Is Hypertension Diagnostic Testing and Diagnosis Associated With Psychological Distress?

BACKGROUND: Psychological impacts of hypertension diagnostic testing and new hypertension diagnoses are unclear. METHODS: BP-CHECK was a randomized diagnostic study conducted in 2017-2019 in an integrated healthcare system. Participants with no hypertension diagnosis or medications and elevated blood pressure (BP) were randomized to one of three diagnostic regimens: (i) Clinic, (ii) Home, or (iii) Kiosk. Participants completed questionnaires at baseline, after completion of the diagnostic regimens, and at 6 months. Outcomes included changes from baseline in health-related quality of life (HRQOL), BP-related worry, and thoughts about having a stroke or heart attack. RESULTS: Participants (n = 482) were mostly over age 50 (77.0%), and White race (80.3%). HRQOL did not significantly change from baseline to 3 weeks or 6 months. Among all participants, BP-related worry and concerns about having a heart attack or stroke increased significantly from baseline to 3 weeks, with heart attack and stroke concerns significantly higher in the Kiosk compared Clinic and Home groups. At 6 months, thoughts about having a heart attack or stroke returned to baseline overall and in the Kiosk group, however BP-related worry was significantly higher among those with, compared to those without, a new hypertension diagnosis. CONCLUSIONS: The hypertension diagnostic process did not lead to short-term or intermediate-term changes in self-reported HRQOL. However, BP-related worry increased short-term and persisted at 6 months among individuals with a new hypertension diagnosis. Results warrant validation in more representative populations and additional exploration of the impacts of this worry on psychological well-being and hypertension control. CLINICALTRIALS.GOV IDENTIFIER: NCT03130257.

Characterisation of the T-cell response to Ebola virus glycoprotein amongst survivors of the 2013-16 West Africa epidemic.

Zaire ebolavirus (EBOV) is a highly pathogenic filovirus which can result in Ebola virus disease (EVD); a serious medical condition that presents as flu like symptoms but then often leads to more serious or fatal outcomes. The 2013-16 West Africa epidemic saw an unparalleled number of cases. Here we show characterisation and identification of T cell epitopes in surviving patients from Guinea to the EBOV glycoprotein. We perform interferon gamma (IFNγ) ELISpot using a glycoprotein peptide library to identify T cell epitopes and determine the CD4+ or CD8+ T cell component response. Additionally, we generate data on the T cell phenotype and measure polyfunctional cytokine secretion by these antigen specific cells. We show candidate peptides able to elicit a T cell response in EBOV survivors and provide inferred human leukocyte antigen (HLA) allele restriction. This data informs on the long-term T cell response to Ebola virus disease and highlights potentially important immunodominant peptides.

A study of the environmental survival of Streptococcus equi subspecies equi.

BACKGROUND: Streptococcus equi represents a common hazard to equids worldwide. Environmental contamination with bacteria shed from an infected horse may represent a significant source of contagion and further knowledge of ex vivo bacterial survival under different conditions is important for disinfection and isolation protocols. OBJECTIVES: To determine the potential duration of survival and vigour of growth of S. equi inoculated onto surfaces relevant to equine veterinary practice and stabling in summer and winter. STUDY DESIGN: Repeat sampling of environmental inocula of S. equi. METHODS: Cultures of S. equi were inoculated onto wood, a shoe sole, cotton overalls, inside a nasogastric tube, inside a dental rasp, in a wet plastic bucket and onto a fence post both in the summer and winter seasons. Frequent resampling and culture from the inoculated sites was conducted until no viable bacteria were found. Bacterial viability was determined by both duration (time to first negative culture) and vigour of growth (growth score over the first 3 days of culture) and compared between inoculated sites and times of year. RESULTS: Bacterial viability was enhanced by a wet local environment and by the winter season. Survival tended to be short in the summer (up to 9 days in wet sites and up to 2 days in dry sites) but much longer in the winter (up to 34 days in wet sites and up to 13 days in dry sites). Vigour of bacterial growth was also greater in the winter than in the summer as judged by 3-day-growth scores. MAIN LIMITATIONS: Direct comparison with the variable size and nature of naturally shed infectious material is difficult. CONCLUSIONS: Veterinarians and personnel handling horses should be aware that S. equi may survive in an equine environment for longer than previously found, especially when protected by wet and cold conditions.

Racial differences in determinants of live donor kidney transplantation in the United States.

Few studies have compared determinants of live donor kidney transplantation (LDKT) across all major US racial-ethnic groups. We compared determinants of racial-ethnic differences in LDKT among 208 736 patients who initiated treatment for end-stage kidney disease during 2005-2008. We performed proportional hazards and bootstrap analyses to estimate differences in LDKT attributable to sociodemographic and clinical factors. Mean LDKT rates were lowest among blacks (1.19 per 100 person-years [95% CI: 1.12-1.26]), American Indians/Alaska Natives-AI/ANs (1.40 [1.06-1.84]) and Pacific Islanders (1.10 [0.78-1.84]), intermediate among Hispanics (2.53 [2.39-2.67]) and Asians (3.89 [3.51-4.32]), and highest among whites (6.46 [6.31-6.61]). Compared with whites, the largest proportion of the disparity among blacks (20%) and AI/ANs (29%) was attributed to measures of predialysis care, while the largest proportion among Hispanics (14%) was attributed to health insurance coverage. Contextual poverty accounted for 16%, 4%, 18%, and 6% of the disparity among blacks, Hispanics, AI/ANs and Pacific Islanders but none of the disparity among Asians. In the United States, significant disparities in rates of LDKT persist, but determinants of these disparities vary by race-ethnicity. Efforts to expand preESKD insurance coverage, to improve access to high-quality predialysis care and to overcome socioeconomic barriers are important targets for addressing disparities in LDKT.

Survival of Mycobacterium tuberculosis during experimental aerosolization and implications for aerosol challenge models.

AIMS: We undertook a series of experiments to investigate factors that contribute to variation in Mycobacterium tuberculosis viability and infectivity, during experimental aerosolization, with an aim to optimize a strategy to enable a more reproducible delivered dose within animal models of tuberculosis. METHODS AND RESULTS: The viability and infectivity of the challenge suspension was determined in relation to aerosolization time, concentration, method of preparation and M. tuberculosis strain. Challenge stocks generated from frozen aliquots of M. tuberculosis were shown to undergo a 1 log(10) CFU ml(-1) decrease in viability during the first 10 min of aerosolization. This correlated with a decrease in surface lung lesions developing in guinea pigs challenged during this time. The phenomenon of decreased viability in vitro was not observed when using freshly grown, nonfrozen cells of M. tuberculosis. The viability of aerosolized bacilli at the point of inhalation relative to the point of aerosolization always remained constant. CONCLUSION: Based on these findings, we have developed an improved strategy by which to reproducibly deliver aerosol infection doses to individually challenged animals and separately challenged groups of animals. SIGNIFICANCE AND IMPACT OF THE STUDY: Study of the aerobiological characteristics of micro-organisms is a critical step in the validation of methodology for aerosol infection animal models, particularly where large numbers of animals and nonhuman primates are used.

Enhancing the expanded criteria donor policy as an intervention to improve kidney allocation: is it actually a 'net-zero' model?

In the United States, relatively little progress has been made in recent years to improve the efficiency and effectiveness of deceased donor kidney allocation. Despite enactment of the Expanded Criteria Donor (ECD) Policy in 2002, known inequities and suboptimal utility of donated kidneys persist. In contrast with dialysis patients with shorter predicted life expectancies, those with longer predicted lifetimes can often improve their survival by waiting longer for a Standard Criteria Donor (SCD) kidney. Yet, a substantial fraction of these candidates accept ECD kidneys, often poorly HLA matched. Meanwhile, waitlist mortality continues to rise, particularly among older transplant candidates. Despite required consent processes for candidates to list for ECD kidneys, centers appear to interpret and implement ECD policy differently­some list candidates selectively while others list nearly their entire candidate pool. To ensure more efficient and effective implementation of ECD policy across centers, we advocate for (1) more oversight and guidance in directing patients to the ECD list who stand to benefit the most from receipt of an ECD kidney; and (2) enhanced transparency of center-level ECD consent and listing practices. More uniform implementation of ECD policy could improve efficiency and effectiveness of deceased donor kidney allocation without deleteriously impacting equity.

Vitamin D deficiency and frailty in older Americans.

OBJECTIVE: To explore the relation between 25-hydroxyvitamin D deficiency and frailty. Frailty is a multidimensional phenotype that describes declining physical function and a vulnerability to adverse outcomes in the setting of physical stress such as illness or hospitalization. Low serum concentrations of 25-hydroxyvitamin D are known to be associated with multiple chronic diseases such as cardiovascular disease and diabetes, in addition to all cause mortality. DESIGN: Using data from the Third National Health and Nutrition Survey (NHANES III), we evaluated the association between low serum 25-hydroxyvitamin D concentration and frailty, defined according to a set of criteria derived from a definition previously described and validated. SUBJECTS: Nationally representative survey of noninstitutionalized US residents collected between 1988 and 1994. RESULTS: 25-Hydroxyvitamin D deficiency, defined as a serum concentration <15 ng mL(-1), was associated with a 3.7-fold increase in the odds of frailty amongst whites and a fourfold increase in the odds of frailty amongst non-whites. This association persisted after sensitivity analyses adjusting for season of the year and latitude of residence, intended to reduce misclassification of persons as 25-hydroxyvitamin D deficient or insufficient. CONCLUSION: Low serum 25-hydroxyvitamin D concentrations are associated with frailty amongst older adults.

Neighborhood poverty and kidney transplantation among US Asians and Pacific Islanders with end-stage renal disease.

The degree to which low transplant rates among Asians and Pacific Islanders in the United States are confounded by poverty and reduced access to care is unknown. We examined the relationship between neighborhood poverty and kidney transplant rates among 22 152 patients initiating dialysis during 1995-2003 within 1800 ZIP codes in California, Hawaii and the US-Pacific Islands. Asians and whites on dialysis were distributed across the spectrum of poverty, while Pacific Islanders were clustered in the poorest areas. Overall, worsening neighborhood poverty was associated with lower relative rates of transplant (adjusted HR [95% CI] for areas with > or =20% vs. <5% residents living in poverty, 0.41 [0.32-0.53], p < 0.001). At every level of poverty, Asians and Pacific Islanders experienced lower transplant rates compared with whites. The degree of disparity increased with worsening neighborhood poverty (adjusted HR [95% CI] for Asians-Pacific Islanders vs. whites, 0.64 [0.51-0.80], p < 0.001 for areas with <5% and 0.30 [0.21-0.44], p < 0.001 for areas with > or =20% residents living in poverty; race-poverty level interaction, p = 0.039). High levels of neighborhood poverty are associated with lower transplant rates among Asians and Pacific Islanders compared with whites. Our findings call for studies to identify cultural and local barriers to transplant among Asians and Pacific Islanders, particularly those residing in resource-poor neighborhoods.

The impact of daily Duddingtonia flagrans application to lactating ewes on gastrointestinal nematodes infections in their lambs in the Netherlands.

Two experiments were performed in 2002 and 2003 to evaluate the effect of biological control of gastrointestinal nematodes in sheep through the daily feeding of 500,000 chlamydospores of Duddingtonia flagrans/kg bodyweight to lactating ewes during the first 9 weeks with their young lambs on pasture. In both experiments four groups of eight ewes and their April-borne lambs were used. They were turned out on four separate plots (plots A) at the beginning of May, moved to similar separate plots after 3 (plots B) and 6 weeks (plots C), respectively, and weaning occurred after 9 weeks. In both experiments, two groups were fed spores daily while the two other groups served as controls. The effect of D. flagrans application was evaluated through faecal egg counts of ewes and lambs, the yield of faecal cultures in ewes, pasture larval counts and worm counts of lambs and tracer lambs. The results demonstrated no effect of D. flagrans application during the first 5 (2002) or 4 (2003) weeks. Subsequently, fungus application strongly reduced the yield in faecal cultures of the ewes. This was, however, not reflected in the pasture larval counts, but lower worm burdens were observed in tracer lambs of 'treated' plots C in 2002 than on those of 'control' plots. In 2003 worm burdens in 'treated' lambs returned to plots B were lower than those of 'control' lambs and a tendency for the same was observed for plots C. However, in all groups, lambs and tracer lambs developed severe haemonchosis.

Microbiological quality of drinking water from mobile food vendors.

A survey of the microbiological quality of drinking water from mobile food vendors in Cheshire found that 50% of the samples were unsatisfactory according to current regulations for bottled water. There was an inverse correlation between total viable counts and frequency with which the water container was cleaned.

Effect of ramipril vs amlodipine on renal outcomes in hypertensive nephrosclerosis: a randomized controlled trial.

CONTEXT: Incidence of end-stage renal disease due to hypertension has increased in recent decades, but the optimal strategy for treatment of hypertension to prevent renal failure is unknown, especially among African Americans. OBJECTIVE: To compare the effects of an angiotensin-converting enzyme (ACE) inhibitor (ramipril), a dihydropyridine calcium channel blocker (amlodipine), and a beta-blocker (metoprolol) on hypertensive renal disease progression. DESIGN, SETTING, AND PARTICIPANTS: Interim analysis of a randomized, double-blind, 3 x 2 factorial trial conducted in 1094 African Americans aged 18 to 70 years with hypertensive renal disease (glomerular filtration rate [GFR] of 20-65 mL/min per 1.73 m(2)) enrolled between February 1995 and September 1998. This report compares the ramipril and amlodipine groups following discontinuation of the amlodipine intervention in September 2000. INTERVENTIONS: Participants were randomly assigned to receive amlodipine, 5 to 10 mg/d (n = 217), ramipril, 2.5 to 10 mg/d (n = 436), or metoprolol, 50 to 200 mg/d (n = 441), with other agents added to achieve 1 of 2 blood pressure goals. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of change in GFR; the main secondary outcome was a composite index of the clinical end points of reduction in GFR of more than 50% or 25 mL/min per 1.73 m(2), end-stage renal disease, or death. RESULTS: Among participants with a urinary protein to creatinine ratio of >0.22 (corresponding approximately to proteinuria of more than 300 mg/d), the ramipril group had a 36% (2.02 [SE, 0.74] mL/min per 1.73 m(2)/y) slower mean decline in GFR over 3 years (P =.006) and a 48% reduced risk of the clinical end points vs the amlodipine group (95% confidence interval [CI], 20%-66%). In the entire cohort, there was no significant difference in mean GFR decline from baseline to 3 years between treatment groups (P =.38). However, compared with the amlodipine group, after adjustment for baseline covariates the ramipril group had a 38% reduced risk of clinical end points (95% CI, 13%-56%), a 36% slower mean decline in GFR after 3 months (P =.002), and less proteinuria (P<.001). CONCLUSION: Ramipril, compared with amlodipine, retards renal disease progression in patients with hypertensive renal disease and proteinuria and may offer benefit to patients without proteinuria.

Assessment of fatigue and psychologic disturbances in patients with hepatitis C virus infection.

BACKGROUND: It is a common clinical impression that fatigue is a frequent, and often debilitating, symptom in patients with chronic hepatitis C virus (HCV) infection. However, despite its obvious clinical importance, several aspects of fatigue, including its relationship with the underlying liver disease and the presence of psychologic disturbances, have not been well examined. GOALS: The current study was carried out to assess these issues. STUDY: A total of 149 subjects were included in the study and were assigned to one of the following study groups: healthy controls (31), chronic HCV infection (24), combined HCV infection and chronic alcohol abuse (32), alcoholic liver disease (22), and chronic non-liver diseases (40). All subjects were administered investigator-assisted questionnaires designed to analyze the presence and severity of fatigue and psychologic abnormalities. RESULTS: The mean (+/-SD) fatigue scores in patients with chronic HCV infection (140 +/- 22.9; p = 0.002), alcoholic liver disease (127 +/- 31.4; p < 0.001), mixed (HCV/alcoholic) liver disease (131 +/- 29.0; p < 0.001), and chronic non-liver diseases (128 +/- 35.9; p = 0.004) were significantly greater compared to with healthy subjects (101 +/- 31.8). The total fatigue scores were higher in HCV-infected subjects compared with the other patient groups, but the differences failed to reach statistical significance. Moreover, the fatigue experienced by patients with HCV did not improve with rest as effectively as in the other study groups. All patient groups had higher scores for psychologic disturbances compared with healthy subjects. CONCLUSIONS: The current study shows that fatigue and psychologic disturbances occur frequently in chronic diseases. The fatigue experienced by patients with HCV infection is more severe and intransigent and responds poorly to relieving factors. Moreover, patients with HCV infection are more depressed and harbor greater feelings of anger and hostility compared with those with non-liver chronic diseases. These observations are important because proper management of the psychologic symptoms may have a favorable impact on the quality of life of patients with HCV infection.

Comparison of nutrient calculation systems.

A set of 54 24-hour dietary recalls collected in 1975-1976 from males aged 35-57 years who were participating in a cardiovascular risk factor intervention program was submitted to three different nutrient calculation systems to investigate how much of a difference exists among systems in calculating nutrient intakes. The three computerized systems were of varying levels of sophistication. Among differences found, one system reported 1.4% more calories derived from polyunsaturated fat than the other two. For studies investigating the effects of dietary fat intake, this difference between systems may be important. Other significant group differences were seen for carbohydrate and alcohol. Although mean differences among the three systems were not great, dramatic differences were encountered when evaluating individual recalls. Nutrient intake data obtained from dietary recalls for individuals and for groups for whatever purpose are subject to the bias of the nutrient calculation system used. These biases should be considered when interpreting results, comparing results with other studies, and when developing treatment plans in the clinical setting. Recommendations for enhanced standardization include: 1) thorough descriptions in research reports of the particular system used; 2) exchange of standard menus between systems; 3) enhanced quality control of the coding process; 4) periodic updating of the nutrient data base to accommodate new food products and changes in composition of foods.

Critical behaviors in the dietary management of hypertension.

An interdisciplinary group convened by the National High Blood Pressure Education Program (NHBPEP) was charged with describing the patient behaviors critical to successful dietary management of high blood pressure. The group's report identifies 10 steps the patient must take to change dietary behavior; it emphasizes a gradual, progressive approach and ongoing patient contact with the health care team. The approach should interest the dietary counselor and might serve as an example of how progressive nutrition counseling programs can be built around a behavioral model. The report should stimulate the continuing efforts of the nutrition counselor, the physician, the health care administrator to improve the nutrition care of the patient.

Nervous tension and serum cholesterol: findings from the Chicago Coronary Prevention Evaluation Program.

Of 519 coronary-prone middle-aged men participating in the Chicago Coronary Prevention Evaluation Program, 416 reported their self-perceived state as one of no tension or tension at various periodic visits over years in the Program. Group mean serum cholesterol was significantly higher by about 4 mg/dl with tension vs. no tension (slight, moderate, or marked). This relationship was independent of weight change, intercurrent infection, use of medication, and month of year.

Smoking cessation in the Chicago Coronary Prevention Evaluation Program.

Quit-rates for cigarette smokers in a lifestyle intervention program aimed at reducing coronary risk were 24 percent for all participants and 34 percent for non-dropouts. Recidivism remained very low during participation in the program. Half of the smokers who quit did so after being in the program more than two years. These data suggest that while engaging in an effort to make other changes in lifestyle, many smokers can be helped to quit. Sustained antismoking efforts in the clinical practice of medicine can be expected to share these same positive aspects. While mass public health programs to eliminate smoking and prevent young people from taking up the habit are being developed, health practitioners can make a significant contribution by including vigorous efforts at smoking cessation as part of routine practice.

Experience in changing food habits of hyperlipidemic men and women.

In this study, the following were planned and tested: Methods of changing adult eating habits to conform with dietary principles for lowering serum lipids; a method to assess adherence to dietary modifications; and use of nutrition aides as instructors. Six slide-tape units--tested by individual, group, and self-teaching methods, and a combination of these--were effective as judged by such indicators as lowered serum cholesterol, reduced intake of saturated fat and dietary cholesterol, and increased intake of polyunsaturated fat. The Diet Achievement Score is an effective tool for assessing adherence. Nutrition aides proved useful in this study, when effectively supervised by professional nutritionists.

Fat-modified menu's ongoing success noted.

In 1972, a hospital food service introduced a fat-modified selective cycle menu program for its patients, staff members, and visitors. Goals and implementation are discussed.

Prevention and control of hypertension by nutritional-hygienic means. Long-term experience of the Chicago Coronary Prevention Evaluation Program.

In the Chicago Coronary Prevention Evaluation Program (CPEP), 115 men had definite mild hypertension at entry; another 101 men had high-normal diastolic blood pressure (BP). The nutritional-hygienic nonpharmacologic CPEP regimen achieved years-long moderate weight loss, slowing of pulse rate, and reduction in serum cholesterol levels. Sustained falls in BP were recorded-about 10/13 mm Hg for hypertensive men, resulting in long-term normalization of BP, and about 7/4 mm Hg for men with high-normal BP at entry. Change in weight and change in BP were significantly correlated. Long-term improvements in eating and exercise habits yielding moderate sustained weight loss are apparently useful in preventing high BP in hypertension-prone persons and in controlling established "mild" hypertension.