Niels Buus

Small artery structure is an independent predictor of cardiovascular events in essential hypertension.

Objective Structural abnormality of resistance arteries is a characteristic pathophysiological phenomenon in essential hypertension and can be assessed in vitro as an increase in the media: lumen ratio (M: L) of isolated small arteries. We have investigated whether M: L is a risk predictor in uncomplicated essential hypertensive patients. Recently, high M: L was demonstrated as a prognostic marker in patients at high cardiovascular risk, including normotensive type 2 diabetic patients. Since diabetes is associated with pressure-independent changes in M: L, the relevance of this finding to essential hypertension has been uncertain. Methods We conducted a follow-up survey of 159 essential hypertensive patients, who had previously been submitted to a M: L evaluation while participating in a clinical trial. They composed a homogeneous moderate-risk group, with no concomitant diseases, and represented 1661 years of follow-up. Results Thirty patients suffered a documented predefined cardiovascular event during follow-up. Increased relative risk (RR) was associated with M: L ≥ 0.083 (mean level of the hypertensive cohort), RR = 2.34 [95% confidence interval (CI) 1.11–4.95], and with M: L ≥ 0.098 (mean level of a normotensive control group + 2SD), RR = 2.49 (95% CI 1.21–5.11). Both results remained significant (RR = 2.19, 95% CI 1.04–4.64, and RR = 2.20, 95% CI 1.06–4.56, respectively) when adjusted for Heart Score level (10-year mortality risk-estimate, integrating age, gender, systolic blood pressure, cholesterol and smoking). Conclusion Abnormal resistance artery structure independently predicts cardiovascular events in essential hypertensive patients at moderate risk.

Myocardial Perfusion During Long-Term Angiotensin-Converting Enzyme Inhibition or β-Blockade in Patients With Essential Hypertension

Hypertension is associated with reduced coronary vasodilatory capacity, possibly caused by structural changes in the coronary resistance vessels. Because vasodilatory treatment may correct abnormal structure better than nonvasodilating treatment, we compared whether long-term angiotensin-converting enzyme (ACE) inhibition has a greater effect on coronary reserve and cardiovascular structure than &bgr;-blockade in patients with essential hypertension. Thirty previously untreated hypertensive patients were randomized in a double-blind design to treatment for 1 year with either perindopril (4 to 8 mg per day, n=15) or atenolol (50 to 100 mg per day, n=15) and furthermore compared with normotensive controls. Cardiac output and left ventricular mass were measured with echocardiography and resistance artery structure was determined in vitro. Using positron emission tomography, myocardial perfusion (MP) was determined at rest and during dipyridamole-induced hyperemia while still on medication. Perindopril reduced left ventricular mass by 14±4% (P<0.01), peripheral vascular resistance by 12±6% (P<0.01), and media thickness-to-lumen diameter ratio of resistance arteries by 16±4% (P<0.05), whereas atenolol had no effect. Resting MP was decreased both by perindopril (−11±4%, P<0.01) and by atenolol (−25±4%, P<0.01) in parallel to the reduction in rate pressure product. Hyperemic MP was unaltered by perindopril (+2±6%, P=NS), but reduced by atenolol (−32±5%, P<0.01). Compared with atenolol, perindopril treatment resulted in higher coronary reserve (P<0.05). We conclude that compared with &bgr;-blockade, ACE inhibition increases coronary reserve and results in regression of hypertensive resistance artery structure and left ventricular hypertrophy. Vasodilating may thus be superior to nonvasodilating treatment in repairing the hypertensive myocardial microcirculation.

Small artery stucture adapts to vasodilatation rather than to blood pressure during antihypertensive treatment

Objective Correction of the abnormal structure of resistance arteries in essential hypertension may be an important treatment goal in addition to blood pressure (BP) reduction. We investigated how this may be achieved in a prospective clinical study. Methods Plethysmography was used to measure forearm resting vascular resistance (Rrest) and minimum vascular resistance (Rmin) as a measure of vascular structure. Two different groups of patients with essential hypertension were examined at baseline and after 6 months of antihypertensive treatment. In group A, 21 patients with never-treated essential hypertension were treated by their general practitioners using a variety of drugs to allow an assessment of the drug-independent effects. In group B, 28 beta-blocker-treated patients were shifted to angiotensin II receptor blocker treatment (eprosartan) to allow vasodilatation with no change in BP. Results In group A, mean ambulatory blood pressure (ABP) fell from 119 ± 2 (SE) to 103 ± 2 mmHg (P < 0.01), whereas mean ABP was unchanged in group B (100 ± 1 to 99 ± 1 mmHg, P = NS). Both groups showed similar reductions in Rrest (−33.4 and −28.5%, respectively) and in Rmin (−15.4 and −15.6%, respectively). There was a strong correlation between changes in Rrest and Rmin within both groups (r = 0.57, P < 0.01 and r = 0.68, P < 0.0001, respectively), whereas the change in BP in group A was not correlated to the change in Rmin (r = −0.03). Conclusion The correction of forearm resistance artery structure during antihypertensive treatment depends on the vasodilatation achieved rather than BP reduction.

Small artery structure during antihypertensive therapy is an independent predictor of cardiovascular events in essential hypertension.

Objective: Structural changes of small resistance arteries occur early in the disease process of essential hypertension and predict cardiovascular events in previously untreated patients. We investigated whether on-treatment small artery structure also identifies patients at elevated risk despite normalization of blood pressure (BP). Methods: We conducted a long-term follow-up survey of cardiovascular events in 134 moderate-risk patients with 9–12 months of well treated essential hypertension. All participants underwent subcutaneous biopsies with determination of small artery structure in terms of media to lumen ratio (M : L) before and during treatment. Results: After 9–12 months of treatment SBP was lowered from 164 ± 15 to 134 ± 14 mmHg (P < 0.01) and M : L reduced from 0.084 ± 0.028 to 0.075 ± 0.024 (P < 0.01). Mean follow-up hereafter was 15 years representing a total of 2035 years for the entire cohort. During this period 47 patients suffered a predefined cardiovascular event. For patients with on-treatment M : L above the mean value of the cohort (≥0.075), the hazard ratio was 2.14 [95% confidence interval (CI) 1.19–3.84, P = 0.01] and also those with M : L above mean +2SD of a normotensive population (≥0.098) had an elevated risk (hazard ratio 2.99, 95% CI 1.60–5.58, P < 0.01). Both results were adjusted for heart score (a 10-year mortality risk estimate integrating age, sex, smoking status, cholesterol level and SBP). Analysis of changes in M : L during treatment showed significantly higher event rates among patients with increased M : L and vice versa (hazard ratio 1.36 per 25% change, 95% CI 1.07–1.73, P = 0.013). Conclusion: On-treatment small artery structure identifies individuals still at increased cardiovascular risk despite long-term BP normalization and may be an additional target for therapy to prevent cardiovascular events.

Renal denervation in treatment-resistant essential hypertension. A randomized, SHAM-controlled, double-blinded 24-h blood pressure-based trial

Background: Renal denervation (RDN), treating resistant hypertension, has, in open trial design, been shown to lower blood pressure (BP) dramatically, but this was primarily with respect to office BP. Method: We conducted a SHAM-controlled, double-blind, randomized, single-center trial to establish efficacy data based on 24-h ambulatory BP measurements (ABPM). Inclusion criteria were daytime systolic ABPM at least 145 mmHg following 1 month of stable medication and 2 weeks of compliance registration. All RDN procedures were carried out by an experienced operator using the unipolar Medtronic Flex catheter (Medtronic, Santa Rosa, California, USA). Results: We randomized 69 patients with treatment-resistant hypertension to RDN (n = 36) or SHAM (n = 33). Groups were well balanced at baseline. Mean baseline daytime systolic ABPM was 159 ± 12 mmHg (RDN) and 159 ± 14 mmHg (SHAM). Groups had similar reductions in daytime systolic ABPM compared with baseline at 3 months [−6.2 ± 18.8 mmHg (RDN) vs. −6.0 ± 13.5 mmHg (SHAM)] and at 6 months [−6.1 ± 18.9 mmHg (RDN) vs. −4.3 ± 15.1 mmHg (SHAM)]. Mean usage of antihypertensive medication (daily defined doses) at 3 months was equal [6.8 ± 2.7 (RDN) vs. 7.0 ± 2.5 (SHAM)]. RDN performed at a single center and by a high-volume operator reduced ABPM to the same level as SHAM treatment and thus confirms the result of the HTN3 trial. Conclusion: Further, clinical use of RDN for treatment of resistant hypertension should await positive results from double-blinded, SHAM-controlled trials with multipolar ablation catheters or novel denervation techniques.

Disproportionally impaired microvascular structure in essential hypertension

Background Increased microvascular resistance and small artery remodelling are key abnormalities in the pathophysiology of essential hypertension. We investigated the relation between the impairment of coronary and forearm minimum vascular resistances (C-Rmin and F-Rmin) and the degree of hypertension. Method Seventy-five never-treated essential hypertension patients with 24-h systolic blood pressure (BP) at least 130 mmHg or diastolic BP at least 80 mmHg were assigned into grade 1 (office BP 140/90–159/99 mmHg) and grade 2 (office BP 160/100–179/109 mmHg) hypertension and compared to normotensive controls (n = 25). The patients were (48 years, 60% men) without cardiovascular disease. C-Rmin and coronary flow reserve (CFR) were derived from flow measurements in the left anterior descending artery using transthoracic echocardiography. F-Rmin was measured using venous occlusion plethysmography. Resting systemic vascular resistance index (SVRI) was measured with a gas rebreathing technique. Results Compared to normotensive controls: 24-h mean BP was raised 14% in grade 1 essential hypertension and 28% in grade 2 essential hypertension, whereas F-Rmin and C-Rmin were elevated by 58 and 87% in grade 1 essential hypertension and 72 and 125% in grade 2 essential hypertension. C-Rmin and F-Rmin were thus both increased more than expected from the BP level. SVRI and left-ventricular mass were increased proportionally to the BP. CFR was decreased by approximately 30% in both essential hypertension groups. Conclusion The results demonstrate excessive microvascular structural abnormalities in hypertension suggesting microvascular alterations occur early and not just as an adaptation to the BP level. Thus the level of BP elevation does not give an accurate indication of the microvascular involvement and impairment in essential hypertension.

Model for investigating the benefits of clinical supervision in psychiatric nursing: a survey study.

The objective of this study was to test a model for analysing the possible benefits of clinical supervision. The model suggested a pathway from participation to effectiveness to benefits of clinical supervision, and included possible influences of individual and workplace factors. The study sample was 136 nursing staff members in permanent employment on nine general psychiatric wards and at four community mental health centres at a Danish psychiatric university hospital. Data were collected by means of a set of questionnaires. Participation in clinical supervision was associated with the effectiveness of clinical supervision, as measured by the Manchester Clinical Supervision Scale (MCSS). Furthermore, MCSS scores were associated with benefits, such as increased job satisfaction, vitality, rational coping and less stress, emotional exhaustion, and depersonalization. Multivariate analyses indicated that certain individual and workplace factors were related to subscales of the MCSS, as well as some of the benefits. The study supported the suggested model, but methodological limitations apply.

Making existential meaning in transition to motherhood—A scoping review

OBJECTIVE to provide a thematic overview of the existing literature on existential meaning-making related to transition to motherhood among mothers of full term born babies in Western oriented countries and to discuss the themes from a existential psychology perspective. DESIGN the review follows the approach of a scoping review. Systematic searches in the electronic databases PubMed, CINAHL and PsycINFO were combined with manual and electronic searches for related references. Studies published between 1990 and 2010 examining dimensions of existential meaning-making in transition to motherhood were selected. Eleven papers were included in the synthesis, all using qualitative interviews. The following data were extracted from each study: (a) author(s), year of publication, study location, (b) aims of the study, (c) participants, (d) research design, (e) data collection method, (f) outcome measures, and (g) results. MEASUREMENTS the studies were synthesised in a thematisation on the basis of the existential psychotherapist and philosopher Emmy van Deurzens concepts of four interwoven life dimensions, through which we experience, interpret, and act in the world: Umwelt, Mitwelt, Eigenwelt, and Überwelt. KEY CONCLUSIONS the findings in this review suggest that transition to motherhood is considered a pivotal and paradoxical life event. Through the lens of existential psychology it can be interpreted as an existentially changing event, reorganising values and what makes life worth living, and to some women also being interpreted as a spiritual experience. However, in present maternity services there is a predominant focus on biomedical issues, which sets the arena for motherhood transition, and the issues related to potentially existentially changing experiences, are not considered important. Without an integrative approach, where personal meaning-making issues are discussed, the potential for growth during existential authenticity is not utilised. Transition to motherhood raises existential questions about mortality and meaning of life, and we should explore this field in research and in clinical work.

Psychiatric Hospital Nursing Staff's Experiences of Participating in Group-Based Clinical Supervision: An Interview Study

Group-based clinical supervision is commonly offered as a stress-reducing intervention in psychiatric settings, but nurses often feel ambivalent about participating. This study aimed at exploring psychiatric nurses’ experiences of participating in group-based supervision and identifying psychosocial reasons for their ambivalence. Semi-structured interviews were conducted with 22 psychiatric nurses at a Danish university hospital. The results indicated that participation in clinical supervision was difficult for the nurses because of an uncomfortable exposure to the professional community. The sense of exposure was caused by the particular interactional organisation during the sessions, which brought to light pre-existing but covert conflicts among the nurses.

Individual and Workplace Factors that Influence Psychiatric Nursing Staff's Participation in Clinical Supervision: A Survey Study and Prospective Longitudinal Registration

This paper reports findings from a survey of 239 psychiatric nursing staff. This study aimed to investigate how often psychiatric nursing staff participates in clinical supervision and any possible associations among individual and workplace factors in relation to participation. The survey findings are followed by a prospective longitudinal registration of participants in clinical supervision. The registration revealed that participation varies considerably and large numbers of the staff may not participate in clinical supervision at all. Characteristics of the workplace, including organisational location, work shift, and work-environmental factors, are related to participation and, consequently, may affect the outcome of clinical supervision.