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Background: Control of hypertension has improved nationally with focus on identifying and treating elevated blood pressures (BPs) to guideline recommended levels. However, once BP control is achieved, the frequency in which BP falls out of control and the factors associated with BP recidivism is unknown. In this retrospective cohort study conducted at 2 large, integrated health care systems we sought to examine rates and predictors of BP recidivism in adults with controlled hypertension. No change for methods, results and conclusion., Methods: Patients with a prior diagnosis of hypertension based on a combination of International Classification of Diseases, Ninth Revision, codes, receipt of antihypertensive medications, and/or elevated BP readings were eligible to be included. We defined controlled hypertension as normotensive BP readings (<140/90 mmHg or <130/80 mmHg in those with diabetes) at 2 consecutive primary care visits. We then followed up patients for BP recidivism defined by the date of the second of 2 consecutive BP readings >140/90 mmHg (>130/80 mmHg for diabetes or chronic kidney disease) during a median follow-up period of 16.6 months. Cox proportional hazards regression assessed the association between patient characteristics, comorbidities, medication adherence, and provider medication management with time to BP recidivism., Results: A total of 23,321 patients with controlled hypertension were included in this study. The proportion of patients with hypertension recidivism was 24.1% over the 16.6-month study period. For those with BP recidivism, the median time to relapse was 7.3 months. In multivariate analysis, those with diabetes (hazard ratio [HR] 3.99, CI 3.67-4.33), high normal baseline BP (for systolic BP HR 1.03, CI 1.03-1.04), or low antihypertensive medication adherence (HR 1.20, CI 1.11-1.29) had significantly higher rates of hypertension recidivism. Limitations of this work include demographics of our patient sample, which may not reflect other communities in addition to the intrinsic limitations of office-based BP measurements., Conclusions: Hypertensive recidivism occurs in a significant portion of patients with previously well-controlled BP and accounts for a substantial fraction of patients with poorly controlled hypertension. Systematic identification of those most at risk for recidivism and implementation of strategies to minimize hypertension recidivism may improve overall levels of BP control and hypertension-related quality measures., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: In sepsis red blood cells (RBCs) have been shown to be less deformable (i.e., more rigid) and have been implicated in decreasing nutrient blood supply and possibly leading to organ dysfunction. However, no studies have demonstrated an association between organ dysfunction and rigid RBCs. This study examined cardiovascular physiologic and histologic changes in two different models to determine whether a relationship may exist between RBC deformability and organ function., Methods: In the following two experiments, cardiac index (CI) was continuously measured, whereas both deformability index and histology were examined at the end of the experimental periods. The first experiment studied nonanesthetized, hydrated rats after a cecal ligation and puncture (CLP), a slow-developing means of inducing RBC rigidity. In a second experiment animals were anesthetized and received a 20% total blood volume transfusion of either diamide-treated (rigid) RBCs or normal RBCs., Results: CLP-treated animals' CI gradually decreased during 18 hours (232 +/- 60 ml/min/kg to 123 +/- 90 ml/min/kg; p = 0.05), with an increase in systemic vascular resistance (1459 +/- 517 dyne.sec/cm5.m2 to 2337 +/- 1213 dyne.sec/cm5.m2; p = 0.02). Diamide-treated animals had a rapid decrease in CI (86 +/- 7.0 ml/min/kg to 58 +/- 13 ml/min/kg; p = 0.05) and increase in SVR (2269 +/- 373 dyne.sec/cm5.m2 to 3897 +/- 988 dyne.sec/cm5.m2; p = 0.05) from baseline to 120 minutes after treatment respectively. The DI was significantly lower in both CLP and diamide groups (p < 0.03) when compared with control animals. Histologic evidence of subendocardial necrosis was shown in both the CLP- and Diamide-treated animals., Conclusions: These data suggest an association with RBC deformability and organ function in both septic and nonseptic animal models.

Background: Bacterial translocation has been implicated in the alteration of the immune response after shock and trauma. This study examined the effect of bacterial translocation on myelopoiesis after hemorrhagic shock in germ-free and conventional rats., Methods: Awake, unrestrained germ-free and conventional rats were bled to a mean arterial pressure of 30 mm Hg until the animal required infusion of 10% of the shed blood. Rats were resuscitated with shed blood and crystalloid. Sham rats were catheterized but not bled. Twenty-four hours after shock or sham, rats were administered lipopolysaccharide 100 micrograms or saline intraperitoneally. Twenty-four hours later, bone marrow cells were cultured for growth of granulocyte-macrophage colony-stimulating factor (CFU-GM)., Results: Lipopolysaccharide increased the number of CFU-GM/femur in sham germ-free rats (801 +/- 129 versus 455 +/- 110; p less than 0.05) and conventional rats (1458 +/- 200 versus 492 +/- 59; p less than 0.05) compared with saline-treated rats. In contrast, hemorrhagic shock inhibited lipopolysaccharide-induced CFU-GM growth in both germ-free and conventional rats. Shock, itself, was a stimulus for CFU-GM growth in germ-free but not conventional rats. Bone marrow white blood cell counts were unaffected by shock, lipopolysaccharide administration, or the germ-free state., Conclusions: Hemorrhagic shock inhibited lipopolysaccharide-induced CFU-GM proliferation independent of the germ-bearing status of the rat, and bacterial translocation exerted no influence on myelopoietic dysfunction after hemorrhagic shock.

Opportunity to assess changes in the management of cancer of the breast over the past 7 years was afforded by analysis of responses to questionnaires that were part of an annual questionnaire course. Comparison of responses to questionnaires conducted in 1971 and 1977 identified important features of approaches to this disease and indicated the way in which changes have occurred. Diagnostic needle aspiration increased from 24% (1971) to 54% (1977). In both surveys surgeons reported employing mammography infrequently. Use of modified radical mastectomy increased from 15% (1971) to 60% (1977). Employment of classical radical mastectomy decreased from 83% (1971) to 37% (1977). Surgeons considering biopsy of the contralateral breast to be unnecessary decreased from 47% (1971) to 14% (1977). Skin grafting, after a mastectomy, decreased from 40% (1971) to 24% (1977). Though oophorectomy is still the preferred initial treatment for premenopausal patients with advanced disease, preference for chemotherapy in postmenopausal patients increased from 5% (1971) to 23% (1977). Surgeons approving of reconstruction with implants after mastectomy for carcinoma increased from 30% (1971) to 49% (1977). Following mastectomy in patients with positive axillary nodes, 58% of our respondents employ chemotherapy with several drugs and 34% prefer irradiation.

It has been stated that breast cancer survival rates follow an exponential distribution. This would mean that the mortality rate is constant. Survival distribution was analyzed by the clinical life table method in one series of 10,752 patients and in another of 656 patients followed up to 8 and 18 years, respectively. Part of the larger series' table is (table: see text). Necessarily, clinical survival data are censored progressively. These kinds of data are analyzed best by examining the hazard function, which is the instantaneous death rate, or force of mortality. If an exponential distribution described survival in breast cancer correctly, the hazard function would be constant. These data clearly are not consistent with an exponential distribution, as the hazard function decreases. The survival distribution calculated from these data shows that the chance of dying of cancer decreases the longer a patient survives. This is more optimistic and consistent with clinical experience than is the exponential distribution.

The ability of exogenous ATP-MgCl2 to reverse the inhibition of ATP-dependent intracellular reactions by hemorrhagic shock was studied. Levels of ornithine in the postperfusion fluid were lower in animals receiving ATP-MgCl2 than in placebo-treated control animals (338.6 +/- 167.0 versus 692.1 +/- 67.2 mumol). Arginine levels were higher (399.1 +/- 130.1 versus 34.3 +/- 59.1 mumol) in ATP-MgCl2-treated animals. Ability of in vitro ATP to enter the cell and inhibit lactate formation (Crabtree effect) was significantly less in those animals receiving in vivo ATP-MgCl2 (81.4 +/- 11.1% versus 57.7 +/- 10.1%). Glutamate levels were not decreased by shock but were significantly increased by treatment with ATP-MgCl2 compared to placebo (190.5 +/- 48.8 versus 122.6 +/- 36.3 mumol). These data indicate that exogenously administered ATP-MgCl2 can reverse the inhibition of ornithine metabolism and the changes in lactate inhibition seen in hemorrhagic shock. These are both intracellular ATP-dependent reactions.

It has been suggested that interval breast cancer (breast cancer found within 12 months of a negative screening examination) exhibits a more virulent behavior than those found by the screening clinic. To test this hypothesis, 120 new cases of breast cancer were retrospectively reviewed from our Breast Screening Center. These patients were divided into three groups--interval cancer cases, lesions found at initial screening, and lesions found at subsequent screening. Statistically significant differences seen in our interval cancer cases included a higher percentage of positive axillary nodes, higher overall mortality rate, and lower 6-year survival rate as calculated by left table analysis. The remaining data, although not statistically significant, demonstrate a parallel trend toward a more malignant behavior. It is concluded that interval breast cancers are more aggressive forms of breast neoplasias.

A mode of teaching is described which introduces a new concept to clinical instruction in addition to the seminars, lectures, conferences, and audiovisual tools ordinarily used. It has the following advantages: (1) It allows the student to evaluate himself. (2) It allows him to detect and repair defects in his knowledge without damage to his class standing or to his ego. (3) It evaluates the areas of strength and weakness in the teaching programs. (4) It is a dynamic teaching process in which the student participates and which appears to stimulate a greater interest in and a greater retention of the material administered.