Report of the Canadian Hypertension Society Consensus Conference: 2. Nonpharmacologic management and prevention of hypertensive disorders in pregnancy

OBJECTIVE: To provide Canadian physicians with comprehensive, evidence-based guidelines for the nonpharmacologic management and prevention of gestational hypertension and pre-existing hypertension during pregnancy. OPTIONS: Lifestyle modifications, dietary or nutrient interventions, plasma volume expansion and use of prostaglandin precursors or inhibitors. OUTCOMES: In gestational hypertension, prevention of complications and death related to either its occurrence (primary or secondary prevention) or its severity (tertiary prevention). In pre-existing hypertension, prevention of superimposed gestational hypertension and intrauterine growth retardation. EVIDENCE: Articles retrieved from the pregnancy and childbirth module of the Cochrane Database of Systematic Reviews; pertinent articles published from 1966 to 1996, retrieved through a MEDLINE search; and review of original randomized trials from 1942 to 1996. If evidence was unavailable, consensus was reached by the members of the consensus panel set up by the Canadian Hypertension Society. VALUES: High priority was given to prevention of adverse maternal and neonatal outcomes in pregnancies with established hypertension and in those at high risk of gestational hypertension through the provision of effective nonpharmacologic management. BENEFITS, HARMS AND COSTS: Reduction in rate of long-term hospital admissions among women with gestational hypertension, with establishment of safe home-care blood pressure monitoring and appropriate rest. Targeting prophylactic interventions in selected high-risk groups may avoid ineffective use in the general population. Cost was not considered. RECOMMENDATION: Nonpharmacologic management should be considered for pregnant women with a systolic blood pressure of 140-150 mm Hg or a diastolic pressure of 90-99 mm Hg, or both, measured in a clinical setting. A short-term hospital stay may be required for diagnosis and for ruling out severe gestational hypertension (preeclampsia). In the latter case, the only effective treatment is delivery. Palliative management, dependent on blood pressure, gestational age and presence of associated maternal and fetal risk factors, includes close supervision, limitation of activities and some bed rest. A normal diet without salt restriction is advised. Promising preventive interventions that may reduce the incidence of gestational hypertension, especially with proteinuria, include calcium supplementation (2 g/d), fish oil supplementation and low-dose acetylsalicylic acid therapy, particularly in women at high risk for early-onset gestational hypertension. Pre-existing hypertension should be managed the same way as before pregnancy. However, additional concerns are the effects on fetal well-being and the worsening of hypertension during the second half of pregnancy. There is, as yet, no treatment that will prevent exacerbation of the condition. VALIDATION: The guidelines share the principles in consensus reports from the US and Australia on the nonpharmacologic management of hypertension in pregnancy.     

Report of the Canadian Hypertension Society Consensus Conference: 3. Pharmacologic treatment of hypertensive disorders in pregnancy

OBJECTIVE: To provide Canadian physicians with evidence-based guidelines for the pharmacologic treatment of hypertensive disorders in pregnancy. OPTIONS: No medication, or treatment with antihypertensive or anticonvulsant drugs. OUTCOMES: Prevention of maternal complications, and prevention of perinatal complications and death. EVIDENCE: Pertinent articles published from 1962 to September 1996 retrieved from the Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews and from MEDLINE; additional articles retrieved through a manual search of bibliographies; and expert opinion. Recommendations were graded according to levels of evidence. VALUES: Maternal and fetal well-being were equally valued, with the belief that treatment side effects should be minimized. BENEFITS, HARMS AND COSTS: Reduction in the rate of adverse perinatal outcomes, including death. Potential side effects of antihypertensive drugs include placental hypoperfusion, intrauterine growth retardation and long-term effects on the infant. RECOMMENDATIONS: A systolic blood pressure greater than 169 mm Hg or a diastolic pressure greater than 109 mm Hg in a pregnant woman should be considered an emergency and pharmacologic treatment with hydralazine, labetalol or nifedipine started. Otherwise, the thresholds at which to start antihypertensive treatment are a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg in women with gestational hypertension without proteinuria or pre-existing hypertension before 28 weeks' gestation, those with gestational hypertension and proteinuria or symptoms at any time during the pregnancy, those with pre-existing hypertension and underlying conditions or target-organ damage, and those with pre-existing hypertension and superimposed gestational hypertension. The thresholds in other circumstances are a systolic pressure of 150 mm Hg or a diastolic pressure of 95 mm Hg. For nonsevere hypertension, methyldopa is the first-line drug; labetalol, pindolol, oxprenolol and nifedipine are second-line drugs. Fetal distress attributed to placental hypoperfusion is rare, and long-term effects on the infant are unknown. Magnesium sulfate is recommended for the prevention and treatment of seizures. VALIDATION: The guidelines are more precise but compatible with those from the US and Australia.     

Report of the Canadian Hypertension Society Consensus Conference: 2. Diagnosis of hypertension in adults.

OBJECTIVE: To update recommendations for the diagnosis of mild hypertension in adults and to assess the role of echocardiography, self-measurement of blood pressure and ambulatory blood pressure monitoring. DATA SOURCES: Literature reviews of previous consensus conferences were updated with searches of MEDLINE for the period Jan. 1, 1988, to Nov. 15, 1991, and supplemented by reference lists and personal files. STUDY SELECTION: Panel members selected relevant articles and rated them according to methodologic criteria. DATA EXTRACTION: The data extracted concerned the measurement of blood pressure, the diagnosis of hypertension, the treatment of mild hypertension, and the reliability and validity of echocardiography, self-measurement of blood pressure and ambulatory blood pressure monitoring in the diagnosis of mild hypertension. The recommendations made were graded according to the level of evidence available, circulated to many experts and approved at a consensus conference. MAIN RESULTS: Previous recommendations for the accurate measurement of blood pressure remain mostly unchanged. Antihypertensive treatment should be prescribed for patients (including the elderly) with an average diastolic blood pressure of at least 100 mm Hg, for those with isolated systolic hypertension (systolic blood pressure of at least 160 mm Hg and diastolic blood pressure of less than 90 mm Hg) and for patients with a diastolic blood pressure of 90 to 99 mm Hg and target-organ damage. Clinical judgement is required in treating patients with a diastolic blood pressure of 90 to 99 mm Hg without target-organ damage, and individual risk for cardiovascular disease must be taken into account. There is insufficient evidence to warrant the routine use of echocardiography, self-measurement of blood pressure or ambulatory blood pressure monitoring in diagnosis. CONCLUSIONS: Recent high-quality evidence supports several new recommendations for the diagnosis of mild hypertension in adults. Additional research is needed to determine the role of echocardiography, self-measurement of blood pressure and ambulatory blood pressure monitoring.     

Rejection of insulin therapy among patients with type 2 diabetes in China: reasons and recommendations

Background Insulin injection therapy is one of the most effective treatments for type 2 diabetes meUitus （T2DM）. Many people with T2DM in western countries resist starting insulin therapy; whether the same is true in China is unknown. This survey-based study assessed acceptance and rejection of insulin therapy among individuals with T2DM in China and self- reported reasons for these therapy choices. It also examined what methods may be useful for increasing the rate of insulin acceptance. Methods A multi-center, cross-sectional survey was conducted between April and July 2010 to a convenience sample of inpatients and outpatients at 50 medical centers across 29 administrative divisions in China. Data were collected on sociodemographic and T2DM characteristics, therapy regime, and attitudes toward insulin therapy. Results A total of 6 043 patients were surveyed, and 5 961 complete questionnaires （98.6%） were used in the analysis. Just over half the respondents （3 460, 58.0%） reported negative attitudes to insulin therapy, including 2 508 of the 4 469 patients （56.1%） whose physicians had recommended it to them. Of the patients counseled to use insulin, 800 （17.9%） were unwilling to start therapy and cited the following reasons： inconvenience （64.3%）; concerns over addiction （24.6%）; pain （14.3%）; side effects （14.1%）; and high cost （13.6%）. Logistic regression suggested that respondents would be more willing to undertake insulin therapy if they had received diabetes education, had positive attitudes to the treatment, had higher glycosylated hemoglobin level, or had suffered diabetes for a longer period or with more complications. Conclusions Patients with T2DM in China are often resistant to insulin therapy if they have been diagnosed with the disease for a relatively short time or if the disease has been relatively mild. Educating patients on the benefits of insulin therapy, not only at the initial diagnosis with T2DM but also when insulin therapy becomes necessary, will l     

Assessing the risk of tuberculosis infection among healthcare workers: the Melbourne Mantoux Study. Melbourne Mantoux Study Group.

OBJECTIVE: To determine the potential prevalence of nosocomial infection with Mycobacterium tuberculosis among hospital employees in teaching hospitals in Melbourne. DESIGN: Cross-sectional survey of positive tuberculin skin test (Mantoux) responses among employees in 14 public hospitals in Melbourne, January 1996 to April 1999. PARTICIPANTS: All consenting employees in participating hospitals (4,070 healthcare and 4,298 non-healthcare workers; participation rates, 13%-66%). OUTCOME MEASURES: Prevalence of positive responses to tuberculin skin tests among healthcare and non-healthcare workers and association with employee and hospital characteristics. RESULTS: Healthcare workers were significantly more likely to have a positive tuberculin response than non-healthcare workers (19.3% versus 13.7%; odds ratio, 1.5; 95% CI, 1.3-1.7; P<0.001). Multivariable analysis revealed that age, country of birth (high versus low tuberculosis [TB] prevalence), history of BCG (bacille Calmette-Guérin) vaccination, years since last BCG, occupation (healthcare versus non-healthcare worker) and years of hospital employment were all significantly associated with a positive response. Rates of positive responses among employees varied greatly between hospitals (6%-35%). These differences were not explained by employee characteristics, hospital TB patient load (number of admissions or bed-days) or percentage of hospital patients from countries with high TB prevalence. The hospital with the highest rate of positive responses was notable for its lack of negative-pressure isolation rooms for TB patients. CONCLUSIONS: Positive tuberculin responses are relatively common among hospital employees in Melbourne, with rates varying between hospitals and being higher among healthcare than non-healthcare workers. Employee characteristics, such as age, country of birth and past BCG status, explain little of this variation. More emphasis on TB infection control measures and regular staff screening may be needed.     

Preventive practice among primary care physicians in British Columbia: relation to recommendations of the Canadian Task Force on the Periodic Health Examination.

OBJECTIVES: To compare the current practice of preventive medicine in British Columbia with the recommendations of the Canadian Task Force on the Periodic Health Examination. Four common, preventable forms of cancer (cervical, breast, lung and colorectal) were used as sentinel conditions. DESIGN: Random sample mailed survey. SETTING: Private primary care practices in British Columbia. PARTICIPANTS: A sample of 300 primary care physicians in 1991; of 285 eligible physicians 185 (65%) responded. OUTCOME MEASURE: Compliance with preventive practices recommended by the task force. RESULTS: Preventive practice complied with the task force's recommendations for breast examinations, mammography, cervical smears and initial counselling against smoking; over 90% of the physicians performed these manoeuvres in all or most cases. However, less than half performed two recommended manoeuvres for all or most patients who smoke: advice to follow a diet high in beta-carotene (reported by 10%) and scheduling of follow-up visits to reinforce antismoking counselling (by 46%). Most of the physicians stated that they perform preventive manoeuvres in the context of an annual general physical examination rather than integrating them into routine patient care. CONCLUSIONS: The task force's carefully constructed recommendations are incompletely followed. Overall, there appears to be a high level of compliance with traditional and recommended manoeuvres but also widespread persistence in performing traditional manoeuvres no longer recommended and failure to adopt new recommendations.     

老年2型糖尿病患者颈内动脉粥样硬化斑块形成危险因素及对策分析

目的 探讨老年2型糖尿病(T2DM)患者颈内动脉粥样硬化斑块(CASP)的发生率及其相关危险因素,为临床早期防治提供依据.方法 选取2017年1月至2019年10月我院收治的254例T2DM患者作为研究对象,依据颈动脉内膜中层厚度是否>1.2 mm将其分为斑块组(n=105)和无斑块组(n=149).采用多因素非条件L...     

A pilot study for evaluation of the efficacy and safety of telmisartan in reducing microalbuminuria in hypertensive patients with type 2 diabetes mellitus

To evaluate efficacy and tolerability of telmisartan, an angiotensim II receptor blocker, in reducing microalbuminuria in adult Indian hypertensive patients with type 2 diabetes mellitus, a prospective, open-label, non-comparative, assessor-blind, multicentric, pilot study was conducted in 60 eligible hypertensive patients with type 2 diabetes mellitus and microalbuminuria after obtaining their informed consent. The study was approved by the respective institutional review boards. Each patient received telmisartan 40 mg initially once daily for first 4 weeks which was titrated upwards to 80 mg once daily for the next 8 weeks. Blood pressure was assessed at the end of every 2 weeks and urinary albumin excretion and creatinine clearance were measured at baseline and after 12 weeks of therapy. Safety outcome measures included monitoring of physical examination, laboratory parameters and monitoring treatment-emergent adverse events. Fifty-five patients completed the study while 5 cases were lost to follow-up. The mean age of the patients was 48.27 years. Of the total patients 63.6% were males and 46.4% were females. At baseline the mean urinary albumin excretion rate was 131.81 +/- 38.82 mg/minute. A statistically significant (p < 0.05) reduction (32.96%) in urinary albumin excretion rate occurred after 12 weeks of therapy (118.36 +/- 37.22). The mean pre-study systolic blood pressure was 165.05 +/- 15.24 mmHg which was significantly (p < 0.05) reduced to 123.72 +/- 5.88 mmHg at the end of 12 weeks. At baseline the mean diastolic blood pressure was 103.55 +/- 9.84 mmHg which was significantly (p < 0.05) reduced to 84.71 +/- 8.54 mmHg. The JNC-VII goal of blood pressure below 130/80 was achieved in 34 (61.8%)of the 55 patients at the end of 12 weeks. Both fasting and postprandial blood sugar levels were well-controlled at the end of the study. Telmisartan was well tolerated with only 9.09% of the patients reported mild and transient adverse events like fatigue, dizziness, nausea and diarrhoea. No abnormalities were detected in the laboratory parameters. The results of this pilot study indicate that telmisartan is effective, safe and well tolerated while reducing microalbuminuria in adult Indian hypertensive patients with type 2 diabetes mellitus.     

Canadian National Breast Screening Study: 2. Breast cancer detection and death rates among women aged 50 to 59 years.

OBJECTIVE: To evaluate the efficacy of annual mammography over and above annual physical examination of the breasts and the teaching of breast self-examination among women aged 50 to 59 on entry. DESIGN: Individually randomized controlled trial. SETTING: Fifteen urban centres in Canada with expertise in the diagnosis and treatment of breast cancer. PARTICIPANTS: Women with no history of breast cancer and no mammography in the previous 12 months were randomly assigned to undergo either annual mammography and physical examination (MP group) or annual physical examination only (PO group). The 39,405 women enrolled from January 1980 through March 1985 were followed for a mean of 8.3 years. DATA COLLECTION: Derived from the participants by initial and annual self-administered questionnaires, from the screening examinations, from the patients' physicians, from the provincial cancer registries and by record linkage to the Canadian National Mortality Data Base. Expert panels evaluated histologic and death data. MAIN OUTCOME MEASURES: Rates of referral from screening, rates of detection of breast cancer from screening and from community care, nodal status, tumour size and rates of death from all causes and from breast cancer. RESULTS: Over 85% of the women in each group attended the screening sessions after screen 1. The characteristics of the women in the two groups were similar. Compared with the Canadian population the participants were more likely to be married, have fewer children, have more education, be in a professional occupation, smoke less and have been born in North America. The rate of screen-detected breast cancer on first examination was 7.20 per 1000 in the MP group and 3.45 per 1000 in the PO group, more node-positive tumours were found in the MP group than in the PO group. At subsequent screens the detection rates were a little less than half the rates at screen 1. During years 2 through 5 the ratios of observed to expected cases of invasive breast cancer were 1.28 in the MP group and 1.18 in the PO group. Of the women with invasive breast cancer through to 7 years, 217 in the MP group and 184 in the PO group had no node involvement, 66 and 56 had one to three nodes involved, 32 and 34 had four or more nodes involved, and 55 and 46 had an unknown nodal status. There were 38 deaths from breast cancer in the MP group and 39 in the PO group. The ratio of the proportions of death from breast cancer in the MP group compared with those in the UC group was 0.97 (95% confidence interval 0.62 to 1.52). The survival rates were similar in the two groups. Women whose cancer had been detected by mammography alone had the highest survival rate. CONCLUSION: The study was internally valid, and there was no evidence of randomization bias. Screening with yearly mammography in addition to physical examination of the breasts detected considerably more node-negative, small tumours than screening with physical examination alone, but it had no impact on the rate of death from breast cancer up to 7 years' follow-up from entry.