Antihypertensive treatment: does the J-curve exist?

In the treatment of arterial hypertension, the optimal reduction in blood pressure is obviously the one that causes the maximum achievable prevention of hypertension-associated cardiovascular morbidity and mortality. This goal has clearly not been reached by today's approach to the treatment of elevated blood pressure. Treated hypertensive patients are still at increased risk of cardiovascular morbidity and mortality in spite of receiving antihypertensive treatment, as shown in many intervention studies. One possible explanation for this outcome could be that treated blood pressure is rarely brought down to strictly normotensive levels, again as shown in numerous studies. This finding would suggest that a more vigorous lowering of blood pressure would be advantageous when treating hypertensive patients. On the other hand, the fact that the relationship between the level of blood pressure and risk is J-shaped obviously means that vigorous lowering of blood pressure may increase cardiovascular risks, if blood pressure is brought down too far. Several open, retrospective, nonrandomized studies have been analyzed with this issue in mind, but so far only two prospective intervention trials have been specifically designed to address this problem: the BBB Study, published in 1994, and the much larger HOT Study, published in 1998. The rationale of these studies as well as some of their findings will be discussed briefly here, with emphasis on the HOT Study.

Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study

BACKGROUND

Calcium antagonists are a first-line treatment for hypertension. The effectiveness of diltiazem, a non-dihydropyridine calcium antagonist, in reducing cardiovascular morbidity or mortality is unclear. We compared the effects of diltiazem with that of diuretics, beta-blockers, or both on cardiovascular morbidity and mortality in hypertensive patients.

METHODS

In a prospective, randomised, open, blinded endpoint study, we enrolled 10,881 patients, aged 50-74 years, at health centres in Norway and Sweden, who had diastolic blood pressure of 100 mm Hg or more. We randomly assigned patients diltiazem, or diuretics, beta-blockers, or both. The combined primary endpoint was fatal and non-fatal stroke, myocardial infarction, and other cardiovascular death. Analysis was done by intention to treat.

FINDINGS

Systolic and diastolic blood pressure were lowered effectively in the diltiazem and diuretic and beta-blocker groups (reduction 20.3/18.7 vs 23.3/18.7 mm Hg; difference in systolic reduction p<0.001). A primary endpoint occurred in 403 patients in the diltiazem group and in 400 in the diuretic and beta-blocker group (16.6 vs 16.2 events per 1000 patient-years; relative risk 1.00 [95% CI 0.87-1.15], p=0.97). Fatal and non-fatal stroke occurred in 159 patients in the diltiazem group and in 196 in the diuretic and beta-blocker group (6.4 vs 7.9 events per 1000 patient-years; 0.80 [0.65-0.99], p=0.04) and fatal and non-fatal myocardial infarction in 183 and 157 patients (7.4 vs 6.3 events per 1000 patient-years; 1.16 [0.94-1.44], p=0.17).

INTERPRETATION

Diltiazem was as effective as treatment based on diuretics, beta-blockers, or both in preventing the combined primary endpoint of all stroke, myocardial infarction, and other cardiovascular death.

Operations for extrahepatic bile duct cancers: are the results really improving?

OBJECTIVE

To find out if our results for the treatment of extrahepatic bile duct cancer have improved we reviewed our latest patients as a comparison to a previously reported series from this department.

DESIGN

Retrospective study.

SETTING

Tertiary referral centre, Sweden.

SUBJECTS

102 patients who presented with extrahepatic bile duct cancer 1979-1995.

MAIN OUTCOME MEASURES

Morbidity, mortality, and short and long term survival.

RESULTS

16 patients had various types of resection, which were radical in 14 according to the surgeon and in 10 according to the pathologist. One patient (6%) died in hospital, and 1 (44%) developed complications. 13 patients had other operations that did not involve resection, 23 had laparotomy alone, 61 had biliary drainage either by percutaneous transhepatic cholangiography (PTC) or endoscopy, and 10 had no active treatment. One patient of the 16 (6%) who had resections has survived for more than five years and another one is still alive after 40 months.

CONCLUSION

Long term survival has not improved for patients with extrahepatic bile duct cancer in our hospital during the last decades.

Headache in mild-to-moderate hypertension and its reduction by irbesartan therapy

BACKGROUND

Although it is generally acknowledged to be a problem in severe hypertension, headache has not been consistently associated with mild-to-moderate hypertension.

PATIENTS AND METHODS

In 7 randomized, double-blind, placebo-controlled trials, which included 2,673 patients with mild-to-moderate hypertension (defined as seated diastolic blood pressure of 95-110 mm Hg), patients were randomized to receive once-daily treatment with irbesartan, an angiotensin II receptor blocker (n= 1,987), or placebo (n=686). The data were pooled and analyzed retrospectively to determine whether the level of hypertension was associated with headache and whether antihypertensive therapy reduced the incidence of headache.

RESULTS

Factors found to be predictive of headache incidence were diastolic blood pressure, sex (female), and age (<50 years). In comparison with placebo, the use of irbesartan was associated with a significant reduction in the incidence of headache (P=.003).

CONCLUSIONS

These data suggest that mild-to-moderate hypertension is not asymptomatic and that the incidence of headache can be reduced by antihypertensive treatment with a favorable adverse effect profile.

Pancreaticogastrostomy after subtotal pancreatectomy for cancer

BACKGROUND

Failure of the pancreaticodigestive anastomosis after pancreatoduodenectomy is still a major clinical problem. Pancreaticogastrostomy has recently been suggested to be associated with a low risk of leakage. The aim of this report was to add to previously reported experience.

METHODS

Data on the postoperative course were prospectively registered in 19 patients operated on with subtotal pancreatectomy because of periampullary cancer. They all had a duct-to-mucosa pancreaticogastrostomy.

RESULTS

There were no recognizable leakages from the pancreaticogastrostomy. However, the overall postoperative complication rate was 47% (9/19), the most common complications being delayed gastric emptying (26%, 5/19), wound infection (21%, 4/19), and wound rupture (11%, 2/19). Excluding delayed gastric emptying, the rate of intra-abdominal complications was 16% (3/19). There was 1 in-hospital death.

CONCLUSION

The results support the opinion that pancreaticogastrostomy can be done with a low risk of leakage.

Changes in glycosylation of human bile-salt-stimulated lipase during lactation

Bile-salt-stimulated lipase (BSSL) is an enzyme in human milk, which is important for the fat digestion in the newborn infant. BSSL is highly glycosylated and includes one site for N-glycosylation and several sites for O-glycosylation. BSSL has previously been found to express Lewis a, Lewis b, and Lewis x carbohydrate antigens. In this study, glycosylation of BSSL was studied at different times during lactation. BSSL was purified from milk collected individually from four donors at several different times during the first 6 months of lactation. The BSSL glycans were characterized through monosaccharide analysis, high-pH anion-exchange chromatography, matrix-assisted laser desorption-ionization mass spectrometry, and ELISA. Both total carbohydrate content and relative amount of sialic acid were higher in BSSL from the first lactation month as compared to BSSL from milk collected later in lactation. BSSL from the first lactation month also showed a different composition of sialylated O-linked glycans and the N-linked oligosaccharides consisted of lower amounts of fucosylated structures compared to later in lactation. We also found a gradual increase in the expression of the carbohydrate epitope Lewis x on BSSL throughout the lactation period. This study shows that glycosylation of BSSL is dependent on blood group phenotype of the donor and changes substantially during the lactation period.

Predictors for readmission risk of new patients: the Nordic Comparative Study on Sectorized Psychiatry

OBJECTIVE

Predictors for readmission risk were investigated in this study, which forms part of the Nordic Comparative Study on Sectorized Psychiatry.

METHOD

Included were a total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted to in-patient stay during a period of 1 year to seven psychiatric hospitals in four Nordic countries.

RESULTS

Multivariate survival analyses showed that younger age predicted increased readmission risk. Stratifying on gender, diagnostic group and sector revealed a general pattern concerning age which was the only consistent main effect. Living alone and unemployed increased readmission risk in the non-psychosis group, while receipt of aftercare decreased readmission risk in the psychosis group. A curvilinear relationship was found between availability of psychiatric resources and readmission risk: an intermediate amount of resources was associated with increased risk.

CONCLUSION

Our findings support a hypothesis that readmission risk is multifactorially determined and that interactions have to be considered.

Influence of gender and age on preventing cardiovascular disease by antihypertensive treatment and acetylsalicylic acid. The HOT study. Hypertension Optimal Treatment

OBJECTIVE

We have assessed the influence of gender and age on the main outcome results of the Hypertension Optimal Treatment (HOT) study.

DESIGN AND INTERVENTIONS

The aims of the HOT study were to study the relationship between three levels of target office diastolic blood pressure (BP) (< or = 90, < or = 85 or < or = 80 mmHg) and cardiovascular (CV) events in hypertensive patients, and to examine the effects of 75 mg acetylsalicylic acid (ASA) daily versus placebo.

SETTING

Outpatient clinical trial in 26 countries.

PATIENTS

A total of 18790 patients (mean age 61.5 years, range 50-80) were randomized and followed for an average of 3.8 years until 71051 patient-years and 683 events had occurred.

MAIN OUTCOME MEASURES

CV death, myocardial infarction (MI) and stroke.

RESULTS

There were significantly fewer MIs in those in the lower diastolic BP target groups (3.0 versus 1.2 and 1.7 MIs/1000 patient-years, P for trend = 0.034) in women (n = 8883), whereas the similar but smaller trend (4.1 versus 4.1 and 3.4 MIs/1000 patient-years) was not statistically significant in men nor in the subgroup analysis of younger and older subjects. The effect of ASA on preventing MI was not influenced by age < 65 years (P= 0.02) or age > or = 65 years (P = 0.04) but was influenced by gender (P = 0.38 in women and P = 0.001 in men, lowered by 42% corresponding to a reduction from 5.0 to 2.9 MIs/1000 patient-years).

CONCLUSIONS

The data of this HOT study sub-analysis suggest somewhat differentiated optimal gender- and age-dependent effects of anti-hypertensive and anti-platelet therapies; lowering of diastolic BP to about 80 mmHg in hypertensive women and, in addition, the administration of 75 mg of ASA to well-treated hypertensive men appear to effectively reduce the most common cardiovascular complication, i.e. myocardial infarction, in patients with essential hypertension.

Study on COgnition and Prognosis in the Elderly (SCOPE): Design and Objectives

Hypertension is a major risk factor for cardiovascular events, including stroke, as well as for white matter lesions of the brain. There is also evidence to link cognitive impairment and dementia to hypertension. However, it has not been established whether antihypertensive treatment of elderly patients with a diastolic blood pressure (DBP) in the range 90-99 mmHg provides protection against major cardiovascular events and cognitive impairment. The Study on COgnition and Prognosis in the Elderly (SCOPE) is the first study designed to assess the effects of antihypertensive drug treatment on major cardiovascular events and cognitive function in elderly patients with mild hypertension. SCOPE is a prospective, randomized, double-blind, parallel comparison of the effects of the angiotensin II type 1 (AT 1 ) receptor blocker candesartan cilexetil and placebo on major cardiovascular events (myocardial infarction [MI], stroke and cardiovascular death), cognitive function as measured by the Mini-Mental State Examination (MMSE), quality of life (QoL) and health economics. The study has included both men and women, aged 70-89 years of age, with systolic blood pressure (SBP) of 160-179 mmHg and/or DBP of 90-99 mmHg and an MMSE score of 24 or above. Nearly 5000 patients have been recruited and will be followed for a mean period of 2.5 years. After a run-in period of 1-3 months, patients were randomized to receive placebo or candesartan cilexetil, 8 mg once daily, which has been shown to provide effective and long-lasting blood pressure reductions, while maintaining placebo-like tolerability, in elderly patients. All previous antihypertensive treatment was standardized to hydrochlorothiazide (HCTZ), 12.5 mg, at enrolment. At any time during the study, the dose of study drug will be doubled if SBP rises above 160 mmHg or DBP rises above 85 mmHg. If an SBP above 160 mmHg or a DBP above 90 mmHg is observed despite the increase in study medication, additional antihypertensive medication with HCTZ is recommended. Assessments to be made during the study will include blood pressure, heart rate, ECG, MMSE, health economics and QoL. Data on adverse events and clinical events will also be collected throughout the study. SCOPE is organized and co-ordinated by an Executive Committee, a Steering Committee, an Independent Safety Committee, an Independent Event Committee and a Co-ordinating Centre. Countries participating in the Study include Belgium, Canada, Finland, France, Germany, UK, Hungary, Israel, Norway, Poland, Portugal, Spain, Sweden, The Netherlands and the USA. Inclusion of patients was completed in January 1999 and at that time 4964 patients were randomized. The baseline characteristics of these patients are shown in the Table.

Family burden, participation in care and mental health--an 11-year comparison of the situation of relatives to compulsorily and voluntarily admitted patients

SUMMARY The changes in family burden and participation in care of relatives to both voluntarily and compulsorily admitted patients were investigated as part of a longitudinal study of the quality of the mental health services in a Swedish county performed between 1986 and 1997. The relationship between the relative's mental health and family burden, participation in care and need of own support was also investigated. The results showed similar and high levels of burden and a non-sufficient participation in care in both periods investigated despite the ongoing changes in the delivery of psychiatric services and a change in the compulsory legislation in Sweden during the period. More relatives experienced an own need of care and support from the psychiatric services in the 1997 investigation. Relatives who experienced mental health problems of their own more often experienced other forms of burden, experienced less participation in the patient's treatment and also more often had own needs of care and support. It is concluded that interventions in families where relatives experience mental health problems will be useful, since a well-functioning network around the mentally ill person has shown to reduce relapse.

What do case managers do? An investigation of case manager interventions and their relationship to client outcome

BACKGROUND

The aim of the present study, which forms part of a wider case management multicenter study, was to explore the content of case managers' work, service patterns, and their relationship to client outcome.

METHODS

Client background characteristics were registered at admission, and needs of care and psychosocial functioning were assessed at admission to the service and after 18 months. In seven of the services an extended follow-up was performed, which included assessments regarding quality of life, level of symptoms and social network. The study comprised 176 severely mentally ill clients, of whom 153 participated in a general 18-month follow-up (87%), with 113 clients out of 134 participating in an extended follow-up sample (84%).

RESULTS

The investigation of service patterns showed that clients received services in a great variety of life areas using a number of different types of interventions. The results support the assumption that severely mentally ill clients are in need of case management services that offer more than brokerage services and coordination. A more active rehabilitation-oriented approach was found towards younger clients and clients who had a job, which may reflect a higher level of ambition in assisting younger clients to gain access to and stay in education and the labor market. Several types of intervention were related to client outcome. Brokerage, intervention planning and more interventions in the area of skills relating to activities of daily living were related to a more pronounced decrease in needs of care. More time spent on indirect work on behalf of the clients was related to a better outcome with regard to psychiatric symptoms and social network.

CONCLUSIONS

The results indicate that specific service components have a more obvious distinct impact than others on outcome, and that this increase in effectiveness varies with the outcome targeted.

Study on COgnition and Prognosis in the Elderly (SCOPE)

The Study on COgnition and Prognosis in the Elderly (SCOPE) is a multicentre, prospective, randomized, double-blind, parallel-group study designed to compare the effects of candesartan cilexetil and placebo in elderly patients with mild hypertension. The primary objective of the study is to assess the effect of candesartan cilexetil on major cardiovascular events. The secondary objectives of the study are to assess the effect of candesartan cilexetil on cognitive function and on total mortality, cardiovascular mortality, myocardial infarction, stroke, renal function, hospitalization, quality of life and health economics. Male and female patients aged between 70 and 89 years, with a sitting systolic blood pressure (SBP) of 160-179 mmHg and/or diastolic blood pressure (DBP) of 90-99 mmHg, and a Mini-Mental State Examination (MMSE) score of 24 or above, are eligible for the study. The overall target study population is 4000 patients, at least 1000 of whom are also to be assessed for quality of life and health economics data. After an open run-in period lasting 1-3 months, during which patients are assessed for eligibility and those who are already on antihypertensive therapy at enrolment are switched to hydrochlorothiazide 12.5 mg o.d., patients are randomized to receive either candesartan cilexetil 8 mg once daily (o.d.) or matching placebo o.d. At subsequent study visits, if SBP remains >160 mmHg, or has decreased by <10 mmHg since the randomization visit, or DBP is >85 mmHg, study treatment is doubled to candesartan cilexetil 16 mg o.d. or two placebo tablets o.d. Recruitment was completed in January 1999. At that time 4964 patients had been randomized. All randomized patients will be followed for an additional 2 years. If the event rate is lower than anticipated, the follow-up will be prolonged.

Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study

BACKGROUND

The efficacy of new antihypertensive drugs has been questioned. We compared the effects of conventional and newer antihypertensive drugs on cardiovascular mortality and morbidity in elderly patients.

METHODS

We did a prospective, randomised trial in 6614 patients aged 70-84 years with hypertension (blood pressure > or = 180 mm Hg systolic, > or = 105 mm Hg diastolic, or both). Patients were randomly assigned conventional antihypertensive drugs (atenolol 50 mg, metoprolol 100 mg, pindolol 5 mg, or hydrochlorothiazide 25 mg plus amiloride 2.5 mg daily) or newer drugs (enalapril 10 mg or lisinopril 10 mg, or felodipine 2.5 mg or isradipine 2-5 mg daily). We assessed fatal stroke, fatal myocardial infarction, and other fatal cardiovascular disease. Analysis was by intention to treat.

FINDINGS

Blood pressure was decreased similarly in all treatment groups. The primary combined endpoint of fatal stroke, fatal myocardial infarction, and other fatal cardiovascular disease occurred in 221 of 2213 patients in the conventional drugs group (19.8 events per 1000 patient-years) and in 438 of 4401 in the newer drugs group (19.8 per 1000; relative risk 0.99 [95% CI 0.84-1.16], p=0.89). The combined endpoint of fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular mortality occurred in 460 patients taking conventional drugs and in 887 taking newer drugs (0.96 [0.86-1.08], p=0.49).

INTERPRETATION

Old and new antihypertensive drugs were similar in prevention of cardiovascular mortality or major events. Decrease in blood pressure was of major importance for the prevention of cardiovascular events.

Need for support and participation in treatment differences among subgroups of relatives to compulsorily and voluntarily admitted mentally ill individuals

The need for support and participation in treatment of relatives to voluntarily and compulsorily admitted patients was addressed in a study of the quality of mental health services in two Swedish county councils. The aims of the study were to investigate differences in the above aspects between subgroups of relatives, the differences between two years of investigation, 1986 and 1991, and the differences between relatives of voluntarily and compulsorily admitted patients. The relatives investigated consisted of 79 spouses, 118 parents and 31 grown-up children. The results showed that there were only minor differences between the subgroups concerning their participation in care. Grown-up children experienced significantly less need of support and received less help for this need. In 1991, relatives participated more in the care situation, were more interested in support with regard to their own life situation, and also showed more positive attitudes towards the psychiatric services than in 1986. The relatives of the voluntarily admitted patients felt more involved in the patient's treatment, whereas the relatives of those compulsorily admitted felt less involved and perceived obstacles to admission.

Glucose utilisation in the lungs of septic rats

Sequestration and degranulation of leucocytes in the pulmonary microcirculation is considered to be a key event in the development of acute respiratory distress syndrome in patients with sepsis. Glucose serves as the main source of energy in activated leucocytes. The aim of this study was to assess whether glucose utilisation in the lungs can be used as an indicator of pulmonary leucocyte accumulation in an experimental model of sepsis of intra-abdominal origin. Sepsis was induced in rats by abdominal implantation of a gelatine capsule containing bacteria and rat colonic contents. Empty gelatine capsules were implanted in control animals. Animals were studied 6 and 12 h after sepsis induction. Glucose utilisation was measured as the tissue uptake of fluorine-18-fluorodeoxyglucose ((18)FDG) 1 h after intravenous injection of the tracer. Micro-autoradiography was also performed after injection of tritiated deoxyglucose. We found increased uptake of (18)FDG in the lungs of septic animals. The uptake also increased with time after sepsis induction. (18)FDG uptake in circulating leucocytes was increased in septic animals compared with controls, and micro-autoradiography showed intense accumulation of deoxyglucose in leucocytes in the lungs of septic animals. We conclude that glucose utilisation is increased in the lungs of septic rats. Measurements of pulmonary glucose utilisation as an index of leucocyte metabolic activity may open new possibilities for studies of the pathophysiology of sepsis and for evaluation of therapeutic interventions.

Rehabilitation of schizophrenic and other long-term mentally ill patients. Results from a prospective study of a comprehensive inpatient treatment program based on cognitive therapy

A total of 28 long-term mentally ill patients, the majority schizophrenic, treated with cognitive therapy in the context of milieu-therapy and group therapy, were investigated at admission and discharge with regard to changes in symptomatology, quality of life, global functioning, need for medication, and perceived target complaints. The results showed a significant relief in perceived burden of illness and an improvement in quality of life. A better pre-admission functioning with regard to social functioning, occupational function, and symptoms predicted a more favourable outcome.

Clinical and social needs of schizophrenic outpatients living in the community: the relationship between needs and subjective quality of life

BACKGROUND

The aims of this study were to assess self-perceived clinical and social needs among 120 schizophrenic outpatients, and the relationship between needs and subjective quality of life.

METHOD

The Camberwell Assessment of Need instrument (CAN) was used to assess needs and the Lancashire Quality of Life Profile was employed to assess subjective quality of life.

RESULTS

More than half of the patients expressed needs in areas concerning psychotic symptoms, daytime activity, company, physical health and information about their condition or treatment. The areas with the highest proportion of unmet needs were information, company, intimate relationship, physical health, daytime activity and psychological distress. A more severe need of care and support in the areas of company, psychological distress, daytime activity and sexual expression was associated with a worse subjective quality of life, controlling for the influence of symptomatology.

CONCLUSIONS

The results point to a need to further emphasise interventions towards the treatment of psychotic symptoms and psychological distress as well as to focus on interventions concerning the social relations and occupational situation of long-term mentally ill patients.

Treatment of Hypertension and the J Curve

The optimal reduction in blood pressure when treating hypertension is obviously the one which reduces hypertension related cardiovascular morbidity and mortality as much as possible. Today's approach to the treatment of high blood pressure usually does not achieve this goal. In other words, treated hypertensive patients are still at increased risk of cardiovascular complications, such as strokes and myocardial infarcts, in spite of being treated with antihypertensive drugs. One possible explanation for this could be that the treated blood pressure rarely is brought down to strictly normotensive levels, as shown in numerous studies. This would suggest that a more vigorous lowering of blood pressure would provide greater benefit when treating hypertensive patients. On the other hand, the fact that the relationship between the level of blood pressure and risk may be J shaped suggests that vigorous lowering of blood pressure may increase cardiovascular risks, if blood pressure is brought down too far. A few open, retrospective, nonrandomized studies and one randomized placebo controlled study in the elderly (SHEP) have analyzed this issue. The Hypertension Optimal Treatment (HOT) study,1,2 which was published in June 1998,3 has addressed this problem in a prospective randomized trial. The discussions around the J curve with some emphasis on the HOT study will be briefly reviewed. (c)1999 by Le Jacq Communications, Inc.

Concluding remarks. Pursuit of the optimal outcome in hypertension

Achieving the optimal outcome in hypertensive patients requires the selection and use of appropriate strategies to lower the blood pressure and reduce the patient's risk of cardiovascular events such as stroke and coronary heart disease. It also requires ongoing monitoring of the patient to ensure that the desirable end-points of treatment are being met, and that the heart, kidneys and other sites are being effectively protected from potential complications. Current guidelines on the treatment of hypertension continue to emphasise the use of low dose diuretics as appropriate first-line therapy whenever pharmacological intervention is indicated, except where there are positive indications (e.g. coexisting congestive heart failure or diabetic nephropathy) for other classes of drugs. Diuretics have repeatedly been shown to reduce the morbidity and mortality associated with hypertension, both in the elderly and in younger adults, and their combination with other antihypertensive agents (when clinically indicated) permits the use of lower total dosages. The thiazide-related diuretic indapamide has been reported to have a number of advantages over the thiazides, including minimal or no adverse influence on plasma lipids and glucose metabolism, or on kidney function in patients with renal insufficiency. It has also been found to produce regression of left ventricular hypertrophy, which is now accepted as an important objective of antihypertensive therapy. The recently developed sustained release (SR) formulation of indapamide allows use of a lower daily dosage of the drug, thereby improving its efficacy:safety ratio in comparison with immediate release formulations. Clinical studies have confirmed the efficacy of indapamide SR 1.5 mg daily in lowering elevated blood pressure, and this formulation can be considered an appropriate choice whenever a diuretic is indicated for the treatment of hypertension, including elderly hypertensives and, because of its metabolic 'neutrality', hypertensive patients with diabetes.

Relationships among patient and therapist ratings of therapeutic alliance and patient assessments of therapeutic process: a study of cognitive therapy with long-term mentally ill patients

The therapeutic alliance as rated by therapists and patients was assessed every 5 weeks throughout the treatment period in an in-patient treatment program for schizophrenic and other long-term mentally ill patients. The patients (N = 26) also assessed perceived curative factors (Curative Factors Questionnaire) and made therapy session evaluations (Session Evaluation Questionnaire). The most important patient rated factors showing a relationship with therapist-rated alliance were in the initial phase of treatment depth in the therapy sessions, in the working phase the experience of involvement in the treatment, and in the discharge phase perceived helpfulness of encouragement and reassurance. The investigation of curative factors, session evaluations, and alliance as rated by patients showed a relationship in the initial phase between alliance and encouragement, reassurance and awareness, in the working phase between alliance and depth in sessions and "talking to someone who understands," and in the discharge phase between alliance and self-understanding and problem solution.

Pancreatic biopsy: why? When? How?

For final diagnosis of pancreatic cancer histologic or cytologic confirmation is needed. Tissue or cell material can be achieved by percutaneous puncture as part of the preoperative workup. During operation core-needle, incisional, and wedge biopsies or fine-needle aspiration cytology (FNAC) can be chosen. Sensitivity and diagnostic accuracy are high for both histologic and cytologic examinations, and false-positive results are exceptional, giving a specificity of 100% in most published series. The complication rate is low, also for knife biopsies in recent reports, provided biopsy of seemingly normal tissue is avoided. Percutaneous puncture is currently restricted to patients found to have advanced disease and who are not candidates for laparotomy. Microscopic confirmation is required in all patients in whom chemotherapy, radiotherapy, or both are planned. However, for attempted radical surgery per se, biopsy is not mandatory if the clinical suspicion of cancer is high and the surgical team has documented low postoperative mortality and morbidity rates.

Subjective quality of life in schizophrenic patients living in the community. Relationship to clinical and social characteristics

The aims of this study were to assess the quality of life among 120 schizophrenic patients who were attending a psychiatric outpatient department and to investigate which socio-demographic and clinical factors influenced their subjective quality of life. Quality of life was assessed by the Lanchashire quality of life profile, social functioning was judged according to the Global Assessment of Functioning (GAF) scale, and psychopathology was rated by means of the Brief Psychiatric Rating Scale (BPRS). Both objective and subjective life conditions indicated an impaired quality of life for the patients. The areas of finance and work had the largest proportion of dissatisfied patients. Socio-demographic indicators showed to have a weak influence on the patient's self-assessed quality of life while clinical factors, such as psychopathology, strongly influenced the patient's life satisfaction. It is concluded that there is a need for further emphasise on the clinical, financial, and social interventions for this group of patients.

The Nordic Comparative Study on Sectorized Psychiatry--length of in-patient stay

OBJECTIVE

Length of stay (LOS) of 'first' in-patient episodes was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry.

METHOD

A total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted as in-patients during a period of 1 year to seven psychiatric hospitals in four Nordic countries were included.

RESULTS

Survival analyses showed considerable differences in LOS between the hospitals, and the factors analysed in this study could not explain this variance. Older age, being female, having no children at home, psychosis, planned admission and out-patient contacts were all associated with increased LOS.

CONCLUSION

Stratifying on gender, diagnostic group and hospital revealed a general pattern of associations except for age.

Molecular cloning and tissue expression of the murine analog to human stratum corneum chymotryptic enzyme

Human stratum corneum chymotryptic enzyme (SCCE) may play a central part in epidermal homeostasis. Its proposed function is to catalyze the degradation of intercellular structures, including desmosomes, in the stratum corneum as part of the desquamation process. In order to facilitate physiologic and pathophysiologic studies on SCCE we have looked for the corresponding murine enzyme. A cDNA obtained by reverse transcription-polymerase chain reaction with total RNA prepared from mouse tails as starting material was cloned, and the expression of the corresponding mRNA studied. The murine cDNA showed 77% homology to human SCCE cDNA. It had an open-reading frame encoding a protein comprising 249 amino acids with 82% amino acid sequence homology to human SCCE including the conserved sequences of the catalytic traid of mammalian serine proteases. The murine protein was deduced to have a 21 amino acid signal peptide and a four amino acid propeptide ending with a tryptic cleavage site, followed by a sequence motif identical to the N-terminal amino acid sequence of native active human SCCE. As in human SCCE the P2 position of the propeptide was occupied by an acidic amino acid residue, and the position corresponding to the suggested bottom of the primary substrate specificity pouch occupied by an asparagine residue. Analyses of mouse tissues by reverse transcriptase-polymerase chain reaction showed high expression in the skin, low expression in lung, kidney, brain, heart, and spleen, and no expression in liver or skeletal muscle. In situ hybridization of mouse skin showed expression in high suprabasal keratinocytes and in the luminal parts of hair follicles. Our results strongly suggest that we have cloned the murine analog of human SCCE cDNA.

[Effect of intensive antihypertensive treatment and of aspirin in a low dose in the hypertensive. The HOT (Hypertension Optimal Treatment) study]

The aim of the HOT Study (Hypertension Optimal Treatment) was to determine the optimal diastolic blood pressure decrease and to assess the effect of the acetyl salicylic acid as a primary prevention on the cardiovascular morbidity and mortality in hypertensive patients. The HOT Study is an open, prospective, randomised, international trial with blinded end points. This study included 18,790 patients, 50 to 80 years old (mean 61.5 years) in 26 countries (1,574 patients in France) with a primary hypertension (100 < or = PAD < or = 115 mmHg). The patients were randomised in 3 target diastolic blood pressure: < or = 80 mmHg (n = 6,262), < or = 85 mmHg (n = 6,264), < or = 90 mmHg (n = 6,264). The felodipine LP, a long acting dihydropyridine, was selected as a first line therapy, other hypertension drugs combined if necessary. The lowest incidence of cardiovascular events was observed at a diastolic blood pressure level of 82.6 mmHg. There was no increased risk below this level even in the hypertensive patients with medical history of coronary heart disease or stroke. In the diabetic population, the diastolic blood pressure decrease from 90 to 80 reduced the incidence of the major cardiovascular events by 51%. The acetyl salicylic acid reduced the myocardial infarction risk in the blood pressure well-controlled population.

Recent intervention trials in hypertension initiated in Sweden--HOT, CAPPP and others. Hypertension Optimal Treatment Study. Captopril Prevention Project

In 1998 the final results were presented of two large intervention trials in hypertension, the Hypertension Optimal Treatment Study (HOT) and the Captopril Prevention Project (CAPPP). Both were initiated from Sweden although the HOT Study was conducted in 26 countries worldwide and the CAPPP Study in Finland and Sweden. The HOT and CAPPP trials and their principal results will be reviewed briefly here. In addition a brief up-date will be provided of three ongoing intervention trials in hypertension that were also initiated from Sweden: the Swedish Trial in Old Patients with Hypertension-2 (STOP-Hypertension-), the Nordic Diltiazem (NORDIL) Study and the Study on Cognition and Prognosis in Elderly Hypertensives (SCOPE).

1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines sub-committee of the World Health Organization

The present Guidelines were prepared by the Guidelines Sub-Committee of the World Health Organization-International Society of Hypertension (WHO-ISH) Mild Hypertension Liaison Committee, the members of which are listed at the end of the text. These guidelines represent the fourth revision of the WHO-ISH Guidelines and were finalised after presentation and discussion at the 7th WHO-ISH Meeting on Hypertension, Fukuoka, Japan, 29th Sept-1st Oct, 1998. Previous versions of the Guidelines were published in Bull WHO 1993, 71:503-517 and J Hypertens 1993, 11:905-918.

Therapy of hypertension and metabolic syndrome: today's standard and tomorrow's perspectives

Treatment of arterial hypertension is known to reduce cardiovascular morbidity and mortality and has a positive effect against stroke, where benefit is strongly linked to reduction in blood pressure per se. The protective effects against coronary heart disease (CHD) have also been significant but numerically less impressive than the effect against stroke. It is conceivable that this due to the fact that not just blood pressure, but also a number of metabolic variables need to be considered in this context. The insight that hypertension is often just one of the components of the so-called metabolic syndrome suggests that a modern antihypertensive drug should not only lower blood pressure; to exert optimal cardioprotective properties it should also have a neutral or even positive metabolic profile as regards its effects on lipids, glucose and insulin in order to achieve a better protection against CHD. Against this background the centrally acting selective imidazoline receptor (I1) agonist moxonidine is of considerable interest. Moxonidine has been shown to improve glucose tolerance in man, probably by two different mechanisms, i.e. by augmenting insulin sensitivity in peripheral tissues and by enhancing glucose-stimulated insulin release from the pancreas. By employing a therapeutic intervention against hypertension that not only lowers elevated arterial pressure but also positively affects some of the frequently occurring concomitant metabolic disturbances, it appears that today's standard of antihypertensive therapy may be surpassed in tomorrow's perspective.

Therapeutic alliance in cognitive therapy for schizophrenic and other long-term mentally ill patients: development and relationship to outcome in an in-patient treatment programme

A total of 26 schizophrenic and other long-term mentally ill patients receiving cognitive therapy sessions twice a week in the context of a comprehensive in-patient treatment programme were assessed every 5 weeks with regard to therapeutic alliance. The therapists rated the alliance according to the Psychotherapy Status Report and the patients rated it according to the Patient Collaboration Scale. The results showed either good or fair and stable therapeutic alliance for the majority of the patients throughout the treatment period. Few correlations were found between patient characteristics and initial alliance. The therapists' ratings showed a positive relationship between initial alliance and a favourable outcome of treatment at discharge.

Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomised trial

BACKGROUND

Angiotensin-converting-enzyme (ACE) inhibitors have been used for more than a decade to treat high blood pressure, despite the lack of data from randomised intervention trials to show that such treatment affects cardiovascular morbidity and mortality. The Captopril Prevention Project (CAPPP) is a randomised intervention trial to compare the effects of ACE inhibition and conventional therapy on cardiovascular morbidity and mortality in patients with hypertension.

METHODS

CAPPP was a prospective, randomised, open trial with blinded endpoint evaluation. 10,985 patients were enrolled at 536 health centres in Sweden and Finland. Patients aged 25-66 years with a measured diastolic blood pressure of 100 mm Hg or more on two occasions were randomly assigned captopril or conventional antihypertensive treatment (diuretics, beta-blockers). Analysis was by intention-to-treat. The primary endpoint was a composite of fatal and non-fatal myocardial infarction, stroke, and other cardiovascular deaths.

FINDINGS

Of 5492 patients assigned captopril and 5493 assigned conventional therapy, 14 and 13, respectively, were lost to follow-up. Primary endpoint events occurred in 363 patients in the captopril group (11.1 per 1000 patient-years) and 335 in the conventional-treatment group (10.2 per 1000 patient-years; relative risk 1.05 [95% CI 0.90-1.22], p=0-52). Cardiovascular mortality was lower with captopril than with conventional treatment (76 vs 95 events; relative risk 0.77 [0.57-1-04], p=0.092), the rate of fatal and non-fatal myocardial infarction was similar (162 vs 161), but fatal and non-fatal stroke was more common with captopril (189 vs 148; 1.25 [1-01-1-55]. p=0.044).

INTERPRETATION

Captopril and conventional treatment did not differ in efficacy in preventing cardiovascular morbidity and mortality. The difference in stroke risk is probably due to the lower levels of blood pressure obtained initially in previously treated patients randomised to conventional therapy.

Effect of mesocaval interposition shunting and repeated sclerotherapy on blood levels of gastrointestinal regulatory peptides, amino acids, and lysosomal enzymes--a prospective randomised trial

AIMS/BACKGROUND

Patients with liver cirrhosis and portal hypertension frequently exhibit a multitude of alterations of hormones and metabolism, but the relation of these alterations to liver function, degree of blood shunting, and hepatic encephalopathy remains unclear.

METHODS

Twenty-four patients were randomised to mesocaval interposition shunt (MIS) and 21 patients to repeated sclerotherapy (ST). Several peptide hormones, amino acids and lysosomal enzymes were monitored during a 4 year follow-up period.

RESULTS

Insulin and glucagon levels were elevated in the MIS group compared to pre-therapy levels, whereas the gastrin level was significantly higher in the ST group. Pancreatic polypeptide, somatostatin and vasoactive intestinal peptide levels were not affected by either treatment. The branched chain amino acids valine, leucine and isoleucine serum levels were all elevated after ST, and the arginine, proline and tyrosine levels were higher in the MIS group at follow-up. Other amino acids were not changed, neither were the lysosomal enzymes beta-hexosaminidase nor beta-glucoronidase during this longterm follow-up.

CONCLUSION

MIS or repeated ST treatment only affected serum levels of hormones, amino acids and lysosomal enzymes to a limited extent. In this trial, the type of treatment had only a small influence on these parameters during long term follow-up.

Clinical studies with candesartan

Candesartan cilexetil is a new AT(1)-receptor antagonist that has been approved for clinical use in many countries. This article gives a brief summary of the clinical studies that have been performed with candesartan cilexetil. One of the major advantages of candesartan cilexetil is its remarkable tolerability. As with all the agents in this class of compounds, the side effect profile is virtually indistinguishable from that of placebo. Candesartan cilexetil appears to be an unusually potent AT(1)-receptor antagonist, as regards its antihypertensive efficacy. Double-blind comparisons with other established antihypertensive agents have shown that candesartan cilexetil is at least equally potent, and in some cases more potent, than the comparison drug. A brief mention is also made of some ongoing intervention studies with candesartan cilexetil, such as the Study on Cognition and Prognosis in Elderly hypertensive patients (SCOPE).

The Hypertension Optimal Treatment study and the importance of lowering blood pressure

OBJECTIVES

The Hypertension Optimal Treatment (HOT) Study had two objectives: (1) to define the optimal target blood pressure when treating hypertensive patients (i.e. the level of blood pressure associated with the lowest incidence of major cardiovascular events such as fatal and non-fatal stroke and myocardial infarction and other cardiovascular mortality); and (2) to assess the effect of a low dose of acetylsalicylic acid (aspirin) compared with placebo on major cardiovascular events.

METHODS

The HOT study recruited 18 790 hypertensive subjects aged 50 to 80 years with diastolic blood pressure (DBP) between 100 and 115 mmHg (mean DBP 105 mmHg). Subjects were randomly assigned to be treated with the goal of reaching one of three target DBPs: < or = 90 mmHg (n = 6264), < or = 85 mmHg (n = 6264), or < or = 80 mmHg (n = 6262) using felodipine as initial therapy with the addition of other agents according to a 5-step regimen. In addition, subjects were randomly assigned to receive either 75 mg/day aspirin (n = 9399) or placebo (n = 9391).

RESULTS

DBP was reduced by 20.3, 22.3, and 24.3 mmHg in the < or = 90, < or = 85, and < or = 80 mmHg target groups, respectively. The incidence of all major cardiovascular events (fatal and non-fatal stroke, myocardial infarction, and other cardiovascular mortality) decreased, although not significantly, in relation to the randomized target blood pressure. There were 84, 64, and 61 fatal and non-fatal myocardial infarctions in the < or = 90 mmHg, < or = 85 mmHg, and < or = 80 mmHg groups, respectively (P = 0.05). The overall effect of aspirin on cardiovascular events was positive, most noticeably on fatal and non-fatal myocardial infarctions; aspirin reduced events by 36%. There were seven fatal episodes of bleeding (two cerebral) in the aspirin group compared with eight (three cerebral) in the placebo group, and 129 versus 70 non-fatal major episodes of bleeding in the two groups, respectively. The lowest incidence of all major cardiovascular events combined was found at an achieved DBP of 82.6 mmHg and at an achieved systolic blood pressure (SBP) of 138.5 mmHg. In the subgroup with diabetes mellitus at baseline (n = 1501), the effect of intensive lowering of blood pressure was especially noticeable.

CONCLUSIONS

Most cardiovascular end-points showed a declining frequency in relation to target blood pressure. The optimal protection against combined major cardiovascular end-points was observed in the range 80-85 mmHg for DBP and in the range 130-140 mmHg for SBP. It is worth noting that 92% of all subjects reached a DBP of < or = 90 mmHg and that side-effects gradually declined from 16.9% at 3 months to 2.2% at the end of the study. A substudy showed that quality of life was linked to the level of blood pressure obtained: the lower the blood pressure, the better the quality of life.

The Nordic comparative study on sectorized psychiatry: rates of compulsory care and use of compulsory admissions during a 1-year follow-up

BACKGROUND

As part of a Nordic comparative study on contact rates of new patients and use of services in seven catchment areas, rates of compulsory care and use of compulsory admissions were explored and analyzed. The total cohort comprised 2834 patients.

RESULTS

A total of 219 patients, 7.7%, were subject to compulsory care during the follow-up. The proportion of compulsorily admitted patients of all admitted patients ranged from 6% to 58% in the seven psychiatric services, and the rate of compulsory care per 1,000 inhabitants, from 0.14 to 0.99. The diagnostic subgroup most commonly committed to inpatient care was functional psychosis, comprising around 50% of all compulsory admissions. The strongest predictor of being compulsorily admitted was the specific psychiatric service the patient was in contact with, followed by having a psychosis diagnosis. High consumption of care was also associated with compulsory care, while social variables played only a minor role in predicting compulsory care.

CONCLUSIONS

There was a great variation in rates of compulsory care. No consistent rural-urban pattern in rates of commitment was found. It is discussed whether a formal referral procedure to the psychiatric service is associated with higher rates of compulsory care.

Predictors of subjective quality of life in schizophrenic patients living in the community. A Nordic multicentre study

As part of a Nordic multi-centre study investigating the life and care situation of community samples of schizophrenic patients the aim of the present part of the study was to examine the relationship between global subjective quality of life and objective life conditions, clinical characteristics including psychopathology and number of needs for care, subjective factors such as satisfaction with different life domains, social network, and self-esteem. A sample of 418 persons with schizophrenia from 10 sites was used. The results of a final multiple regression analysis, explaining 52.3% of the variance, showed that five subjective factors were significantly associated with global subjective quality of life, together with one objective indicator, to have a close friend. No clinical characteristics were associated with global subjective quality of life. The largest part of the variance was explained by satisfaction with health, 36.3% of the variance, and self-esteem, 7.3% of the variance. It is concluded that the actual relationship between objective life conditions and subjectively experienced quality of life still remains unclear. Furthermore, it seems obvious that personality related factors such as self-esteem, mastery and sense of autonomy also play a role in the appraisal of subjective quality of life, which implies that factors like these are important to consider in clinical and social interventions for patients with schizophrenia in order to improve quality of life for these persons.

The Nordic comparative study on sectorised psychiatry: repeated emergency admissions to inpatient care during a 1-year follow-up

The emergency admissions to hospital care in six psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorised psychiatry. One year treated incidence cohorts were used, with the total cohort comprising 2,454 patients. Of the 803 patients who were admitted to inpatient care during a 1-year follow-up, 82% had at least one emergency admission and 23% repeated emergency admissions. The definition for the repeated emergency admissions was at least two admissions during the follow-up. The mean length of stay in emergency inpatient care per treatment episode for this patient subgroup was 28 days. Their emergency inpatient episodes constituted 30% of all inpatient days during the follow-up. However, the variations between the services and diagnostic subgroups were large. The results of a logistic regression analysis indicated that the following variables predicted repeated emergency admissions: inpatient care at index contact, emergency outpatient contacts or no planned hospital admissions during the follow-up, psychiatric service, age under 45 years, and a diagnosis of psychosis, personality disorder or dependency. The repeated emergency admissions were related to the existence of a special service unit for abusers but not to the rates of outpatient staff or acute beds in the services, to geographical distances, referral practice or existence of emergency services.

The Nordic Comparative Study on Sectorized Psychiatry: continuity of care related to characteristics of the psychiatric services and the patients

The problem addressed in this paper is how continuity of care is related to characteristics of psychiatric services, previous events in a patient's pattern of care and patient characteristics. The present paper is a part of a Nordic Comparative Study on Sectorized Psychiatry in seven catchment areas in four Nordic countries. One-year-treated-incidence cohorts were used. Each patient was followed for 1 year after the first contact with the psychiatric service. Continuity of care was measured by the time from discharge from hospital to the first subsequent day-patient or outpatient contact. Notable findings were large differences in the continuity of care in the seven services, high proportions of discharges without any aftercare contacts and long time lags between discharges and aftercare contacts in most of the catchment areas. A Cox regression analysis revealed that aftercare following hospitalisation seems to be more probable if the outpatient services are located geographically close to the patients, if the hospitalisation lasted between 2 and 4 weeks, if there was a community care contact shortly before the hospital admission and if the patient is not retired and not divorced. Staff resources were not related to continuity of care.