Characteristics of young-onset white coat hypertension identified by targeted screening for hypertension at a university health check-up

Previously we estimated the prevalence of essential hypertension (EH) as around 0.1% and suggested that male gender, obesity, and strong genetic background (hypertension in parents) were risk factors for EH in a young population aged less than 30 based on targeted screening for hypertension at a university health check-up. This study also revealed a high incidence of white coat hypertension (WCH) in university students, and thus, we continued this screening for four consecutive years, and examined the prognosis and clinical characteristics of young-onset WCH. Three occasions of casual blood pressure (BP) measurement and additional home BP measurement revealed 72 WCH and 15 EH students (all males) during the 4-year study period. None of the WCH students had elevated home BP to the level of hypertension during their stay at university, and 26 out of 38 WCH students participating screening in the following years showed normal casual BP. Although WCH students showed a significantly higher pulse rate than controls, WCH could not be fully differentiated from EH either by pulse rate or by correlation between casual BP value and pulse rate. These findings indicate the requirement of longer follow-up after graduation to determine the prognosis of young-onset WCH, though EH and WCH in the young population share the same risk factors and, possibly, autonomic nervous system dysfunction. Since diagnosis of WCH has limited importance for university students, screening of EH following a general health check-up would elevate the clinical validity of casual BP measurement at the university.     

Clinical characteristics of young-onset and medical treatment-requiring hypertension identified by targeted screening in university health check-up

Based on targeted screening for hypertension at a university health check-up, we previously reported a high incidence of white-coat hypertension and estimated prevalence of hypertension requiring medical treatments (HT) as around 0.1% in young population aged less than 30. In spite of such low prevalence, continuous screening for seven consecutive years (2003-2009) increased the number of HT students to 20 (19 males and 1 female). We presently assessed the clinical characteristics of these HTs. Renovascular hypertension was found in the only female HT and aortic valve regurgitation in two HTs. Resting 17 HTs were diagnosed as having essential hypertension (EH). A father and/or a mother had EH in 16 out of 17 EHs, and blood pressure (BP) at home was slightly elevated (135-145 mm Hg in systolic) except three obese EHs (body mass index more than 30) who demonstrated more than 160 mm Hg in systolic. Plasma aldosterone-renin ratio (ARR) of EHs did not differ from that of normal controls, and Pearson correlation coefficient (R) between ARR and systolic BP (SBP) was -0.2. Its partial correlation coefficient, however, was statistically significant (R = -0.55, P = .026) after correcting for body mass index, which was significantly correlated with both SBP (P = .006, after correcting for ARR) and ARR (P = .004, after correcting for SBP). In conclusion, most of young-onset HTs are male EHs, and aortic valve regurgitation should be carefully checked. Excess plasma renin activity would be one of additional characteristics of young-onset EH to male gender, genetic background, and increased body mass.     

Investigation of major genetic polymorphisms in the Renin-Angiotensin-aldosterone system in subjects with young-onset hypertension selected by a targeted-screening system at university

Although polymorphisms in renin-angiotensin-aldosterone (RAA) system genes for angiotensinogen (AGT M235T), angiotensin-converting enzyme (ACE I/D), angiotensin II type 1 receptor (AT1 A/C1166), and aldosterone synthase (CYP11B2-344T/C) have been major targets for genetic investigation in association with essential hypertension (EH), the influence of these genetic factors is still to be determined. Because patients with young-onset EH are thought to possess a stronger genetic background than EH patients who show elevated BP relatively late in life, the targeted screening of hypertensive students in Tohoku University was completed for the selection of subjects for genetic investigation. Out of 16,434 students (12,794 males and 3,670 females) younger than 30, 22 students showed a high blood pressure (BP) (systolic and diastolic BP of 140 and/or 90 mmHg or greater, respectively, on two occasions and more than 135 and/or 85 mmHg, respectively, at a third measurement during casual BP measurements at the Tohoku University Health Center. These 22 students were asked to measure their BP at home (HBP). Six of the students had a systolic HBP of more than 135 mmHg and/or a diastolic HBP of more than 85 mmHg, and these students subsequently received medical examinations at Tohoku University Hospital and were diagnosed with EH. Genotyping for the four major genetic polymorphisms mentioned above was performed on the six students with EH and on 12 of the remaining 16 students whose HBP was within the normal range (white coat hypertension: WCH). Neither the EH nor the WCH students showed a different distribution of genotypes and allelic frequencies, compared to those found in the general Japanese population. Hence, the present study suggests that none of the major genetic polymorphisms in the RAA system strongly influence the onset of EH.     

Accuracy of a salivary examination kit for the screening of periodontal disease in a group medical check-up (Japanese-specific health check-up)

The purpose of the present study was to investigate the accuracy of a screening method using salivary tests to screen for periodontal disease.In total, 1888 individuals older than 30 years in 2017 and 2296 in 2018 who underwent medical check-ups for metabolic syndrome agreed to participate and simultaneously underwent a dental examination by dentists and salivary tests. Salivary occult blood, protein, and ammonia levels and white blood cell counts were evaluated in salivary tests using commercially available kits. The relationship between the results of the salivary tests and dental examination was examined and classification performance was analyzed.The prevalence of periodontal disease was 69.9% in 2017 and 66.8% in 2018. Salivary ammonia showed the highest classification performance in both years (sensitivity 83.5 and 83.1%, precision 73.0 and 69.3%, F-measure 0.779 and 0.756). Occult blood, which was assessed using a monoclonal antibody to human hemoglobin, also showed good performance (sensitivity 69.5%, precision 70.6%, F-measure 0.701). Questions regarding self-reported gingival bleeding were not sufficient to screen for periodontitis. The present results suggest that screening tests using salivary samples may detect periodontal disease in approximately 70% to 80% of subjects in a large population.Conclusion: Salivary ammonia and hemoglobin have potential as salivary markers in the screening of periodontal disease.     

Coccidioidomycosis at a university health service

At a single university health service within an endemic area, 172 cases of coccidioidomycosis were retrospectively identified by fungal cultures, serologic studies, or intercurrent skin test conversions. The average annual incidence of symptomatic infection was 0.43% for susceptible students. Peak case rates occurred in November and June (11 cases/10,000 clinic visits) and were 1.5 to 6 times greater than in other months. Although mononucleosis was diagnosed approximately twice as frequently as coccidioidomycosis, coccidioidal infections required 74% more visits per patient and over 3 times longer clinical supervision than did mononucleosis. Although only 2 patients disseminated, diagnosis and management of patients with coccidioidomycosis constituted more than 2% of our clinic's visits, for an estimated annual cost of more than $34,000. Because our patient population is young and otherwise healthy, our estimates of the impact of primary coccidioidal infection may underestimate that on civilian public health as a whole.     

The efficacy of mass screening for chronic obstructive pulmonary disease using screening questionnaires in a medical health check-up population

BackgroundChronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, highlighting the need for efficient screening strategies to identify patients with COPD. However, there is little evidence regarding the efficacy of mass screening for COPD, and no epidemiological studies on COPD have been conducted in the Shikoku region of Japan.MethodsIn this cross-sectional study, we originally investigated the efficacy of mass screening for COPD among community residents in the aforementioned region using two COPD screening questionnaires.ResultsFrom July 2018 through January 2019, 688 participants were enrolled. COPD was diagnosed using the Global Initiative for the Chronic Obstructive Lung Disease criteria. Twenty-one patients were newly diagnosed with COPD and 19 (90.5%) had early stages COPD. The prevalence of COPD in this study was 3.1%. The COPD Population Screener (COPD-PS) questionnaire and the International Primary Care Airways Guidelines (IPAG) questionnaire had extremely high negative predictive values in discriminating participants with COPD from those without. The scores of both questionnaires were correlated with spirometric tests and with each other. The COPD-PS questionnaire had significantly better specificity and area under the receiver operating characteristic curve value than the IPAG questionnaire. Moreover, only the COPD-PS questionnaire was identified as an independent factor for predicting COPD diagnosis in the multivariate analysis.Conclusions: Mass screening for COPD using screening questionnaires, particularly the COPD-PS questionnaire, might be useful to identify the early stages of COPD in a medical health check-up population.     

Effect of HbA1c combined FPG on screening diabetes in health check-up

ObjectiveTo appraise the effectiveness of HbA_1c and fasting plasma glucose (FPG) on screening diabetes in health check-up.MethodsA total of 1 337 individuals (male 850, female 487), aged 27 to 91 years with HbA_1c test were included. Participates with HbA_1c ?6.0% or FPG?6.1 mmol/L underwent oral glucose tolerance test (OGTT). Diabetes mellitus was diagnosed according to the criteria of WHO in 1999, FPG?7.0 mmol/L and/or OGTT 2 h-postload plasm glucose (2 h-PG)?11.1 mmol/L. The sensitivity and specificity of HbA_1c thresholds and FPG or combination test on screening of diabetes were analyzed.ResultsA total of 842 subjects had HbA_1c <6.0%, in which 32 had isolated FPG?6.1 mmol/L, of 495 had HbA_1c?6.0%. Subjects with HbA_1c?6.0% had significant increased disorder indexes than those with HbA_1c<6.0%. 527 subjects who had HbA_1c?6.0% or FPG?6.1 mmol/L underwent OGTT. A total of 234 subjects were newly diagnosed diabetes, including 123 (123/234, 52.56%) with FPG?7.0 mmol/L, and 111 subjects (111/234, 47.43%) with isolated 2 h-PG?11.1 mmol/L. Among 234 new diabetes, 91.88% (215 subjects) had HbA_1c?6.3%, and 77.40% (181 subjects) had HbA_1c?6.5%. HbA_1c?6.3% combined FPG ?7.0 mmol/L increased the positive rate of newly diagnosed diabetes from 91.88% to 96.58%.ConclusionsHbA_1c is a practical and convenient tool for screening undiagnosed diabetes in routine health check-up of a large population. Combined use of HbA_1c?6.3% and/or FPG?7.0 mmol/L is efficient for early detection of diabetes.     

Reimbursement denial and reversal by health plans at a university hospital

PURPOSE: Denial and downgrading of reimbursement for hospital days are two strategies utilized by health plans to maintain profitability. The goal of this study was to describe patterns of discounted reimbursement at a university hospital. METHODS: We performed a retrospective cohort study of consecutive per diem patients hospitalized in 1999. We defined a discounted day as a day fully denied or downgraded and a reversal day as a day reimbursed at a higher level after appeal. The study outcomes included the probability of a discounted day and the probability of a discounted day to be later reversed. Covariance logistic regression was used to compare these outcomes by plan and physician specialty after adjusting for age, sex, race, length of stay, and diagnosis. Correlations with plan characteristics were analyzed. RESULTS: Of 59,265 hospital days, 6074 days (10.2%) were initially denied or downgraded. On appeal, 1755 discounted days (28.9%) were reversed. The percentage of days discounted per plan ranged from 1.2% to 18.8% (P <0.001), whereas the percentage of discounted days that were later reversed ranged from 23.2% to 85.3% (P <0.001). The qualitative magnitude of these associations and statistical significance were unchanged in adjusted models. Strong correlations were found between the adjusted odds ratio for a discounted day and net profit margin (R = 0.81) and medical loss ratio (R = -0.77). CONCLUSION: Denials and downgrades are frequent, with marked variation by health plan. More profitable plans had higher denial and discount rates. Evidence-based standards for denials and downgrades are needed to maintain optimal patient care and the fiscal health of hospitals and health plans.     

Valvular flow abnormalities are often identified by a resting focused Doppler examination performed at the time of stress echocardiography

BACKGROUND: Patients are usually referred for stress echocardiography to assess whether there is inducible myocardial ischemia. At some centers, a focused Doppler examination is also performed. We sought to determine the clinical value of this additional study by examining how often valvular flow abnormalities were identified that might affect clinical care. METHODS: We reviewed 1272 consecutive stress echocardiogram reports from a 1-year period, including 1223 tests that contained focused Doppler data. Important Doppler findings were defined as at least moderate mitral regurgitation, at least mild aortic regurgitation, any aortic or mitral valve stenosis, or any resting left ventricular outflow tract gradient. RESULTS: Overall, focused Doppler identified an important Doppler abnormality in 214 patients (17%). At least moderate mitral regurgitation was identified in 67 patients (5%) and at least mild aortic regurgitation was identified in 163 patients (13%). In addition, aortic stenosis (n = 14; 1%), mitral stenosis (n = 5; 0.4%), and resting outflow tract gradient (n = 2; 0.2%) were noted. A prior echocardiogram had been performed at our institution in 317 patients (26%). For this subset, a new important Doppler finding, a two-step change in regurgitant grade, or a one-step change in stenosis severity was noted in 28 patients (9%). Among patients who had a previous study, the prevalence of new findings was the same (9%) in those who had been studied within the previous year as in those whose previous study had been performed more than 2 years before. CONCLUSION: Focused Doppler documents valvular flow abnormalities in 17% of patients referred for stress echocardiography, thereby enhancing the potential overall value of the test. The frequency of new findings was independent of the time interval from the previous Doppler study. These data should be considered when clinicians choose a stress imaging modality.     

Neonatal screening for hypothyroidism at a university hospital in Thailand

Neonatal screening is an essential program for early identification of congenital hypothyroidism. Between July 1991 and May 1998, 37, 262 infants born at Chulalongkorn Hospital were enrolled to the screening program. Blood TSH levels were determined on infants at > or = 48 hours after birth. They were performed in dried blood sample taken by heel prick on filter papers. TSH levels were measured by fluoroimmunoassay from July 1991 to December 1997 and by immunoradiometric assay from January to May 1998. Infants with TSH screening level higher than the cut off level (20 mu/l) were recalled for re-evaluation which consist of complete physical examination and blood test for serum T4 and TSH. Bone age determination and thyroid scan using technetium-pertechnetate were performed if the serum T4 and TSH levels were abnormal. The recall rate was 0.28% and response rate was only 69%. Primary congenital hypothyroidism was diagnosed in 15 infants. Prevalence was 1: 2,484. Among these infants, 8 had ectopic thyroid, 3 had normal glands and 3 were athyrotic. One infant died before the thyroid scan could be performed and did not receive treatment. The median age at initiation of thyroxin therapy was 29 days (range, 20-67 days). The follow up result was satisfactory. This study demonstrated the potential vulnerability of congenital hypothyroid screening program in Thailand. Improvement of parents' education, communication and monitoring should be emphasized for a large screening program.     

The prevalence and clinical implications of pancreatic fat accumulation identified during a medical check-up

Fatty pancreas (FP) is characterized by pancreatic fat accumulation and the subsequent development of pancreatic and metabolic complications. However, FP has not been categorized in the manual for abdominal ultrasound in cancer screening and health check-ups in Japan, and the pathology of FP has not been fully elucidated.Nine hundred and nineteen people who underwent a medical check-up had the severity of their pancreatic fat accumulation categorized after transabdominal ultrasonographic examination. The relationships between FP, lifestyle-related diseases, and fatty liver disease at this time were assessed using stratification analysis.The prevalence of FP was 46.8% (430/919). People with FP were more likely to be male and had higher prevalences of lifestyle-related diseases, including fatty liver disease. Men and women were similarly represented in each tertile of pancreas brightness. Older age; high waist circumference, triglyceride and glucose index, serum low-density lipoprotein-cholesterol, hepatic steatosis index; and low serum amylase were associated with the presence of severe FP. Moreover, the group with severe liver steatosis had a higher prevalence of FP and a higher pancreatic brightness score. Logistic regression analysis showed that individuals with liver steatosis were more likely to have severe FP.The severity of FP is associated with features of lifestyle-related diseases and the severity of liver steatosis. These findings suggest that high visceral fat content is associated with more severe fatty pancreas as a phenotype of ectopic fat accumulation, as well as fatty liver disease.     

Survival of hypertensive subjects identified on screening: results for sustained and unsustained diastolic hypertension.

Casual readings of blood pressure predict mortality and may reflect either the risk of sustained hypertension, additional components of 'white coat' hypertension or variable blood pressure. This study investigated mortality in 442 men and 360 women with a diastolic pressure (Phase IV) of 90 mmHg and over, unsustained on two subsequent monthly visits, followed for an average of 11 years and compared with a matched control cohort with an initial diastolic pressure (DBP) of less than 90 mmHg. Subjects were identified between 1975 and 1979 by screening 28,257 subjects aged 18-65 years on the lists of general practitioners in seven practices in the United Kingdom. Additionally, 912 men and 844 women with sustained hypertension (DBP > 90 mmHg on at least two out of three occasions) were identified and matched with normotensive controls. In men with sustained hypertension the relative risk (RR) for death from circulatory disease was 1.76, P < 0.01, 95% confidence interval 1.21, 2.58 and in women 1.85, P < 0.05, 95% confidence interval 1.06, 3.24 respectively, while in men with unsustained hypertension the RR = 1.52, P = 0.2, 95% confidence interval 0.81, 2.84. Few circulatory deaths occurred in women with transient hypertension or their controls (five and seven respectively). Despite the screening programme and further treatment, newly discovered subjects with sustained hypertension, both men and women, remain at high risk of cardiovascular mortality. The 95% confidence interval for men with transient hypertension does not exclude a similar adverse effect.     

The combined effect of serum cystatin C and dyslipidemia on hypertension in a large health check-up population in China

ABSTRACT

OBJECTIVE: Some studies have reported that both serum cystatin C (Cys C) and dyslipidemia are independently associated with hypertension. However, the combined effect of the two factors is still unknown. The present study was aimed at investigating the effect of Cys C combined with dyslipidemia on hypertension in a large health check-up population in China.

METHODS: A total of 203 233 health check-up subjects from January 2011 to July 2016 were recruited into this cross-sectional study. A multivariate logistic regression model was used to evaluate the combined effect of Cys C and dyslipidemia on hypertension.

RESULTS: In univariate analysis, Cys C, high-density lipoprotein cholesterol, low-density lipoprotein, total cholesterol, and triglycerides were independently correlated with hypertension (p < 0.001). A concentration-dependent combined effect of serum Cys C and dyslipidemia on hypertension was observed in multivariate regression analysis. When compared with Cys C of <0.82 mg/L, the risk of hypertension in Cys C of <0.82 mg/L with dyslipidemia, Cys C of 0.82–0.94 mg/L with dyslipidemia, Cys C of 0.94–1.08 mg/L with dyslipidemia, and Cys C of ≥1.08 mg/L with dyslipidemia was increased 1.946 (95% confidence interval [CI]: 1.827–2.074), 1.973 (95% CI: 1.864–2.088), 2.047 (95% CI: 1.941–2.158), and 2.038 (95% CI: 1.937–2.143) folds, respectively, after adjustment.

CONCLUSION: There was an association between hypertension and the combined effect of Cys C with dyslipidemia.     

Analysis of pulmonary function test results in a health check-up population

Background

To explore the incidences of chronic obstructive pulmonary disease (COPD), obstructive ventilatory dysfunction, and obstructive small airway disease and their risk factors in a health check-up population, with an attempt to inform the early diagnosis and treatment of COPD.

Methods

Subjects who aged 20 years and older and received health check-up in the Health Management Center, Third Xiangya Hospital, Central South University from June 2013 to June 2015 were enrolled in this study. The results of detection and survey for COPD, obstructive ventilatory dysfunction, and obstructive small airway disease were analyzed.

Results

Among 6,811 subjects enrolled in this study, the detection rate of COPD, obstructive ventilator dysfunction, and obstructive small airway disease was 0.8%, 2.6%, and 4.0%, respectively, which showed a positive correlation with male gender, age, and smoking index.

Conclusions

Health check-up is an important approach for screening COPD, obstructive ventilator dysfunction, and obstructive small airway disease. Smoking cessation and controlling of relevant risk factors are helpful to lower the incidences of these conditions.     

Nonalcoholic fatty liver disease and risk of incident young-onset hypertension: Effect modification by sex

Background and aimsAlthough nonalcoholic fatty liver disease (NAFLD) and hypertension are increasingly common among young adults, it is uncertain if NAFLD affects incidence of young-onset hypertension, and if the association is modified by sex. We investigated potential effect modification by sex on the association between NAFLD and incident hypertension in young adults (<40 years).Method and resultsThis cohort study comprised 85,789 women and 67,553 men aged <40 years without hypertension at baseline. Hepatic steatosis was assessed by liver ultrasound and classified as mild or moderate/severe. Hypertension was defined as blood pressure (BP) ≥130/80 mmHg; self-reported history of physician-diagnosed hypertension; or current use of BP-lowering medications. Cox proportional hazard models were used to estimate hazard ratios (HRs; 95% confidence intervals [CIs]) for incident hypertension by NAFLD status (median follow-up 4.5 years). A total of 25,891 participants developed incident hypertension (incidence rates per 10³ person-years: 15.6 for women and 63.5 for men). Multivariable-adjusted HRs (95% CIs) for incident hypertension comparing no NAFLD (reference) with mild or moderate/severe NAFLD were 1.68 (1.56–1.80) and 1.83 (1.60–2.09) for women and 1.21 (1.17–1.25) and 1.23 (1.17–1.30) for men, respectively. Stronger associations were consistently observed between NAFLD and incident hypertension in women, regardless of obesity/central obesity (all p-values for interaction by sex <0.001).ConclusionsNAFLD is a potential risk factor for young-onset hypertension with a relatively greater impact in women and in those with more severe hepatic steatosis.     

Incidence of tuberculosis among health care workers at a private university hospital in South Korea.

SETTING: A private university hospital in South Korea. OBJECTIVE: To investigate the incidence of tuberculosis (TB) among health care workers (HCWs) employed at a university hospital in South Korea. DESIGN: The occurrence of TB cases among HCWs over a 6-year period (2001-2006) was reviewed. The prevalence of TB was compared with that of the general population using a prevalence ratio (PR) adjusted by age and sex. RESULTS: The study involved 8433 people. TB developed in 61 HCWs (0.72%). The prevalence ratio among all HCWs was 1.05 (95%CI 0.80-1.35). In occupational subgroups, the PRs for doctors, nurses and employees in other departments were respectively 0.58 (95%CI 0.30-1.01), 1.81 (95%CI 1.21-2.59) and 0.95 (95% CI 0.58-1.46). For nurses working in TB-related departments, the relative risk of developing TB was 3.4 times higher (95%CI 1.52-8.25) than for employees in other departments (P=0.005). The PR for nurses working in TB-related department was 5.1 (95%CI 3.23-8.42). CONCLUSION: Among HCWs, nurses working in TB-related departments were at increased risk of developing TB. This suggests that some TB develops via in-hospital infection.