Session of yoga, with and without slow (Ujjayi) breathing, reduces anxiety; no change on acute pain sensitivity and endogenous pain modulation.

OBJECTIVES: Yoga is an increasingly popular mode of exercise that boasts health promoting effects including pain relief. A single bout of exercise induces a reduced sensitivity to noxious heat, but the mechanism for this effect and whether it occurs after a single session of yoga is unexplored. The primary aim of this study was to test, using a post-test only between-subjects design, main and interactive effects of yoga and slow breathing on both sensitivity to heat pain and endogenous pain modulation processing in healthy young women DESIGN: Fifty-four women were block randomized into one of four conditions: yoga with slow breathing instructions (Vinyasa), yoga with no breathing instructions, seated rest with slow breathing instructions and seated rest with no breathing instructions. The conditions were completed alone is a small room in which participant followed video-based instructions and models. The yoga was perceived as low-to-moderate intensity. RESULTS: Two factor ANOVA demonstrated no significant association between yoga postures and slow breathing, and there was no significant interaction observed for sensitivity to heat pain or endogenous pain modulation. These findings were unchanged in ANCOVAs that controlled for four potential confounding variables: post-condition reduction in systolic blood pressure or state anxiety, pain induced by the conditions and expectations. Compared to the non-yoga conditions, participant in yoga conditions resulted in a significant reduction in state anxiety scores. CONCLUSIONS: It is concluded that a single session of low-to-moderate intensity yoga with, or without slow breathing, reduces state anxiety but has no effect on heat pain sensitivity or endogenous pain modulation.

The effects of 9 months of formulated whole-egg or milk powder food products as meal or snack replacements on executive function in preadolescents: A randomized, placebo-controlled trial.

BACKGROUND: Elevated brain choline is associated with better executive functions in preadolescents. Manipulating dietary choline prospectively in preadolescents using egg supplementation could improve executive functions via effects on brain cellular and neurotransmitter functions. OBJECTIVES: We tested the 9-month impacts of egg supplementation on executive functions. It was hypothesized that preadolescents who consumed meal or snack replacement products containing powder made from whole eggs would have the largest improvements in executive functions after 9 months compared to those consuming similar products with either added milk powder or gelatin as a placebo. METHODS: A randomized, parallel-group, double-blinded, placebo-controlled trial design was used. The executive functions of 122 preadolescents (58 females) aged 9-13 were analyzed before and after the 9-month intervention. The primary outcomes were 3 NIH Toolbox-Cognitive Battery measures of executive function: mental flexibility, working memory, and selective attention and inhibitory control. Participants were randomized to consume food products with either: 1) whole egg powder; 2) milk powder; or 3) gelatin as a placebo, all matched on macronutrient content and used as replacements for commonly consumed foods (i.e., waffles, pancakes, macaroni and cheese, ice cream, and brownies). Hypothesis testing used mixed-effects models that included physical activity and sleep scores as covariates. RESULTS: A statistically significant group × time interaction for selective attention and inhibitory control was found (P = 0.049) for the milk group. This interaction resulted from no change for the placebo group and an improvement in selective attention and inhibitory control performance for the milk group by a T-score of 5.8; the effect size (d) was 0.44 SD units. Other comparisons were statistically insignificant. CONCLUSIONS: Consumption of foods with added milk powder as a replacement for snacks or meals for 9 months improves selective attention and inhibitory control in preadolescents. Replacement of foods with added whole egg powder does not impact 9-month changes in preadolescent executive functions. This trial was registered at clinicaltrials.gov as NCT03739424.

Association of Cardiovascular Outcomes and Mortality With Sustained Long-Acting Insulin Only vs Long-Acting Plus Short-Acting Insulin Treatment.

Importance: Cardiovascular events and mortality are the principal causes of excess mortality and health care costs for people with type 2 diabetes. No large studies have specifically compared long-acting insulin alone with long-acting plus short-acting insulin with regard to cardiovascular outcomes. Objective: To compare cardiovascular events and mortality in adults with type 2 diabetes receiving long-acting insulin who do or do not add short-acting insulin. Design, Setting, and Participants: This retrospective cohort study emulated a randomized experiment in which adults with type 2 diabetes who experienced a qualifying glycated hemoglobin A1c (HbA1c) level of 6.8% to 8.5% with long-acting insulin were randomized to continuing treatment with long-acting insulin (LA group) or adding short-acting insulin within 1 year of the qualifying HbA1c level (LA plus SA group). Retrospective data in 4 integrated health care delivery systems from the Health Care Systems Research Network from January 1, 2005, to December 31, 2013, were used. Analysis used inverse probability weighting estimation with Super Learner for propensity score estimation. Analyses took place from April 1, 2018, to June 30, 2019. Exposures: Long-acting insulin alone or with added short-acting insulin within 1 year from the qualifying HbA1c level. Main Outcomes and Measures: Mortality, cardiovascular mortality, acute myocardial infarction, stroke, and hospitalization for heart failure. Results: Among 57 278 individuals (39 279 with data on cardiovascular mortality) with a mean (SD) age of 60.6 (11.5) years, 53.6% men, 43.5% non-Hispanic White individuals, and 4 years of follow-up (median follow-up of 11 [interquartile range, 5-20] calendar quarters), the LA plus SA group was associated with increased all-cause mortality compared with the LA group (hazard ratio, 1.27; 95% CI, 1.05-1.49) and a decreased risk of acute myocardial infarction (hazard ratio, 0.89; 95% CI, 0.81-0.97). Treatment with long-acting plus short-acting insulin was not associated with increased risks of congestive heart failure, stroke, or cardiovascular mortality. Conclusions and Relevance: Findings of this retrospective cohort study suggested an increased risk of all-cause mortality and a decreased risk of acute myocardial infarction for the LA plus SA group compared with the LA group. Given the lack of an increase in major cardiovascular events or cardiovascular mortality, the increased all-cause mortality with long-acting plus short-acting insulin may be explained by noncardiovascular events or unmeasured confounding.

Mental energy: plausible neurological mechanisms and emerging research on the effects of natural dietary compounds.

Objective: Lack of mental energy is one of the leading reasons adults turn to dietary supplements, with three out of ten supplement users hoping to improve their energy level; even more consume caffeine-containing products for the same reason. Despite this interest from consumers, there is no consensus scientific definition of mental energy or sole validated instrument for measuring it. We performed this review to summarize main findings from research regarding the influence of natural dietary compounds on three aspects of mental energy: cognition (vigilance), motivation (to do mental work), and mood (feelings of energy and/or absence of feelings of fatigue).Methods: A narrative review of key papers.Results: In addition to caffeine, a number of other compounds, including the polyphenols, which are found in all plant-derived products, and the phytochemicals in culinary herbs and herbal products such as Panax ginseng and Ginkgo biloba, have been shown in animal models to modulate neurotransmitter activity potentially relevant to mental energy. Inadequate intake of B vitamins could also potentially have a negative effect on mental energy due to their role in overall energy production, as precursors of key cofactors in the citric acid cycle, as well as their role in brain function and neurotransmitter synthesis. Consumption of some of these products may have direct or indirect effects on one or more elements of mental energy.Conclusion: Large, prospective clinical trials of these products using appropriate, validated instruments designed to measure mental energy may be worthwhile if sufficient evidence exists to justify such trials.

Predictors of Hyperkalemia and Hypokalemia in Individuals with Diabetes: a Classification and Regression Tree Analysis.

BACKGROUND: Both hyperkalemia and hypokalemia can lead to cardiac arrhythmias and are associated with increased mortality. Information on the predictors of potassium in individuals with diabetes in routine clinical practice is lacking. OBJECTIVE: To identify predictors of hyperkalemia and hypokalemia in adults with diabetes. DESIGN: Retrospective cohort study, with classification and regression tree (CART) analysis. PARTICIPANTS: 321,856 individuals with diabetes enrolled in four large integrated health care systems from 2012 to 2013. MAIN MEASURES: We used a single serum potassium result collected in 2012 or 2013. Hyperkalemia was defined as a serum potassium ≥ 5.5 mEq/L and hypokalemia as < 3.5 mEq/L. Predictors included demographic factors, laboratory measurements, comorbidities, medication use, and health care utilization. KEY RESULTS: There were 2556 hypokalemia events (0.8%) and 1517 hyperkalemia events (0.5%). In univariate analyses, we identified concordant predictors (associated with increased probability of both hyperkalemia and hypokalemia), discordant predictors, and predictors of only hyperkalemia or hypokalemia. In CART models, the hyperkalemia "tree" had 5 nodes and a c-statistic of 0.76. The nodes were defined by prior potassium results and eGFRs, and the 5 terminal "leaves" had hyperkalemia probabilities of 0.2 to 7.2%. The hypokalemia tree had 4 nodes and a c-statistic of 0.76. The hypokalemia tree included nodes defined by prior potassium results, and the 4 terminal leaves had hypokalemia probabilities of 0.3 to 17.6%. Individuals with a recent potassium between 4.0 and 5.0 mEq/L, eGFR ≥ 45 mL/min/1.73m2, and no hypokalemia in the previous year had a < 1% rate of either hypokalemia or hyperkalemia. CONCLUSIONS: The yield of routine serum potassium testing may be low in individuals with a recent serum potassium between 4.0 and 5.0 mEq/L, eGFR ≥ 45 mL/min/1.73m2, and no recent history of hypokalemia. We did not examine the effect of recent changes in clinical condition or medications on acute potassium changes.

Clinical Decision Support for Recognizing and Managing Hypertensive Blood Pressure in Youth: No Significant Impact on Medical Costs.

OBJECTIVE: To evaluate economic costs from the health system perspective of an electronic health record-based clinical decision support (CDS) tool, TeenBP, designed to assist in the recognition and management of hypertension in youth. METHODS: Twenty primary care clinics within an integrated health system were randomized to the TeenBP CDS or usual care (UC), with patient enrollment from 4/15/14 to 4/14/16. The 12-month change in standardized medical care costs for insured patients aged 10 to 17 years without prior hypertension were calculated for each study arm. The primary analysis compared patients with ≥1 visit with blood pressure (BP) ≥95th percentile (isolated hypertensive BP), and secondary analyses compared patients with ≥3 visits within one year with BP ≥95th percentile (incident hypertension). Generalized estimating equation models estimated the difference-in-differences in costs between groups over time. RESULTS: Among 925 insured patients with an isolated hypertensive BP, the pre-to-post change in overall costs averaged $22 more for TeenBP CDS versus UC patients over 12 months, but this difference was not statistically significant (P = .723). Among 159 insured patients with incident hypertension, the pre-to-post change in overall costs over 12 months was higher by $227 per person on average for TeenBP CDS versus UC patients, but this difference also was not statistically significant (P = .313). CONCLUSIONS: The TeenBP CDS intervention was previously found to significantly improve identification and management of hypertensive BP in youth, and in this study, we find that this tool did not significantly increase care costs in its first 12 months of clinical use.

Interactive Virtual Reality Reduces Quadriceps Pain during High-Intensity Cycling.

PURPOSE: Brief, high-intensity cycling is popular because physiological benefits accrue with a short workout time, but burning pain in the quadriceps is a potential barrier to engaging in this type of exercise. Virtual reality (VR) can temporarily decrease pain, but its effect on muscle pain during high-intensity exercise is unknown. The primary purpose of this experiment was to test whether adding interactive VR (I-VR) to high-intensity cycling could reduce quadriceps pain or improve performance. METHODS: Ninety-four adults who were physically active in their leisure time and age 18 to 29 yr completed three 30-s sprint interval cycling trials at a high resistance (0.085- and 0.075-kg resistance to the flywheel per kilogram body weight for men and women, respectively). In this randomized between-subject experiment, participants cycled while wearing a head-mounted display and viewing either (i) a dynamically changing cityscape perceived as interactively cycling through a virtual city (I-VR group) or (ii) a static picture of the cityscape with instructions to mentally imagine cycling through that city (static VR/motor imagery control group). RESULTS: Sphericity-adjusted 2 × 3 (group-time) ANOVA revealed a significant group-time interaction (F = 4.568; df = 1.499, 133.301; ηp = 0.047, P = 0.021) for pain intensity. With I-VR, pain intensities were 13.3% (mean, 4.60 vs 5.31; d = 0.28) and 11.8% (mean, 5.68 vs 6.44; d = 0.27) lower at sprint trials 2 and 3, respectively. The group-time interaction (P = 0.412) was not significant for total work. CONCLUSION: Compared with a static VR/motor imagery control condition, I-VR during brief, high-intensity, fatigue-inducing leg cycling attenuates quadriceps pain intensity without reducing performance.

Association Between Bariatric Surgery and Macrovascular Disease Outcomes in Patients With Type 2 Diabetes and Severe Obesity.

Importance: Macrovascular disease is a leading cause of morbidity and mortality for patients with type 2 diabetes, and medical management, including lifestyle changes, may not be successful at lowering risk. Objective: To investigate the relationship between bariatric surgery and incident macrovascular (coronary artery disease and cerebrovascular diseases) events in patients with severe obesity and type 2 diabetes. Design, Setting, and Participants: In this retrospective, matched cohort study, patients with severe obesity (body mass index ≥35) aged 19 to 79 years with diabetes who underwent bariatric surgery from 2005 to 2011 in 4 integrated health systems in the United States (n = 5301) were matched to 14 934 control patients on site, age, sex, body mass index, hemoglobin A1c, insulin use, observed diabetes duration, and prior health care utilization, with follow-up through September 2015. Exposures: Bariatric procedures (76% Roux-en-Y gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) were compared with usual care for diabetes. Main Outcomes and Measures: Multivariable-adjusted Cox regression analysis investigated time to incident macrovascular disease (defined as first occurrence of coronary artery disease [acute myocardial infarction, unstable angina, percutaneous coronary intervention, or coronary artery bypass grafting] or cerebrovascular events [ischemic stroke, hemorrhagic stroke, carotid stenting, or carotid endarterectomy]). Secondary outcomes included coronary artery disease and cerebrovascular outcomes separately. Results: Among a combined 20 235 surgical and nonsurgical patients, the mean (SD) age was 50 (10) years; 76% of the surgical and 75% of the nonsurgical patients were female; and the baseline mean (SD) body mass index was 44.7 (6.9) and 43.8 (6.7) in the surgical and nonsurgical groups, respectively. At the end of the study period, there were 106 macrovascular events in surgical patients (including 37 cerebrovascular and 78 coronary artery events over a median of 4.7 years; interquartile range, 3.2-6.2 years) and 596 events in the matched control patients (including 227 cerebrovascular and 398 coronary artery events over a median of 4.6 years; interquartile range, 3.1-6.1 years). Bariatric surgery was associated with a lower composite incidence of macrovascular events at 5 years (2.1% in the surgical group vs 4.3% in the nonsurgical group; hazard ratio, 0.60 [95% CI, 0.42-0.86]), as well as a lower incidence of coronary artery disease (1.6% in the surgical group vs 2.8% in the nonsurgical group; hazard ratio, 0.64 [95% CI, 0.42-0.99]). The incidence of cerebrovascular disease was not significantly different between groups at 5 years (0.7% in the surgical group vs 1.7% in the nonsurgical group; hazard ratio, 0.69 [95% CI, 0.38-1.25]). Conclusions and Relevance: In this observational study of patients with type 2 diabetes and severe obesity who underwent surgery, compared with those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascular outcomes. The findings require confirmation in randomized clinical trials. Health care professionals should engage patients with severe obesity and type 2 diabetes in a shared decision making conversation about the potential role of bariatric surgery in the prevention of macrovascular events.

Understanding Primary Care Provider Attitudes and Behaviors Regarding Cardiovascular Disease Risk and Diabetes Prevention in the Northern Midwest.

IN BRIEF We sought to fill critical gaps in understanding primary care providers' (PCPs') beliefs regarding diabetes prevention and cardiovascular disease risk in the prediabetes population, including through comparison of attitudes between rural and non-rural PCPs. We used data from a 2016 cross-sectional survey sent to 299 PCPs practicing in 36 primary clinics that are part of a randomized control trial in a predominately rural northern Midwestern integrated health care system. Results showed a few significant, but clinically marginal, differences between rural and non-rural PCPs. Generally, PCPs agreed with the importance of screening for prediabetes and thoroughly and clearly discussing CV risk with high-risk patients.

Microvascular Outcomes in Patients With Diabetes After Bariatric Surgery Versus Usual Care: A Matched Cohort Study.

Background: Bariatric surgery improves glycemic control in patients with type 2 diabetes mellitus (T2DM), but less is known about microvascular outcomes. Objective: To investigate the relationship between bariatric surgery and incident microvascular complications of T2DM. Design: Retrospective matched cohort study from 2005 to 2011 with follow-up through September 2015. Setting: 4 integrated health systems in the United States. Participants: Patients aged 19 to 79 years with T2DM who had bariatric surgery (n = 4024) were matched on age, sex, body mass index, hemoglobin A1c level, insulin use, diabetes duration, and intensity of health care use up to 3 nonsurgical participants (n = 11 059). Intervention: Bariatric procedures (76% gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) compared with usual care. Measurements: Adjusted Cox regression analysis investigated time to incident microvascular disease, defined as first occurrence of diabetic retinopathy, neuropathy, or nephropathy. Results: Median follow-up was 4.3 years for both surgical and nonsurgical patients. Bariatric surgery was associated with significantly lower risk for incident microvascular disease at 5 years (16.9% for surgical vs. 34.7% for nonsurgical patients; adjusted hazard ratio [HR], 0.41 [95% CI, 0.34 to 0.48]). Bariatric surgery was associated with lower cumulative incidence at 5 years of diabetic neuropathy (7.2% for surgical vs. 21.4% for nonsurgical patients; HR, 0.37 [CI, 0.30 to 0.47]), nephropathy (4.9% for surgical vs. 10.0% for nonsurgical patients; HR, 0.41 [CI, 0.29 to 0.58]), and retinopathy (7.2% for surgical vs. 11.2% for nonsurgical patients; HR, 0.55 [CI, 0.42 to 0.73]). Limitation: Electronic health record databases could misclassify microvascular disease status for some patients. Conclusion: In this large, multicenter study of adults with T2DM, bariatric surgery was associated with lower overall incidence of microvascular disease (including lower risk for neuropathy, nephropathy, and retinopathy) than usual care. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.

High rates of severe hypoglycemia among African American patients with diabetes: the surveillance, prevention, and Management of Diabetes Mellitus (SUPREME-DM) network.

AIMS: Seven-year surveillance study (2005-2011) to evaluate race/ethnic differences in the trends in rates of severe hypoglycemia (SH) in a population of insured, at-risk adults with diabetes. METHODS: SH events were identified via any primary or principal diagnosis from emergency department or inpatient encounters among African American, Asian, Latino and White adult diabetes patients treated with insulin or secretagogues (Sulfonylureas or Meglitinides), receiving care from integrated healthcare delivery systems across the United States. We calculated age- and sex-standardized annual SH rates and average annual percent change (AAPC) in SH rates. RESULTS: Annual SH rates ranged from 1.8% to 2.1% during this 7-year observation period (2,200,471 person-years). African Americans had consistently higher SH rates compared with Whites, while Latinos and Asians had consistently lower rates compared with Whites in each of the 7 years (all p < 0.01). The trend increased significantly only among African Americans (AAPC = +4.3%; 95% CI: +2.1, +6.5%); in the other groups, the AAPC was not significantly different from zero. CONCLUSIONS: Surveillance efforts should monitor the racial/ethnic-specific rates. The factors underlying substantially higher rates of hypoglycemia in African Americans should be evaluated. Clinically and culturally-appropriate strategies to reduce the risk of SH need to be developed and tested.

Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes.

BACKGROUND: Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes. METHODS: We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8 % (n = 37,873), low-density lipoprotein cholesterol (LDL-C) >100 mg/dl (n = 27,954), and systolic blood pressure (SBP) >130 mm Hg (n = 63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator. RESULTS: We observed poorer medication adherence among black patients than white patients (p < 0.01): 50.6 % of blacks versus 39.7 % of whites were not highly adherent (i.e., MRA <80 %) to HbA1c oral medication(s); 58.4 % of blacks and 46.7 % of whites were not highly adherent to lipid medication(s); and 33.4 % of blacks and 23.7 % of whites were not highly adherent to BP medication(s). Across all cardiometabolic risk factors, blacks were significantly less likely to achieve control (p < 0.01): 41.5 % of blacks and 45.8 % of whites achieved HbA1c <8 %; 52.6 % of blacks and 60.8 % of whites achieved LDL-C <100; and 45.7 % of blacks and 53.6 % of whites achieved SBP <130. Adjusting for medication adherence/treatment intensification did not alter these patterns or model fit statistics. CONCLUSIONS: Medication adherence failed to explain observed racial differences in the achievement of HbA1c, LDL-C, and SBP control among insured patients with diabetes.

Severe Hypoglycemia Requiring Medical Intervention in a Large Cohort of Adults With Diabetes Receiving Care in U.S. Integrated Health Care Delivery Systems: 2005-2011.

OBJECTIVE: Appropriate glycemic control is fundamental to diabetes care, but aggressive glucose targets and intensive therapy may unintentionally increase episodes of hypoglycemia. We quantified the burden of severe hypoglycemia requiring medical intervention in a well-defined population of insured individuals with diabetes receiving care in integrated health care delivery systems across the U.S. RESEARCH DESIGN AND METHODS: This observational cohort study included 917,440 adults with diabetes receiving care during 2005 to 2011 at participating SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) network sites. Severe hypoglycemia rates were based on any occurrence of hypoglycemia-related ICD-9 codes from emergency department or inpatient medical encounters and reported overall and by age, sex, comorbidity status, antecedent A1C level, and medication use. RESULTS: Annual rates of severe hypoglycemia ranged from 1.4 to 1.6 events per 100 person-years. Rates of severe hypoglycemia were higher among those with older age, chronic kidney disease, congestive heart failure, cardiovascular disease, depression, and higher A1C levels, and in users of insulin, insulin secretagogues, or ß-blockers (P < 0.001 for all). Changes in severe hypoglycemia occurrence over time were not clinically significant in the cohort as a whole but were observed in subgroups of individuals with chronic kidney disease, congestive heart failure, and cardiovascular disease. CONCLUSIONS: Risk of severe hypoglycemia in clinical settings is considerably higher in identifiable patient subgroups than in randomized controlled trials. Strategies that reduce the risk of hypoglycemia in high-risk patients are needed.

Potential Misclassification of Blood Pressure Status in Children and Adolescents With Short or Tall Stature.

Blood pressure (BP) is measured in percentiles that are adjusted for sex, age, and height percentile in children and adolescents. Standard tables for the conversion of BP percentiles do not present exact BP percentile cutoffs for extremes in stature, either short (<5th percentile) or tall (>95th percentile). An algorithm can be used to calculate exact BP percentiles across a range of height z scores. We compared values from standard BP tables with exact calculations of BP percentiles to see which were better at identifying hypertension in more than 5,000 children with either short or tall stature. Study subjects were 3-17-year-old patients within HealthPartners Medical Group, an integrated health care delivery system in Minnesota, at any time between 2007 and 2012. Approximately half of the subjects who met the criteria for hypertension using exact calculation would be misclassified as normal using available thresholds in the published BP tables instead of the recommended algorithm, which was not included in the tables.

Factors Associated With Adherence to Blood Pressure Measurement Recommendations at Pediatric Primary Care Visits, Minnesota and Colorado, 2007-2010.

INTRODUCTION: Elevated blood pressure in childhood may predict increased cardiovascular risk in young adulthood. The Task Force on the Diagnosis, Evaluation and Treatment of High Blood pressure in Children and Adolescents recommends that blood pressure be measured in children aged 3 years or older at all health care visits. Guidelines from both Bright Futures and the Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents recommend annual blood pressure screening. Adherence to these guidelines is unknown. METHODS: We conducted a cross-sectional study to assess compliance with blood pressure screening recommendations in 2 integrated health care delivery systems. We analyzed electronic health records of 103,693 subjects aged 3 to 17 years. Probability of blood pressure measurement documented in the electronic health record was modeled as a function of visit type (well-child vs nonwell-child); patient age, sex, race/ethnicity, and body mass index; health care use; insurance type; and type of office practice or clinic department (family practice or pediatrics). RESULTS: Blood pressure was measured at 95% of well-child visits and 69% of nonwell-child outpatient visits. After adjusting for potential confounders, the percentage of nonwell-child visits with measurements increased linearly with patient age (P < .001). Overall, the proportion of children with annual blood pressure measurements was high and increased with age. Family practice clinics were more likely to adhere to blood pressure measurement guidelines compared with pediatric clinics (P < .001). CONCLUSION: These results show good compliance with recommendations for routine blood pressure measurement in children and adolescents. Findings can inform the development of EHR-based clinical decision support tools to augment blood pressure screening and recognition of prehypertension and hypertension in pediatric patients.

Recidivism to uncontrolled blood pressure in patients with previously controlled hypertension.

BACKGROUND: Control of hypertension has improved nationally with focus on identifying and treating elevated blood pressures (BPs) to guideline recommended levels. However, once BP control is achieved, the frequency in which BP falls out of control and the factors associated with BP recidivism is unknown. In this retrospective cohort study conducted at 2 large, integrated health care systems we sought to examine rates and predictors of BP recidivism in adults with controlled hypertension. No change for methods, results and conclusion. METHODS: Patients with a prior diagnosis of hypertension based on a combination of International Classification of Diseases, Ninth Revision, codes, receipt of antihypertensive medications, and/or elevated BP readings were eligible to be included. We defined controlled hypertension as normotensive BP readings (<140/90 mmHg or <130/80 mmHg in those with diabetes) at 2 consecutive primary care visits. We then followed up patients for BP recidivism defined by the date of the second of 2 consecutive BP readings >140/90 mmHg (>130/80 mmHg for diabetes or chronic kidney disease) during a median follow-up period of 16.6 months. Cox proportional hazards regression assessed the association between patient characteristics, comorbidities, medication adherence, and provider medication management with time to BP recidivism. RESULTS: A total of 23,321 patients with controlled hypertension were included in this study. The proportion of patients with hypertension recidivism was 24.1% over the 16.6-month study period. For those with BP recidivism, the median time to relapse was 7.3 months. In multivariate analysis, those with diabetes (hazard ratio [HR] 3.99, CI 3.67-4.33), high normal baseline BP (for systolic BP HR 1.03, CI 1.03-1.04), or low antihypertensive medication adherence (HR 1.20, CI 1.11-1.29) had significantly higher rates of hypertension recidivism. Limitations of this work include demographics of our patient sample, which may not reflect other communities in addition to the intrinsic limitations of office-based BP measurements. CONCLUSIONS: Hypertensive recidivism occurs in a significant portion of patients with previously well-controlled BP and accounts for a substantial fraction of patients with poorly controlled hypertension. Systematic identification of those most at risk for recidivism and implementation of strategies to minimize hypertension recidivism may improve overall levels of BP control and hypertension-related quality measures.

A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why Did it Work?

BACKGROUND: It is important to understand which components of successful multifaceted interventions are responsible for study outcomes, since some components may be more important contributors to the intervention effect than others. OBJECTIVE: We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure (BP) after 6 months in a trial to improve hypertension control. DESIGN: The study was a preplanned secondary analysis of a cluster-randomized clinical trial. Eight clinics in an integrated health system were randomized to provide usual care to their patients (n = 222), and eight were randomized to provide a telemonitoring intervention (n = 228). PARTICIPANTS: Four hundred three of 450 trial participants completing the 6-month follow-up visit were included. INTERVENTIONS: Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists, who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits. MAIN MEASURES: Path analytic models estimated indirect effects of the seven potential mediators of intervention effect (defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6 months). The potential mediators were change in home BP monitor use, number of BP medication classes, adherence to BP medications, physical activity, salt intake, alcohol use, and weight. KEY RESULTS: The difference in change in systolic BP was 11.3 mmHg. The multivariable mediation model explained 47 % (5.3 mmHg) of the intervention effect. Nearly all of this was mediated by two factors: an increase in medication treatment intensity (24 %) and increased home BP monitor use (19 %). The other five factors were not significant mediators, although medication adherence and salt intake improved more in the intervention group than in the usual care group. CONCLUSIONS: Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification. High adherence at baseline and the relatively low intensity of resources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP.

Prevalence of chronic kidney disease among individuals with diabetes in the SUPREME-DM Project, 2005-2011.

AIMS: Diabetes is a leading cause of chronic kidney disease (CKD). Different methods of CKD ascertainment may impact prevalence estimates. We used data from 11 integrated health systems in the United States to estimate CKD prevalence in adults with diabetes (2005-2011), and compare the effect of different ascertainment methods on prevalence estimates. METHODS: We used the SUPREME-DM DataLink (n = 879,312) to estimate annual CKD prevalence. Methods of CKD ascertainment included: diagnosis codes alone, impaired estimated glomerular filtration rate (eGFR) alone (eGFR < 60 mL/min/1.73 m(2)), albuminuria alone (spot urine albumin creatinine ratio > 30 mg/g or equivalent), and combinations of these approaches. RESULTS: CKD prevalence was 20.0% using diagnosis codes, 17.7% using impaired eGFR, 11.9% using albuminuria, and 32.7% when one or more method suggested CKD. The criteria had poor concordance. After age- and sex-standardization to the 2010 U.S. Census population, prevalence using diagnosis codes increased from 10.7% in 2005 to 14.3% in 2011 (P < 0.001). The prevalence using eGFR decreased from 9.7% in 2005 to 8.6% in 2011 (P < 0.001). CONCLUSIONS: Our data indicate that CKD prevalence and prevalence trends differ according to the CKD ascertainment method, highlighting the necessity for multiple sources of data to accurately estimate and track CKD prevalence.