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Background: Hypertension is a common disease accounting for the highest number of lost healthy life years globally and is strongly associated with stroke and myocardial infarction. Early detection of individuals with high blood pressure can be ensured by screening also those who consider themselves "healthy". Screening has both positive and negative effects where a diagnosis of hypertension can lead to worry about the future. These effects need to be elucidated in order to balance between benefit and harm before screening is introduced. The aim of the study was to describe individuals’ experiences of being screened for hypertension in dental health care.Method: Data from individual semi-structured interviews, with twenty participants screened for cardiovascular risk factors in connection with dental examination and aged 55-80 years, were analysed by means of qualitative content analysis.Results: The results describe individuals’ experiences of blood pressure screening in dental health care by means of the following theme: “No big deal” based on two categories: “Convenient way of measuring blood pressure” and “Increased awareness of health”. Conclusions: The overall message from the interviews was that having one’s blood pressure measured when visiting the dentist was convenient, easy and “No big deal”. Blood pressure screening did not create any major concerns and contributed to an increased awareness of health.

Objective: To study the long-term effects of weight reduction, quality of life and sense of coherence in a primary health care (PHC)-based programme with two different intensities. Design: Prospective two-armed randomised intervention. Setting: Three PHC centres in south west of Sweden. Subjects: In total, 289 women and men aged 40-65 years with a BMI of 28-35 were recruited for a two-year weight-reduction programme. Participants were randomized to high-intensity or low-intensity groups. Blood samples, physical measurements and questionnaires were analysed. Participants received cookbooks and dietary lectures. The high-intensity group also received Motivational interviewing (MI), dietary advice on prescription (DAP- advice), a grocery store lecture, a website and weekly e-mails. Main outcome measures: Weight, quality of life, risks and health factors. Results: In total, 182 (64%) participants completed the 2-year follow-up. The total sample reduced their weight by 1 kg (p = 0.006). No significant differences regarding weight were found between the groups. Anxiety/depression decreased in EQ5-D (p = 0.021), EQ5-D VAS (p = 0.002) and SOC (p = 0.042). Between the groups, there were significant differences in EQ5-D usual activities (p = 0.004), anxiety/depression (p = 0.013), pain/discomfort (p = 0.041), fruit and vegetables (p = 0.005), HLV anxiety (p = 0.005), and visits to nurses (p = 0.012). Conclusion: The total population lost weight, and the high-intensity and low-intensity programmes did not result in significant differences in terms of weight. The high-intensity programme reported health benefits linked to lower levels of anxiety and depression, increased activity and intake of greens and reduced visits to physicians and nurses.Key pointsBoth groups had a consisting weight- reduction after two years.High intensity did not lead to a significant difference in weight reduction between the groups.The high-intensity group reported more health effects, such as better quality of life, reduced anxiety, and increased greenery intake. It is unknown how much support patients in a weight- reduction programme in PHC require to succeed with weight loss and a healthy lifestyle

Håkan Bergh,1,2 Margit Albrektson,3 Clovis Kastberg,4 Amir Baigi,1,2 Lennart Hedström3 1School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; 2Department of Research & Development Unit, Hospital Varberg, Region Halland, Sweden; 3Public Dental Services, Västra Vall, Varberg, Sweden; 4Tre Tandläkare, Varberg, SwedenCorrespondence: Håkan Bergh, School of Public Health and Community Medicine, Institute of Medicine, P.O. Box 463, Gothenburg, 405 30, Sweden, Email hakan.e.bergh@gmail.com Lennart Hedström, Public Dental Service, Västra Vallgatan 14, Varberg, S-43244, Region Halland, Sweden, Email h.lennart.hedstrom@gmail.comObjective: To study the association between sublingual varices (SV) and cardiovascular (CVD) risk factors.Methods: A total of 989 consecutive dental patients aged 55– 84 years participated in the study, which applied a survey about risk factors, diseases and medications. Digital photos of the lateral borders of the tongue, height, weight, waist, hip and blood pressure were registered, and blood samples were analyzed. Those with SV were compared with those without SV (nSV).Results: Those with SV had more hypertension 41.8% vs 27.0% (p< 0.0001), a higher systolic blood pressure (BP) 139.5 (SD 18.6) mmHg vs 134.3 (SD 18.8) mmHg (95% CI − 7.73 &boxh; − 2.72), more diabetes type 2 (DM-2) 7.4% vs 3.8% (p=0.014), a higher fasting plasma glucose 5.9 (SD 1.5) mmol/L vs 5.7 (SD 1.0) mmol/L (95% CI − 0.42 &boxh; − 0.05), more dyslipidemia 24.1% vs 17.7% (p=0.018), lower HDL 1.6 vs 1.7 (p=0.003), a greater waist circumference 97.0 cm vs 93.9 cm (95% CI − 4.66 &boxh; − 1.46), a greater waist/hip ratio 0.92 cm/cm vs 0.90 cm/cm (95% CI − 0.03 &boxh; − 0.01), and a higher BMI 26.6 kg/m2 vs 26.0 kg/m2 (95% CI − 1.11 &boxh; − 0.03). The following associations with SV were found in multivariate analysis: hypertension OR=1.6 (95% CI 1.19 &boxh;2.13), a high systolic BP OR =1.5 (95% CI 1.11 &boxh;2.13), a high fP-glucose OR= 1.8 (95% CI 1.03 &boxh;3.21), a low HDL OR= 1.8 (95% CI 1.15 &boxh;2.92), a greater waist circumference OR= 1.68 (95% CI 1.10 &boxh;2.58), a greater waist/hip ratio OR=2.21 (95% CI 1.36 &boxh;3.58), and a higher BMI OR=1.05 (95% CI 1.02 &boxh;1.09).Conclusion: This study shows an association between SV and a high BP, a high fP-glucose, hypertension, diabetes mellitus type 2, dyslipidemia, abdominal obesity, older age and smoking.Keywords: sublingual varices, cardiovascular riskfactors

Objective To study white-coat hypertension (WCHT, blood pressure ≥140/90 mmHg in a clinic and normal blood pressure

Purpose An important task in primary health care (PHC) is to address lifestyle-related diseases. Overweight (OW) individuals make up a large proportion of PHC patients, and they increasingly have lifestyle-related illnesses that influence their quality of life. Structured health promotion and weight reduction programs could help these patients. The objective of this study was to explore the characteristics, lifestyle habits, and health conditions of individuals seeking a health promotion and weight reduction program in PHC. Patients and methods The study involved a comparative cross-sectional design performed in PHC in southwestern Sweden. The study population comprised 286 participants (231 women, aged 40-65 years, body mass index [BMI] 28-35 kg/m2) who were recruited between March 2011 and April 2014 to the 2-year program by adverts in local newspapers and recruitment from three PHC centers. Two reference populations were used: a general population group and an OW group. The study population data were collected using a questionnaire, with validated questions regarding health, lifestyle, illnesses, and health care utilization. Results People seeking a health promotion and weight reduction program were mostly women. They had a higher education level and experienced worse general health than the OW population, and they visited PHC more frequently than both reference groups. They also felt more stressed, humiliated, had more body pain, and smoked less compared to the general population. However, they did not exercise less or had a lower intake of fruits and vegetables than either reference population. Conclusion Individuals seeking a weight reduction program were mostly women with a higher education level and a worse general health than the OW population. They used more health care services compared to the reference groups.

Background Hypertension is one of the largest contributors to the disease burden and a major economic challenge for health-care systems. Early detection of persons with high blood pressure can be achieved through screening and has the potential to reduce morbidity and mortality. We evaluate the cost-effectiveness of an opportunistic hypertension screening programme in a dental-care facility for individuals aged 40–75 in comparison to care as usual (the no-screening baseline scenario). Methods A cost-effectiveness analysis (CEA) was carried out from the payer and societal perspectives, and the short-term (from screening until diagnosis has been established) cost per identified case of hypertension and long-term (20 years) cost per quality-adjusted life year (QALY) were reported. Data on the short-term cost were based on a real-world screening programme in which 2025 healthy individuals were screened for hypertension. Data on the long-term cost were based on the short-term outcomes combined with modelling in a Markov cohort model. Deterministic and probabilistic sensitivity analyses were carried out to assess uncertainty. Results The short-term analysis showed an additional cost of 4,800 SEK (€470) per identified case of hypertension from the payer perspective and from the societal perspective 12,800 SEK (€1,240). The long-term analysis showed a payer cost per QALY of 2.2 million SEK (€210,000) and from the societal perspective 2.8 million SEK per QALY (€270,000). Conclusion The long-term model results showed that the screening model is unlikely to be cost-effective in a country with a well-developed health-care system and a relatively low prevalence of hypertension.

Marie Bräutigam Ewe,1 Marie Lydell,2 Håkan Bergh,1,3 Cathrine Hildingh,2 Amir Baigi,1,3 Jörgen Månsson1 1Department of Public Health and Community Medicine/Primary Health Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; 2CVHI-Centre of Research on Welfare, Health and Sport, School of Health and Welfare, Halmstad University, Halmstad, Sweden; 3Research and Development Unit Halland, Region of Halland, Halmstad, Sweden Purpose: An important task in primary health care (PHC) is to address lifestyle-related diseases. Overweight (OW) individuals make up a large proportion of PHC patients, and they increasingly have lifestyle-related illnesses that influence their quality of life. Structured health promotion and weight reduction programs could help these patients. The objective of this study was to explore the characteristics, lifestyle habits, and health conditions of individuals seeking a health promotion and weight reduction program in PHC.Patients and methods: The study involved a comparative cross-sectional design performed in PHC in southwestern Sweden. The study population comprised 286 participants (231 women, aged 40–65 years, body mass index [BMI] 28–35 kg/m2) who were recruited between March 2011 and April 2014 to the 2-year program by adverts in local newspapers and recruitment from three PHC centers. Two reference populations were used: a general population group and an OW group. The study population data were collected using a questionnaire, with validated questions regarding health, lifestyle, illnesses, and health care utilization.Results: People seeking a health promotion and weight reduction program were mostly women. They had a higher education level and experienced worse general health than the OW population, and they visited PHC more frequently than both reference groups. They also felt more stressed, humiliated, had more body pain, and smoked less compared to the general population. However, they did not exercise less or had a lower intake of fruits and vegetables than either reference population.Conclusion: Individuals seeking a weight reduction program were mostly women with a higher education level and a worse general health than the OW population. They used more health care services compared to the reference groups. Keywords: lifestyle, overweight, primary health care, weight loss

Aim: The purpose of this study was to evaluate a two-step screening method for hypertension in dentistry regarding the number needed to screen (NNS) and positive predictive value (PPV) and to risk-classify those with newly diagnosed hypertension. Methods: In connection with their regular dental care check-up, 2025 subjects aged 40–75 years were screened for high blood pressure. Via a health questionnaire, data were collected concerning risk factors. Blood pressure was screened comprehensively in two steps, which included screening in a dental clinic and home measurements for one week. Recently discovered hypertensive participants were assessed for 10-year risk of cardiovascular mortality according to the guidelines of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC). Results: A total of 170 new hypertensive participants were found (NNS = 12; 95% confidence interval (CI): 11–13). The method yielded a PPV of 0.73 (95% CI: 0.68–0.78) and eliminated 84.8% of the false-positive participants. The results also showed that based on ESH/ESC risk estimation, 76.5% of those newly diagnosed hypertensive participants had a moderate or high risk of cardiovascular mortality within 10 years. Conclusions: The study shows that a two-step method for blood pressure screening in a dental setting including home measurement resulted in a high PPV and eliminated most of those with a false high blood pressure reading. The findings also show that two-step screening for hypertension is feasible in a larger population with more screening providers involved.

Aim. The aim of the study was to describe primary healthcare nurses' experiences with motivational interviewing as a method for health promotion practice. Background. A person's lifestyle has a maj ...

Objective: This study evaluated changes in self-efficacy in non-physically active adolescent girls (13–19 years old) who participated in a six-month, empowerment-based exercise intervention programme (EIP). Design: The study used a pre- and post-test randomized group design and included one pre- and one post-test (at six months) and non-physically active adolescent girls ( N = 110) were assigned to an intervention group ( n = 54) or a comparison group ( n = 56). Setting: Two upper secondary schools and five secondary schools, located in the low socio-economic areas of two communities in southern Sweden were involved in the study. Method: The Swedish version of a 10-item General Self-efficacy Scale (GSES) and the Social Barriers to Exercise Self-efficacy Questionnaire (SPBESQ) were used. In addition, BMI and results from a physical fitness test were measured. For statistical analysis, the Mann-Whitney U-test and the Wilcoxon’s matched-pairs signed-rank test were used. Results: Analysis showed a statistically significant difference in GSES scores ( p = 0.037) between the groups after the EIP was implemented. Girls in the intervention group had increased their levels of general perceived self-efficacy ( p = 0.004). Both groups increased their level of physical fitness (intervention, p = 0.06 and control, p = 0.013). BMI increased in the control group ( p = 0.031). Conclusions: The EIP had an impact on adolescent girls’ general perceived self-efficacy and can be regarded as an outcome of empowerment that indicates the development of the adolescent girls’ ability to effectively deal with a variety of stressful situations in general.

Aims The aim of this study is to compare the effects of a 24 h intravenous infusion of levosimendan and a 48 h infusion of dobutamine on invasive haemodynamics in patients with acutely decompensated chronic NYHA class III–IV heart failure. All patients were receiving optimal oral therapy including a β-blocker. Methods and results This was a multinational, randomized, double-blind, phase IV study in 60 patients; follow-up was 1 month. There was a significant increase in cardiac index and a significant decrease in pulmonary capillary wedge pressure (PCWP) at 24 and 48 h for both dobutamine and levosimendan. The improvement in cardiac index with levosimendan was not significantly different from dobutamine at 24 h (P = 0.07), but became significant at 48 h (0.44 ± 0.56 vs. 0.66 ± 0.63 L/min/m2; P = 0.04). At 24 h, the reduction in the mean change in PCWP from baseline was similar for levosimendan and dobutamine, however, at 48 h the difference was more marked for levosimendan (−3.6 ± 7.6 vs. −8.3 ± 6.7 mmHg; P = 0.02). No difference was observed between the groups for change in NYHA class, β-blocker use, hospitalizations, treatment discontinuations or rescue medication use. Reduction in B-type natriuretic peptide (BNP) was significantly greater with levosimendan at 48 h (P = 0.03). According to physician's assessment, the improvement in fatigue (P = 0.01) and dyspnoea (P = 0.04) was in favour of dobutamine treatment, and hypotension was significantly more frequent with levosimendan (P = 0.007). No increase in atrial fibrillation or ventricular tachycardia was seen in either group. Conclusion A 24 h levosimendan infusion achieved haemodynamic and neurohormonal improvement that was at least comparable at 24 h and superior at 48 h to a 48 h dobutamine infusion.

Transplant indications for right ventricular (RV) cardiomyopathy have not been defined. We report on two boys, aged 18 and 17 years, one with arrhythmogenic right ventricular cardiomyopathy (ARVC) and one with Uhl's anomaly. Both had implantable cardioverter defibrillator (ICD) for the prevention of sudden death (SD), but were not considered urgent heart transplant candidates due to the absence of heart failure symptoms. A ventricular tachycardia-induced cardiac collapse occurred at school in the Uhl patient and in hospital in the ARVC patient. In both patients, ICD shocks intermittently restored sinus rhythm but with inadequate circulation. Only the ARVC patient received early chest compressions and was saved to heart transplantation. Due to RV failure, both patients had evidence of Fontan-type physiology, in whom pulmonary blood flow is passive and propelled by the transpulmonary pressure gradient and intrathoracic pressure alterations produced by breathing. In these cases, at resuscitation, systemic circulation is not established until after pulmonary blood flow is restored by breathing or chest compressions. An ICD alone is therefore not sufficient for the prevention of SD. When invasive data show evidence of Fontan-type circulation, the patient may be considered for heart transplantation.

To describe the use of pedagogically related keywords and the content of notes connected to these keywords, as they appear in nursing records in a coronary artery bypass graft (CABG) surgery rehabilitation unit.Nursing documentation is an important component of clinical practice and is regulated by law in Sweden. Studies have been carried out in order to evaluate the educational and rehabilitative needs of patients following CABG surgery but, as yet, no study has contained an in-depth evaluation of how nurses document pedagogical activities in the records of these patients.The records of 265 patients admitted to a rehabilitation unit following CABG surgery were analysed. The records were structured in accordance with the VIPS model. Using this model, pedagogically related keywords: communication, cognition/development and information/education were selected. The analysis of the data consisted of three parts: the frequency with which pedagogically related keywords are used, the content and the structure of the notes.Apart from the term 'communication', pedagogically related keywords were seldom used. Communication appeared in all records describing limitations, although no explicit reference was made to pedagogical activities. The notes related to cognition/development were grouped into the following themes: nurses' actions, assessment of knowledge and provision of information, advice and instructions as well as patients' wishes and experiences. The themes related to information were the provision of information and advice in addition to relevant nursing actions. The structure of the documentation was simple.The documentation of pedagogical activities in nursing records was infrequent and inadequate.The patients' need for knowledge and the nurses' teaching must be documented in the patient records so as to clearly reflect the frequency and quality of pedagogical activities.

Background Assessment of pulmonary artery pressures, cardiac output (CO) and pulmonary vascular resistance (PVR) is crucial in the management of patients with pulmonary arterial hypertension (PAH). The aim of the present study was to investigate whether Doppler echocardiography can be used to determine PVR in patients with PAH. Methods Forty-two patients were included and Doppler echocardiography was performed simultaneously ( n = 22) and non-simultaneously ( n = 60) with right heart catheterization. The tricuspid regurgitation velocity was used to estimate pulmonary arterial peak systolic and diastolic (PADP) pressures (Bernoulli equation). At the time of pulmonary valve opening, right ventricular pressure equals PADP. The tricuspid regurgitation velocity at the time of pulmonary valve opening was measured by superimposing the time from the QRS to the onset of pulmonary flow on the tricuspid regurgitation velocity envelope. Pulmonary capillary wedge pressure, right atrial pressure and CO were assessed using standard Doppler echocardiography methods. Right heart catheterization was performed using Swan–Ganz catheters and thermodilution for CO determination. Results The differences (mean ± SD) between catheter and simultaneous/non-simultaneous Doppler echocardiography were 0.3 ± 0.8 ( p = 0.10)/−0.3 ± 1.1 ( p = 0.06) liter/min for CO, 2.9 ± 5.1 ( p = 0.02)/−1.2 ± 7.4 ( p = 0.2) mm Hg for the transpulmonary gradient (TPG) and 0.3 ± 2.1 ( p = 0.65)/0.8 ± 2.4 ( p = 0.02) Wood unit for PVR. The correlation coefficients between catheter and simultaneous/non-simultaneous Doppler echocardiography were 0.86/0.75 for CO, 0.92/0.90 for TPG and 0.93/0.92 for PVR. Conclusions A comprehensive hemodynamic assessment that includes CO, TPG and PVR can be provided by Doppler echocardiography in patients with severe pulmonary hypertension.

Objective: To study the achievability of device weaning in patients receiving left ventricular assist devices (LVADs) as a bridge to transplantation. Methods: Eighteen consecutive patients receiving a LVAD between September 1997 and June 2002 were included in the study. During a four-month follow-up, patients were repeatedly evaluated with right heart catheterization and echocardiography and, if functional improvement was observed, studied with the device turned off. Cardiac recovery was defined as off-pump LVEF >= 40% together with a significant improvement in invasive haemodynamic measurements (CI >= 2.5 and PCWP

Summary Objectives To find predictive factors for long-term sick leave (SL) and disability pension (DP) among frequent attenders (FAs) and normal attenders (NAs) in primary health care. Study design A cohort study with follow-up over 5 years. Methods Groups of FAs and NAs were followed over 5 years. Information about background, situation, sociodemography, life events, social support and sense of coherence were gathered at baseline. Multiple logistic regression analysis was used to determine the influence of each variable on long-term SL and receipt of a DP. Results During the study period, 18.9% of FAs received long-term SL/DP compared with 6% of NAs. Chronic disease was a predictive factor for long-term SL/DP among FAs [odds ratio (OR) 7.0] and NAs (OR 3.4). Among FAs, a life event was also a predictive factor (OR 2.1). Each additional life event increased the ratio of FAs with long-term SL/DP by 110%. Conflicts and losses had the greatest negative effects on FAs. Conclusions FAs are a high-risk group for long-term SL/DP. Besides chronic disease, a life event was the only predictive factor for long-term SL/DP among FAs. These findings indicate that FAs are a vulnerable group for stressful events. Consequently, healthcare personnel should take more notice of life events among FAs.

Although β-adrenergic blockade is beneficial in heart failure, inhibition of central sympathetic outflow using moxonidine has been associated with increased mortality. In the present study, we studied the acute effects of the imidazoline-receptor agonist moxonidine on haemodynamics, NA (noradrenaline) kinetics and myocardial metabolism. Fifteen patients with CHF (chronic heart failure) were randomized to a single dose of 0.6 mg of sustained-release moxonidine or matching placebo. Haemodynamics, NA kinetics and myocardial metabolism were studied over a 2.5 h time period. There was a significant reduction in pulmonary and systemic arterial pressures, together with a decrease in cardiac index in the moxonidine group. Furthermore, there was a simultaneous reduction in systemic and cardiac net spillover of NA in the moxonidine group. Analysis of myocardial consumption of substrates in the moxonidine group showed a significant increase in non-esterified fatty acid consumption and a possible trend towards an increase in myocardial oxygen consumption compared with the placebo group (P=0.16). We conclude that a single dose of moxonidine (0.6 mg) in patients already treated with a β-blocker reduced cardiac and overall sympathetic activity. The finding of increased lipid consumption without decreased myocardial oxygen consumption indicates a lack of positive effects on myocardial metabolism under these conditions. We suggest this might be a reason for the failure of moxonidine to prevent deaths in long-term studies in CHF.

Aims: A study was carried out to determine whether frequent attenders' (FAs') consultations for injuries are medically appropriate or not. Methods: A retrospective review was undertaken of medical records in a primary healthcare centre. All injury consultations by frequent attenders and controls during a period of one year were evaluated by two general practitioners (GPs). Outcome variables were: number of injuries, chronic diseases, type of injuries, and their treatments. The GPs made a comprehensive picture of each case and evaluated whether it was medically appropriate to consult a doctor or not. Results: Injuries were 7.2 times more common among frequent attenders compared with the controls. Frequent attenders had significantly more chronic diseases. Mean number of injury consultations was the same for frequent attenders with or without chronic disease. There was no difference concerning medically appropriate consultations between frequent attenders and controls. Conclusions: Consultations for injuries with frequent attenders were considered medically appropriate. Chronic diseases did not explain the higher injury incidence among frequent attenders. These findings are interesting and contradict the opinion that increased healthcare consumption by FAs is a waste of resources. Our findings may suggest that FAs are more vulnerable individuals.

Objective. The aim of this project was to compare an oral glucose tolerance test (OGTT) partly performed in the patient's home (OGTTh) with a clinic-obtained OGTT with regard to the ability of the tests to identify patients with impaired glucose tolerance (IGT) and type 2 diabetes mellitus (DM-2). Design. A method comparison. Setting. The study was completed at two primary health care centres. Subjects. Fifty-one patients with hypertension aged 50–79 years completed both OGTT tests. Main outcome measures. Values for capillary P-glucose obtained two hours after a glucose load were compared between the two OGTT tests. Fasting plasma glucose (fP-glucose) and HbA1c were also measured. Results. Thirty-seven patients were classified in the same group (normal/IGT/DM-2) by the two tests. The index of validity based on the test's ability to identify normal or pathological values (≥ 8.9 mmol/l) was 0.75. The value for kappa was 0.66 with a sensitivity of 0.54 and a specificity of 0.82. Conclusion. OGTTh may be a useful screening method for IGT in risk groups such as hypertensive patients.

The purpose of this study was to investigate the relation between sublingual varices, cardiovascular disease (CVD), and smoking. We studied 281 patients over 40 years old in this observational clinical study. During a dental check up visit, sublingual varices were sought on the lateral border of the tongue. Results were classified into two groups: grade 0 (few or none) and grade 1 (moderate or severe). Information about CVD and smoking was obtained from the patients and recorded. Multiple logistic regression analysis was used to assess the influence of particular variables on the incidence of sublingual varices. The presence and number of varices increased with increasing age, and the overall incidence was 98/281 (35%). Fifty-one of the patients were smokers (18%) and 45 (16%) had CVD, usually hypertension. Sublingual varices were significantly associated with age (odds ratio (OR) 1.1), smoking (OR 2.4), and CVD (OR 2.7).

Over a 9-yr period, heart transplantation was performed in 200 patients at Sahlgrenska University Hospital. Of these 200 patients, 151 were followed for 1 to 9 yr with regard to renal function, hemodynamics, cyclosporin A concentrations, and complications. Patients with a preoperative serum creatinine130 micromol/L received inotropic drugs to test for reversibility of renal dysfunction. The end point was graft failure. The average preoperative GFR of 66 +/- 17 ml/min per 1.73 m(2) declined to 52 +/- 19, 44 +/- 16, and 37 +/- 17 at 1, 5, and 9 yr after heart transplantation, respectively. Altogether, the average GFR declined by 44%. There was no significant correlation between the preoperative GFR and postoperative renal function or survival. Recipient age was a predictor of renal function during the entire follow-up. Severe renal dysfunction (GFR20 ml/min per 1.73 m(2)) developed in 20% of the patients, which was predicted by the recipient age at transplantation together with the GFR 1 yr after transplantation. A nomogram that shows the risk of developing severe renal dysfunction after heart transplantation is presented. Cyclosporin A concentrations and treatment with statins, calcium channel blockers, or angiotensin-converting enzyme inhibitors did not correlate with the evolution of renal function. Patients with a preoperative depressed renal function who improved on inotropic treatment seemed to have a poorer outcome compared with the other study patients.

OBJECTIVETo evaluate the dose response relationship of moxonidine on plasma concentration of norepinephrine during acute and chronic administration in patients with congestive heart failure (CHF).BACKGROUNDSympathetic activation is increased in heart failure. Moxonidine is an imidazoline ligand acting on the central nervous system (CNS) receptors to decrease sympathetic activation.METHODSNinety-seven patients with heart failure and New York Heart Association class II–III symptoms and ejection fraction 8 h). The number of adverse events was similar in the moxonidine and placebo groups.CONCLUSIONSThe increased sympathetic activation in CHF can be reduced by moxonidine through CNS inhibition.

A 27-year-old man was admitted to hospital because of severe cardiac failure. Investigation revealed dilated cardiomyopathy with a left ventricular ejection fraction of 15–20%. During adolescence the patient had been investigated for growth retardation and he also had progressive external ophthalmoplegia. There had been no symptoms of cardiac disease until 2 weeks before admittance. An endomyocardial biopsy showed cardiomyocytes deficient in cytochrome c oxidase (COX) in a mosaic pattern. A skeletal muscle biopsy showed mitochondrial myopathy with COX-deficient ragged-red fibers. Molecular genetic analysis revealed a heteroplasmic, 3.8-kb, mitochondrial DNA (mtDNA) deletion in heart and muscle. PCR-based quantification of the proportion of mtDNA with deletion showed 47% mutated mtDNA in the myocardial biopsy and 68% in muscle. In spite of treatment, the condition deteriorated and the patient died 5 days after admittance. This case demonstrates that mtDNA deletions may occasionally be the cause of severe dilated cardiomyopathy, and that morphological and molecular genetic diagnosis may be obtained by endomyocardial biopsy.

Aim Experimental data in heart failure models and an open trial of seven patients with idiopathic dilated cardiomyo-pathy have suggested beneficial effects of growth hormone on cardiac function. The aim of the present study was to evaluate growth hormone effects on cardiac function in a placebo-controlled study. Methods Twenty two patients with congestive heart failure of different aetiologies in NYHA II and III and an echocardiographic ejection fraction

Earlier studies have shown that spinal cord stimulation (SCS) has antianginal and anti-ischemic effects in severe coronary artery disease. In the present study, 14 patients were subjected to right-sided atrial catheterization and atrial pacing. The patients were paced to angina during a control session and during spinal cord stimulation. Myocardial extraction of β-endorphin (BE) during control pacing (8 ± 22%) changed to release at the maximum pacing rate during treatment (–21 ± 47%, a negative value representing release). Furthermore, the results indicate local myocardial turnover of leuenkephalin, BE and calcitonin-gene-related peptide. In addition, it is implied that SCS may induce myocardial release of BE which could explain the beneficial effects in myocardial ischemia.

Aims Spinal cord stimulation has been used in the treatment of intractable angina pectoris since the beginning of the 1980s. This study was designed to investigate whether the documented anti-ischaemic effects of spinal cord stimulation are mediated through a decrease in sympathetic activity. Methods and Results Ten patients with a spinal cord stimulator implanted as anti-anginal treatment were included in the study. Atrial pacing until the patient experienced moderate angina was performed and after 50 min rest the procedure was repeated during spinal cord stimulation. Total body and cardiac norepinephrine spillover was calculated and the former was found to have increased during pacing (47%, P =0·02). When spinal cord stimulation was applied, total body norepinephrine spillover decreased at a comparable pacing rate (18%, P =0·02). Cardiac norepinephrine spillover was not affected during the procedure. Conclusion The results of this study indicate that the anti-ischaemic effect of spinal cord stimulation is not due to reduced cardiac sympathetic activity. However, spinal cord stimulation decreases overall sympathetic activity which may benefit the heart, possibly by reducing oxygen demand.

The aim of the study was to determine whether low-level laser therapy (LLLT) has an analgesic effect in patients with recurrent aphthous stomatitis (RAS).A randomized single-blinded placebo-controlled trial was conducted with LLLT (wavelength, 809 nm; power, 60 mW; pulse frequency, 1800 Hz; duration, 80 seconds per treatment; dose, 6.3 J/cm(2)) in 40 patients with RAS. The intervention group was treated with LLLT on 3 occasions, with a 1-day interval. The control group was treated similarly, without any laser power. Pain perception (visual analog scale [VAS] rating) and patients' experience of eating, drinking, and brushing teeth was registered.VAS rating decreased (day 0 until day 2) from 84.7 to 31.5 (LLLT) and from 81.7 to 76.1 (placebo) (P.0001). LLLT also relieved the difficulty of drinking, eating, and brushing teeth.LLLT reduced the pain and the inconvenience of eating, drinking, and brushing teeth for patients with RAS, compared with placebo.

Health promotion practice in health care has a high priority in the endeavour to achieve equal opportunities for health and diversity in health among the population. The purpose of the study was to investigate whether there is any connection between the lifestyle advice given by healthcare professionals and the lifestyle change of the population, focusing on age, gender and education level. The study is based on the data from a national population survey in Sweden in which 52 595 patients who had attended health care were interviewed by phone. The participants were asked whether healthcare professionals had raised the subject of lifestyle during the visit and whether the advice they gave had contributed to a lifestyle change. The results indicated that lifestyle issues were raised with 32.2% of those who attended health care, particularly among men, younger patients and those with a high education level. When lifestyle issues were raised, the advice contributed to 39.2% of patients making a lifestyle change, to a higher extent among men, older patients and those with a low education level. The study shows that lifestyle advice given by healthcare professionals, during both emergency and outpatient healthcare visits, is an important contributor to patients' lifestyle change.

The inhibitory guanine nucleotide binding regulatory protein (Gi)-mediated muscarinic receptor-adenylyl cyclase system was studied in myocardium from adult male Wistar rats with 10 weeks of diabetes induced by a single intravenous injection of streptozotocin (60 mg/kg). Neither the messenger ribonucleic acid level nor the amount of Gi was changed in the streptozotocin diabetic group as compared to the control group. The activity of the adenylyl cyclase stimulated by guanyliminodiphosphate was decreased by 48% in the streptozotocin diabetic group whereas stimulated activities of adenylyl cyclase by sodium fluoride and forskolin remained unchanged. The inhibition of forskolin-stimulated adenylyl cyclase activity by carbachol was more potent in membranes from the streptozotocin diabetic group than that in membranes from the control group. The competition binding curve between (3H)- quinuclidinyl benzilate and carbachol obtained from the streptozotocin diabetic group was shifted to the left as compared to the control group. These results suggest that the myocardium of streptozotocin-induced diabetic rats exhibited an increase in Gi function as demonstrated by the increased inhibition of guanyliminodiphosphate-mediated adenylyl cyclase and the superhigh affinity for carbachol of the muscarinic receptors. As there were signs, similar to those seen in clinical heart failure, in the streptozotocin diabetic group, these results demonstrate that functional alteration of Gi might underlie, at least in part, the cardiac dysfunction that is associated with diabetes.

BACKGROUND.: The proliferation signal inhibitor everolimus offers the potential to reduce calcineurin inhibitor (CNI) exposure and alleviate CNI-related nephrotoxicity. Randomized trials in maintenance thoracic transplant patients are lacking. METHODS.: In a 12-month, open-labeled, multicenter study, maintenance thoracic transplant patients (glomerular filtration rate >/=20 mL/min/1.73m and 1 year posttransplant were randomized to continue their current CNI-based immunosuppression or start everolimus with predefined CNI exposure reduction. RESULTS.: Two hundred eighty-two patients were randomized (140 everolimus, 142 controls; 190 heart, 92 lung transplants). From baseline to month 12, mean cyclosporine and tacrolimus trough levels in the everolimus cohort decreased by 57% and 56%, respectively. The primary endpoint, mean change in measured glomerular filtration rate from baseline to month 12, was 4.6 mL/min with everolimus and -0.5 mL/min in controls (P

Objective: The aim was to investigate involvement of oxygen free radicals and any changes in the Gs mediated β adrenergic signalling system of stunned porcine myocardium. Methods: Myocardial stunning was induced in eight pentobarbitone anaesthetised pigs by brief occlusions of the distal left anterior descending coronary artery for periods of up to 10 min. Segment length function was measured in the ischaemic region and in a control region supplied by the circumflex artery. Left ventricular biopsies were obtained from the two regions 1 h after the last occlusion for ultrastructural and biochemical studies. Timolol was been used to prevent arrhythmia during ischaemia. Results: At the time when biopsies were obtained, percent systolic shortening was reduced to 58% in the region subjected to ischaemia and was only minimally reduced in the control region. In the biopsies from the stunned region: (1) electron microscopy showed mild and reversible intracellular changes in the stunned myocardium; (2) the activities of superoxide dismutase and glutathione peroxidase were decreased by 66% and 52%, respectively; (3) the content of malondialdehyde was increased by 49%; (4) neither density nor affinity of β adrenoceptors showed any changes; (5) there were no alterations in messenger RNA encoding for the α subunit of the stimulatory guanine necleotide binding protein (Gs), demonstrated by northern and dot-blot hybridisations; (6) ELISA technique utilising a specific antipeptide antibody showed no quantitative change in Gs; (7) the activity of adenyl cyclase was unchanged. Conclusions: Even though the stunned porcine myocardium showed substantial evidence of free radical injury, the β adrenergic signalling system was intact.

The aim of our study was to assess the levels of growth factors and interleukin (IL)-6 across the pulmonary circulation in patients with pulmonary arterial hypertension (PAH) and correlate them with clinical and haemodynamic data and outcome. Simultaneous arterial and pulmonary arterial blood samples in patients with PAH (n = 44) and controls (n = 20) were obtained during right heart catheterisation. Vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF)-BB, transforming growth factor (TGF)-beta1 and IL-6 were measured using ELISA. Arterial median (interquartile range) values for VEGF, PDGF-BB, TGF-beta1 and IL-6 were significantly higher in patients (377 (218-588) versus 9.0 pg.mL(-1); 1,955 (1,371-2,519) versus 306 (131-502) pg.mL(-1); 26.42 (11.3-41.1) versus 7.0 (1.8-18.4) ng.mL(-1); and 3.98 (0.7-8.1) versus 0.7 pg.mL(-1), respectively; p

The endothelin-1 (ET-1) system plays a pathophysiologic role in patients with pulmonary arterial hypertension (PAH). Results from previous studies assessing the transpulmonary gradient of ET-1 have been inconsistent. The influence of an intravenous epoprostenol infusion on the transpulmonary ET-1 gradient is unknown.In a prospective investigation, serum concentrations of ET-1 were measured in 39 consecutive patients (31 women; mean age, 20-77 years) with pulmonary hypertension (33 with PAH) and compared with 20 controls. The effect of intravenous epoprostenol administration on the transpulmonary gradient of ET-1 was analyzed in 13 patients with pulmonary hypertension. Blood samples were taken simultaneously from the pulmonary artery and radial artery.The serum levels of ET-1 were significantly higher in the arterial (3.9 +/- 1.28 vs 2.53 +/- 0.24 pg/ml, p0.001) and mixed venous blood samples (3.9 +/- 1.21 vs 2.52 +/- 0.29 pg/ml, p0.001) in patients with pulmonary hypertension than in controls. The arterial/venous ratio of ET-1 in patients (1.0 +/- 0.1) and in the control group (1.0 +/- 0.05) was similar (p = 0.79). During intravenous epoprostenol infusion, there were no changes in the mean transpulmonary ET-1 gradient (0.98 +/- 0.07 vs 0.96 +/- 0.09, p = 0.52), despite significant hemodynamic changes.The ET-1 radial artery/pulmonary artery ratio of unity indicates a balanced release and clearance of ET-1 across the lung circulation in controls and in patients with different forms of pulmonary hypertension. ET-1 levels across the pulmonary circulation did not change during epoprostenol infusion.

Substantial evidence supports a role for the growth hormone (GH)/insulin-like growth factor 1 (IGF-1) axis in regulation of normal cardiac growth, structure and function. Moreover, experimental data suggest beneficial effects of GH and IGF-1 on contractility and peripheral resistance in rats with impaired cardiac function. An increased Ca(++) responsiveness is one possible underlying cause for the improvement in contractility, although effects of GH and IGF-1 on apoptosis may also play a more long term role for cardiomyocyte survival. Until recently, studies regarding GH treatment in heart failure were limited to case reports where administration dramatically improved cardiac function. In a small non-blind study of 7 patients with idiopathic dilated cardiomyopathy and congestive heart failure (CHF) without GH deficiency who received treatment with recombinant GH (somatropin) for 3 months, considerable improvement of cardiac function was reported. More recent studies have demonstrated beneficial effects in patients with CHF due to both ischaemic and idiopathic dilated cardiomyopathy, with improvements in haemodynamics when somatropin was added both as a maintenance therapy and as a short term infusion. So far, 2 placebo-controlled studies with somatropin as adjunctive therapy in patients with CHF have been reported, although neither study could confirm previously reported improvement in systolic function and lowering of wall stress. In summary, it is clear that further placebo-controlled clinical trials are mandatory to verify positive effects and to monitor long term safety when somatropin is administered as an agent in the treatment of CHF.

Patients referred for heart transplantation evaluation may be accepted for transplantation, or denied due to existing contraindications or judged to be too well. There is little knowledge about long-term outcome in patients considered too well for transplantation. Ninety-five patients (mean age 47 ± 12 years, 73% men) judged “too well” at evaluation were included in this study. Acceptance for transplantation followed international guidelines. The follow-up (mean 4.5 years) was complete. Twenty of the 95 patients (21%) were eventually accepted for transplantation during the follow-up period. Twenty-one patients (22%) died, 13 without preceding acceptance for transplantation, 4 on the waiting list for transplantation, and 4 after transplantation. Cumulative and transplant-free survival at 1, 5, and 10 years were 91%, 82%, and 65%, and 90%, 70%, and 50%, respectively. In conclusion, long-term survival in patients considered too well for transplantation is better than in most contemporary series of heart transplant recipients, which suggests that the guidelines for acceptance are appropriate. However, almost one fifth of the patients die without preceding acceptance for transplantation or while on the waiting list, which illustrates the need for frequent reevaluation and tools to identify heart failure patients with an increased risk for sudden death.

Daclizumab, a humanized monoclonal antibody against the interleukin-2 receptor, reduced the risk of rejection without increasing the risk of infection among renal-transplant recipients and, in a single-center trial, among cardiac-transplant recipients. We conducted a multicenter, placebo-controlled, double-blind study to confirm these results in cardiac-transplant patients.We randomly assigned 434 recipients of a first cardiac transplant treated with standard immunosuppression (cyclosporine, mycophenolate mofetil, and corticosteroids) to receive five doses of daclizumab or placebo. The primary end point was a composite of moderate or severe cellular rejection, hemodynamically significant graft dysfunction, a second transplantation, or death or loss to follow-up within six months.By six months, 104 of 218 patients in the placebo group had reached the primary end point, as compared with 77 of the 216 patients in the daclizumab group (47.7 percent vs. 35.6 percent, P=0.007), a 12.1 percent absolute risk reduction and a 25 percent relative reduction. The rate of rejection was lower in the daclizumab group than in the placebo group (41.3 percent vs. 25.5 percent). Among patients reaching the primary end point, the median time to the end point was almost three times as long in the daclizumab group as in the placebo group during the first 6 months (61 vs. 21 days) and at 1 year (96 vs. 26 days). More patients in the daclizumab group than in the placebo group died of infection (6 vs. 0) when they received concomitant cytolytic therapy.Daclizumab was efficacious as prophylaxis against acute cellular rejection after cardiac transplantation. Because of the excess risk of death, concurrent or anticipated use of cytolytic therapy with daclizumab should be avoided.

The aim of this survey was to compare stressful life events, social support and sense of coherence (SOC) between frequent attenders (FAs) and normal attenders (controls) in primary health care.A cross-sectional study was conducted in a primary healthcare centre in the south-west of Sweden.A postal questionnaire was sent to 263 frequent attenders and 703 normal attenders. The questionnaire comprised sociodemographic variables and scales of stressful life events, social support and SOC. The results from the questionnaire were compared between the groups, and the significance of the variables in terms of attendance was tested in a multiple regression analysis.More of the FAs were secondarily single, they had more chronic diseases and were more often living on a sickness/disablement pension than the controls. FAs did not report more stressful life events than the controls nor was their experience of events more negative. Social support was as strong among FAs as among controls, and it had no significant effect on their frequent attendance. FAs had a significantly weaker SOC compared with controls. The variables that significantly influenced frequent attendance were high age [odds ratio (OR) = 1.02], chronic disease (OR = 3.08), sickness/disablement pension (OR = 2.46) and SOC (OR = 0.97).SOC had a significant influence on frequent attendance in primary health care, but stressful life events and social support did not. FAs did not report more stressful life events. However, due to an inadequate coping strategy, indicated by a weak SOC, the life events probably caused them more symptoms and diseases, and thereby a higher consulting frequency.

To compare frequent attenders in different age and sex groups with a control group according to characteristics and use of primary health care.Descriptive study of medical records.Primary health care centre.341 frequent attenders, divided by age and sex, were compared with 1025 controls from the same area.Consultation rate, diagnoses, prescribed medicine, referrals and certificates of illness during one year.Frequent attenders constituted 3.3% of the population but accounted for 25% of all visits to the GP and 44% of all illness certificates allocated. They were given more antibiotic prescriptions and consulted the GP more often for most medical problems. Frequent attenders had a morbidity, with a preponderance of infections at a young age, musculoskeletal and respiratory problems in middle age, and, among the oldest, circulatory, endocrine and musculoskeletal diseases.Frequent attenders had a morbidity within different ages similar to that of the controls, but also a higher consulting frequency for most medical problems and a significantly higher consumption of antibiotics. Are frequent attenders more vulnerable individuals and more prone to all kinds of diseases, or do they just consult more often for the usual medical problems?

Background and objective: Beta-adrenoreceptor blocking agents are important for the treatment of myocardial infarction (MI). Accumulating evidence also indicates that growth hormone (GH) improves cardiac function after MI in rats. We aimed to investigate the cardiovascular effects of combined treatment in an animal model of MI. Methods: MI was induced in rats by ligation of the left coronary artery. Three days after MI, animals were randomly assigned to one of four groups: controls (C) (n-19); GH (n-19) receiving s.c. 2 mg/kg per day rhGH; metoprolol (M) group (n-19) receiving 24 mg/kg per day and combined group (GHM) (n-20) treated with both GH (2 mg/kg per day s.c.) and M (24 mg/kg per day) for 9 days. Transthoracic echocardiography was performed before and after treatment. Results: Serum levels of insulin-like growth factor I were significantly elevated in the GH-group but not in the GHM group compared to controls. Left ventricular volumes, cardiac index, systolic blood pressure, were similar in all groups. Percent changes in ejection fraction compared to baseline were; GH (6.1±5.0%) and GHM (6.1±4.2%) vs. C (−12.5±3.0%), P

Aims To identify risk factors for the development of coronary artery disease after heart transplantation. Methods and Results In consecutive heart transplanted patients, who underwent coronary angiography at the first year follow-up, the aetiology of heart failure in 113 was ischaemic heart disease or dilated cardiomyopathy. Development of clinically significant graft coronary artery disease was analysed vs recipient and donor pre- and post-transplantation variables. At 1, 5 and 9 years follow-up, coronary artery disease had developed in 4%, 16%, and 20% of the included patients, respectively. Among patients with ischaemic heart disease as the aetiology of heart failure, 38% developed graft coronary artery disease, while the corresponding figure for patients with dilated cardiomyopathy was 9% ( P

Study objective: Elevated pulmonary vascular resistance is a risk factor in heart transplantation and reversibility of high pulmonary vascular resistance is evaluated preoperatively in potential recipients using IV vasodilators or inhaled nitric oxide. Prostacyclin is a potent vasodilator, which when inhaled, has selective pulmonary vasodilatory properties. The aim of this study was to compare the central hemodynamic effects of inhaled prostacyclin with those of inhaled nitric oxide in heart transplant candidates. Design: A pharmacodynamic comparative study. Setting: Cardiothoracic ICU or laboratory for diagnostic heart catheterization at a university hospital. Patients: Ten heart transplant candidates with elevated pulmonary vascular resistance (>200 dynes o s o cm −5 and/or a transpulmonary pressure gradient > 10 mm Hg) were included in the study. Interventions: Nitric oxide (40 ppm) and aerosolized prostacyclin (10 μg/mL) were administered by inhalation in two subsequent 10-min periods. Hemodynamic measurements preceeded and followed inhalation of each agent. Measurements and results: Both inhaled nitric oxide and inhaled prostacyclin reduced mean pulmonary artery pressure (–7% vs −7%), pulmonary vascular resistance (–43% vs −49%), and the transpulmonary gradient (–44% vs −38%). With inhaled prostacyclin, an 11% increase in cardiac output was observed. Other hemodynamic variables, including the systemic BP, remained unaffected by each of the agents. Conclusions: Inhaled prostacyclin induces a selective pulmonary vasodilation that is comparable to the effect of inhaled nitric oxide. Major advantages with inhaled prostacyclin are its lack of toxic reactions and easy administration as compared with the potentially toxic nitric oxide requiring more complicated delivery systems. (CHEST 1998; 114:780–786) Abbreviations: CO=cardiac output; CVP=central venous pressure; HR=heart rate; LV=left ventricle; MAP=mean arterial BP; MPAP=mean pulmonary artery pressure; NO=nitric oxide; NO 2 =nitrogen dioxide; PCWP=pulmonary capillary wedge pressure; PGI 2 =prostacyclin; PVR=pulmonary vascular resistance; SaO 2 = arterial oxygen saturation; SV=stroke volume; SvO 2 =mixed venous oxygen saturation; SVR = systemic vascular resistance; TPG=transpulmonary pressure gradient