Pediatric cartilaginous lateral femoral condyle Hoffa fracture: a case report and review of the literature

INTRODUCTION

Hoffa fractures are challenging coronally-oriented articular injuries of the femoral condyle. These fractures are rare in adults and extremely rare in the skeletally immature, with few cases reported in literature. To prevent mal- or non-union, Hoffa fractures require prompt surgical stabilisation with anatomic reduction and internal fixation.

CASE REPORT

We discuss the case of a lateral distal femoral condyle cartilaginous Hoffa fracture in a ten-year-old male patient. The patient presented after a football non-contact "twist and pop" injury with radiographic imaging described as an osteochondritis dissecans lesion. An MRI was obtained which demonstrated a lateral distal femoral condyle osteochondral fracture. An operative plan was formulated to perform arthroscopic reduction and bio-compression screw fixation to minimize damage to the physis and surrounding tissues. Hyperflexion of the knee allowed for anatomic fracture reduction with the placement of 2 bio-compression screws serving as maintenance of fixation. The patient did well postoperatively and returned to full activity after 6 months.

CONCLUSION

Hoffa fractures in the pediatric population are rare and can occur not only through bone but also through the thick chondral layer in younger patients. These are extremely difficult to diagnose through X-Ray alone. The prompt use of MRI imaging allows for operative fixation in a timely fashion, while an arthroscopic-only approach allows for minimal tissue damage. With an appropriate fracture type, hyper-flexion reduces and stabilizes the fracture, permitting the placement of minimally invasive bio-compression fixation.

Prevalence of elevated blood lead levels and risk factors among children living in Patna, Bihar, India 2020

Childhood lead exposure remains a key health concern for officials worldwide, contributing some 600,000 new cases of intellectually disabled children annually. Most children affected by high exposure to lead live in low- and middle-income countries. The leaded gasoline phase out in India was completed in 2000. Yet, in 2020, an estimated 275 million children aged 0 to 9 years had blood lead levels (BLLs) ≥ 5 μg/dL known to adversely affect intelligence and behavior. Lead sources reported in India include spices, cookware, paint, traditional medicines and cosmetics, and lead-acid battery recycling and repair. However, their relative contribution has not been characterized. More than 200 lead pollution sites related to battery recycling and repair activities were identified in Bihar and Jharkhand, India. Ninety percent of the recycling sites had soil lead concentrations exceeding the US Environmental Protection Agency's standards. We compared blood and environmental lead levels in two groups of children in Patna, Bihar. Households in proximity to battery recycling operations (Proximal n = 67) versus households distal to these operations (Distal n = 68). The average age of children was 40 months; 46% were female. Overall, the geometric mean (GM) BLL was 11.6 μg/dL. GM BLLs of children in Proximal and Distal households were not significantly different (10.2 μg/dL vs. 13.1 μg/dL respectively; p≤0.07). About 87% children, 56 Proximal and 62 Distal had BLLs ≥5 μg/dl. Lead concentrations in environmental samples were significantly higher in Proximal households (soil mean 9.8 vs. 1.6 μg/ft2; dust mean 52.9 vs. 29.9 μg/ft2 p<0.001; Proximal vs. Distal respectively) whereas concentrations in all spices were higher in Distal households (mean 46.8 vs 134.5 ppm p<0.001; Proximal vs. Distal respectively), and turmeric (mean 59.4 vs. 216.9 ppm Proximal vs. Distal respectively). In multivariate analyses for all children lead in spices and turmeric and number of rooms in the house were significant while for the Proximal group only lead in spices remained in the model. The predictive value of these models was poor. For the Distal group, a model with lead concentration in spices, turmeric and soil and number of rooms in the house was a much better fit. Of the 34 water samples collected, 7 were above the Indian standard of 10 ppb for lead in drinking water (2 in the Proximal area, 5 in the Distal area). Children in Patna, Bihar, India are exposed to multiple sources of lead, with lead levels in house dust and loose, locally sourced spices the most likely to increase blood lead levels. A holistic approach to blood lead testing and source identification and remediation are necessary to prevent lead exposure.

Multiscale Self-Assembly of Distinctive Weblike Structures from Evaporated Drops of Dilute American Whiskeys

When a sessile droplet of a complex mixture evaporates, its nonvolatile components may deposit into various patterns. One such phenomena, the coffee ring effect, has been a topic of interest for several decades. Here, we identify what we believe to be a fascinating phenomenon of droplet pattern deposition for another well-known beverage-what we have termed a "whiskey web". Nanoscale agglomerates were generated in diluted American whiskeys (20-25% alcohol by volume), which later stratified as microwebs on the liquid-air interface during evaporation. The web's strandlike features result from monolayer collapse, and the resulting pattern is a function of the intrinsic molecular constituents of the whiskey. Data suggest that, for our conditions (diluted 1.0 μL drops evaporated on cleaned glass substrates), whiskey webs were unique to diluted American whiskey; however, similar structures were generated with other whiskeys under different conditions. Further, each product forms their own distinct pattern, demonstrating that this phenomenon could be used for sample analysis and counterfeit identification.

Mediator and moderator effects on the relationship between HIV-positive status disclosure concerns and health-related quality of life

HIV-related stigma and the effect on quality of life is an on-going public health concern despite decades of education, prevention, and intervention efforts. The main purposes of this study were to examine the mediating role of four coping styles and the moderating role of gender on the relationship between HIV-positive status disclosure concerns and eight health-related quality of life outcomes. Data were collected from 346 women and men living with HIV. Results indicated that two coping styles - acquiring social support and positive reframing - mediated the negative relationship between disclosure concerns and health-related quality of life outcomes. There was no support for a moderated mediation. Interventions aimed at helping people living with HIV should focus on identifying and acquiring coping styles that transform perceptions of HIV-related stigma to support disclosure and improve health-related quality of life.

Change in Biotypic Diversity of Russian Wheat Aphid (Hemiptera: Aphididae) Populations in the United States

A key component of Russian wheat aphid, Diuraphis noxia (Kurdjumov), management has been through planting resistant wheat cultivars. A new biotype, RWA2, appeared in 2003 which caused widespread damage to wheat cultivars containing the Dn4 gene. Biotypic diversity in Russian wheat aphid populations has not been addressed since 2005 when RWA2 dominated the biotype complex. Our objectives were to determine the biotypic diversity in the Central Great Plains and Colorado Plateau at regional (2010, 2011, 2013) and local (2012) levels and detect the presence of new Russian wheat aphid biotypes. Regional and within-field aphid collections were screened against Russian wheat aphid-resistant wheat genotypes containing genes Dn3, Dn4, Dn6, Dn7, Dn9, CI2401; and resistant barley STARS 9301B. In 2010, all aphid collections from Texas were avirulent to the Dn4 resistance gene in wheat. Regional results revealed Dn4 avirulent RWA6 was widespread (55-84%) in populations infesting wheat in both regions. Biotypes RWA1, 2, and 3/7 were equally represented with percentages<20% each while RWA8 was rarely detected. Combining percentages of RWA1, 6, and 8 across regions to estimate avirulence to Dn4 gene revealed high percentages for both 2011 (64-80%) and 2013 (69-90%). In contrast, the biotype structure at the local level differed where biotype percentages varied up to ≥2-fold between fields. No new biotypes were detected; therefore, Dn7, CI2401, and STARS9301B remained resistant to all known Russian wheat aphid biotypes. This study documents a shift to Dn4 avirulent biotypes and serves as a valuable baseline for biotypic diversity in Russian wheat aphid populations prior to the deployment of new Russian wheat aphid-resistant wheat cultivars.

Information needs for the OR and PACU electronic medical record

OBJECTIVE

The amount of clinical information that anesthesia providers encounter creates an environment for information overload and medical error. In an effort to create more efficient OR and PACU EMR viewer platforms, we aimed to better understand the intraoperative and post-anesthesia clinical information needs among anesthesia providers.

MATERIALS AND METHODS

A web-based survey to evaluate 75 clinical data items was created and distributed to all anesthesia providers at our institution. Participants were asked to rate the importance of each data item in helping them make routine clinical decisions in the OR and PACU settings.

RESULTS

There were 107 survey responses with distribution throughout all clinical roles. 84% of the data items fell within the top 2 proportional quarters in the OR setting compared to only 65% in the PACU. Thirty of the 75 items (40%) received an absolutely necessary rating by more than half of the respondents for the OR setting as opposed to only 19 of the 75 items (25%) in the PACU. Only 1 item was rated by more than 20% of respondents as not needed in the OR compared to 20 data items (27%) in the PACU.

CONCLUSION

Anesthesia providers demonstrate a larger need for EMR data to help guide clinical decision making in the OR as compared to the PACU. When creating EMR platforms for these settings it is important to understand and include data items providers deem the most clinically useful. Minimizing the less relevant data items helps prevent information overload and reduces the risk for medical error.

Characterization of eight Russian wheat aphid (Hemiptera: Aphididae) biotypes using two-category resistant-susceptible plant responses

Eight biotypes of the Russian wheat aphid, Diuraphis noxia (Kurdjumov), have been discovered in the United States since 2003. Biotypes are identified by the distinct feeding damage responses they produce on wheat carrying different Russian wheat aphid resistance genes, namely, from Dn1 to Dn9. Each Russian wheat aphid biotype has been named using plant damage criteria and virulence categories that have varied between studies. The study was initiated to compare the plant damage caused by all the eight known Russian wheat aphid biotypes, and analyze the results to determine how Russian wheat aphid virulence should be classified. Each Russian wheat aphid biotype was evaluated on 16 resistant or susceptible cereal genotypes. Plant damage criteria included leaf roll, leaf chlorosis, and plant height. The distribution of chlorosis ratings followed a bimodal pattern indicating two categories of plant responses, resistant or susceptible. Correlations were significant between chlorosis ratings and leaf roll (r(2) = 0.72) and between chlorosis ratings and plant height (r(2) = 0.48). The response of 16 cereal genotypes to feeding by eight Russian wheat aphid biotypes found RWA1, RWA2, RWA6, and RWA8 to differ in virulence, while Russian wheat aphid biotypes RWA3, RWA4, RWA5, and RWA7 produced similar virulence profiles. These biotypes have accordingly been consolidated to what is hereafter referred to as RWA3/7. Our results indicated that the five main biotypes RWA1, RWA2, RWA3/7, RWA6, and RWA8 can be identified using only four wheat genotypes containing Dn3, Dn4, Dn6, and Dn9.

Influenza and congenital anomalies: a systematic review and meta-analysis

STUDY QUESTION

Does first trimester maternal influenza infection increase the risk of non-chromosomal congenital anomalies (CA)?

SUMMARY ANSWER

First trimester maternal influenza exposure is associated with raised risk of a number of non-chromosomal CA, including neural tube defects, hydrocephaly, congenital heart defects, cleft lip, digestive system defects and limb reduction defects.

WHAT IS KNOWN ALREADY

Hyperthermia is a well-established risk factor for neural tube defects. Previous studies suggest influenza may be a risk factor not only for neural tube defects, but also other CA. No systematic review has previously been undertaken.

STUDY DESIGN, SIZE, DURATION

Systematic review and meta-analysis. A search of EMBASE and PUBMED was performed for English and Dutch studies published up to July 2013. A total of 33 studies (15 case-control, 10 cohort and 8 ecological) were included in the systematic review of which 22 studies were included in the meta-analysis.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

A total of 29 542 babies with congenital anomaly (1112 exposed) from case-control studies and 1608 exposed pregnancies resulting in 56 babies with congenital anomaly from cohort studies were included in the meta-analysis. Maternal influenza exposure was defined as any reported influenza, influenza-like illness or fever with flu, with or without serological or clinical confirmation during the first trimester of pregnancy. Data for 24 (sub)groups with congenital anomaly available from ≥3 studies were analysed using the DerSimonian-Laird random effects model. The hypothesis of publication bias was assessed using funnel plots and risk of bias of included studies was assessed using a slightly modified version of the Newcastle-Ottawa scale.

MAIN RESULTS AND THE ROLE OF CHANCE

First trimester maternal influenza exposure was associated with an increased risk of any congenital anomaly [adjusted odds ratio (AOR) 2.00, 95% CI: 1.62-2.48], neural tube defects [odds ratio (OR) 3.33, 2.05-5.40], hydrocephaly (5.74, 1.10-30.00), congenital heart defects (1.56, 1.13-2.14), aortic valve atresia/stenosis (AOR 2.59, 1.21-5.54), ventricular septal defect (AOR 1.59, 1.24-2.14), cleft lip (3.12, 2.20-4.42), digestive system (1.72, 1.09-2.68) and limb reduction defects (2.03, 1.27-3.27). An increased risk for cleft lip (but not for cleft palate) was also reported by ecological studies not included in the meta-analysis. Study outcomes reported for 27 subgroups of congenital anomaly could not be included in the meta-analysis. Visual inspection of funnel plots did not suggest evidence for publication bias.

LIMITATIONS, REASONS FOR CAUTION

This study enrolled observational studies that can be subject to limitations such as confounding, retrospective maternal exposure reports and non-response of intended participants. Influenza exposed pregnancies can also have been exposed to influenza related medication.

WIDER IMPLICATIONS OF THE FINDINGS

Prevention of influenza in pregnant women may reduce congenital anomaly risk, and would be relevant to more than just neural tube defects. More research is needed to determine whether influenza and/or its related medication is teratogenic, to determine the role of hyperthermia in teratogenicity and the role of other environmental factors such as nutritional status in determining susceptibility.

Biosurfactants for cosmetic applications

Synopsis Biosurfactants are biologically-produced, natural surface active agents and are synthesized by a range of microorganisms. These compounds include glycolipids, lipopeptides and phospholipids. The yields of biosurfactants in microbial fermentations may be as high as 150g l(-1) and may be increased by optimizing production conditions and by strain improvement. Biosurfactants display very low critical micelle concentration (CMC) values when compared with conventional surfactants and are stable at a wide range of temperatures, pH values and salinities. They show many promising characteristics for cosmetic applications.

An overview of the biology and status of undulate ray Raja undulata in the north-east Atlantic Ocean

The undulate ray Raja undulata is one of the lesser-known skates occurring on the continental shelf of the north-east Atlantic Ocean. It is patchily distributed throughout its range, with sites of local abundance in the central English Channel and off the coasts of Ireland, France, Spain and Portugal. Raja undulata is most abundant in coastal waters (<50 m deep) and is often found in proximity to large estuaries, rias and bays. It is a relatively large-bodied species, attaining a maximum total length (L(T) ) of at least 114 cm, with females maturing at an L(T) of c. 84 cm in Portuguese waters. Although infrequently taken in existing trawl surveys, it can be locally abundant in certain areas, where it can be the dominant skate species. Given its large size, patchy distribution and concern over the possibilities of localized depletions, the IUCN listed R. undulata as an endangered species and, since 2009, the European Union has established regulations to prohibit commercial fisheries landing the species. Given the increased interest in the species, a synopsis of current knowledge is provided, and available data from internationally co-ordinated trawl surveys presented.

Infusion with the antioxidant N-acetylcysteine attenuates early adaptive responses to exercise in human skeletal muscle

AIM

Production of reactive oxygen species (ROS) in skeletal muscle is markedly increased during exercise and may be essential for exercise adaptation. We, therefore, investigated the effects of infusion with the antioxidant N-acetylcysteine (NAC) on exercise-induced activation of signalling pathways and genes involved in exercise adaptation in human skeletal muscle.

METHODS

Subjects completed two exercise tests, 7 days apart, with saline (control, CON) or NAC infusion before and during exercise. Exercise tests comprised of cycling at 71% VO(2peak) for 45 min, and then 92% VO(2peak) to fatigue, with vastus lateralis biopsies at pre-infusion, after 45-min cycling and at fatigue.

RESULTS

Analysis was conducted on the mitogen-activated protein kinase signalling pathways, demonstrating that NAC infusion blocked the exercise-induced increase in JNK phosphorylation, but not ERK1/2, or p38 MAPK. Nuclear factor-κB p65 phosphorylation was unaffected by exercise; however, it was reduced in NAC at fatigue by 14% (P < 0.05) compared with pre-infusion. Analysis of exercise and/or ROS-sensitive genes demonstrated that exercise-induced mRNA expression is ROS dependent of MnSOD, but not PGC-1α, interleukin-6, monocyte chemotactic protein-1, or heat-shock protein 70.

CONCLUSION

These results suggest that inhibition of ROS attenuates some skeletal muscle cell signalling pathways and gene expression involved in adaptations to exercise.

Disseminated visceral coccidiosis in Eurasian cranes (Grus grus) in the UK

Clinical disease and mortalities due to disseminated visceral coccidiosis were identified for the first time in a group of captive juvenile Eurasian cranes (Grus grus) in the UK during 2008. Presumptive diagnosis was made from the finding of granulomatous nodules in the liver, spleen and other organs at gross postmortem examination, and confirmed histologically by the presence of intracellular coccidial stages within lesions. The species of coccidian was determined to be Eimeria reichenowi on the basis of faecal oocyst morphology and sequencing of 18S rDNA by PCR. A further outbreak of clinical disease occurred in the same enclosure in 2009, affecting a new group of juvenile Eurasian cranes and demoiselle cranes (Anthropoides virgo) and indicating the persistence of infective oocysts in the environment. Clinical sampling of birds during both years demonstrated positive results from examination of both faecal samples and peripheral blood smears.

A comparison of parametric and non-parametric approaches to target-controlled infusion of propofol

Nineteen adult patients of either gender received intravenous infusions of propofol, scaled to estimated lean body mass (LBM), for 150 minutes as part of a balanced anaesthetic. Arterial blood was assayed for whole blood propofol. The first subject received propofol at a fixed rate of 0.058 mg x min(-1) x kg(LBM)(-1). Subsequent groups received variable rate infusions based on the ratio of the infusion rate to the propofol concentration at each sampling point in the previous group, multiplied by the target concentration. After groups of one, two, five and 11 subjects, the median weighted residual was 0.040 and median absolute weighted residual was 0.153. Population pharmacokinetic analysis of the final group of six females and five males, aged 29 to 70 years and of 16.5 to 44.2% body fat, resulted in a two compartment pharmacokinetic model with coefficients and standard errors of V = 0.102 (0.0155) l/kg(LBM), V2 = 0.257 (0.079) l/kg(LBM), k10 = 0.423 (0.069)/min, k12 = 0.222 (0.051)/min, k21 = 0.084 (0.02)/min and clearance = 0.0418 (0.0023) L x min(-1) x kg(LBM)(-1). The only significant covariate was LBM. Within infusion data improved prediction when compared with data derived in previous studies from random observations.

Catecholamine neurotransmitters and the heart

The possible role of adrenaline as a cardiac neurotransmitter was studied following its infusion in 6 healthy volunteers. After the end of the infusion, heart rate remained elevated for several hours despite a rapid fall in plasma adrenaline concentration. Stimulation of sympathetic activity by standing caused a further marked increase in heart rate, which was greater than that found on a control occasion. These effects were abolished or reduced by pretreatment with either desipramine or (in the dog) alpha-methyl-p-tyrosine, suggesting that they depend both on uptake of the adrenaline into sympathetic nerve endings during infusion and on increased release of endogenous noradrenaline. These results are consistent with stimulation of the beta-presynaptic receptor by adrenaline when re-released from sympathetic nerves.

The experiences of adults with intellectual disabilities and their carers in general hospitals: a focus group study

BACKGROUND

People with intellectual disabilities (ID) have higher levels of health needs compared with the general population, many of which are unrecognised and unmet. While there has been interest and research into the primary health provision for this group, there has been a more limited focus on addressing their care received in general hospitals. Access to health care has predominated in the literature, with less attention being paid to the experiences of people with ID as users of general hospital care.

METHOD

A qualitative focus group methodology was used. Eleven adults with ID, nine parents and five paid carers of adults with ID participated. The focus groups were audiotaped and transcriptions were analysed using principles of grounded theory.

RESULTS

The analysed data highlighted key themes identified from the experiences of participants. These were the interrelated issues of feelings, particularly anxiety and fear, communication and behaviour problems; the practicalities of being in or attending hospitals, including the role played by carers; and issues around perceived discrimination and negative comments.

CONCLUSIONS

The experiences of participants in this study concur with and add to concern expressed in recent reports and published research. Wide ranging implications are discussed for further research, wider policy development, clinical practice, local health service provision and education of health professionals.

Modeling Uhthoff's phenomenon in MS patients with internuclear ophthalmoparesis

OBJECTIVE

The goal of this investigation was to demonstrate that internuclear ophthalmoparesis (INO) can be utilized to model the effects of body temperature-induced changes on the fidelity of axonal conduction in multiple sclerosis (Uhthoff's phenomenon).

METHODS

Ocular motor function was measured using infrared oculography at 10-minute intervals in patients with multiple sclerosis (MS) with INO (MS-INO; n = 8), patients with MS without INO (MS-CON; n = 8), and matched healthy controls (CON; n = 8) at normothermic baseline, during whole-body heating (increase in core temperature 0.8 degrees C as measured by an ingestible temperature probe and transabdominal telemetry), and after whole-body cooling. The versional disconjugacy index (velocity-VDI), the ratio of abducting/adducting eye movements for velocity, was calculated to assess changes in interocular disconjugacy. The first pass amplitude (FPA), the position of the adducting eye when the abducting eye achieves a centrifugal fixation target, was also computed.

RESULTS

Velocity-VDI and FPA in MS-INO patients was elevated (p < 0.001) following whole body heating with respect to baseline measures, confirming a compromise in axonal electrical impulse transmission properties. Velocity-VDI and FPA in MS-INO patients was then restored to baseline values following whole-body cooling, confirming the reversible and stereotyped nature of this characteristic feature of demyelination.

CONCLUSIONS

We have developed a neurophysiologic model for objectively understanding temperature-related reversible changes in axonal conduction in multiple sclerosis. Our observations corroborate the hypothesis that changes in core body temperature (heating and cooling) are associated with stereotypic decay and restoration in axonal conduction mechanisms.

The use of 18-fluoro-dihydroxyphenylalanine and 18-fluorodeoxyglucose positron emission tomography scanning in the assessment of metaiodobenzylguanidine-negative phaeochromocytoma

123I-metaiodobenzylguanidine (123I-MIBG) scintigraphy scanning is commonly used in the imaging of phaeochromocytoma (and paraganglioma) to confirm the site of disease and whether any spread has occurred. However, 123I-MIBG imaging is negative in 15% of cases of benign phaeochromocytoma and around 50% of cases of malignant phaeochromocytoma. In recent years, positron emission tomography (PET) scanning using various different radiotracers has been shown to be a good alternative or supplementary investigation in phaeochromocytoma. We present the cases of four patients with symptoms and signs suggestive of phaeochromocytoma, but who had negative 123I-MIBG scans, and illustrate the usefulness of 18-fluoro-dihydroxyphenylalanine PET scanning in their assessment. In one of the patients, we illustrate how fluorodeoxyglucose PETscanning can provide useful information about the extent of malignant disease. These illustrative cases lend further support for the use of PET scanning in the assessment of phaeochromocytoma and suggest that it may have a particularly important role in the investigation of patients in whom 123I-MIBG scanning is negative.

The heritability of plasma homocysteine, and the influence of genetic variation in the homocysteine methylation pathway

BACKGROUND

The extent of genetic influence on plasma homocysteine, a risk factor for ischaemic heart disease, is uncertain. Many association studies have investigated common polymorphisms and their role in hyperhomocysteinaemia, but only the thermolabile variant of methylene tetrahydrofolate reductase (MTHFR) has shown an association (small but robust).

AIM

To estimate the heritability of plasma homocysteine and the contributions of well-studied common SNPs in the three main candidate genes in the homocysteine methylation pathway.

DESIGN

Twin study.

METHODS

We studied 216 monozygotic and 790 dizygotic pairs of twins; all were women. Blood was collected after overnight fasting for measurement of homocysteine, folate, vitamin B12, and extraction of DNA. Heritability was estimated by structural modelling, including correction for known environmental influences, particularly serum folate. The frequency of a common coding SNP in MTHFR and methionine synthase (MTR), and two coding SNPs in methionine synthase reductase (MTRR) were measured in dizygotic twins by ABI 7700 Sequence Detection, and the contribution of each to homocysteine variance was determined.

RESULTS

The heritability of homocysteine was 57% (95%CI 51-63%). The highest contribution to homocysteine was serum folate, accounting for 10.13% of variance. This was twice the total genetic contribution of 4.56%, and only the C1763T SNP of MTRR showed significant association with homocysteine.

DISCUSSION

Homocysteine has one of the highest heritabilities of common risk factors for ischaemic heart disease. This is not accounted for by the commonly studied SNPs in MTHFR, MTR and MTRR.

Grand Rounds at the British Hypertension Society: renal artery stenosis

Renal artery angioplasty for renovascular hypertension is a controversial subject with considerable data but few certainties. This article is a summary of the Grand Round on Renovascular Hypertension held at the British Hypertension Society Annual Conference in September 2006.