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1.
BMC Health Serv Res ; 19(1): 16, 2019 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-30621689

RESUMO

BACKGROUND: To detect possible threats to quality and safety, multiple systems have been developed. One of them is retrospective chart review. A team of experts scrutinizes medical records, selected by trigger systems, to detect possible adverse events (AEs). The most important AEs and more hints for possible improvement of care appear in deceased patients. Using triggers in a sample of these patients might increase the performance and lower the burden of scrutinizing records without possible preventable AEs. The aim of this study was therefore to determine the performance of the trigger system in a sample of deceased patients and to calculate the specificity and the sensitivity of this trigger system for predicting AEs. METHODS: We performed a study in which the records of deceased patients were screened for triggers by a team of trained nurses. A sample of 100 medical records was randomly selected out of records which had been screened between 2012 and 2015 for the first time, prior to the study in 2016. For the determination of significant differences between the first and second screening, McNemar's test of symmetry was used. Also, observed agreement, Cohen's Kappa and prevalence-adjusted and-bias-adjusted-kappa (PABAK) statistics were calculated. This was done for the two trigger rounds on both any trigger present and for every trigger separately. RESULTS: The observed agreement for any given trigger was 75% with a Kappa and PABAK of 0.5. For the individual triggers, the observed agreement was on average 90%. The corresponding Kappa was on average 0.42 (range: - 0.03-0.78) and the average PABAK was 0.8 (range: 0.44-0.92). Two adverse events were found in cases without triggers previously. The recalculated specificity and sensitivity for the original population were 58 and 92% respectively. CONCLUSIONS: For the reproducibility of triggers it seems that some perform better than others, but on average this is to our opinion suboptimal. The low specificity implies that many records are selected without AEs. This leads to a high false-positive rate making this labour-intensive record review process costly. Therefore, research for better and more expedient systems is required.


Assuntos
Morte , Erros Médicos/estatística & dados numéricos , Registros Médicos/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Fatores Desencadeantes , Software , Auditoria Clínica , Confiabilidade dos Dados , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Humanos , Reprodutibilidade dos Testes , Estudos Retrospectivos
2.
PLoS One ; 13(11): e0208087, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30496243

RESUMO

OBJECTIVE: To assess the reproducibility of adverse event evaluation by a medical record review committee. DESIGN: Cross-sectional reanalysis of medical records. INTERVENTION: Reviewers re-examined fifty medical records of deceased patients regarding the presence of adverse events, their potential preventability and their possible contribution to death. Also we investigated the root causes of the preventable AEs. Differences between the first and second assessment were calculated. RESULTS: The Kappa on the presence of an adverse event was 0.64 and 0.32 for the potential preventability. The intrarater agreement showed a Kappa of 0.61 on the adverse event presence and 0.64 for the potential preventability. Interrater agreement showed a Kappa of 0.66 for the adverse event presence and 0.03 for the potential preventability. CONCLUSION: We found a fair reproducibility for the detection of adverse events, but a poor reproducibility for the potential preventability. Possibly this was caused by lack of a definition for the preventability of adverse events. We think giving feedback to professionals using the results of medical record review remains valuable, but an improvement of its reproducibility is essential. To our opinion an international consensus on what exactly constitutes preventability of adverse events and agreement on a definition is necessary. This would result in more comparable studies in this field and could then be more informative on the ideal procedure to avoid certain potentially preventable adverse events in the future.

3.
Clin Chem ; 64(5): 851-860, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29483105

RESUMO

BACKGROUND: Estimated glomerular filtration rate (eGFR) is widely used in clinical practice. This study assessed the within-subject biological variation (CVI) of different eGFR equations in people with chronic kidney disease (CKD) and people without CKD. The aims of this study were (a) to determine the 24-h biological variation profiles of creatinine, cystatin C, and eGFR and (b) to determine whether CVI of creatinine, cystatin C, and eGFR changes on deterioration of glomerular filtration. METHODS: Hourly blood samples were analyzed from 37 individuals (17 without CKD, 20 with CKD) during 24 h. Creatinine (enzymatic method) and cystatin C were measured using a Cobas 8000 (Roche Diagnostics). eGFR was estimated using the Modification of Diet in Renal Disease and the Chronic Kidney Disease Epidemiology Collaboration based on creatinine and/or cystatin C. Plasma samples were stored at -80 °C before analysis. Outlier and homogeneity analyses were checked before performing a nested ANOVA to determine biological variation. RESULTS: CVI of creatinine was higher in people without CKD than in those with CKD (6.4% vs 2.5%) owing primarily to the more profound effect of meat consumption on creatinine variability in individuals with lower baseline creatinine concentrations. Unlike creatinine, cystatin C concentrations were unaffected by meat consumption. Cystatin C showed some diurnal rhythmic variation and less in people with CKD. Reference change values (RCVs) of all eGFR equations were within 13% to 20% in both study groups. CONCLUSIONS: Despite differences in CVI of creatinine, the CVI and RCV of the eGFR equations were relatively similar for people with or without CKD.

4.
Prev Med Rep ; 8: 250-255, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29181297

RESUMO

Several trigger systems have been developed to screen medical records of hospitalized patients for adverse events (AEs). Because it's too labor-intensive to screen the records of all patients, usually a sample is screened. Our sample consists of patients who died during their stay because chances of finding preventable AEs in this subset are highest. Records were reviewed for fifteen triggers (n = 2182). When a trigger was present, the records were scrutinized by specialized medical doctors who searched for AEs. The positive predictive value (PPV) of the total trigger system and of the individual triggers was calculated. Additional analyses were performed to identify a possible optimization of the trigger system. In our sample, the trigger system had an overall PPV for AEs of 47%, 17% for potentially preventable AEs. More triggers present in a record increased the probability of detecting an AE. Adjustments to the trigger system slightly increased the positive predictive value but missed about 10% of the AEs detected with the original system. In our sample of deceased patients the trigger system has a PPV comparable to other samples. However still, an enormous amount of time and resources are spent on cases without AEs or with non-preventable AEs. Possibly, the performance could be further improved by combining triggers with clinical scores and laboratory results. This could be promising in reducing the costly and labor-intensive work of screening medical records.

5.
BMJ Open ; 7(9): e015854, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28864694

RESUMO

OBJECTIVES: When monitoring patients over time, clinicians may struggle to distinguish 'real changes' in consecutive blood parameters from so-called natural fluctuations. In practice, they have to do so by relying on their clinical experience and intuition. We developed Labtracker+, a medical app that calculates the probability that an increase or decrease over time in a specific blood parameter is real, given the time between measurements. DESIGN: We presented patient cases to 135 participants to examine whether there is a difference between medical students, residents and experienced clinicians when it comes to interpreting changes between consecutive laboratory results. Participants were asked to interpret if changes in consecutive laboratory values were likely to be 'real' or rather due to natural fluctuations. The answers of the study participants were compared with the calculated probabilities by the app Labtracker+ and the concordance rates were assessed. SETTING AND PARTICIPANTS: Medical students (n=92), medical residents from the department of internal medicine (n=19) and internists (n=24) at a Dutch University Medical Centre. PRIMARY AND SECONDARY OUTCOME MEASURES: Concordance rates between the study participants and the calculated probabilities by the app Labtracker+ were compared. Besides, we tested whether physicians with clinical experience scored better concordance rates with the app Labtracker+ than inexperienced clinicians. RESULTS: Medical residents and internists showed significantly better concordance rates with the calculated probabilities by the app Labtracker+ than medical students, regarding their interpretation of differences between consecutive laboratory results (p=0.009 and p<0.001, respectively). CONCLUSION: The app Labtracker+ could serve as a clinical decision tool in the interpretation of consecutive laboratory test results and could contribute to rapid recognition of parameter changes by physicians.


Assuntos
Análise Química do Sangue , Telefone Celular , Competência Clínica , Técnicas de Apoio para a Decisão , Aplicativos Móveis , Smartphone , Hospitais , Humanos , Medicina Interna , Internato e Residência , Intuição , Países Baixos , Médicos , Probabilidade , Estudantes de Medicina , Universidades
6.
Clin Chem Lab Med ; 55(7): 1013-1024, 2017 Jun 27.
Artigo em Inglês | MEDLINE | ID: mdl-28002028

RESUMO

BACKGROUND: Middle- and long-term biological variation data for hematological parameters have been reported in the literature. Within-day 24-h variability profiles for hematological parameters are currently lacking. However, comprehensive hour-to-hour variability data are critical to detect diurnal cyclical rhythms, and to take into account the 'time of sample collection' as a possible determinant of natural fluctuation. In this study, we assessed 24-h variation profiles for 20 hematological parameters. METHODS: Blood samples were collected under standardized conditions from 24 subjects every hour for 24 h. At each measurement, 20 hematological parameters were determined in duplicate. Analytical variation (CVA), within-subject biological variation (CVI), between-subject biological variation (CVG), index of individuality (II), and reference change values (RCVs) were calculated. For the parameters with a diurnal rhythm, hour-to-hour RCVs were determined. RESULTS: All parameters showed higher CVG than CVI. Highest CVG was found for eosinophils (46.6%; 95% CI, 34.9%-70.1%) and the lowest value was mean corpuscular hemoglobin concentration (MCHC) (3.2%; 95% CI, 2.4%-4.8%). CVI varied from 0.4% (95% CI, 0.32%-0.42%) to 20.9% (95% CI, 19.4%-22.6%) for red cell distribution width (RDW) and eosinophils, respectively. Six hematological parameters showed a diurnal rhythm. CONCLUSIONS: We present complete 24-h variability profiles for 20 hematological parameters. Hour-to-hour reference changes values may help to better discriminate between random fluctuations and true changes in parameters with rhythmic diurnal oscillations.


Assuntos
Ritmo Circadiano , Testes Hematológicos/normas , Manejo de Espécimes/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Postura , Valores de Referência
7.
Phlebology ; 31(1 Suppl): 24-7, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26916765

RESUMO

INTRODUCTION: Venous thromboembolism is a frequently occurring phenomenon with a high risk of acute and chronic complications. To prevent these, subjects are treated with surgical options to restore venous blood flow combined with medical treatment or medical treatment alone. Despite great therapeutic advances considerable morbidity still persists. For example, thrombosis of the leg can result in post-thrombotic syndrome, which has a great impact on quality of life. The best management to prevent the post-thrombotic syndrome is a topic of research and debate. In this study, we searched the literature to identify studies that used oral anticoagulants and evaluated their properties for resolution of thrombus and hence prevention of the post-thrombotic syndrome. METHODS: We searched PubMed, The Cochrane Library, and four international medical journals frequently reporting on venous thromboembolism. Furthermore, we looked at Clinicaltrials.gov for current research on this topic. RESULTS: Only three suitable articles were identified. DISCUSSION: We found experimental evidence that direct thrombin inhibitors and factor Xa inhibitors have an influence on clot lysis favoring a quicker recanalization compared to warfarin. Future studies investigating these effects in humans are warranted.


Assuntos
Anticoagulantes/uso terapêutico , Síndrome Pós-Trombótica/prevenção & controle , Terapia Trombolítica/métodos , Tromboembolia Venosa/tratamento farmacológico , Administração Oral , Humanos , Terapia Trombolítica/efeitos adversos
8.
Nutrients ; 7(11): 8905-15, 2015 Oct 28.
Artigo em Inglês | MEDLINE | ID: mdl-26516910

RESUMO

Coronary artery calcification (CAC) develops early in the pathogenesis of atherosclerosis and is a strong and independent predictor of cardiovascular disease (CVD). Arterial calcification is caused by an imbalance in calcification regulatory mechanisms. An important inhibitor of calcification is vitamin K-dependent matrix Gla protein (MGP). Both preclinical and clinical studies have shown that inhibition of the vitamin K-cycle by vitamin K antagonists (VKA) results in elevated uncarboxylated MGP (ucMGP) and subsequently in extensive arterial calcification. This led us to hypothesize that vitamin K supplementation may slow down the progression of calcification. To test this, we designed the VitaK-CAC trial which analyses effects of menaquinone-7 (MK-7) supplementation on progression of CAC. The trial is a double-blind, randomized, placebo-controlled trial including patients with coronary artery disease (CAD). Patients with a baseline Agatston CAC-score between 50 and 400 will be randomized to an intervention-group (360 microgram MK-7) or a placebo group. Treatment duration will be 24 months. The primary endpoint is the difference in CAC-score progression between both groups. Secondary endpoints include changes in arterial structure and function, and associations with biomarkers. We hypothesize that treatment with MK-7 will slow down or arrest the progression of CAC and that this trial may lead to a treatment option for vascular calcification and subsequent CVD.


Assuntos
Artérias/efeitos dos fármacos , Cálcio/metabolismo , Doença da Artéria Coronariana/tratamento farmacológico , Suplementos Nutricionais , Calcificação Vascular/tratamento farmacológico , Vitamina K 2/análogos & derivados , Vitaminas/uso terapêutico , Adulto , Artérias/metabolismo , Artérias/patologia , Proteínas de Ligação ao Cálcio/metabolismo , Protocolos Clínicos , Doença da Artéria Coronariana/metabolismo , Doença da Artéria Coronariana/patologia , Progressão da Doença , Método Duplo-Cego , Proteínas da Matriz Extracelular/metabolismo , Humanos , Projetos de Pesquisa , Vitamina K 2/farmacologia , Vitamina K 2/uso terapêutico , Vitaminas/farmacologia
9.
Ned Tijdschr Geneeskd ; 157(12): A6044, 2013.
Artigo em Holandês | MEDLINE | ID: mdl-23515046

RESUMO

Today, hospitals are being confronted with increasing costs for additional safety measures. Not all of these measures are evidence-based; for example, the Dutch practice guidelines on the prevention of contrast-induced nephropathy were implemented in recent years, but their long-term efficacy and any possible harm caused by these protocols are not well known. Many questions remain about the exact mechanisms of contrast-induced damage to the kidney. The current protocols recommending preventive hydration have a great impact on costs and hospital management, because an increasing number of patients need to be admitted. More evidence on the efficacy of such preventive measures is needed before we start spending large sums of money following new practice guidelines of which the efficacy has not been adequately substantiated.


Assuntos
Medicina Baseada em Evidências/economia , Custos de Cuidados de Saúde , Qualidade da Assistência à Saúde , Análise Custo-Benefício , Humanos , Países Baixos
10.
Front Genet ; 3: 290, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23248645

RESUMO

Vascular disease is still the leading cause of morbidity and mortality in the Western world, and the primary cause of myocardial infarction, stroke, and ischemia. The biology of vascular disease is complex and still poorly understood in terms of causes and consequences. Vascular function is determined by structural and functional properties of the arterial vascular wall. Arterial stiffness, that is a pathological alteration of the vascular wall, ultimately results in target-organ damage and increased mortality. Arterial remodeling is accelerated under conditions that adversely affect the balance between arterial function and structure such as hypertension, atherosclerosis, diabetes mellitus, chronic kidney disease, inflammatory disease, lifestyle aspects (smoking), drugs (vitamin K antagonists), and genetic abnormalities [e.g., pseudoxanthoma elasticum (PXE), Marfan's disease]. The aim of this review is to provide an overview of the complex mechanisms and different factors that underlie arterial remodeling, learning from single gene defect diseases like PXE, and PXE-like, Marfan's disease and Keutel syndrome in vascular remodeling.

12.
Eur Heart J ; 32(20): 2555-62, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21775389

RESUMO

AIMS: Vitamin K antagonists (VKA) are currently the most frequently used drug to prevent ischaemic stroke in atrial fibrillation (AF) patients. However, VKA use has been associated with increased vascular calcification. The aim of this study was to investigate the contribution of VKA use to coronary artery calcification in low-risk AF patients. METHODS AND RESULTS: A prospective coronary calcium scan was performed in 157 AF patients without significant cardiovascular disease (108 males; mean age 57 ± 9 years). A total of 71 (45%) patients were chronic VKA users. The duration of VKA treatment varied between 6 and 143 months (mean 46 months). No significant differences in clinical characteristics were found between patients on VKA treatment and non-anticoagulated patients. However, median coronary artery calcium scores differed significantly between patients without and patients with VKA treatment [0, inter-quartile range (IQR) 0-40, vs. 29, IQR 0-184; P = 0.001]. Mean coronary calcium scores increased with the duration of VKA use (no VKA: 53 ± 115, 6-60 months on VKA: 90 ± 167, and >60 months on VKA: 236 ± 278; P < 0.001). Multivariable logistic regression analysis revealed that age and VKA treatment were significantly related to increased coronary calcium score. CONCLUSION: Patients using VKA show increased levels of coronary calcification. Age and VKA treatment were independently related to increased coronary calcium score.


Assuntos
Fibrilação Atrial/complicações , Doença da Artéria Coronariana/induzido quimicamente , Acidente Vascular Cerebral/prevenção & controle , Calcificação Vascular/induzido quimicamente , Vitamina K/antagonistas & inibidores , Idoso , Doença da Artéria Coronariana/diagnóstico por imagem , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Calcificação Vascular/diagnóstico por imagem
13.
J Cell Mol Med ; 14(9): 2203-10, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20716128

RESUMO

Arterial calcifications as found with various imaging techniques, like plain X-ray, computed tomography or ultrasound are associated with increased cardiovascular risk. The prevalence of arterial calcification increases with age and is stimulated by several common cardiovascular risk factors. In this review, the clinical importance of arterial calcification and the currently known proteins involved are discussed. Arterial calcification is the result of a complex interplay between stimulating (bone morphogenetic protein type 2 [BMP-2], RANKL) and inhibitory (matrix Gla protein, BMP-7, osteoprotegerin, fetuin-A, osteopontin) proteins. Vascular calcification is especially prevalent and related to adverse outcome in patients with renal insufficiency and diabetes mellitus. We address the special circumstances and mechanisms in these patient groups. Treatment and prevention of arterial calcification is possible by the use of specific drugs. However, it remains to be proven that reduction of vascular calcification in itself leads to a reduced cardiovascular risk.


Assuntos
Artérias/patologia , Calcinose/patologia , Doenças Cardiovasculares/patologia , Calcinose/epidemiologia , Calcinose/terapia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Humanos , Fatores de Risco
14.
Eur J Clin Invest ; 40(4): 344-9, 2010 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-20486996

RESUMO

BACKGROUND: Vascular calcification in humans is associated with an increased cardiovascular risk. Carboxylated matrix Gla protein (cMGP) inhibits vascular calcification. Vitamin K is an essential cofactor for the activation of uncarboxylated matrix Gla protein (ucMGP). It has been suggested that patients on long-term treatment with vitamin K antagonists develop aortic valve calcifications because of lower levels of circulating MGP. We therefore hypothesized that arterial calcification and a low vitamin K status are associated with ucMGP. To that aim, we measured arterial calcium scores, the osteocalcin ratio (OCR), as a proxy for vitamin K status, and ucMGP. MATERIALS AND METHODS: In 36 hypertensive patients, we determined the Agatston score with computer tomography scans of the abdominal aorta, carotid and coronary arteries. The total calcium score was calculated as the sum of the separate Z-scores. RESULTS: The total calcium Z-score was significantly correlated to age (r = 0.683, P < 0.001), smoking (r = 0.372, P = 0.026), total cholesterol (r = 0.353, P = 0.034), LDL cholesterol (r = 0.490, P = 0.003), triglycerides (r = 0.506, P = 0.002), fasting glucose (r = 0.454, P = 0.005), systolic blood pressure (r = 0.363, P = 0.029) and pulse pressure (r = 0.685, P < 0.001). In multivariate regression analyses, OCR and total calcium score were significantly associated with ucMGP. CONCLUSIONS: We found a positive association of total arterial calcium score and a high OCR (reflecting low vitamin K status) with ucMGP serum levels. This warrants further studies to explore the pathophysiological background of this phenomenon.


Assuntos
Calcinose , Proteínas de Ligação ao Cálcio/metabolismo , Cálcio/metabolismo , Proteínas da Matriz Extracelular/metabolismo , Osteocalcina/metabolismo , Vitamina K/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Cálcio/sangue , Proteínas de Ligação ao Cálcio/sangue , Cardiomiopatias , Proteínas da Matriz Extracelular/sangue , Feminino , Humanos , Hipertensão , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X , Vitamina K/sangue
15.
Blood ; 115(24): 5121-3, 2010 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-20354170

RESUMO

Vascular calcification is a marker of increased cardiovascular risk. Vitamin K-dependent matrix Gla protein (MGP) is important in inhibiting calcification. Because MGP activation is vitamin K dependent, we performed a cross-sectional study investigating the relationship between the use of vitamin K antagonists and extracoronary vascular calcification. From the Dutch thrombosis services we selected 19 patients younger than 55 years who had no other cardiovascular risk factors and who had used coumarins for more than 10 years, and compared these to 18 matched healthy controls. MGP was measured, and a plain x-ray of the thighs was taken to assess femoral arterial calcifications. The odds ratio for calcification in patients versus controls was 8.5 (95% confidence interval [CI] 2.01-35.95). Coumarin use and MGP were associated with calcification, even after adjusting for other risk factors. We conclude that long-term use of coumarins is associated with enhanced extracoronary vascular calcification, possibly through the inhibition of MGP carboxylation.


Assuntos
Anticoagulantes/efeitos adversos , Calcinose/induzido quimicamente , Doenças Cardiovasculares/induzido quimicamente , Cumarínicos/efeitos adversos , Trombose/tratamento farmacológico , Adulto , Anticoagulantes/administração & dosagem , Calcinose/diagnóstico por imagem , Calcinose/epidemiologia , Proteínas de Ligação ao Cálcio/metabolismo , Doenças Cardiovasculares/diagnóstico por imagem , Doenças Cardiovasculares/epidemiologia , Cumarínicos/administração & dosagem , Bases de Dados Factuais , Proteínas da Matriz Extracelular/metabolismo , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/metabolismo , Artéria Femoral/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Análise de Regressão , Fatores de Risco , Trombose/epidemiologia
16.
Hypertens Res ; 31(9): 1745-51, 2008 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-18971553

RESUMO

Vascular calcifications are common among patients with hypertension. The vitamin K-dependent protein matrix Gla-protein plays an important role in preventing arterial calcification. Since a decrease in renal clearance is a prevalent clinical problem in patients with hypertension, we aimed to study the renal clearance of matrix Gla-protein from the circulation in these patients having a wide range of creatinine clearances. Ninety moderate to severe hypertensive patients who were scheduled for renal angiography were enrolled in the study. In these patients, renal arterial and renal venous blood was sampled prior to the administration of contrast material in order to determine the total renal and single kidney clearance of matrix Gla-protein. The average renal fractional extraction of matrix Gla-protein was 12.8%. There was no significant correlation between creatinine clearance (range 26-154) and renal fractional extraction of matrix Gla-protein in this population. The extraction of matrix Gla-protein was not influenced by the presence of a renal artery stenosis. In conclusion, we demonstrate that the kidney is able to extract matrix Gla-protein from the plasma at a constant level of 12.8%, independent of renal function in hypertensive subjects.


Assuntos
Calcinose/metabolismo , Proteínas de Ligação ao Cálcio/sangue , Proteínas da Matriz Extracelular/sangue , Hipertensão Renal/metabolismo , Rim/metabolismo , Adulto , Creatinina/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Renal , Obstrução da Artéria Renal/metabolismo , Circulação Renal , Veias Renais , Índice de Gravidade de Doença
17.
Hypertension ; 50(6): 1019-25, 2007 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17938383

RESUMO

It is still uncertain whether one can safely base treatment decisions on self-measurement of blood pressure. In the present study, we investigated whether antihypertensive treatment based on self-measurement of blood pressure leads to the use of less medication without the loss of blood pressure control. We randomly assigned 430 hypertensive patients to receive treatment either on the basis of self-measured pressures (n=216) or office pressures (OPs; n=214). During 1-year follow-up, blood pressure was measured by office measurement (10 visits), ambulatory monitoring (start and end), and self-measurement (8 times, self-pressure group only). In addition, drug use, associated costs, and degree of target organ damage (echocardiography and microalbuminuria) were assessed. The self-pressure group used less medication than the OP group (1.47 versus 2.48 drug steps; P<0.001) with lower costs ($3222 versus $4420 per 100 patients per month; P<0.001) but without significant differences in systolic and diastolic OP values (1.6/1.0 mm Hg; P=0.25/0.20), in changes in left ventricular mass index (-6.5 g/m(2) versus -5.6 g/m(2); P=0.72), or in median urinary microalbumin concentration (-1.7 versus -1.5 mg per 24 hours; P=0.87). Nevertheless, 24-hour ambulatory blood pressure values at the end of the trial were higher in the self-pressure than in the OP group: 125.9 versus 123.8 mm Hg (P<0.05) for systolic and 77.2 versus 76.1 mm Hg (P<0.05) for diastolic blood pressure. These data show that self-measurement leads to less medication use than office blood pressure measurement without leading to significant differences in OP values or target organ damage. Ambulatory values, however, remain slightly elevated for the self-pressure group.


Assuntos
Anti-Hipertensivos/uso terapêutico , Determinação da Pressão Arterial , Hipertensão/tratamento farmacológico , Autocuidado , Adulto , Idoso , Anti-Hipertensivos/economia , Monitorização Ambulatorial da Pressão Arterial , Método Duplo-Cego , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico , Estudos Prospectivos
18.
Lancet Neurol ; 4(12): 877-88, 2005 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-16297845

RESUMO

Cerebral hyperperfusion syndrome (CHS) after carotid endarterectomy is characterised by ipsilateral headache, hypertension, seizures, and focal neurological deficits. If not treated properly it can result in severe brain oedema, intracerebral or subarachnoid haemorrhage, and death. Knowledge of CHS among physicians is limited. Most studies report incidences of CHS of 0-3% after carotid endarterectomy. CHS is most common in patients with increases of more than 100% in perfusion compared with baseline after carotid endarterectomy and is rare in patients with increases in perfusion less than 100% compared with baseline. The most important risk factors in CHS are diminished cerebrovascular reserve, postoperative hypertension, and hyperperfusion lasting more than several hours after carotid endarterectomy. Impaired autoregulation as a result of endothelial dysfunction mediated by generation of free oxygen radicals is implicated in the pathogenesis of CHS. Treatment strategies are directed towards regulation of blood pressure and limitation of rises in cerebral perfusion. Complete recovery happens in mild cases, but disability and death can occur in more severe cases. More information about CHS and early institution of adequate treatment are of paramount importance in order to prevent these potentially severe complications.


Assuntos
Circulação Cerebrovascular/fisiologia , Transtornos Cerebrovasculares/etiologia , Endarterectomia das Carótidas/efeitos adversos , Perfusão/efeitos adversos , Algoritmos , Transtornos Cerebrovasculares/epidemiologia , Transtornos Cerebrovasculares/fisiopatologia , Lateralidade Funcional , Humanos , Complicações Pós-Operatórias , Fatores de Risco
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