive operated dissecting aortic aneurysms were obtained for the study time period. Results for the temperature indicators and atmospheric pressure indicators including comparisons between pairs are shown in Table Table The distribution of dissections through the year is represented in Figure Figure Aortic dissection is a condition that presents infrequently to hospitals and is sometimes initially misdiagnosed. Increasingly as hospitals and sub-speciality departments merge to form larger institutions, they will cover a greater population, and the incidence in hospitals will apparently rise.In our study the most significant result (p = 0.022) showed a trend towards the standard deviation of pressure in the 48 hour period prior to the dissection, being greater than the standard deviation of pressure for that whole month (2.73 vs. 2.22 millibars). This did not reach statistical significance however, after the Bonferroni correction has been applied.The pressure range was calculated by subtracting the lowest from the highest reading of the day. The mean pressure range for the whole month (6.99 millibars) had a trend towards being lower than the mean 48 hours before dissection  and 24 hours before dissection . This was not statistically significant.The incidence of aortic dissection had no seasonal or monthly correlation. This is demonstrated by the bar chart Figure . Other sPrevious work has shown that the only physiological parameter positively associated with atmospheric pressure is arterial blood gas concentrations . HoweverThe analysis in our study involved using accurate meteorological data and operation dates from a regional cardiothoracic centre covering a large geographical area. Despite careful methodology there are potential errors that must be remembered. The weather station, although centrally placed over the catchment area, may not have reflected the patients' movements over the region in that time period and does not account for weather variations over an area 50 miles in diameter.There is also likely to be variability in the timing of presentation. Some patients may have begun aortic dissection a long time prior to presenting to hospital and a tamponading effect may have slowed the progression of collapse. We have attempted to account for this by looking at weather data in both the 24 and 48 hour time periods prior to the day of operation. It may be that a sudden change in the indicator being examined between 48 and 24 hours prior to dissection may be related to the onset of dissection.Only patients who had surgery were included in this study and there are undoubtedly others who either did not survive long enough to have surgery or who were managed without surgery. It is presumed that the inclusion of these patients would not have changed the trends obtained in relation to weather conditions. In practice this study may not have any immediate applications to alter clinical practice, but serves to further elucidate the complex aetiology of a rare and sometimes lethal condition.This study is the first to examine the relationship between atmospheric pressure, temperature and dissecting thoracic aorta, and was unable to demonstrate any statistically significant relationship.The author(s) declare that they have no competing interests.CR and NC drafted the manuscript. CR conceived the study. Statistical analysis was performed by ED of the statistics department (see acknowledgements). CR and NC participated in its design and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Lipid profile disturbances could be due to internal desynchronization. The aim of this study was to analyze whether there is relationship between shift work and serum lipids, fasting blood glucose and hypertension.2 and fisher's exact test was used for comparing the qualitative variables and for quantitative variables with normal distribution we used the parametric tests. Odds ratio (OR) with the 95% confidence interval (95% CI) was used for comparing the proportions of risk variables.A total of 424 rail road workers between the ages of 21 and 64 years in this study filled out a questionnaire, and total cholesterol, triglyceride and HDL-C concentration were measured after 12-hours fasting. Association between shift work and biochemical variables and blood pressure were measured. The XSub-populations in this study were consisting of 158 (37.3%) shift workers and 266 (62.7%) day workers. High levels of total cholesterol (> 200 mg/dl) and LDL-cholesterol (> 130 mg/dl) were significantly more prevalent in nearly all groups of shift workers irrespective of age. But there is no differences in the serum levels of triglyceride, HDL-C, fasting blood glucose and blood pressure between shift workers and day workers.Adjusted Odd's ratio for the effect of shift working on high serum total cholesterol and LDL-C level were 2.11(95%CI: 1.33–3.36) and 1.76(95%CI: 1.09–2.83), respectively.This study showed that high serum total cholesterol and LDL-C level were more common in shift workers than in day workers. This finding persisted after adjustment was made for age and food type. But there was no difference in the prevalence of HDL-C, triglyceride, fasting blood glucose and hypertension between shift working and day working. It was concluded that shift work is a risk factor for lipid profile disturbances. Broadly defined, shift work involves work at times other than normal daylight hours of approximately 7:00 A.M, to 6:00 P.M. because 24-hours operations are an inevitable component of numerous industries, night work or shift work is a necessary condition of employment for a significant segment of the work force. Critical 24-hours operations include police and fire protection, medical care, transportation, communication, and energy and water utilities. Other industries require continuous processing or operate around the clock to optimize capital investment in machinery and other production materials.Estimates of the number of person doing shift work range from 10% to 25% of all those employed. Almost all occupations or industries have employees engaged in shift workBecause of the necessity of 24-hours operations, shift workers often live at variance with the conventional pattern of human activity, which is highest in the day and evening hours. These deviations from the daytime  activity pattern place the shift worker in opposition to many human functions that oscillate within a 24-hours period. Physiologic process (e.g. metabolic rate), psychological process (e.g. short term memory), and social process (e.g. family interaction) all have demonstrated rhythmic increases and decreases in daily activity. These patterns are called circadian rhythm because they cycle about once a day. When working at night and sleeping during day these circadian rhythms move about even after weeks of night work no complete adjustment of the rhythms are made. The single rhythm moves at its own pace and several rhythms may come in disharmony with each other or the surrounding. This is labeled internal desynchronizatin .Also lipids have a circadian rhythm. And in day orientation the circadian variation  was 5.6% for HDL/total cholesterol ratio, 30.5% and 31.6% for HDL and total cholesterol, 33.5% for LDL and 38.5% for triglycerides. These cThere is also a yearly rhythmicity, cholesterol and LDL-cholesterol being up to 3–5% higher in winter (cold period), while HDL and triglycerides are modestly changed .Working irregular hours, including night work and shift work, has been found to be associated with higher levels of lipid ,6,18. InThe aim of the present epidemiological study was to investigate whether shift work is associated with lipid disturbances, fasting blood sugar and hypertension.The mean age of the shift workers was 46.40 ± 7.68 years old and day workers was 38.69 ± 9.75 years old.The mean duration of job experience of the shift workers was 21.13 ± 7.42 years and day workers was 14.53 ± 9.21 years. Table The total cholesterol > 200 mg/dl and LDL-C> 130 mg/dl were more prevalent in shift workers  than day workers .The prevalence of Fasting blood glucose ≥126 mg/dl was 3.2% in shift workers and 3% in day workers and for HDL-C< 45 mg/dl, Triglyceride> 200 mg/dl, Hypertension ≥140/90 mmHg and Body mass index (BMI) ≥30 in shift workers were 53.8%, 49.4%, 17.1%, 39.9% and in day workers were 60.6%, 49.2%, 11.7%, 41.3%.Table The results of relative risk were crude OR: 2.51 (95% CI: 1.64–3.83) and Adjusted OR: 2.11 (95% CI: 1.33–3.36) for total Cholesterol, crude OR: 1.75 (95% CI: 1.14–2.68) and Adjusted OR: 1.76 (95% CI: 1.09–2.83) for LDL-C, crude OR: 0.75 (95% CI: 0.50–1.12) and Adjusted OR: 0.91 (95% CI: 0.58–1.42) for HDL-C, crude OR: 1.00 (95% CI: 0.67–1.49) and Adjusted OR:1.25 (95% CI: 0.80–1.95) for Triglyceride, crude OR: 1.04 (95% CI: 0.33–3.25) and Adjusted OR: 1.2 (95% CI: 0.33–4.32) for Fasting blood glucose, crude OR: 1.41 (95% CI: 0.80–2.50) and Adjusted OR: 0.73 (95% CI: 0.38–1.39) for Hypertension.This study showed that high serum total cholesterol and LDL-C level were more common in shift workers than in day workers. This finding persisted after adjustment was made for age and food type. Our results are in agreement with the results in previous studies . But othLennernas et al documented that dietary intake is lower during night shift than during morning and afternoon shifts. According to them, the redistribution of food intake from diurnal eating to nocturnal eating is related to serum total cholesterol, LDL- cholesterol. Even if the dietary intake and quality are similar in day workers as well as shift workers, there are still differences in eating habits that might contribute to differences in levels of serum lipids .We found no differences in the prevalence of hypertriglyceridemia when comparing shift workers and day workers. But previous studies have been shown high serum triglyceride levels to be more prevalent among shift workers than the day workers -11,14,17In our study, there was no difference in the prevalence HDL-cholesterol level between day workers and shift workers, so this results in agreement with the results in previous study ,11. But We found no difference in the prevalence of hypertension when comparing shift workers and day workers. These results are consistent with previous study . But oneWe didn't find difference in the prevalence of hyperglycemia between shift and day workers, so this result in agreement with the result in previous study .On the basis of study by our group and other, it is recommended that in every work place where shift work is mandatory, a chronoclinic should be established. Trained health care personnel of the chronoclinic should monitor intermittently  the state of the biological clock (synchronized or desynchronized?) of each shift worker. Upon discovering rhythm desynchronization his/her transfer from shift work to day work for at least one year should be recommended to the employer/management. This would perhaps real out the possibilities of ill-effects of shift work that are expected to be impinged upon the workers.It has been proposed that while examining tolerance/in tolerance of a shift worker to rotational shift work, the levels of anxiety and mental health status of the individual under careful and thorough examination should be taken into consideration. Sleep-wake disorder is another important variable that cannot be simply ignored while ascertaining intolerance to shift work.In addition appropriate chronotherapy should also be administered in to intolerant shift workers while they are being transferred from shift duty to day duty.All these counter-measures, either individually or in combination may improve the coping ability of shift workers thus minimizing the occupational health hazards and maximizing their performance. This would substantially increase the productivity of the organization for which they are working.Among a cross-sectional study, a total of 424 male railroad workers filled out a questionnaire with questions about working condition, smoking habits, diet, level of physical activity, and family history of hypertension, diabetes, hyperlipidemia, and hypothyroidism. These subjects were all workers of repair workshops.2). Those with a BMI of 30 or more were classified as obese.Shift workers were defined as work at times other than normal daylight hours of approximately 7:00 AM to 6:00 PM or work during the weekends. Blood pressure was measured in the sitting position after 5 minutes rest. Hypertension was defined as having a systolic blood pressure of 140 mmHg or more, or a diastolic blood pressure of 90 mmHg or more and answering yes about being on antihypertensive medication. Body weight was measured in light indoor clothing and recorded to the nearest Kg. height was measured to the nearest centimeter without shoes. Body mass index (BMI) was calculate as weight (Kg) divided by height squared . Serum samples from cases and controls were always analyzed in the same run. The within-assay coefficients of variation were 1.3% for TG, 1.9% for cholesterol, 1.1% for LDL, 1.4% for HDL and 0.8% for FBS. Triglyceride value >200 mg/dl, HDL-cholesterol <45 mg/dl, Cholesterol >200 mg/dl, LDL>130 mg/dl were defined as lipid disturbances.The study was conducted on an outpatient basis according to the principles of the Declaration of Helsinki and was approved by the medical ethics review board of the Endocrinology and Metabolism Research Center (EMRC) of Tehran University of Medical sciences (TUMS). Informed consent was obtained from all volunteers after oral and written information had been given.2 and fisher's exact test were used for comparing the qualitative variables and for quantitative variables with normal distribution we used the parametric tests. Odd's ratio (OR), and 95% confidence interval (95% CI) was used for estimating the effect of shift working on lipid profile, hypertension and high blood glucose levels. Logistic regression modeling was used for multivariable analysis and adjusting the effect of different variables The SPSS software version 11.5 and STATA version 8 were used. For statistical analysis the XBP = blood pressure, BMI = body mass index, CHOL = cholesterol, HDL-C=high density lipoprotein-cholesterol, LDL-C = low density lipoprotein-cholesterol, TG = triglycerideMG, RG participated in the design of the study and performed the data collectionRH, RG performed the statistical analysis, interpretation of dataVH, RH conceived of the study, and participated in its design and coordinationMG drafted the manuscriptVH, AS, PS, SMT revising it critically for important intellectual contentBL final approval of the version to be publishedAll authors read and approved the final manuscript


While we have international guidelines and various national guidelines for asthma diagnosis and management, asthma remains poorly controlled in many children and adults. In this paper we review the limitations of current asthma guidelines and describe important issues and remaining questions regarding asthma guidelines for use, particularly in primary care.Clinical practice guidelines based on evidence from randomized controlled trials are considered the most rigorous and accurate. Current evidence-based guidelines are written predominantly from the perspective of the patient with a clear-cut asthma diagnosis, however, and tend not to consider the heterogeneity of asthma or to accommodate individual patient variations in response to treatment or their needs, differences in practice settings, or local differences in availability and cost of therapies. The results of randomized controlled trials, which are designed to establish efficacy of treatment under ideal conditions, may not apply to 'real-world' clinical practice, where patients are unselected, monitoring is less frequent, and effectiveness – the benefit of treatment in routine clinical practice – is the most relevant outcome. Moreover, most guidelines see asthma in isolation rather than considering other factors that may impact on asthma and response to asthma therapy, particularly age, allergic rhinitis, cigarette smoking, adherence, and genetic factors. When these links are recognized, guidelines rarely provide practical recommendations for treatment in these scenarios. Finally, there is some evidence that general practitioners are not convinced of the applicability of asthma guidelines to their practice settings, especially when those writing the guidelines principally work in specialist practice.Developing country-specific guidelines or, ideally, local guidelines could provide more practical solutions for asthma care and could account for regional factors that influence patient choice and adherence to therapy. Pragmatic clinical trials and well-designed observational trials are needed in addition to randomized controlled trials to assess real-world effectiveness of therapies, and such evidence needs also to be considered by guideline writers. Finally, practical tools to facilitate the diagnosis and assessment of asthma and factors responsible for poor control, such as associated allergic rhinitis, limited adherence, and smoking behavior, are needed to supplement treatment information provided in clinical practice guidelines for asthma. Asthma is estimated to affect 300 million people worldwide, with an expected increase to 400 million worldwide by 2025 ,2. A chrThe systematic establishment of a thorough evidence base is currently considered the most rigorous and accurate means to develop clinical practice guidelines ,7. DevelThe Global Initiative for Asthma (GINA) was first launched in 1993 as a program to reduce asthma prevalence, morbidity, and mortality in collaboration with the World Health Organization and the National Heart, Lung, and Blood Institute of the National Institutes of Health in the United States. GINA has published evidence-based asthma guidelines since 2002 . These gOther examples of English-language, strict evidence-based guidelines are the British Asthma Guidelines, which were revised most recently in November 2005 and are available on the Scottish Intercollegiate Guidelines Network website , and theClinical practice guidelines are by their nature general recommendations aimed for broad applicability in the clinical setting. Applicability, however, is limited by several factors. One of the challenges to the daily use of current asthma guidelines by physicians is that these guidelines tend to be disease-oriented, not patient-oriented. Guidelines are written not from the perspective of the patient who comes to the physician's office with symptoms, but rather from the perspective of the patient with a clear-cut asthma diagnosis. Symptom-based guidelines are needed . In addiIn addition, clinical practice guidelines for asthma tend not to consider the heterogeneity of asthma or to accommodate individual patient variations in response to treatment or their needs, differences in practice settings, or local differences in availability and cost of therapies. Guideline recommendations are generally made on the basis of grouped mean data, and fail to recognize individual heterogeneity. For instance, a recent crossover trial comparing an inhaled corticosteroid with a leukotriene receptor antagonist for the treatment of persistent childhood asthma found that, while both treatments were effective, on average the effect was greater in those treated with inhaled corticosteroid. When individual patient responses on each treatment were compared, however, 29% of children had better asthma control (asthma control days/week) on the leukotriene receptor antagonist, indicating that for this subgroup the leukotriene receptor antagonist would be the ideal monotherapy .Asthma is most commonly managed in the community in general practice settings, and the organization of medical care will affect how asthma care can be delivered. Differential diagnoses vary according to location, with infectious disease being more common in less developed countries. Moreover, currently available guidelines are based on the assumption that the recommended drugs are available and affordable , an assuefficacy of treatment; namely, the benefit of the treatment under ideal conditions. RCTs are not primarily concerned with the external validity or generalizability of the findings to whole populations, and differences between the homogeneity of the trial population and the heterogeneity of the general population labeled as having asthma may limit the generalizability of RCT findings [effectiveness – the benefit that treatment produces in routine clinical practice [The results of well-designed randomized controlled trials (RCTs) and meta-analyses of RCTs are awarded the highest level of evidence in hierarchies of evidence-based data collection used to formulate clinical practice guidelines ,8. RCTs,findings . These tpractice  – is theHerland and coworkers  found thInformation gained from pragmatic trials and observational studies can be a valuable adjunct to that gained by RCTs. Pragmatic trials, which may be blinded or open label, are designed to more closely replicate conditions in clinical practice, including variability in patient characteristics and the use of a management protocol rather than a predetermined assigned treatment . ObservaEvidence-based guidelines are further limited by the time lag involved in the process, typically entailing 1–2 years, of reviewing the literature, arriving at a consensus, and actually writing and publishing the guidelines. This allows for potentially relevant studies to be published but not assessed. One mechanism for acknowledging more recent papers might be to provide electronic links to them from the guidelines, noting that the information they contain may be relevant but will not be commented on in the present guidelines.Most guidelines see asthma in isolation rather than considering other factors that may impact on asthma and the response to asthma therapy, particularly allergic rhinitis, cigarette smoking, adherence to therapy, and genetic factors.The association between the upper airways and the lower airways has been recognized for two millennia: as long ago as 200 AD, Galen recommended purging the nostrils of secretions in order to relieve the lungs. In the late nineteenth century, Charles Blackley linked hay fever and asthma . CurrentThe GINA guidelines note that 'special considerations are required in managing asthma in relation to ... rhinitis'; however, there is no further guidance – such as a recommendation to examine the nose or to ask the patient whether or how allergic rhinitis worsens their asthma . MoreoveThe ARIA guidelines  were theThe early evidence indicates that treating allergic rhinitis may help to control asthma symptoms. A recent post-hoc evaluation of the Clinical Observation of Montelukast as a Partner Agent for Complementary Therapy study showed the benefit of montelukast, a potent leukotriene receptor antagonist, for patients with coexisting asthma and rhinitis . CysteinCigarette smoking is another factor that can adversely affect asthma control. The prevalence of active smoking among adults with asthma is similar to that among those without asthma, tending to be about 25% in developed countries . CigaretAdherence to therapy and compliance with physician recommendations are other important components of successful asthma management. Many factors contribute to level of adherence to controller therapy for asthma, including beliefs about the benefits of treatment, concerns about potential adverse effects of treatment, perceived asthma severity, and duration of asthma ,44. In aA complete understanding of the goals of asthma therapy could improve patient adherence to prescribed therapy. Both physicians and patients often overestimate asthma control relative to guideline definitions of control; moreover, patients tend to accept their asthma symptoms and may consider their asthma better controlled than their physicians do ,4,47. A 4 synthase and excess leukotriene production, with responsiveness to leukotriene receptor antagonist therapy [4 synthase) has been identified that shows moderate association with aspirin-intolerant asthma [2-adrenergic receptor (ADRB2) appear to play a role in bronchodilator responsiveness and constitute an area of active research [Finally, as a better understanding is gained of the genetic factors controlling asthma phenotypes, this information should be included in asthma guidelines. Genetic factors are important in determining responders and nonresponders to specific treatments for asthma. For example, patients with aspirin-intolerant asthma show upregulation of leukotriene C therapy ,49. A sit asthma . Polymorresearch , the resSimple questionnaires to assess the presence of asthma and rhinitis symptoms have been proposed in the new International Primary Care Respiratory Group guidelines for the diagnosis of respiratory diseases in primary care  display and 4. MA practical tool to assess asthma control, the 6-Point Asthma and Allergic Rhinitis Status Measure, has been developed by the General Practice Airways Group with Allergy UK, and is available for download from the General Practice Airways Group website . This shGuideline recommendations are only as successful as are the human individuals – the healthcare providers and the patients – in applying them in clinical practice. Primary care physicians often do not follow guidelines ,53-55. TPractice guidelines are more likely to be followed if they are simple and flexible . The devARIA = Allergic Rhinitis and its Impact on Asthma; GINA = Global Initiative for Asthma; RCT = randomized controlled trial.DP has received honoraria for speaking at sponsored meetings from the following companies marketing respiratory products: 3 M, Altana, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, IVAX, Merck Sharp & Dohme, Novartis, Pfizer and Schering-Plough. DP has also received honoraria for advisory panels with 3 M, Altana, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, IVAX, MSD, Novartis, Pfizer and Schering-Plough. DP or his research team have received funding for research projects from 3 M, Altana, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, IVAX, Merck, Sharp & Dohme, Novartis, Pfizer, Schering-Plough, Viatris.MT has no shares in any pharmaceutical company. Either through his role at the University of Aberdeen or personally MT has received grants, honoraria or educational support from the following companies as well as the UK NHS R&D programme and Asthma UK: Altana, AstraZeneca, GlaxoSmithKline, Ivax, Merck, Sharp and Dohme, Novartis, Schering Plough, Trinity Pharmaceuticals, Viatris.


The functionally relevant polymorphisms of the β2-adrenergic receptor polymorphisms and investigated the five most frequent haplotypes for their modifying effects on OSA-induced changes in blood pressure, heart rate, and lipid levels. The prevalence of cardiovascular risk factors and coronary heart disease  and survived myocardial infarction  were compared between the genotypes and haplotypes.We investigated a group of 429 patients  with moderate to severe obstructive sleep apnea (apnea/hypopnea index (AHI) 29.1 ± 23.1/h) and, on average, a high cardiovascular risk profile . We typed the β2-adrenergic receptor genotypes and haplotypes showed no modifying effects on these relationships or on the prevalence of dyslipidemia, diabetes, and coronary heart disease, yet, for all three polymorphisms, heterozygous carriers had a significantly lower relative risk for myocardial infarction  = 0.32, P = 0.012; Arg16Gly: n = 197, OR = 0.39, P = 0.031; Gln27Glu: OR = 0.37, P = 0.023). Carriers of the most frequent haplotype (n = 113)  showed a five-fold lower prevalence of survived myocardial infarction .Multivariate linear/logistic regressions revealed a significant and independent  influence of AHI on daytime systolic and diastolic blood pressure, heart rate, prevalence of hypertension, and triglyceride and HDL levels. The β2-adrenergic receptor polymorphisms on OSA-induced blood pressure, heart rate, or lipid changes. Nevertheless, heterozygosity of these polymorphisms is associated with a lower prevalence of survived myocardial infarction in this group with, on average, a high cardiovascular risk profile.Our study showed no significant modifying effect of the functionally relevant β The receptors are expressed in a wide variety of tissues, including the vascular and bronchial smooth muscles, the heart, and adipocytes. Thus, β2-adrenergic receptors play a critical role in the regulation of blood pressure (BP), heart rate, and lipid metabolism. Several polymorphisms of the β2-adrenergic receptor gene have been identified. For three polymorphisms, which are the subject of the present study, functional consequences have been described .Table 2-adrenergic receptor polymorphisms in a study group of untreated patients with OSA in whom a linear and independent relationship between the frequency of nocturnal apnea/hypopnea and daytime systolic and diastolic BP, daytime heart rate, prevalence of arterial hypertension, and HDL serum levels were shown previously [We analysed βeviously ,7. The eeviously -3 is sugin vivo is minor, and confirms previous negative results [et al investigated 195 Korean subjects and found no difference between β2-adrenergic receptor genotypes (Arg16Gly and Gln27Glu) in relation to plasma glucose, fasting serum insulin, LDL, HDL, or triglyceride levels. However, in another study of 19 healthy individuals with propanolol-induced dyslipidemia, a significantly decreased HDL serum level was found in subjects homozyous for Gln27 homozygotes, and raised triglyceride levels in subjects homozygous for Glu27 [The underlying mechanisms between the severity of OSA and modulation of lipid serum level have been discussed in detail elsewhere . The fac results . Kim et 2-adrenergic receptor gene in the development of hypertension has been the subject of many population-based studies. The distal segment of chromosome 5 (5q31.1-qtr), which harbors the β2-adrenergic receptor gene, has been linked both to systolic and to post-exercise diastolic BP in genome-wide scans performed in large study populations [2-adrenergic receptor gene. However, no significant association of the Arg16Gly and Gln27Glu polymorphisms was detected with these parameters in the same study [The genetic role of the βulations ,18. In ame study .The published studies that have shown an influence of these polymorphisms on BP and hypertension are confusing. On the one hand, the Gly16 and Glu27 genotypes were significantly associated with the prevalence of hypertension and systolic BP in two large populations of Chinese individuals ,21. On tin vitro would be likely to be detected in vivo in such patients. The fact that we could not detect any significant result underlines the minor effect of β2-adrenergic receptor polymorphisms in the development of these cardiovascular risk factors, and supports the results of the Cardiovascular Health Study.In contrast to the aforementioned studies, we investigated a cohort of patients in which an OSA-induced, elevated sympathetic activity exacerbated BP, heart rate, and HDL levels. Thus, the known functional relevance of these polymorphisms 2-adrenergic receptor genotypes on survived MI. This result again supports the hypothesis that was deducted form the Cardiovascular Health Study; namely, that variations of the β2-adrenergic receptor gene influence vulnerability to coronary events.Sympathetic activation also influences the risk of MI . Thus, p2-adrenergic receptor has already been shown in pulmonary research. Joos et al examined 587 smokers from the Lung Health Study. Those subjects who were heterozygous at position 27 of the β2-adrenergic receptor gene had a significantly lower decline in lung function at 1-year follow-up compared with the homozygous genotypes (P < 0.001) [In the statistical model that was chosen in the Cardiovascular Health Study, carriers of the Gly variation were pooled into one group. It is not apparent whether heterozygosity alone is protective, but a protective effect of heterozygosity in the βet al, [2-adrenergic receptors form dimers like other G-protein-coupled receptors. The formation of β2-adrenergic receptor dimers was shown to have functional effects on receptor-stimulated adenylate cyclase activity [2-adrenergic receptor (Cys341Gly) suggested that the dimer is the active form of the receptor [As discussed previously by Loos et al,  a reasonet al, . A possiactivity . Furtherreceptor .Lipid and lipoprotein serum levels were not available for all patients. Therefore, the diagnosis of dyslipidemia had to be determined by anamnesis alone in some cases, which may have led to inaccuracies in the multivariate regression. The diagnosis of CHD was determined by anamnesis and was not controlled by coronary arteriography. Thus, our proportion of 12.8% may not reflect the real incidence of CHD.Because our hypothesis included several risk factors for CHD and MI, Bonferroni correction after the statistical analysis should be discussed. After this correction, the results for MI would become insignificant. Because of the explorative character of our study, we refrained from performing Bonferroni corrections here.2-adrenergic receptor polymorphisms do not modulate cardiovascular risk factors in patients with OSA-induced elevated sympathetic activity. However, heterozygosity of these polymorphisms may be protective in reducing the vulnerability to survived MI, especially if heterozygosity is present for all polymorphisms. Because the statistical haplotype with heterozygosity in all three polymorphisms was not included in previous studies, we believe that this potentially protective genetic combination should be focussed on in future.We conclude that the investigated βThe author(s) declare that they have no competing interests.N.K.B. and J.B. developed the study design, carried out the molecular genetic studies, participated in the statistical analysis, drafted and edited the manuscript. S.W. participated in the DNA isolation and assisted in the SSCP-analysis. J.T.E. participated in the study design and supervised the genetic research procedures, N.B., B.M.S, D.B. and L.C.R. organized the patient collection, developed the patient's queries and participated in the management of the clinical data. C.H. and A.M. participated in the statistical analysis and in editing of the manuscript.The pre-publication history for this paper can be accessed here:


Many kidney transplant recipients have hypertension. Elevated systolic blood pressures are associated with lower patient and kidney allograft survival.This retrospective analysis examined the prevalence of clinical inertia (failure to initiate or increase therapy) in the treatment of hypertension before and after the introduction of an automated device (BpTRU) in the kidney transplant clinic.Historically only 36% (49/134) of patients were prescribed a change in therapy despite a systolic blood pressure ≥ 130 mmHg. After the introduction of BpTRU, 56% (62/110) of the patients had a change in therapy. In a multivariate logistic regression analysis of the entire cohort (n = 244) therapeutic changes were associated with higher blood pressures  and use of the BpTRU . In addition patients on more medications were also more likely to have a change in therapy.Blood pressure measurement with automated devices may help reduce clinical inertia in the kidney transplant clinic. Several studies have shown that higher blood pressures are associated with reduced kidney allograft and patient survival -3. For eBlood pressure is difficult to control in kidney transplant recipients in part because of the associated immunosuppressive medication, impaired graft function, older age, obesity and diabetes mellitus . Many stIn a recent American Heart Association scientific statement, the authors point out the shortcomings of auscultatory office blood pressures in the clinical practice despite their long standing importance in clinical research . PatientIn October 2005, the clinic introduced the BpTRU device . This device employs the oscillometric technique used by most home and ambulatory blood pressure devices. It reads 6 blood pressure measurements every 2 minutes while the patient is seated quietly alone in a room. The first measurement is ignored and the last 5 measurements are averaged.In November the clinic prospectively used the device on patients with a blood pressure ≥ 130 mmHg systolic by the clinic's aneroid syhygmomanometer. Both blood pressure values were recorded. To test the hypothesis that the device had an impact on initiating or intensifying therapy, these patients (BpTRU group) were retrospectively reviewed. The comparators were historic patients (Control group) with a systolic blood pressure ≥ 130 mm Hg who had been in clinic within the year prior to the introduction of the BpTRU. Inclusion into both cohorts was based on the clinic's aneroid syhygmomanometer blood pressure. This was a retrospective analysis and individual informed consent was not obtained. Permission to perform the study was provided by our institution research ethics committee.All patients were adults (>18) and were either kidney alone or combined kidney pancreas transplant recipients. Patients transplanted within 6 months were excluded. For patients who had several BpTRU measurements only the first was analyzed. Data on patient age, weight, height, sex, serum creatinine, glomerular filtration rate, diabetes mellitus status, resistant hypertension, attending physician, antihypertensive and immunosuppression medication use were collected. Glomerular filtration rate was estimated by the MDRD 4 variable equation . ResistaA statistically significant increase in therapy with the introduction of BpTRU was tested by Chi-square analysis. Differences between group (Control versus BpTRU) demographics were tested by Chi-square for dichotomous variables and ANOVA for continuous variables. A level of significance was set at 5%. A multivariate logistic regression analysis was performed on the entire cohort (n = 244) to look at independent predictors of a therapeutic change.Table There were more changes in therapy (p = 0.002) in the BpTRU group (56%) compared to historic controls (36%) Table . ChangesAnalysis of the entire cohort by logistic regression analysis Table  found thWithin the BpTRU group not all patients were hypertensive by the automated device. Only 72 of the 110 patients (66%) had a blood pressure that was ≥ 130 mmHg systolic with the BpTRU. Therapeutic changes were made in 49 of the 72 (68%). In those with BpTRU <130 mmHg systolic therapeutic changes were made in 13 of the 38 (38%) patients.The results show that more significantly therapeutic changes were made in hypertensive kidney transplant recipients being followed in the clinic during the period of BpTRU use. The device may have provided some measurement certainty to both patient and physician to the extent that more changes were made. The two other factors associated with therapeutic changes also provide measures of certainty. Patients on more medications may be perceived by the clinician as more likely to have uncontrolled blood pressure. Similarly patients with higher blood pressures are more likely to have truly elevated pressures.Clinical inertia in the treatment of hypertension is not a new phenomenon but has not been reported in the kidney transplant literature. In a recent study of outpatient general population practices in the southeastern United States, 7253 hypertensive patients were evaluated . AlthougThere are several limitations of the study. This study was not randomized, nor blinded. We also cannot say that other secular influences might have also been associated with changes in prescribing patterns. We used historic rather than concurrent controls. Follow up blood pressures were not obtained. However, more than two thirds of patients in both groups did not meet the criteria for hypertension resistance, suggesting more intense therapy should be helpful. Our clinic blood pressures were best described as casual. Our clinic does not ensure the research standard for a clinical trail  . ClinicsAlthough there are no randomized control trials in the kidney transplant population there is a wealth of cohort data and considerable evidence in the general population supporting blood pressure control to preserve kidney function and reduce mortality. It is not clear from this small single center retrospective review whether an automated device or other strategies to increase measurement certainty will reduce clinical inertia over the long run and improve overall patient outcomes. This degree of evidence would require a large randomized trial. Nonetheless we hope this study encourages others to scrutinize their practice and consider the necessary steps to ensure that blood pressure targets are achieved with the ultimate goal of increasing patient and allograft survival.The author(s) declare that they have no competing interests.All authors participated in the design, data collection, discussion of the results and approval of the manuscript. BK performed the statistical analysis and wrote the initial draft of the paper.The pre-publication history for this paper can be accessed here:


Hypertension, notably untreated or uncontrolled, is a major risk factor for cardiovascular diseases (CVD) morbidity and mortality. In countries in transition, little is known about the epidemiology of hypertension, and its biochemical correlates. This study was carried out in Al Ain, United Arab Emirates, to characterize self-reported (SR) normotensives and hypertensives in terms of actual hypertension status, demographic variables, CVD risk factors, treatment, and sequalae.A sample, stratified by SR hypertensive status, of 349 SR hypertensives  and 640 SR normotensives  among nationals and expatriates was used. Hypertensives and normotensive subjects were recruited from various outpatient clinics and government organizations in Al-Ain city, United Arab Emirates (UAE) respectively. Anthropometric and demographic variables were measured by conventional methods.Both under-diagnosis of hypertension (33%) and under-treatment (76%) were common. Characteristics of undiagnosed hypertensives were intermediate between normotensives and SR hypertensives. Under-diagnosis of hypertension was more common among foreigners than among nationals. Risk factors for CVD were more prevalent among SR hypertensives. Obesity, lack of exercise and smoking were found as major risk factors for CVD among hypertensives in this population.Hypertension, even severe, is commonly under-diagnosed and under-treated in the UAE. Preventive strategies, better diagnosis and proper treatment compliance should be emphasized to reduce incidence of CVD in this population. Hypertension, notably untreated or poorly controlled, is a major risk factor for cardiovascular diseases (CVD) in almost every population -4. AlthoIt appears that the average blood pressure (BP) level and its age-related increase differs across populations and may explain much of the observed disparities in stroke mortality . To dateA specific example of a nation in transition is the United Arab Emirates (UAE). As late as the 1960s the population consisted largely of nomadic Bedouin Arabs. However, the discovery of oil in 1970s has changed their life style dramatically and the UAE is now a modern, wealthy society, heavily influenced by Western living patterns, including a sedentary life style with high CVD risk profiles . Indeed,The present study specifically addresses the characteristics of self reported hypertensives, and self reported normotensives in terms of demographic variables, the prevalence of life-style risk factors, under-diagnosis, and treatment outcome.The study was approved by the Ethics Committee of the Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE.Subjects were enrolled over the period February 2001 to May 2005. The sample was stratified by SR hypertension (yes/no) and consisted of 349 SR hypertensives, and 640 SR normotensives (controls) among Arab nationals and expatriates . There were 670 males and 319 females. Hypertensive subjects were recruited from various outpatients' clinics in Al-Ain city, UAE. Controls were enrolled from among University staff, teachers of secondary schools, factory workers, and various other institutions, to obtain a broad and representative cross-section of the adult population of Al-Ain.Individuals between the age of 20 and 75 years with SR hypertension were referred to a special project physician in the hypertension clinic in Tawam Hospital, Al-Ain, to exclude secondary hypertension and known kidney disease or heart problems . Both patients and controls were then informed, in either Arabic or English, about the project's objectives and methods. Informed, written consent was obtained in all cases. Each individual was interviewed by a healthcare professional, using a one-page questionnaire, in Arabic or English, regarding demographic variables including ethnic background (country of origin), history of hypertension, diabetes, history of dyslipidaemia, current smoking (smoking cigarettes every day), current exercise (exercising at least for one hour/three times per week), and current alcohol intake . The questionnaire was piloted among primary health care patients and adapted accordingly. Although all patients had been prescribed anti-hypertensive treatment, no details on the exact medication were elicited. Besides to their prescribed conventional anti hypertensive drugs, many SR hypertensives were on lipid-lowering treatment if they had concomitant diabetes or dyslipidaemia.All subjects were instructed to relax in a sitting position for at least 15 minutes prior to BP measurements. A mercury sphygmomanometer with appropriate cuff size was used for BP measurements. A specially trained nurse took two BP measurements for each individual in two different positions (sitting and standing) the average of which was used for analyses. Individuals with high BP levels among the SR normotensive group (incident of hypertension) were referred to a physician.Hypertension was defined according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) definition : normal 2 (kg/m2), and waist to hip ratio (WHR) was also calculated. Obesity was defined as BMI ≥ 30 kg/m2 and central body fat distribution was defined as a WHR ≥ 0.9 for men and ≥ 0.8 for women. These variables were measured by trained staff nurses in either the outpatient hypertension clinic in the case of hypertensives or in a special room in other organizations. Measurements were taken without shoes, and no heavy clothing was worn at the time of the investigations.In this study, weight, height, waist and hip circumference were all measured according to the WHO MONICA protocol . Body maFor statistical analysis of the total data set, the Statistical Package for the Social Sciences (SPSS) Version 13.0 for Windows  was used. Associations between categorical  variables were analyzed using cross tabulations and Chi-square tests, and the strength of the association was expressed in terms of Odds Ratios (OR), adjustment for confounding variables was carried out using the Mantel-Haenszel estimate of the OR. Continuous variables are presented as means +/- SD. Differences, adjusted for sex, among groups in continuous variables were analyzed using Analysis of Variance, and the Tukey method was used for post-hoc tests . P-values < 0.05 were considered statistically significant.The number of individuals in each of the three BP groups  broken down by sex and nationality is shown in Table Table In view of the uncertainty about the pathophysiology of many cardiovascular disorders, their association with life-style in different societies is of particular interest. This was one of the motivating factors for the 7 countries study by Ancel Keys . The rapThis study shows that in one of these countries (the UAE), despite a modern and accessible health infra-structure, the levels of both under-diagnosis and under-treatment of hypertension are high, as a large percentage of the SR normotensives and the SR hypertensives actually had BP in the hypertensive range. This situation is similar to that found in many other places in the world, both developed and developing. Even in the USA most hypertension is not properly controlled and among those with untreated or treated but uncontrolled hypertension a majority are aware of their condition . AlthougThe undiagnosed, "incident", hypertensives in out study are in many ways an intermediate group Table , perhapsAmong the Emirati nationals, most hypertension had been diagnosed previously and presumably had been treated. It is noteworthy that under-diagnosis of hypertension among non-Emiratis was much more common than among nationals. This may reflect poorer access to health care for immigrants. A large percentage of immigrants are low-income workers, e.g. employed in agriculture or construction. Until recently, the vast majority of such workers had access to  free health care. Currently, the health system is in transition, and it is unclear what the future situation will be. The fact that until recently, their health care had been free, suggests that under-diagnosis is probably not due to financial reasons, but may reflect a different attitude to health and health care among these foreign workers, and perhaps a problem of communication between these workers, who often speak only Urdu or Pashtu, and health care professionals. One possible way to address this situation is to include a more extensive cardiovascular screening component in the periodic health check up (every 2–3 years) that is required for residence permit extensions.Of special concern is the high level of under-treatment of hypertension. Despite the fact that the SR hypertensives were, by definition, aware of their condition, almost half of them did not have their BP adequately controlled Table . It is uIn this population, the problem of under-diagnosis and under-treatment of hypertension is compounded by a high prevalence of other CVD life-style risk factors including smoking, lack of exercise, and obesity. In this context, the levels of obesity, for example, were extremely high with average BMIs in the overweight to obese range Table .In summary, obesity, lack of exercise and smoking will clearly have a negative impact on the population's health status. Clearly, non- pharmacologic (as well as pharmacologic) approaches to the prevention of CVD among hypertensives and somewhat among normotensives are also needed in this population. The focus therefore should be on prevention, and efforts should address modifiable life style risk factors, such as diet, smoking and lack of exercise. Health authorities in the UAE have recognized smoking of both cigarettes and sheesha (water pipe), as a major health problem and steps have been taken to curb the sale of tobacco to minors and to raise awareness about the dangers of smoking. However, stimulation of regular exercise, known to be associated with substantial reductions in the incidence of coronary events , has recInter alia, provision of community sports facilities , adapted to local culture and climate is recommended. Also, there is a pressing need to raise awareness among physicians and patients of the importance of adherence to treatment guidelines and recommendations, and to the potential complications of hypertension.Hypertension in the UAE should be approached more aggressively in terms of prevention strategies, diagnosis and treatment. The author(s) declare that they have no competing interest.AA designed the project, collected and interpreted the data, conducted the laboratory analysis and participated in the statistical analysis of the data, and drafted the manuscript.NN performed the statistical analysis, and further coauthored the manuscript.SA participated in the patient and control recruitment, carried out clinical examinations for the subjects, and critically reviewed the manuscript.JP, participated in the measurement of the demographic variables, participated in the recruitment of the subjects and collected blood samples.AA, participated in the design of the project, and commented on the manuscript.EO, participated in its design and coordination, provided funds for the project, and critically reviewed the manuscript.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here: