bluuebunny/crossref_metadata_2025 huggingface dataset:
Cheilitis granulomatosa and Melkersson–Rosenthal syndrome: evaluation of gastrointestinal involvement and therapeutic regimens in a series of 14 patients
Authors: Ratzinger G , Sepp N , Vogetseder W , Tilg H
Published: May 2007

Background  Cheilitis granulomatosa and Melkersson–Rosenthal syndrome are both rare and benign diseases. Because of their granulomatous character, a relationship to Crohn's disease has been suggested. Furthermore, because of their unknown aetiology, treatment is difficult, and evaluation of response is hampered by the natural tendency to spontaneous resolution and recurrence.

Objectives and methods  To evaluate gastrointestinal involvement by clinical history, conventional endoscopy, and capsule endoscopy as well as to compare efficacy of treatment modalities on a series of 14 patients, one of the biggest collectives reported.

Results  Four patients (4 of 14) were previously, simultaneously, or subsequently diagnosed with Crohn's disease. In six patients (6 of 14) with minor gastrointestinal symptoms as flatulence, occasional constipation, diarrhoea, or admixture of mucus with the stool, we could not detect any signs of inflammatory bowel disease by capsule endoscopy. Nine patients received clofazimine, and eight patients responded to treatment (four complete responses, four partial responses). Two patients were successfully treated with infliximab. Systemic methylprednisone was not successful in two patients.

Conclusion  Close to 30% of patients showed an association of cheilitis granulomatosa and Crohn's disease. Forty‐three per cent of patients reported minor gastrointestinal irregularities without any detectable changes of Crohn's disease. Clofazimine seems to be an effective treatment, although long‐term application is necessary with frequent aggravation in the beginning. Infliximab, an effective drug in Crohn's disease, could be a promising treatment option for severe cases.
A Conceptualisation of Emotion within Art and Design Education: A Creative, Learning and Product‐Orientated Triadic Schema
Authors: Spendlove David
Published: May 2007

There is a resurgence of interest in the powerful concept of emotion in current educational policy and practice. This article calls for the recognition and conceptualisation of a triadic schema for theorising the location of emotion within a creative educational experience. The schema represents emotion within three domains within current practice: Person, Process and Product.

The principal focus of the article is pupils aged 5‐16 and consideration is given to the application of the conceptualised schema within art and design education as represented by the national curriculum statement of importance. The central hypothesis of the work is that greater recognition of an emotional dimension within a triadic schema ‐ developing emotional capacity in students to engage in a creative process (person); stimulating emotional engagement through appropriate learning contexts (process) and facilitating the emotional interfacing with outcomes (product) ‐ will help conceptualise the powerful interrelationship between emotion, creativity and learning.

Based upon an extensive synthesised literature review a schema, developed through abductive reasoning and grounded theory, ultimately conceptualises the overarching theme of emotion within a creative, learning and product‐orientated experience within the primary and secondary stages of England's education system.
An Analysis of the Presentation of Art in the British Primary School Curriculum and its Implications for Teaching
Authors: Hallam Jenny , Lee Helen , Gupta Mani Das
Published: May 2007

This article presents an analysis of the way art is conceptualised in the British primary school curriculum and provides an historical framework that maps an evolution of ideas that have shaped the way art is presented in the modern day primary curriculum. In order to achieve this a Foucauldian style genealogical analysis is utilised to trace the discourses (systems of meaning) surrounding the nature of children's artistic development and how these discourses are used in the present day British primary curriculum to construe art in different ways. The analysis in this article is threefold. It explores the presentation of art in the curriculum as (1) an expressive subject, (2) a skills based subject, (3) a subject which focuses on art history and art appreciation. Second, the teaching positions associated with each approach are identified as follows (a) the facilitator, (b) the expert and (c) the philosopher; as well as the issues teachers face when adopting these positions. Third, attention is given to how these theoretical principles might be linked to practice. In so doing this article contributes to the debate surrounding the value of art in the primary curriculum and the way in which the curriculum serves to shape teaching practice.
Negative pressure therapy is effective to manage a variety of wounds in infants and children
Authors: McCord Shannon S. , Naik‐Mathuria Bindi J. , Murphy Kathy M. , McLane Kathy M. , Gay Andre N. , Bob Basu C. , Downey Cara R. , Hollier Larry H. , Olutoye Oluyinka O.
Published: May 2007

Negative pressure therapy (NPT) has been accepted as a valuable adjunct for wound closure in adults; however, reports on its effectiveness in young children and infants, including neonates, are limited. A retrospective chart review was conducted on children treated with NPT at a single institution between January 2003 and December 2005. Wound volumetric measurements were calculated at the start and end of therapy. Sixty‐eight patients with 82 wounds were identified. The mean age was 8.5 years (range 7 days–18 years). Twenty patients (29%) were 2 years of age or younger, including eight neonates. Wound types included: pressure ulcers (n=13), extremity wounds (n=18), dehisced surgical wounds (n=19), open sternal wounds (n=10), wounds with fistulas (n=3), and complex abdominal wall defects (n=6). Low suction pressures (<100 mmHg) were generally used in children younger than 4 years of age. Following NPT, 93% of wounds decreased in volume. The average wound volume decrease was 80% (p<0.01, n=56). NPT can be effectively used to manage a variety of wounds in children and neonates. No major complications were identified in our retrospective review. Prospective studies are required to better refine the use of this technology in children.
Surgical wound‐healing complications in heart transplant recipients treated with rapamycin
Authors: Zakliczynski Michael , Nozynski Jerzy , Kocher Alfred , Lizak Maria K. , Zakliczynska Helena , Przybylski Roman , Wojarski Jacek , Zembala Marian
Published: May 2007

The aim of this retrospective analysis was to assess the influence of rapamycin (RAPA) used perioperatively on surgical complications in heart transplant recipients. The study group consisted of 28 heart transplant recipients (26M/2F, 49.2±11 years) receiving 15 mg of RAPA before operation, 10 mg of RAPA on the first postoperative day (POD) and 5 mg daily (n=20) thereafter, or 5 mg daily starting on POD 2 (n=8), until the introduction of cyclosporine‐A. A matched historical control group was composed of 28 patients (26M/2F, 49.7±9 years) receiving cyclosporine‐A from POD 1. We compared a number of surgical complications and reinterventions among groups. Statistical significance was assessed using the chi‐square test and the Mann–Whitney U‐test. There were 16 (57%) patients in the study group vs. six (21%) in the control group requiring reintervention (p=0.014). Pericardial tamponade decompression was performed in seven (25%) vs. zero patients, and sternum refixation in seven (25%) vs. zero patients (p=0.015). None of the wounds was infected. The overall drainage volume was 4,213±5,996 vs. 1,911±1,728 mL (p=NS). The frequencies of biopsy‐proven rejection and infection were comparable, except lower cytomegalovirus infection rates in the study group: three (11%) vs. 11 (39%) for the control group (p=0.023). The use of RAPA in the perioperative period of heart transplantation increases the risk of surgical wound‐healing complications.
Antibacterial activity of positive and negative polarity low‐voltage pulsed current (LVPC) on six typical Gram‐positive and Gram‐negative bacterial pathogens of chronic wounds
Authors: Daeschlein Georg , Assadian Ojan , Kloth Luther C. , Meinl Christina , Ney Frank , Kramer Axel
Published: May 2007

The positive effect of electrical stimulation (ES) on wound healing has been shown in vitro and in vivo. On the basis of increased blood flow, protein denaturation, and stimulation of cellular defense, an antibacterial effect of ES is to be expected. Although the antibacterial effect of ES already has been demonstrated in vitro, little attention has been paid to the direct antibacterial effect of changing polarity of the applied current. The aim of this study was to investigate the antibacterial effect of positive and negative monophasic low‐voltage pulsed current on typical Gram‐positive and Gram‐negative pathogens of chronic wounds. Using the Dermapulse®‐System, three Gram‐negative (Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae) and three Gram‐positive (Staphylococcus aureus, Staphylococcus epidermidis, Escherichia faecium) organisms were tested against positive and negative polarity low voltage pulsed current. All tested organisms were significantly reduced by ES. The reduction differed significantly between positive polarity and control and negative polarity and control, with the highest log10 reduction factor (RF) achieved with positive polarity. Using positive polarity, the maximum RF was measured for E. coli (median log10 RF 0.83; 25th percentile 0.59, 75th percentile 0.98) and the lowest for S. epidermidis (median log10 RF 0.20; 25th percentile 0.17, 75th percentile 0.24). Yet, there was no significant difference with positive ES against Gram‐positive or Gram‐negative organisms.
Microalbuminuria in Type 2 Diabetics: An Important, Overlooked Cardiovascular Risk Factor
Authors: Weir Matthew R.
Published: May 2007

The presence of microalbumin in the urine of persons with type 2 diabetes is perhaps the most important early signal heralding the onset of systemic vasculopathy and associated target organ damage to the brain, the heart, and the kidneys. It is easily measured and, unfortunately, frequently overlooked as a screening tool in clinical medicine. If present, it identifies patients at risk for early cardiovascular death and progressive renal disease. Microalbuminuria also identifies patients who need more rigorous cardiovascular risk management, especially more intensive blood pressure control, preferably below 130/80 mm Hg, and strict attention to glycemic control and lipid levels. Therapeutic strategies to facilitate better blood pressure control and reduce microalbuminuria likely will prove to be the most effective way to retard not only the progression of renal disease but also cardiovascular disease. Consequently, the identification and normalization of urine microalbumin excretion should be an important consideration in patients with diabetes.
Predictors of Progression in Hypertensive Renal Disease in Children
Authors: Lurbe Empar , Alvarez Vicente , Redon Josep
Published: May 2007

In hypertensive renal disease in children, several risk factors influence the development and the rate of progression of renal damage, including blood pressure levels, proteinuria, lipid disorders, and genetic differences. The impact of blood pressure on renal structures, the most important of the factors, depends not only on blood pressure levels, but also on the persistence of the blood pressure levels over time, mainly during the hours when the patient is resting or sleeping. Abnormal circadian variability is frequently observed in patients with renal damage, and nocturnal blood pressure reduction should be a major therapeutic objective to protect against a decline in renal function. Proteinuria is a guide for establishing targets and for monitoring treatment. It should be reduced as much as possible to obtain maximal renoprotective effect. The role of the other factors, such as lipid disorders and genetics, remains elusive.
Antihypertensive Efficacy of Angiotensin Receptor Blockers in Combination With Hydrochlorothiazide: A Review of the Factorial‐Design Studies
Authors: S. Ram C. Venketa
Published: May 2007

Most hypertensive patients require more than one drug for adequate blood pressure (BP) control. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends starting treatment with a thiazide diuretic or, when BP is >20/10 mm Hg above goal or in patients with diabetes, using two different antihypertensive agents. Searches of MEDLINE, EMBASE, and BIOSIS databases identified four similarly designed, randomized, factorial studies comparing various doses of angiotensin II receptor blockers with hydrochlorothiazide as monotherapy and in combination. The methodology and results of these studies were compared. The primary efficacy end point in these studies was a decrease from baseline in mean diastolic BP after 8 weeks of therapy. All currently available angiotensin I receptor blocker/hydrochlorothiazide combinations evaluated (irbesartan, olmesartan medoxomil, telmisartan, and valsartan plus hydrochlorothiazide) produced significant systolic BP and diastolic BP reductions. Olmesartan medoxomil/hydrochlorothiazide 40 mg/25 mg provided the largest mean reduction in absolute and placebo‐corrected systolic BP/diastolic BP. For all angiotensin II receptor blocker/hydrochlorothiazide combinations evaluated, ≥63% of patients achieved a diastolic BP response (diastolic BP <90 mm Hg or ≥10‐mm Hg reduction). In conclusion, the combination of an angiotensin II receptor blocker and hydrochlorothiazide produces more substantial BP responses than monotherapy with either component.
EUROPA: Has Anything New Been Learned With Angiotensin‐Converting Enzyme Inhibitors?
Authors: Sica Domenic A.
Published: May 2007

The European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease (EUROPA) involved 12,218 patients with stable coronary artery disease. Patients in this trial were randomized to the angiotensin‐converting enzyme inhibitor perindopril (8 mg/d) or placebo in addition to optimized conventional therapy and followed for an average of 4 years. Perindopril reduced the primary end points of cardiovascular disease, myocardial infarction, and cardiac arrest by 20% (p=0.0003). Moreover, the angiotensin‐converting enzyme inhibitor reduced the rate of fatal and nonfatal myocardial infarction by 24% (p=0.001). The results from EUROPA complement those observed in the Heart Outcomes and Prevention Evaluation (HOPE) study and provide further support for the concept of angiotensin‐converting enzyme inhibitors conferring cardiovascular protection as a class effect.
Blood Pressure Measures and Electrocardiogram‐Defined Myocardial Infarction in an Iranian Population: Tehran Lipid and Glucose Study
Authors: Ghanbarian Arash , Rashidi Arash , Madjid Mohammad , Azizi Fereidoun
Published: May 2007

The purpose of this study was to describe blood pressure values in Iranian adults with electrocardiogram (ECG) evidence of a myocardial infarction (MI). High blood pressure is a risk factor, and an ECG can be diagnostic of coronary artery disease. In recent studies the role of pulse pressure in predicting coronary artery disease has been suggested to be more important than that of blood pressure. From among participants of the Tehran Lipid and Glucose study, data for 2479 men and 3060 women aged ≥30 years not currently using any antihypertensive medication were collected. The study used the mean of two separate blood pressure measurements for each individual. ECG findings of all subjects were coded according to Minnesota ECG coding criteria, and they were categorized into probable/possible MI or no MI. ECG evidence of probable or possible MI was found in 1.2% of subjects (1.8% in men vs. 0.8% in women, p<0.001). Prevalence of ECG‐defined MI in hypertensive persons was two‐fold higher than in normotensives. Adjusted for age, sex, and body mass index, mean diastolic blood pressure was significantly lower in cases with ECG‐defined MI than in subjects without MI (p<0.03). There was a strong positive correlation between pulse pressure and systolic blood pressure in both hypertensive/normotensive and MI/no MI groups at the p<0.001 level. There was a weak inverse correlation between diastolic blood pressure and pulse pressure in hypertensive/normotensive/no MI groups (−0.32 and −0.14, both p<0.001). Diastolic blood pressure was not correlated with pulse pressure in cases with MI. Prevalence of ECG‐defined MI in hypertensive cases was higher than in normotensives. Systolic blood pressure is a better predictor for pulse pressure than diastolic blood pressure in both normotensive and hypertensive populations with or without ECG‐defined MI.
Pharmacoeconomics of Antihypertensive Drug Treatment: An Analysis of How Long Patients Remain on Various Antihypertensive Therapies
Authors: Esposti Luca Degli , Martino Mirko Di , Saragoni Stefania , Sgreccia Andrea , Capone Alessandro , Buda Stefano , Esposti Ezio Degli
Published: May 2007

The objective of the research was to perform a clinical practice‐based analysis of how long patients remain on various antihypertensive drugs. An administrative database listing of patient baseline characteristics, drug prescriptions, and hospital admissions was used. All new users of antihypertensive drugs, ≥20 years of age, receiving a first prescription for diuretics, β blockers, calcium channel blockers, angiotensin‐converting enzyme inhibitors, or angiotensin II receptor antagonists between January 1, 2000, and December 31, 2000, were included and observed for 365 days. Persistence was defined as a duration of therapy >273 days. A total of 14,062 patients were included in the study, 39.7% of whom remained on treatment (persistent patients). Persistent patients were more likely to be older, taking other drugs for concurrent disorders, hospitalized for cardiovascular diseases, and initially prescribed angiotensin II receptor antagonists. Persistent patients accounted for 80.6% of the overall cost for antihypertensive drugs. Factors associated with drug cost were age, pattern of persistence, number of prescribed classes, and specific medication at enrollment. Measuring persistence with treatment is needed to evaluate the appropriateness and the cost‐effectiveness of drug use.
The Natural Treatment of Hypertension
Authors: Wilburn Amanda James , King Deborah S. , Glisson James , Rockhold Robin W. , Wofford Marion R.
Published: May 2007

The goal of this review is to evaluate the efficacy of commonly available dietary supplements in the treatment of hypertension, using the average blood pressure reduction achieved with the implementation of lifestyle modifications as a standard. For this reason, the authors focus on the antihypertensive potential of these agents rather than pharmacology, pharmacokinetics, adverse effects, or supplement‐drug interactions. For the purpose of this review, dietary supplements are defined as exhibiting some evidence of benefit if a systolic blood pressure reduction of 9.0 mm Hg or greater and/or a diastolic blood pressure reduction of 5.0 mm Hg or greater has been observed in previously published, peer‐reviewed trials. These defining limits are based on the average blood pressure reduction associated with the implementation of certain lifestyle modifications. Agents with some evidence of benefit include coenzyme Q10, fish oil, garlic, vitamin C, and L‐arginine.
Hypertension Treatment in the Ambulatory Setting: Comparison by Race and Gender in a National Survey
Authors: Bonds Denise E. , Palla Shana , Bertoni Alain G. , Mellen Philip , Goff David C.
Published: May 2007

To determine if different therapies are used in different racial groups and by gender, data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey (national probability samples of outpatient visits) were used. All visits for hypertension in 1999 and 2000 were reviewed. Survey weights were applied to obtain national estimates. Provision of therapies by gender and race/ethnicity (white, African American, Hispanic, Asian) was examined. Over 137 million visits for hypertension care were made during 1999 and 2000. Diet and exercise counseling were performed at a low percentage of visits (35% and 26% of visits, respectively). The most common antihypertensive agent prescribed was angiotensin‐converting enzyme inhibitors or angiotensin‐receptor blockers (28%), while first‐line drugs, diuretics (23%) and β blockers (15%), which are recommended by national committees, were prescribed less frequently. Asians and Hispanics were more likely to receive counseling on diet (Asians: odds ratio [OR], 2.29; 95% confidence interval [CI], 1.45–3.60; Hispanics: OR, 2.51; 95% CI, 1.18–5.33) and exercise (Asians: OR, 2.44;
95% CI, 1.35–4.42; Hispanics: OR, 3.28; 95% CI, 1.50–7.21) than non‐Hispanic whites. African Americans were more likely to be prescribed calcium channel blockers (OR, 1.51; 95% CI, 1.20–1.91) and diuretics (OR, 1.37; 95% CI, 1.08–1.74). Low use of recommended therapies was found. Although variation by race was seen, it did not systematically favor groups associated with poor outcomes.
Effect of Drug Therapy for Heart Failure on Quality of Life
Authors: Wong Maylene , Tavazzi Luigi
Published: May 2007

Symptomatic heart failure interferes with a patient's quality of life (QOL) by limiting his or her ability to perform physical tasks and daily activities and by lowering his or her sense of psychological well‐being. Therefore, in addition to decreasing mortality and morbidity, improving QOL should be an important goal when selecting pharmacotherapy. QOL questionnaires, both generic and disease specific, are used widely, but in randomized controlled trials of heart failure treatments, QOL has not been a routine study end point. Beta blockers and angiotensin‐converting enzyme inhibitors, medications widely used in the management of heart failure and hypertension—one of the most common causes of heart failure—have been associated with negative, neutral, and modestly positive QOL effects. Angiotensin receptor blockers, combined with other therapy, including angiotensin‐converting enzyme inhibitors (usually with a diuretic) and/or β blockers in heart failure, have produced improvements in QOL. Patients with hypertension whose blood pressure has been lowered have also experienced an improvement in QOL scores. With current heart failure regimens prolonging life, improving QOL becomes an even more essential end point in assessing the effectiveness of new medications, whether used alone or in combination with standard therapy.
Interview With Suzanne Oparil, MD
Authors: Moser Marvin
Published: May 2007

In this month's issue of The Journal of Clinical Hypertension, we highlight another hypertension icon. Dr. Suzanne Oparil is a clinical cardiologist who has been involved in the investigation of some of the fundamental mechanisms of vascular disease. Information derived from her studies has been used to develop specific treatments for hypertension. Dr. Oparil was one of those few women who attended medical school at a time when most of the students were males. She graduated at the top of her class at Columbia University College of Physicians and Surgeons and trained at Columbia and the Massachusetts General Hospital. She was on the faculty of the University of Chicago until 1977, when she transferred to become Professor of Medicine, Physiology, and Biophysics at the University of Alabama at Birmingham, where she has continued her research. Early in her career, Dr. Oparil observed that angiotensin‐converting enzyme (ACE) was capable of generating a vasoconstrictor hormone, angiotensin II. Her work, along with that of investigators at the Massachusetts General Hospital and other institutions, led to the development of ACE inhibitors. Initially, Dr. Oparil's interest was focused on the pulmonary circulation. She identified endothelin as a major mediator of pulmonary hypertension and as a potent vasoconstrictor. In recent years, she has been investigating novel pathways by which estrogens protect against vascular injury. Her work has led to important clues about how female sex hormones protect blood vessels. Throughout her career as a basic scientist, Dr. Oparil has also maintained a clinical interest. She has been involved in numerous hypertension clinical trials with different medications. She served as President of the American Heart Association and was the first woman president of the American Federation of Medical Research. Dr. Oparil has always been an outspoken critic of those in medicine who speak to hear themselves heard. She has been a strong advocate of approaches to treatment that may not have been popular. Throughout her career, she has combined scientific judgment with stern clinical discipline. Her contributions to the understanding of hypertension have been significant.
Antihypertensive Efficacy of Candesartan‐Lisinopril in Combination vs. Up‐Titration of Lisinopril: The AMAZE Trials
Authors: Izzo Joseph L. , Weinberg Marc S. , Hainer James W. , Kerkering Joseph , Tou Conrad K.P.
Published: May 2007

The AMAZE (A Multicenter Trial Using Atacand and Zestril vs. Zestril to Evaluate the Effects on Lowering Blood Pressure) program included two identical studies sponsored by AstraZeneca LP. The oral form of candesartan is cilexetil; for simplicity, the term “candesartan” is used throughout this manuscript. Two identical multicenter, randomized, double‐blind studies were performed to determine if addition of the angiotensin receptor blocker candesartan was more effective in lowering blood pressure than up‐titration of lisinopril. Hypertensive patients (N=1096) who were uncontrolled on lisinopril 20 mg daily were randomized (1:1) to receive either 8 weeks of high‐dose lisinopril (40 mg) or the addition of candesartan (16 mg) for 2 weeks followed by 32 mg for 6 weeks. Study 1 (n=538) demonstrated decreases in trough sitting systolic/diastolic blood pressures at Week 8 by 6.2/5.9 mm Hg, respectively, for the lisinopril up‐titration treatment group and by 11.6/8.3 mm Hg, respectively, for the lisinopril plus candesartan treatment group (p<0.01 in comparing both blood pressures reductions between the two treatment groups). Corresponding results for Study 2 (n=558) are reductions of 8.7/6.2 mm Hg and 9.5/7.4 mm Hg, respectively, for each of the two treatment groups. For Study 2, comparisons of systolic/diastolic blood pressures between the two treatment groups were not statistically significantly different (p=0.51/p=0.08, respectively). Post hoc pooled analysis (N=1096) demonstrated a slightly greater blood pressure reduction with lisinopril plus candesartan compared with lisinopril (3.1/1.7 mm Hg). A 95% confidence interval limit for the difference in least squares mean change from baseline in systolic blood pressure between the two treatment groups is ‐4.8 to ‐1.5 and is ‐2.8 to ‐0.7 in mm Hg for diastolic blood pressure. The blood pressure control rates (<140/<90 mm Hg) were 42.7% and 36.9%, respectively. Both treatment regimens were well tolerated in all groups. In conclusion, for hypertensive patients not controlled by lisinopril 20 mg once daily, addition of candesartan (32 mg once daily) or doubling the dose of lisinopril provides safe, additional reduction of blood pressure.
Physiology, Genetics, and Cardiovascular Disease: Focus on African Americans
Authors: Gibbons Gary H
Published: May 2007

The disproportionate impact of cardiovascular disease in African Americans is well recognized. Not only do risk factors such as obesity occur at a higher rate in the African‐American community, but this population experiences a greater mortality from cardiovascular disease than their white counterparts. The cardiovascular system is regulated in part by two opposing mediators linking the risk factors of obesity, vascular dysfunction, and diabetes. One of these mediators—angiotensin II–increases blood pressure, impairs endothelial function, decreases peroxisome proliferator activated‐receptor γ, and is proinflammatory, growth stimulating, profibrotic, and proatherogenic. The other mediator, peroxisome proliferator activated‐receptor γ, lowers blood pressure, improves endothelial function, decreases angiotensin II type 1 receptor function, and is anti‐inflammatory, growth‐inhibiting, antifibrotic, and antiatherogenic. Genotypic variants have been discovered that affect the functioning of both of these important systems. Some of these variants—like some genotypic variants discovered in the adrenergic system—occur with different frequencies in African Americans than in Americans of European descent and may help to explain racial/ethnic differences in susceptibility to cardiovascular disease and aspects of the response to treatment. Recognition of these genotypic differences may permit the development of therapies tailored to individual patients.
Managing Hypertension in African‐American Patients
Authors: Saunders Elijah
Published: May 2007

Epidemiologic evidence indicates that African Americans are at greater risk for hypertension compared with other ethnic groups in the United States. The prevalence of hypertension is estimated to be approximately 37% for this group, compared with 20%–25% for non‐Hispanic whites. Hypertension seems to follow a more malignant course in African Americans, possibly as a result of the higher prevalence of concomitant cardiovascular risk factors in this population. Compared with white persons with hypertension, these patients are at increased risk for left ventricular hypertrophy, heart failure, and end‐stage renal disease. Data suggest that ethnicity may influence the response to certain types of antihypertensive medication. Additional data indicate that more aggressive use of combination therapy may improve clinical outcomes among high‐risk hypertensive patients. Based on these findings, recommendations are made for the optimal clinical management of hypertension in African‐American patients.
Trends in Hypertension‐Related Death in the United States: 1980–1998
Authors: Ayala Carma , Croft Janet B. , Wattigney Wendy A. , Mensah George A.
Published: May 2007

Trends in hypertension‐related mortality for groups by race/ethnicity, sex, and age have not been examined previously. National multiple‐cause mortality files for 1980–1998 were analyzed for adult decedents with hypertension listed as one of 20 conditions causing death. Racial/ethnic comparisons of hypertension‐related death were performed using age‐standardized and age‐specific rates in years (per 100,000). Age‐standardized rate increased from 183.1 in 1980 to 243.7 in 1998, a relative increase of 33% and an average annual increase of 1.5% (p<0.0001). From 1981 to 1998, age‐specific death rates increased for persons >85 years (average annual increase of 10.4% for blacks, 7.9% for whites), 75–84 years (5.9% for blacks, 3.6% for whites), and 65–74 years (3.2% for blacks, 1.4% for whites). By 1997–1998, blacks had greater death rates compared with whites at all ages. Over the past two decades, there has been a step‐by‐step increase in hypertension‐related mortality, which has continued to show a male over female and black over white predominance. Prevention and control of hypertension must continue to be pursued as a strategy to reduce cardiovascular disease morbidity and mortality.
Thiazide‐Type Diuretics: Ongoing Considerations on Mechanism of Action
Authors: Sica Domenic A.
Published: May 2007

Thiazide‐type diuretics have enjoyed a considerable success in the management of hypertension. These drugs have assumed a standard‐of‐care position in the minds of many health care providers; however, a number of questions remain unresolved in relation to their use. Such questions include issues of mechanism of action, comparability to loop‐diuretics in their actions, class‐effect, and the basis for their additivity with non‐diuretic antihypertensive medication classes. Understanding these issues is important to the effective use of these compounds.
From Hypertension to Heart Failure
Authors: Papademetriou Vasilios
Published: May 2007

The prevalence of heart failure is increasing in modern societies. Hypertension is a major contributor to the development of heart failure, whether through the development of left ventricular hypertrophy and diastolic dysfunction or by promoting atherosclerosis and myocardial infarction, which eventually leads to systolic dysfunction and left ventricular dysfunction. Effective therapy for hypertension can prevent more than 50% of heart failure events. Most studies done in the last three decades have used β blockers with diuretics as the modality of therapy. These agents have been shown to effectively prevent the development of heart failure. More recent comparative studies have shown that use of angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers are also effective in preventing heart failure. Calcium channel blockers, however, seem to be less effective in preventing development of heart failure in patients with hypertension. It needs to be emphasized that the most important variable in preventing heart failure is the appropriate treatment of hypertension.
Hypertension, Renal Disease, and Drug Considerations
Authors: Sica Domenic A.
Published: May 2007

The incidence of chronic kidney disease is steadily increasing in the United States. The magnitude of this problem is such that virtually all health care providers are being called upon to manage these patients. The interplay between chronic kidney disease and drug therapy is complex in that the kidney is both a target for drug effect as well as a moderator of drug elimination. Renal drug elimination occurs by filtration, secretion, and/or metabolism. For renally‐cleared compounds, drug clearance typically falls in tandem with the loss of renal function. This process is noteworthy for drug accumulation when the glomerular filtration rate approaches the 30‐cc/min range. The kidney is a target for drug effect in relationship to blood pressure and protein excretion. Angiotensin‐converting enzyme inhibitor and angiotensin receptor blocker therapy (usually given along with a diuretic) are the drug classes that have been shown to be effective for reduction in both blood pressure and protein excretion in the chronic kidney disease patient. A number of questions still remain unanswered in the pharmacotherapy of chronic kidney disease, including the optimal dose for these drugs as well as what represents the most favorable achieved blood pressure.
The Efficacy and Safety of Low‐ and High‐ Dose Fixed Combinations of Irbesartan/Hydrochlorothiazide in Patients With Uncontrolled Systolic Blood Pressure on Monotherapy: The INCLUSIVE Trial
Authors: Neutel Joel M. , Saunders Elijah , Bakris George L. , Cushman William C. , Ferdinand Keith C. , Ofili Elizabeth O. , Sowers James R. , Weber Michael A. ,   on behalf of the INCLUSIVE Investigators
Published: May 2007

This multicenter, prospective, open‐label, single‐arm study determined the efficacy and safety of irbesartan/hydrochlorothiazide (HCTZ) fixed combinations in patients (n=1005), aged 18 years and older, with uncontrolled systolic blood pressure (SBP) of 140–159 mm Hg (130–159 mm Hg for type 2 diabetes mellitus) after at least 4 weeks of antihypertensive monotherapy. Treatment was sequential: placebo (4–5 weeks), HCTZ 12.5 mg (2 weeks), irbesartan/HCTZ 150/12.5 mg (8 weeks), and irbesartan/HCTZ 300/25 mg (8 weeks). Enrolled patients (n=844) were aged 57.3±11.2 years; 52% were women, 23% were African American, and 14% were Hispanic. Thirty percent had type 2 diabetes mellitus, 46% had metabolic syndrome, and baseline blood pressure was 154.0±10.3/91.3±8.8 mm Hg. The mean change in SBP from placebo end to the primary end point, Week 18 (intent‐to‐treat population, n=736) was −21.5±14.3 mm Hg (p<0.001). The mean change in diastolic blood pressure (DBP) was −10.4 ±8.7 mm Hg (p<0.001). The mean Week 18 SBP/DBP was 132.9±13.8/81.1±9.7 mm Hg. Overall, 77% (95% confidence interval, 74%–80%) of patients achieved SBP goal (<140 mm Hg; <130 mm Hg for type 2 diabetes mellitus); 83% (95% confidence interval, 80%–86%) achieved DBP goal (<90 mm Hg; <80 mm Hg for type 2 diabetes mellitus); and 69% (95% confidence interval, 66%–72%) achieved dual SBP/DBP goal. Treatments were well tolerated. This irbesartan/HCTZ treatment regimen achieved SBP goals in more than 75% of patients uncontrolled on monotherapy.
Angiotensin‐Converting Enzyme I/D Polymorphism in Patients With Malignant Hypertension
Authors: Espinel Eugenia , Tovar Jose Luis , Borrellas Javier , Piera Luis , Jardi Rosendo , Frias Francisco Rodriguez , Armadans Luis , Bachs Ana Gonzalez
Published: May 2007

The angiotensin‐converting enzyme (ACE) gene has been implicated in the manifestation of the phenotype of malignant hypertension (MH). In 1990 the ACE gene polymorphism characterized by the insertion or deletion of a 287‐base pair fragment in the 17q23 chromosome was identified. The DD genotype is associated with increased tissue and circulating ACE levels and elevated angiotensin II. ACE polymorphism was studied in 48 patients with MH, 25 patients with non‐MH, and a control group of 78 normotensive individuals by real‐time polymerase chain reaction using the LightCycler system (Roche Diagnostics Corporation, Indianapolis, IN). The DD genotype was found statistically more frequently in MH patients than controls (p=0.028; odds ratio, 2.5; confidence interval, 1.1–5.5). Presence of the DD genotype of the ACE gene is more frequent in MH patients than in controls, indicating that this genotype could be a significant risk factor and a predictor for the development of MH.
Carvedilol: New Considerations for Its Use in the Diabetic Patient With Hypertension
Authors: Sica Domenic A.
Published: May 2007

Beta blocker use improves outcomes for the diabetic patient with a history of acute myocardial infarction or coronary artery disease even more so than for the nondiabetic patient similarly afflicted. Beta blockers shift myocardial metabolism away from dependence on free fatty acids and toward greater utilization of glucose; in the process, cardiac workload drops and myocardial ischemia becomes less likely. Beta blockers also reverse the fetal gene induction program, which undoes myocardial remodeling and improves ventricular function; however, β blocker side effects in the diabetic patient can often prove their undoing. Beta blockers can deteriorate glycemic control by increasing insulin resistance. Beta blockers can also increase triglyceride levels and lower levels of high‐density lipoprotein cholesterol. In addition, vasoconstriction, caused by unopposed α activity, can worsen the symptom profile of patients with peripheral vascular disease; however, carvedilol, a combination α‐blocker/nonselective β blocker with vasodilating and insulin‐sensitizing properties, largely avoids these problems. The recently reported Glycemic Effects in Diabetes Mellitus: Carvedilol‐Metoprolol Comparison in Hypertensives (GEMINI) trial, which compared the effects of carvedilol and metoprolol tartrate on glycemic control and microalbuminuria, showed a better maintenance of glycemic control and improvement in metabolic syndrome parameters with carvedilol compared with metoprolol.
Ethnicity and Blood Pressure
Authors: Oparil Suzanne , Wright Jackson T.
Published: May 2007

The prevalence, impact, and control of hypertension differ across racial and ethnic subgroups in the United States population. Whether race/ethnicity should be a significant consideration in the choice of individual antihypertensive drugs continues to be a topic of intense interest and debate. This brief review will discuss recent findings that bear on the management of hypertension in these special patient groups.
Gynecomastia and Hypertension
Authors: Prisant L. Michael , Chin Edward
Published: May 2007

Palpable dense and mobile subareolar tissue in the male breast defines the presence of gynecomastia. For the hypertension specialist, breast enlargement in men provides a clue to a secondary cause of hypertension or an adverse antihypertensive drug reaction. Hyperthyroidism, chronic renal failure, adrenal hyperplasia or tumors, amphetamine, cyclosporine, and anabolic steroids are secondary causes of hypertension associated with gynecomastia. Reserpine, methyldopa, and spironolactone are older drugs associated with gynecomastia; however, calcium antagonists (more commonly), angiotensin‐converting enzyme inhibitors, and α1 blockers may also be associated with this finding. Treatment is directed to removal of the underlying cause.
Transdermal Clonidine: Therapeutic Considerations
Authors: Sica Domenic A. , Grubbs Rebecca
Published: May 2007

Transdermal clonidine was approved by the US Food and Drug Administration in 1984 for the treatment of mild‐to‐moderate hypertension alone or in combination with a diuretic. Clonidine is released from the patch at a constant rate and thus displays a pharmacokinetic pattern not dissimilar to that of infusion therapy. Transdermal clonidine, like oral clonidine, is effective first‐ or second‐line therapy for most forms of hypertension. More recently, transdermal clonidine has found alternative uses in the areas of smoking cessation, posttraumatic stress disorder, menopausal hot flashes, and alcohol and opiate withdrawal syndromes. The not infrequent development of a dermatitis, together with a substantially greater cost than oral clonidine, have been the major undoings for transdermal clonidine.
Prevalence of Self‐Reported High Blood Pressure Awareness, Advice Received From Health Professionals, and Actions Taken to Reduce High Blood Pressure Among US Adults—Healthstyles 2002
Authors: Ayala Carma , Neff Linda J. , Croft Janet B. , Keenan Nora L. , Malarcher Ann M. , Hyduk Alexandra , Bansil Pooja , Mensah George A.
Published: May 2007

High blood pressure awareness, advice received from health care providers, and adoption of heart‐healthy behaviors were assessed using the Healthstyles 2002 survey. About 20% of respondents reported that they had high blood pressure, and 53% of these were currently taking medications to lower blood pressure. Black men had the highest adjusted prevalence of high blood pressure (32%). Medication use among persons with high blood pressure was lower among Hispanics (45%) than among blacks (54%) and whites (54%). Persons reporting having high blood pressure were five times more likely to report having received advice from a health care professional to go on a diet or change eating habits (p<0.05) and reduce salt or sodium in their diet (p<0.05), but five times less likely to have received advice to exercise (p<0.05) than those reporting not having high blood pressure, after adjustment for differences in sex, race/ethnicity, and age. Persons with self‐reported high blood pressure were also more likely to be making these modifications (p<0.05). Among people with high blood pressure, current medication use was associated with both receiving and following advice for diet change and salt reduction (p<0.05). Future initiatives are needed to improve the proportion of Hispanics and blacks taking prescribed medications to improve high blood pressure control and reduce risk for serious sequelae such as heart disease and stroke.
Effect of Diet and Exercise on Pulse Pressure and Cardiac Function in Morbid Obesity: Analysis of 24‐Hour Ambulatory Blood Pressure
Authors: Randall Otelio S. , Kwagyan John , Huang Zhenqui , Xu Shichen , Ketete Muluemebet , Maqbool Abid R.
Published: May 2007

Blood pressure is a major risk factor for cardiovascular events, although the role of pulse pressure, an independent predictor of arterial stiffness, has recently been emphasized. This study examines the baseline relationship between body mass index (BMI) and blood pressure indexes in 215 obese African Americans enrolled in a diet—exercise program. The subject population was 77% female, with a mean ± SD age of 46.7±10.7 years and a mean BMI of 42.5±7.5 kg/m2. In addition, the authors prospectively examined the effect of weight loss on cardiovascular parameters in a subset of 25 participants. The results show a closer significant correlation between pulse pressure and BMI (β=1.97 kgm−1; p=0.001) than between systolic blood pressure and BMI (β=1.58 kgm1; p=0.020). After 3 months of diet and exercise, average reductions were as follows: BMI, 4.2 kg/m2 (p<0.01); systolic blood pressure, 7.2 mm Hg (p<0.01); pulse pressure, 4.8 mm Hg (p<0.01); and cardiac output, 975 mL/min (p<0.01). Compliance index increased by 0.1 mL/mm Hg/m2 (p=0.03). The results highlight the potential value to cardiovascular health of a modest reduction in body weight in obese individuals.
Angiotensin‐Converting Enzyme Inhibitor Use in the Year 2005
Authors: Sica Domenic A.
Published: May 2007

The angiotensin‐converting enzyme (ACE) inhibitor drug class is one with considerable staying power. ACE inhibitors are not only well established antihypertensive agents but also are compounds that fairly regularly provide end‐organ protection. Several of the ACE inhibitors are entangled in an active debate regarding class effect. Class effect for ACE inhibitors is a hopelessly confused term because its definition is not standardized and is subject to interpretation that in many cases is self‐serving. For the most part, ACE inhibitor side effects are readily identifiable, and management strategies put in place can be logical and sequential. The future of this drug class remains bright. Other drug classes, such as angiotensin receptor blockers, have narrowed—but not entirely closed—the outcomes gap that exists between these two drug classes.
Hypertension, Renal Disease, and Cardiovascular Outcomes
Authors: Moser Marvin , Basile Jan , Cushman William
Published: May 2007

During the meeting of the American Society of Hypertension in San Francisco, CA on May 17, 2005, a roundtable was convened to discuss the relationship between hypertension, renal disease, and cardiovascular outcomes. Dr. Marvin Moser, Clinical Professor at Yale University School of Medicine, New Haven, CT, chaired the session. Dr. Jan Basile, Professor of Medicine at the Ralph Johnson VA Medical Center and the Medical University of South Carolina in Charleston, SC and Dr. William Cushman, Professor of Preventive Medicine and Medicine at the University of Tennessee in Memphis, TN participated in the discussion.
ACE Inhibitors: Over Two Decades of Use
Authors: Sica Domenic A , Giles Thomas D , Black Henry R , Campese Vito M
Published: May 2007

During the meeting of the American Society of Hypertension, Inc. in San Francisco, CA, on May 16, 2005, a roundtable was convened to discuss angiotensin‐converting enzyme inhibition as it relates to both blood pressure control and issues of end‐organ protection. Dr. Domenic A. Sica of Virginia Commonwealth University, Richmond, VA, moderated the panel discussion. Participants included Dr. Thomas D. Giles of the Louisiana State University Health Sciences Center, New Orleans, LA, and President of The American Society of Hypertension, Inc.; Dr. Henry R. Black of Rush University Medical Center, Chicago, IL; and Dr. Vito M. Campese of the University of Southern California, Los Angeles, CA.