To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with high blood pressure (BP).
For persons in whom a high BP value is recorded, the assignment of a diagnosis of hypertension is dependent on the appropriate measurement of BP, the level of the BP elevation and the duration of follow-up. In addition, the presence of cardiovascular risk factors and target organ damage should be assessed to determine the urgency, intensity and type of treatment. For persons diagnosed as having hypertension, estimating overall risk of adverse cardiovascular outcomes requires an assessment of other vascular risk factors and hypertensive target organ damage.
MEDLINE searches were conducted from November 2003 to October 2004 to update the 2004 recommendations. Reference lists were scanned, experts were polled, and the personal files of the authors and subgroup members were used to identify other studies. Identified articles were reviewed and appraised using prespecified levels of evidence by content and methodological experts. As per previous years, only studies that had been published in the peer-reviewed literature were included; evidence from abstracts, conference presentations and unpublished personal communications was not included.
This document contains recommendations for BP measurement, diagnosis of hypertension and assessment of cardiovascular risk for adults with high BP. These include the accurate measurement of BP, criteria for diagnosis of hypertension, and recommendations for follow-up, assessment of overall cardiovascular risk, routine and optional laboratory testing, assessment for renovascular and endocrine causes, home and ambulatory BP monitoring, and the role of echocardiography for those with hypertension. Key features of the 2005 recommendations include an expedited diagnostic algorithm for hypertension and an endorsement of the use of home/self and ambulatory BP assessment as validated techniques in establishing the diagnosis of hypertension.
All recommendations were graded according to the strength of the evidence and voted on by the 43 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported in the present paper received at least 95% consensus. These guidelines will continue to be updated annually.
BACKGROUND: Mortality that is due to cervical cancer among American Indian and Alaska Native women in the Pacific Northwest exceeds that among women of other races. Nevertheless, little information is available regarding the prevalence and follow-up of abnormal Papanicolaou smears among American Indian and Alaska Native women in the region. METHODS: We conducted a retrospective review of medical records of American Indian and Alaska Native women seen at 12 Indian Health Service and tribally operated clinics in Washington, Oregon, and Idaho who had an abnormal Papanicolaou smear in 1992. RESULTS: Of 4547 Papanicolaou smear results reviewed, 280 (6.2 percent) had an abnormal result (dysplasia or carcinoma in situ). Of the recommended colposcopies, 167 of 224 (75 percent) were completed. Women with high-grade squamous intraepithelial lesions were more likely to obtain recommended colposcopy than were women with low-grade squamous intraepithelial lesions. Women treated at clinics that referred patients to outside providers for colposcopy were more likely to have colposcopy than were those who were offered the procedure on site. CONCLUSIONS: The proportion of Pacific Northwest American Indian and Alaska Native women in Indian Health Service and tribal clinics with abnormal Papanicolaou smears and the proportion who receive colposcopy are similar to those in other populations. The higher rate of cervical cancer mortality among American Indian and Alaska Native women could be due to failure to screen high-risk women. Cytologic screening rates, methods to improve adherence to colposcopy recommendations, and the contribution of other factors to the cause of cervical cancer mortality need to be characterized in this population.
Renal cell carcinoma (RCC) encompasses different histologic subtypes. Distinguishing between the subtypes is usually made by morphologic assessment, which is not always accurate.
Our aim was to identify microRNA (miRNA) signatures that can distinguish the different RCC subtypes accurately.
A total of 94 different subtype cases were analysed. miRNA microarray analysis was performed on fresh frozen tissues of three common RCC subtypes (clear cell, chromophobe, and papillary) and on oncocytoma. Results were validated on the original as well as on an independent set of tumours, using quantitative reverse transcription-polymerase chain reaction (qRT-PCR) analysis with miRNA-specific primers.
Microarray data were analysed by standard approaches. Relative expression for qRT-PCR was determined using the ??C(T) method, and expression values were normalised to small nucleolar RNA, C/D box 44 (SNORD44, formerly RNU44). Experiments were done in triplicate, and an average was calculated. Fold change was expressed as a log(2) value. The top-scoring pairs classifier identified operational decision rules for distinguishing between different RCC subtypes and was robust under cross-validation.
We developed a classification system that can distinguish the different RCC subtypes using unique miRNA signatures in a maximum of four steps. The system has a sensitivity of 97% in distinguishing normal from RCC, 100% for clear cell RCC (ccRCC) subtype, 97% for papillary RCC (pRCC) subtype, and 100% accuracy in distinguishing oncocytoma from chromophobe RCC (chRCC) subtype. This system was cross-validated and showed an accuracy of about 90%. The oncogenesis of ccRCC is more closely related to pRCC, whereas chRCC is comparable with oncocytoma. We also developed a binary classification system that can distinguish between two individual subtypes.
MiRNA expression patterns can distinguish between RCC subtypes.
Acute chest pain is a frequently occurring symptom in patients with medical emergencies and imposes potentially life threatening situations outside hospitals. Little is known about the epidemiology of patients with acute chest pain in a primary care setting in Norway, and we aimed to obtain more representative data on such patients using data from emergency medical communication centres (EMCCs).
Data were collected prospectively during three months in 2007 from three EMCCs, covering 816 000 inhabitants. The EMCCs gathered information on every situation that was triaged as a red response (defined as an "acute" response, with the highest priority), according to the Norwegian Index of Medical Emergencies. Records from ambulances and primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes and The National Committee on Aeronautics (NACA) System scores were assigned retrospectively. Only chest pain patients were included in the study.
5 180 patients were involved in red response situations, of which 21% had chest pain. Estimated rate was 5.4 chest pain cases per 1000 inhabitants per year. NACA-scores indicated that 26% of the patients were in a life-threatening medical situation. Median prehospital response time was 13 minutes; an ambulance reached the patient in less than 10 minutes in 30% of the cases. Seventy-six per cent of the patients with chest pain were admitted to a hospital for further investigation, 14% received final treatment at a casualty clinic, while 10% had no further investigation by a doctor ("left at the scene").
The majority of patients with acute chest pain were admitted to a hospital for further investigation, but only a quarter of the patients were assessed prehospitally to have a severe illness. This sheds light on the challenges for the EMCCs in deciding the appropriate level of response in patients with acute chest pain. Overtriage is to some extent both expected and desirable to intercept all patients in need of immediate help, but it is also well known that overtriage is resource demanding. Further research is needed to elucidate the challenges in the diagnosis and management of chest pain outside hospitals.
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Cites: Tidsskr Nor Laegeforen. 2004 Dec 2;124(23):3058-6015586187
Cites: Am Fam Physician. 2005 Nov 15;72(10):2012-2116342831
BACKGROUND: No guidelines exist for the planning of aeromedical repatriation after acute myocardial infarction (AMI). In 2004, we employed a risk evaluation-based decision-making system for repatriation of patients after AMI. The objective was to evaluate the safety of transports during 2005 managed by this system. METHODS: A total of 116 patients were transported according to the algorithm, 64 unescorted and 52 escorted. The decision-making system was based on the recommendations given by the European Society of Cardiology. Whenever possible, patients were evaluated by coronary angiogram or exercise electrocardiogram. Patients at high risk were treated locally if appropriate facilities were available or evacuated to the nearest heart center. Patients at low risk were allowed to fly unescorted home if no other concomitant diseases needed the attention of a physician. The composite end point of death of any cause during transport or departure from the planned repatriation due to worsening of the condition was registered. RESULTS: No patients reached the end point. Patients who were not risk evaluated more often needed escort (p
There is a clear need for increased standardization of placement and therefore greater equity among long-term-care patients with similar clinical needs and environmental constraints. This article describes a multidimensional instrument that incorporates a decision rule for placement recommendations across 4 levels of care. Interrater reliability for the assessment items as well as the placement levels are reported.
This article describes an algorithm to classify respondents to cycle 1.1 (2000/2001) of the Canadian Community Health Survey (CCHS) according to whether they have type 1, type 2 or gestational diabetes.
The data are from the chronic disease module and the drug module of cycle 1.1 of the CCHS.
A total of 6,361 respondents to cycle 1.1 of the CCHS reported that a health care professional had diagnosed them as having diabetes. The Ng-Dasgupta-Johnson algorithm classifies this group according to whether they have type 1, type 2 or gestational diabetes, based on their answers to CCHS questions about diabetes during pregnancy, use of oral medications to control diabetes, use of insulin, timing of initiation of insulin treatment, and age at diagnosis.
Application of an earlier algorithm to CCHS cycle 1.1 results in a 10%-90% split for type 1 and type 2 diabetes. By contrast, the Ng-Dasgupta-Johnson algorithm yields a 5%-95% split. This is not unreasonable, given the rapid rise in obesity, a major risk factor for type 2 diabetes, in Canada.
The aim was to develop a theoretical understanding of the decision-making process leading to appendectomy. A qualitative interview study was performed in the grounded theory tradition using the constant comparative method to analyze data. The study setting was one county hospital and two local hospitals in Sweden, where 11 surgeons and 15 surgical nurses were interviewed. A model was developed which suggests that surgeons' decision making regarding appendectomy is formed by the interplay between their medical assessment of the patient's condition and a set of contextual characteristics. The latter consist of three interacting factors: (1) organizational conditions, (2) the professional actors' individual characteristics and interaction, and (3) the personal characteristics of the patient and his or her family or relatives. In case the outcome of medical assessment is ambiguous, the risk evaluation and final decision will be influenced by an interaction of the contextual characteristics. It was concluded that, compared to existing, rational models of decision making, the model presented identified potentially important contextual characteristics and an outline on when they come into play.
This paper applies contingent valuation and decision tree analysis to investigate public preferences for water quality improvements, and in particular reduced eutrophication. Such preferences are important given that the development of EU water quality legislation is imposing significant costs on European economies. Results are reported of a survey undertaken of residents of Arhus County, Denmark for water quality improvements in the Randers Fjord. Results demonstrate strong public support for reduced eutrophication and identify key determinants of such support.