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Sometime during the middle to late Holocene (8.2 ka to ∼ 1850–1900 CE), the Greenland Ice Sheet (GrIS) was smaller than its current configuration. Determining the exact dimensions of the Holocene ice-sheet minimum and the duration that the ice margin rested inboard of its current position remains challenging. Contemporary retreat of the GrIS from its historical maximum extent in southwestern Greenland is exposing a landscape that holds clues regarding the configuration and timing of past ice-sheet minima. To quantify the duration of the time the GrIS margin was near its modern extent we develop a new technique for Greenland that utilizes in situ cosmogenic 10Be–14C–26Al in bedrock samples that have become ice-free only in the last few decades due to the retreating ice-sheet margin at Kangiata Nunaata Sermia (n=12 sites, 36 measurements; KNS), southwest Greenland. To maximize the utility of this approach, we refine the deglaciation history of the region with stand-alone 10Be measurements (n=49) and traditional 14C ages from sedimentary deposits contained in proglacial–threshold lakes. We combine our reconstructed ice-margin history in the KNS region with additional geologic records from southwestern Greenland and recent model simulations of GrIS change to constrain the timing of the GrIS minimum in southwest Greenland and the magnitude of Holocene inland GrIS retreat, as well as to explore the regional climate history influencing Holocene ice-sheet behavior. Our 10Be–14C–26Al measurements reveal that (1) KNS retreated behind its modern margin just before 10 ka, but it likely stabilized near the present GrIS margin for several thousand years before retreating farther inland, and (2) pre-Holocene 10Be detected in several of our sample sites is most easily explained by several thousand years of surface exposure during the last interglaciation. Moreover, our new results indicate that the minimum extent of the GrIS likely occurred after ∼5 ka, and the GrIS margin may have approached its eventual historical maximum extent as early as ∼2 ka. Recent simulations of GrIS change are able to match the geologic record of ice-sheet change in regions dominated by surface mass balance, but they produce a poorer model–data fit in areas influenced by oceanic and dynamic processes. Simulations that achieve the best model–data fit suggest that inland retreat of the ice margin driven by early to middle Holocene warmth may have been mitigated by increased precipitation. Triple 10Be–14C–26Al measurements in recently deglaciated bedrock provide a new tool to help decipher the duration of smaller-than-present ice over multiple timescales. Modern retreat of the GrIS margin in southwest Greenland is revealing a bedrock landscape that was also exposed during the migration of the GrIS margin towards its Holocene minimum extent, but it has yet to tap into a landscape that remained ice-covered throughout the entire Holocene.

BACKGROUND: Management of elevated blood pressure (BP) during hospitalization varies widely, with many hospitalized adults experiencing BPs higher than those recommended for the outpatient setting. PURPOSE: To systematically identify guidelines on elevated BP management in the hospital. DATA SOURCES: MEDLINE, Guidelines International Network, and specialty society websites from 1 January 2010 to 29 January 2024. STUDY SELECTION: Clinical practice guidelines pertaining to BP management for the adult and older adult populations in ambulatory, emergency department, and inpatient settings. DATA EXTRACTION: Two authors independently screened articles, assessed quality, and extracted data. Disagreements were resolved via consensus. Recommendations on treatment targets, preferred antihypertensive classes, and follow-up were collected for ambulatory and inpatient settings. DATA SYNTHESIS: Fourteen clinical practice guidelines met inclusion criteria (11 were assessed as high-quality per the AGREE II [Appraisal of Guidelines for Research & Evaluation II] instrument), 11 provided broad BP management recommendations, and 1 each was specific to the emergency department setting, older adults, and hypertensive crises. No guidelines provided goals for inpatient BP or recommendations for managing asymptomatic moderately elevated BP in the hospital. Six guidelines defined hypertensive urgency as BP above 180/120 mm Hg, with hypertensive emergencies requiring the addition of target organ damage. Hypertensive emergency recommendations consistently included use of intravenous antihypertensives in intensive care settings. Recommendations for managing hypertensive urgencies were inconsistent, from expert consensus, and focused on the emergency department. Outpatient treatment with oral medications and follow-up in days to weeks were most often advised. In contrast, outpatient BP goals were clearly defined, varying between 130/80 and 140/90 mm Hg. LIMITATION: Exclusion of non-English-language guidelines and guidelines specific to subpopulations. CONCLUSION: Despite general consensus on outpatient BP management, guidance on inpatient management of elevated BP without symptoms is lacking, which may contribute to variable practice patterns. PRIMARY FUNDING SOURCE: National Institute on Aging. (PROSPERO: CRD42023449250).

Abstract Hypertension guidelines recommend team‐based care for the treatment of high blood pressure (BP). Clinical pharmacists can help patients get to goal BP with rapid medication titration in conjunction with telehealth visits. We conducted a pharmacist‐led home BP monitoring pilot program from June 2020 to September 2021. Forty‐two patients with a SBP ≥140 despite using ≤2 antihypertensive medications were referred for pharmacist telehealth with expedited medication titration to achieve a BP goal

Abstract Changes in ice‐sheet size impact atmospheric circulation, a phenomenon documented by models but constrained by few paleoclimate records. We present sub‐centennial‐scale records of summer temperature and summer precipitation hydrogen isotope ratios (δ2H) spanning 12–7 ka from a lake on Baffin Island. In a transient model simulation, winds in this region were controlled by the relative strength of the high‐pressure systems and associated anticyclonic circulation over the retreating Greenland and Laurentide ice sheets. The correlation between summer temperature and precipitation δ2H proxy records changed from negative to positive at 9.8 ka. This correlation structure indicates a shift from alternating local and remote moisture, governed by the two ice‐sheet high‐pressure systems, to only remote moisture after 9.8 ka, governed by the strong Greenland high‐pressure system after the Laurentide Ice Sheet retreated. Such rapid atmospheric circulation changes may also occur in response to future, gradual ice‐sheet retreat.

BackgroundIdentifying factors that impair bone accrual during childhood is a critical step toward osteoporosis prevention. Exposure to per- and polyfluoroalkyl substances (PFASs) has been associated with lower bone mineral density, but data are limited, particularly in children.MethodsWe studied 576 children in Project Viva, a Boston-area cohort of mother/child pairs recruited prenatally from 1999 to 2002. We quantified plasma concentrations of several PFASs and measured areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry (DXA) in midchildhood. We used linear regression to examine associations between plasma concentrations of individual PFASs and aBMD z-score. We used weighted quantile sum (WQS) regression to examine the association of the PFAS mixture with aBMD z-score. All models were adjusted for maternal age, education, annual household income, census tract median household income, and child age, sex, race/ethnicity, dairy intake, physical activity, and year of blood draw.ResultsChildren were [[Formula: see text]] [Formula: see text] of age. The highest PFAS plasma concentrations were of perfluorooctanesulfonic acid (PFOS) {median [interquartile range (IQR)]: 6.4 (5.6) ng/mL} and perfluorooctanoic acid (PFOA) [median (IQR): 4.4 (3.2) ng/mL]. Using linear regression, children with higher plasma concentrations of PFOA, PFOS, and perfluorodecanoate (PFDA) had lower aBMD z-scores [e.g., [Formula: see text]: [Formula: see text]; 95% confidence interval (CI): [Formula: see text], [Formula: see text] per doubling of PFOA]. The PFAS mixture was negatively associated with aBMD z-score ([Formula: see text]: [Formula: see text]; 95% CI: [Formula: see text], [Formula: see text] per IQR increment of the mixture index).ConclusionsPFAS exposure may impair bone accrual in childhood and peak bone mass, an important determinant of lifelong skeletal health. https://doi.org/10.1289/EHP4918.

Forecasts of sea surface temperature anomalies (SSTAs) provide essential information to stakeholders of marine resources in coastal ecosystems, such as the California Current Large Marine Ecosystem (CCLME), at management-relevant monthly-to-annual time scales. Diagnosing dynamical sources of predictability and the mechanisms differentiating skill among forecasts is required for verification and improvement in operational forecasting systems. Using retrospective forecasts (1982–2020) from a four-member subset of the North American Multi-Model Ensemble (NMME), we evaluate the conditional skill of SSTA forecasts in the CCLME at monthly resolution for lead times up to 10.5 months. Forecasts from ensemble members with relatively small SSTA errors at shorter lead times retain higher skill at longer lead times, with the most substantial and long-lasting increases for forecasts initialized in the fall and early spring. The "best" low-error SSTA forecasts are characterized by increased skill in the prediction of North Pacific atmospheric circulation [sea level pressure (SLP) and 200-hPa geopotential height] the month prior to the evaluation of SSTA errors in the CCLME and exhibit more realistic progressions of anomalous SLP. The Pacific meridional mode (PMM) emerges as a diagnostic of skillful North Pacific atmosphere–ocean coupling, as forecasts that correctly simulate the PMM and its associated SLP variability increase the SSTA prediction skill in the CCLME in the fall through spring. Predictable coupled ocean–atmosphere modes provide a target for enhancing predictability with early detection of the onset of a deterministic progression emerging from stochastic atmospheric variability. Significance Statement: Global forecast systems provide near-term climate predictions that inform the management of marine resources, such as those of the California Current Large Marine Ecosystem. In this study, we probe the processes which lead forecasts to succeed or fail at predicting sea surface temperatures in the California Current at seasonal time scales among retrospective forecasts from the North American Multimodel Ensemble. We demonstrate that forecasts which best simulate sea surface temperatures at the earliest lead times sustain advantages in forecast skill and find that correctly simulating extratropical atmospheric circulation increases the predictive skill of sea surface temperatures in the northeast Pacific in the following lead times. Our results offer North Pacific atmospheric circulation as a target for forecast model improvement that would additionally enhance ocean forecasts. [ABSTRACT FROM AUTHOR]

Hypertension is a leading risk factor for cardiovascular morbidity and mortality. Despite the widespread availability of both pharmacological and lifestyle therapeutic options, blood pressure control rates across the globe are worsening. In fact, only 23% of individuals with high blood pressure in the United States achieve treatment goals. In 2023, the US Food and Drug Administration approved renal denervation, a catheter-based procedure that ablates the renal sympathetic nerves, as an adjunctive treatment for patients in whom lifestyle modifications and antihypertensive medications do not adequately control blood pressure. This approval followed the publication of multiple randomized clinical studies using rigorous trial designs, all incorporating renal angiogram as the sham control. Most but not all of the new generation of trials reached their primary end point, demonstrating modest efficacy of renal denervation in lowering blood pressure across a spectrum of hypertension, from mild to truly resistant. Individual patient responses vary, and further research is needed to identify those who may benefit most. The initial safety profile appears favorable, and multiple ongoing studies are assessing longer-term efficacy and safety. Multidisciplinary teams that include hypertension specialists and adequately trained proceduralists are crucial to ensure that referrals are made appropriately with full consideration of the potential risks and benefits. Incorporating patient preferences and engaging in shared decision-making conversations will help patients make the best decisions given their individual circumstances. Although further research is clearly needed, renal denervation presents a novel treatment strategy for patients with uncontrolled blood pressure. [ABSTRACT FROM AUTHOR]

This article explores the challenges of managing hypertension in patients with hypertrophic obstructive cardiomyopathy (HCM). It presents a case study of a 52-year-old man with a history of hypertension and other medical conditions. The article emphasizes the importance of understanding the underlying causes of HCM and the different types of antihypertensive medications for effective treatment. It also highlights the need to differentiate between obstructive and nonobstructive forms of HCM and to closely monitor symptoms and avoid certain medications in patients with obstructive physiology. The article concludes by discussing the potential impact of hypertension on HCM and the recommended target blood pressure for patients with this condition. It suggests that a combination of beta-blockers or nondihydropyridine calcium channel blockers may be used as first-line therapy for symptomatic obstructive HCM, but the evidence for this approach is limited. Diuretics should generally be avoided unless there is heart failure. The management of hypertension in HCM should be personalized, considering symptoms, the degree of obstruction, and the risk of exacerbating left ventricular outflow tract obstruction. Collaboration among cardiologists, hypertension specialists, and pharmacists is crucial for optimizing therapy. The article also mentions the potential integration of innovative pharmacotherapies, such as mavacamten, with existing treatments in the future. [Extracted from the article]

Purpose of Review: This review provides a practical, evidence-based summary of the physiology, major trial data and clinical role of renal denervation in the treatment of hypertension. Recent Findings: The cornerstone of hypertension therapy remains anti-hypertensive medications although this strategy has significant limitations with poor rates of blood pressure control for most patients. Renal denervation was designed to bypass concerns about medication adherence and provide an "always-on" treatment. Recent trial data and meta-analyses are presented demonstrating a modest, although heterogeneous, response to renal denervation which led to the treatment's recent FDA approval. Improvements in catheter design and renal artery treatment strategy may underlie the improved clinical response to denervation in more recent trials. Summary: Hypertension centers involving multi-disciplinary care teams are equipped to provide patients with advanced diagnostic testing for secondary hypertension, comprehensive non-invasive management strategies and invasive renal denervation to address hypertension. Early referral for patients with uncontrolled hypertension can provide patients with nuanced conservative and interventional options which have the potential to improve hypertension related morbidity and mortality. Future studies are needed to identify which patients are most likely to respond to renal denervation. [ABSTRACT FROM AUTHOR]

Abstract Prescription stimulants are an important cause of secondary hypertension and their use is increasing in adult patients who are also at risk for essential hypertension. Although stimulants increase blood pressure, a systematic approach for assessing their impact in individual patients is lacking. We developed a protocol using ambulatory blood pressure monitoring for up to 36 h to compare blood pressure over two sequential days. Average blood pressure on the first day (without stimulant medication) was compared to average blood pressure on the second day (after re‐starting stimulant medication). We describe the outcomes of this protocol for a case series of eleven adults. Patients demonstrated one of three outcomes: normal blood pressure on both days, hypertension on both days, or hypertension only on the day patients received their stimulant medications. This novel protocol provides valuable information on the blood pressure effects of stimulant medications and allows clinicians to make personalized decisions regarding treatment.

The article discusses the challenges of accurately determining a patient's blood pressure (BP) due to its highly variable nature. Factors such as ambient noise, body position, and emotional status can influence BP readings. The article suggests that repeated, standardized measurements over time using home BP monitoring or 24-hour ambulatory BP monitoring can provide more accurate results. Home BP monitoring has advantages such as increasing patient engagement, enabling remote data collection, and demonstrating clinically important reductions in BP. Patient perspectives on the use of home BP monitoring are also discussed, with participants viewing it as convenient and useful but expressing concerns about proper technique and device cost. The article concludes by emphasizing the need to align reimbursement requirements with evidence-based guidelines to support the use of home BP monitoring. [Extracted from the article]

BACKGROUND Self-measured blood pressure (SMBP) monitoring is increasingly used for remote hypertension management, but the real-world performance of home blood pressure (BP) devices is unknown. We examined BP measurements from patients' home devices using the American Medical Association's (AMA) SMBP Device Accuracy Test tool. METHODS Patients at a single internal medicine clinic underwent up to five seated, same-arm BP readings using a home device and an automated BP device (Omron HEM-907XL). Following the AMA's three-step protocol, we used the patient's home device for the first, second, and fourth measurements and the office device for the third and fifth (if needed) measurements. Device agreement failure was defined as an absolute difference in systolic BP >10 mm Hg between the home and office devices in either of two confirmatory steps. Performance was examined by brand (Omron vs. non-Omron). Moreover, we examined patient factors associated with agreement failure via logistic regression models adjusted for demographic characteristics. RESULTS We evaluated 152 patients (mean age 60 ± 15 years, 58% women, 31% Black) seen between October 2020 and November 2021. Device agreement failure occurred in 22.4% (95% CI: 16.4%, 29.7%) of devices tested, including 19.1% among Omron devices and 27.6% among non-Omron devices (P  = 0.23). No patient characteristics were associated with agreement failure. CONCLUSIONS Over one-fifth of home devices did not agree based on the AMA SMBP device accuracy protocol. These findings confirm the importance of office-based device comparisons to ensure the accuracy of home BP monitoring. [ABSTRACT FROM AUTHOR]

Management of elevated blood pressure during hospitalization varies widely. This systematic review summarizes clinical practice guideline recommendations on management of elevated blood pressure in the hospital. It encompasses guidelines on hypertension management in any setting and summarizes guideline recommendations for thresholds for treatment, circumstances for different recommendations, and preparation for safe transition to a posthospitalization setting. Background: Management of elevated blood pressure (BP) during hospitalization varies widely, with many hospitalized adults experiencing BPs higher than those recommended for the outpatient setting. Purpose: To systematically identify guidelines on elevated BP management in the hospital. Data Sources: MEDLINE, Guidelines International Network, and specialty society websites from 1 January 2010 to 29 January 2024. Study Selection: Clinical practice guidelines pertaining to BP management for the adult and older adult populations in ambulatory, emergency department, and inpatient settings. Data Extraction: Two authors independently screened articles, assessed quality, and extracted data. Disagreements were resolved via consensus. Recommendations on treatment targets, preferred antihypertensive classes, and follow-up were collected for ambulatory and inpatient settings. Data Synthesis: Fourteen clinical practice guidelines met inclusion criteria (11 were assessed as high-quality per the AGREE II [Appraisal of Guidelines for Research & Evaluation II] instrument), 11 provided broad BP management recommendations, and 1 each was specific to the emergency department setting, older adults, and hypertensive crises. No guidelines provided goals for inpatient BP or recommendations for managing asymptomatic moderately elevated BP in the hospital. Six guidelines defined hypertensive urgency as BP above 180/120 mm Hg, with hypertensive emergencies requiring the addition of target organ damage. Hypertensive emergency recommendations consistently included use of intravenous antihypertensives in intensive care settings. Recommendations for managing hypertensive urgencies were inconsistent, from expert consensus, and focused on the emergency department. Outpatient treatment with oral medications and follow-up in days to weeks were most often advised. In contrast, outpatient BP goals were clearly defined, varying between 130/80 and 140/90 mm Hg. Limitation: Exclusion of non–English-language guidelines and guidelines specific to subpopulations. Conclusion: Despite general consensus on outpatient BP management, guidance on inpatient management of elevated BP without symptoms is lacking, which may contribute to variable practice patterns. Primary Funding Source: National Institute on Aging. (PROSPERO: CRD42023449250) [ABSTRACT FROM AUTHOR]