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1.  A survey of Aleutian mink disease virus infection of feral American mink in Nova Scotia 
Spleen samples from 14 mink that were trapped in 4 counties of Nova Scotia were tested for the presence of the Aleutian mink disease virus (AMDV) by polymerase chain reaction. Viral DNA was not detected in samples from Kings County (n = 2), but was detected in all the mink sampled from Colchester (n = 2) and Halifax (n = 6) counties, and 3 of 4 mink from Yarmouth County. The high level of AMDV-infected mink in Colchester and Halifax counties may pose a serious threat to the captive mink and wild animal populations. Because treatment of infected free-ranging mink is not an option, AMDV control strategies for the captive mink should be primarily focused on bio-security to protect clean ranches.
PMCID: PMC2797353  PMID: 20357945
2.  Legionellaceae in the potable water of Nova Scotia hospitals and Halifax residences. 
Epidemiology and Infection  1994;112(1):143-150.
Water was cultured from 39 of 48 hospitals (7 Halifax hospitals and 32 non-Halifax hospitals) in the province of Nova Scotia and from 90 residences (74 private dwellings, 16 apartments) in Halifax to determine the frequency of legionella contamination. Six of seven Halifax hospitals had Legionellaceae isolated from their potable water compared with 3 of 32 non-Halifax hospitals (P < 0.0001). Overall, 19 of 59 (32%) of the water samples from Halifax hospitals were positive for legionellae compared with 5 of 480 (1%) samples from non-Halifax hospitals (P < 0.0000). Five of the six positive Halifax hospitals had Legionella pneumophila serogroup 1 and 1 had L. longbeachae serogroup 2 recovered from their potable water. Legionella contamination was associated with older, larger (> or = 50 beds) hospitals with total system recirculation. These hospitals also had water with a higher pH and calcium content but lower sodium, potassium, nitrate, iron and copper content. Fourteen of the 225 (6.2%) water samples from Halifax residences were positive for legionellae -8% (6/74) of the single family dwellings were positive, compared with 25% (4/16) apartments. The positivity rate of 15.7% for the 19 electric hot-water heaters in Halifax homes was not significantly different from the 32% positivity for Halifax hospitals. L. longbeachae accounted for 2 of the 14 isolates of legionellae from Halifax homes.
PMCID: PMC2271493  PMID: 8119354
3.  Identifying potential need for cancer palliation in Nova Scotia 
OBJECTIVE: To assess the degree to which Nova Scotia cancer patients who may need palliative care are being referred to the comprehensive Halifax-based Palliative Care Program (PCP). METHODS: The authors conducted a retrospective, population-based study using administrative health data for all adults in Nova Scotia who died of cancer from 1988 to 1994. Proportions and odds ratios (ORs) were used to determine where there were differences in age, sex, place of residence, cancer cause of death, year of death and use of palliative radiotherapy between those who were referred to the PCP at the Halifax Infirmary and those who were not, and between those who were referred late (within 14 days of death) and those who were referred earlier. RESULTS: Of the 14,494 adults who died of cancer during the study period, 2057 (14.2%) were registered in the PCP. Within Halifax County, 1582 (36.4%) of the 4340 patients with terminal cancer were seen in the PCP. Predictors of PCP registration were residence in Halifax County (OR 19.2, 95% confidence interval [CI] 15.4-23.9), younger age compared with those 85 years of age or older (for those 20-54 years of age, OR 4.9, 95% CI 3.2-7.6; 55-64 years, OR 3.4, 95% CI 2.2-5.1; 65-74 years, OR 3.1, 95% CI 2.1-4.5; 75-84 years, OR 2.1, 95% CI 1.4-3.1), and having received palliative radiation (OR 1.8, 95% CI 1.5-2.2). PCP referral was associated directly with head and neck cancer (OR 5.4, 95% CI 3.0-9.7) and inversely with hematopoietic (OR 0.2, 95% CI 0.4-0.9), lymph node (OR 0.3, 95% CI 0.1-0.4) and lung (OR 0.6, 95% CI 0.4-0.9) cancer. Predictors of late referral (being referred to the PCP within 14 days of death) were age 65-84 years (OR 1.4, 95% CI 1.1-1.8) and 85 years and over (OR 1.8, 95% CI 1.1-3.0), no palliative radiation (OR 2.0, 95% CI 1.4-3.1) and cancer cause of death. People dying within 6 months of diagnosis were somewhat less likely to have been referred to the PCP (OR 0.8, 95% CI 0.6-0.9), but those who were referred were more likely to have been referred late (OR 2.6, 95% CI 2.0-3.5). INTERPRETATION: Referral to the PCP and earlier rather than late referral were more likely for younger people with terminal cancer, those who received palliative radiation and those living closer to the PCP. Referral rates also varied by cancer cause of death and the time between diagnosis and death.
PMCID: PMC1229439  PMID: 9676544
4.  Prevalence, Awareness, Treatment, and Control of Hypertension in United States Counties, 2001–2009 
PLoS ONE  2013;8(4):e60308.
Hypertension is an important and modifiable risk factor for cardiovascular disease and mortality. Over the last decade, national-levels of controlled hypertension have increased, but little information on hypertension prevalence and trends in hypertension treatment and control exists at the county-level. We estimate trends in prevalence, awareness, treatment, and control of hypertension in US counties using data from the National Health and Nutrition Examination Survey (NHANES) in five two-year waves from 1999–2008 including 26,349 adults aged 30 years and older and from the Behavioral Risk Factor Surveillance System (BRFSS) from 1997–2009 including 1,283,722 adults aged 30 years and older. Hypertension was defined as systolic blood pressure (BP) of at least 140 mm Hg, self-reported use of antihypertensive treatment, or both. Hypertension control was defined as systolic BP less than 140 mm Hg. The median prevalence of total hypertension in 2009 was estimated at 37.6% (range: 26.5 to 54.4%) in men and 40.1% (range: 28.5 to 57.9%) in women. Within-state differences in the county prevalence of uncontrolled hypertension were as high as 7.8 percentage points in 2009. Awareness, treatment, and control was highest in the southeastern US, and increased between 2001 and 2009 on average. The median county-level control in men was 57.7% (range: 43.4 to 65.9%) and in women was 57.1% (range: 43.0 to 65.46%) in 2009, with highest rates in white men and black women. While control of hypertension is on the rise, prevalence of total hypertension continues to increase in the US. Concurrent increases in treatment and control of hypertension are promising, but efforts to decrease the prevalence of hypertension are needed.
PMCID: PMC3618269  PMID: 23577099
5.  1999–2009 Trends in Prevalence, Unawareness, Treatment and Control of Hypertension in Geneva, Switzerland 
PLoS ONE  2012;7(6):e39877.
There are no time trends in prevalence, unawareness, treatment, and control of hypertension in Switzerland. The objective of this study was to analyze these trends and to determine the associated factors.
Population-based study conducted in the Canton of Geneva, Switzerland, between 1999 and 2009. Blood pressure was measured thrice using a standard protocol. Hypertension was defined as mean systolic or diastolic blood pressure ≥140/90 mmHg or self-reported hypertension or anti-hypertensive medication. Unawareness, untreated and uncontrolled hypertension was determined by questionnaires/blood pressure measurements. Yearly age-standardized prevalences and adjusted associations for the 1999–2003 and 2004–2009 survey periods were reported. The 10-year survey included 9,215 participants aged 35 to 74 years. Hypertension remained stable (34.4%). Hypertension unawareness decreased from 35.9% to 17.7% (P<0.001). The decrease in hypertension unawareness was not paralleled by a concomitant absolute increase in hypertension treatment, which remained low (38.2%). A larger proportion of all hypertensive participants were aware but not treated in 2004–2009 (43.7%) compared to 1999–2003 (33.1%). Uncontrolled hypertension improved from 62.2% to 40.6% between 1999 and 2009 (P = 0.02). In 1999–2003 period, factors associated with hypertension unawareness were current smoking (OR = 1.27, 95%CI, 1.02–1.59), male gender (OR = 1.56, 1.27–1.92), hypercholesterolemia (OR = 1.31, 1.20–1.44), and older age (OR 65–74yrs vs 35–49yrs  = 1.56, 1.21–2.02). In 1999–2003 and 2004–2009, obesity and diabetes were negatively associated with hypertension unawareness, high education was associated with untreated hypertension (OR = 1.45, 1.12–1.88 and 1.42, 1.02–1.99, respectively), and male gender with uncontrolled hypertension (OR = 1.49, 1.03–2.17 and 1.65, 1.08–2.50, respectively). Sedentarity was associated with higher risk of hypertension and uncontrolled hypertension in 1999–2003.
Hypertension prevalence remained stable since 1999 in the canton of Geneva. Although hypertension unawareness substantially decreased, more than half of hypertensive subjects still remained untreated or uncontrolled in 2004–2009. This study identified determinants that should guide interventions aimed at improving hypertension treatment and control.
PMCID: PMC3384604  PMID: 22761919
6.  Long-term Follow-up of Blood Pressure in Family Members of Soldiers Killed During the War in Bosnia and Herzegovina 
Croatian medical journal  2006;47(3):416-423.
To asses prevalence of essential arterial hypertension in family members of soldiers killed in 1992-1995 war in Bosnia and Herzegovina.
The study enrolled 1144 subjects who lost a family member in the war and 582 of their close neighbors who experienced no such loss. Data on their medical history and habits were collected, and their blood pressure was recorded in 1996 and 2003. Arterial hypertension was defined as systolic blood pressure ≥140 mm Hg (≥130 mm Hg in patients with diabetes mellitus), or diastolic blood pressure ≥90 mm Hg (≥80 mm Hg in patients with diabetes mellitus), or taking antihypertensive therapy. Additional laboratory and clinical tests were performed in subjects with hypertension.
The prevalence of hypertension at both time points was higher in the group with a killed family member than in the group without the loss (55.1% vs 42.1%, P<0.001 in 1996, and 50.7% vs 39.0%, P<0.001 in 2003, respectively). However, there was also a significant decrease in the prevalence of hypertension in the group with the loss in 2003 (P<0.001), but not in group without the loss. Posttraumatic stress disorder (PTSD), smoking, and alcohol consumption were more prevalent in the group with a killed family member, but not cholesterol and triglyceride blood concentrations. In both groups, hypertension was more prevalent in subjects with PTSD and smoking or drinking habit. Proportion of subjects with hypertension who smoked and used alcohol was similar in both groups. Proportion of subjects with hypertension who did not smoke or drink was higher in the group with the loss (51.1% vs 36.7%, P<0.001; 46.2% vs 35.0%, P = 0.006; respectively).
This study showed higher prevalence of hypertension in family members of killed soldiers, regardless of the presence of other cardiovascular risk factors. Only the stress of mourning was associated with higher prevalence of hypertension. Over time, proportion of hypertensive subjects with the loss decreased in the group with a killed family member, further suggesting that at least a part of their hypertension might have been of psychological origin.
PMCID: PMC2080420  PMID: 16758520
7.  Hypertension among Mexican Americans in Starr County, Texas. 
Public Health Reports  1996;111(Suppl 2):15-17.
THE MEXICAN-AMERICAN POPULATION in the United States has generally elevated frequencies of several chronic conditions, including non-insulin-dependent diabetes mellitus (NIDDM), gallbladder disease, and obesity. Prevalence of cardiovascular disease and hypertension is less clear. To document prevalence and risk factors of hypertension in this population, we measured blood pressure in 1004 randomly selected Mexican Americans in Starr County, Texas, ages 15 to 74. We defined hypertension as systolic blood pressure greater than or equal to 140 mmHg or diastolic pressure greater than or equal to 90 mmHg or current (within the last 48 hours) use of antihypertensive medications. Prevalences by age and gender are elevated in this population group compared with those in the general population. In addition to age and gender, body mass and diabetes status were also predictors of hypertension. Comparison of the Starr County results with those reported from the Third National Health and Nutrition Examination Survey (NHANES III) sampling of Mexican Americans indicates a slight increase in frequency of hypertension in Starr County, while comparison with results from San Antonio Mexican Americans indicates a marked increase in frequency in Starr County. These differences are not simple functions of measurement protocols, but are likely to be caused by differences in population structure, employment and socioeconomic status, education, and other such factors.
PMCID: PMC1381654  PMID: 8898763
8.  Trends in prevalence, awareness, treatment, and control of hypertension, and the risk of mortality among middle-aged Lithuanian urban population in 1983–2009 
Arterial hypertension (AH) is a main risk factor for the risk from cardiovascular (CVD) and stroke mortality. Only few data was published on prevalence, awareness and management of AH in Lithuania. Development of objective approaches to the treatment and control of AH reduces the risk of mortality. The aim of this study was to evaluate time trends, the prevalence, awareness, treatment and control of AH and risk of mortality among Lithuanian urban population aged 45–64 years during the period of 1983–2009.
Time trends of AH and risk of mortality were examined in three MONICA health surveys in 1983, 1986, 1992, and in one health survey according to MONICA protocol in 2002 included randomly recruited of 2,218 men and 2,491 women. AH was defined as systolic blood pressure (BP) ≥140 mmHg and/or diastolic BP of ≥90 mmHg or current use of antihypertensive medication. The main outcome measures were all-cause mortality, mortality from CVD, coronary heart disease (CHD) and stroke. The mean duration of follow-up was 11.8 ± 9.2 years. All survey periods were age standardized to the year 2006 of Kaunas population. The estimates of hazard ratio and 95% confidence interval were based on the multivariate Cox proportional hazards regression.
In men during 1983–2002 period hypertension prevalence was 52.1–58.7% and did not significantly change whereas in women decreased from 61.0 to 51.0%. There was a significant increase in hypertension awareness among hypertensive men and women (45.0 to 64.4% and 47.7 to 72.3%, respectively) and in treated hypertensives (55.4 to 68.3% in men and 65.6 to 86.2% in women). Adjusted Cox proportional hazard regression analyses revealed a strong dose–response association between blood-pressure level and all-cause, CVD, CHD and stroke-mortality risk in both men and women groups.
In Lithuanian urban population the prevalence of hypertension remains high. Despite positive changes in hypertension awareness and treatment, hypertension control remains poor. A strong dose–response association between the level of BP and all-cause, CVD, CHD and stroke mortality risk was indicated.
PMCID: PMC3480954  PMID: 22937997
Hypertension; Awareness; Treatment; Control; Risk of mortality
9.  Prevalence and control of hypertension in an Ontario county 
Canadian Medical Association Journal  1985;132(9):1019-1024.
A survey of a representative population sample was carried out to evaluate the prevalence and control of hypertension in Middlesex County, Ontario. Of the 3067 subjects selected 2735 completed the initial interview. If the diastolic blood pressure was greater than 89 mm Hg in three readings, up to two further visits were made. The prevalence rate of hypertension in the sample was estimated to be 115/1000. Only 5.1% of the hypertensive subjects were unaware of their condition, and 5.4% were aware but not receiving treatment. In 16.9% the hypertension was treated but uncontrolled, while in 72.6% it was treated and controlled. The prevalence rate was significantly higher in the older subjects (p < 0.0001). Control was better in the women and the older subjects. The results indicate that physicians in Middlesex County are detecting and treating most patients with hypertension; screening programs are thus not needed. Control of hypertension could be further improved by determining why the condition in those receiving treatment is not being controlled.
PMCID: PMC1346179  PMID: 3986726
10.  Higher Prevalence and Awareness, but Lower Control Rate of Hypertension in Patients with Diabetes than General Population: The Fifth Korean National Health and Nutrition Examination Survey in 2011 
Diabetes & Metabolism Journal  2014;38(1):51-57.
We investigated the prevalence, awareness, treatment, and control rate of hypertension in Korean adults with diabetes using nationally representative data.
Using data of 5,105 adults from the fifth Korea National Health and Nutrition Examination Survey in 2011 (4,389 nondiabetes mellitus [non-DM]), 242 newly diagnosed with DM (new-DM), and 474 previously diagnosed with DM (known-DM), we analyzed the prevalence of hypertension (mean systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or use of antihypertensive medication) and control rate of hypertension (blood pressure [BP] <130/80 mm Hg).
The prevalence of hypertension in diabetic adults was 54.6% (44.4% in new-DM and 62.6% in known-DM, P<0.0001 and P<0.0001, respectively) compared with non-DM adults (26.2%). Compared to non-DM, awareness (85.7%, P<0.001) and treatment (97.0%, P=0.020) rates were higher in known-DM, whereas no differences were found between new-DM and non-DM. Control rate among all hypertensive subjects was lower in new-DM (14.9%), compared to non-DM (35.1%, P<0.001) and known-DM (33.3%, P=0.004). Control rate among treated subjects was also lower in new-DM (25.2%), compared to non-DM (68.4%, P<0.0001) and known-DM (39.9%, P<0.0001).
Higher prevalence and low control rate of hypertension in adults with diabetes suggest that stringent efforts are needed to control BP in patients with diabetes, particularly in newly diagnosed diabetic patients.
PMCID: PMC3950195  PMID: 24627828
Blood pressure; Diabetes mellitus; Hypertension; Korea National Health and Nutrition Examination Survey
11.  Fasting Insulin Level Is Positively Associated With Incidence of Hypertension Among American Young Adults 
Diabetes Care  2012;35(7):1532-1537.
Although hyperinsulinemia, a surrogate of insulin resistance, may play a role in the pathogenesis of hypertension (HTN), the longitudinal association between fasting insulin level and HTN development is still controversial. We examined the relation between fasting insulin and incidence of HTN in a large prospective cohort.
A prospective cohort of 3,413 Americans, aged 18–30 years, without HTN in 1985 (baseline) were enrolled. Six follow-ups were conducted in 1987, 1990, 1992, 1995, 2000, and 2005. Fasting insulin and glucose levels were assessed by a radioimmunoassay and hexokinase method, respectively. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% CIs of incident HTN (defined as the initiation of antihypertensive medication, systolic blood pressure ≥140 mmHg, or diastolic blood pressure ≥90 mmHg).
During the 20-year follow-up, 796 incident cases were identified. After adjustment for potential confounders, participants in the highest quartile of insulin levels had a significantly higher incidence of HTN (HR 1.85 [95% CI 1.42–2.40]; Ptrend < 0.001) compared with those in the lowest quartile. The positive association persisted in each sex/ethnicity/weight status subgroup. A similar dose-response relation was observed when insulin-to-glucose ratio or homeostatic model assessment of insulin resistance was used as exposure.
Fasting serum insulin levels or hyperinsulinemia in young adulthood was positively associated with incidence of HTN later in life for both men and women, African Americans and Caucasians, and those with normal weight and overweight. Our findings suggested that fasting insulin ascertainment may help clinicians identify those at high risk of HTN.
PMCID: PMC3379592  PMID: 22511258
12.  Blood Pressure Reactivity to an Anger Provocation Interview Does Not Predict Incident Cardiovascular Disease Events: The Canadian Nova Scotia Health Survey (NSHS95) Prospective Population Study 
We examined the association between blood pressure (BP) reactivity to an anger provocation interview and 10-year incident CVD events in 1,470 adults from the population-based 1995 Nova Scotia Health Survey (NSHS95). In an unadjusted model, those in the highest decile of systolic BP reactivity were more than twice as likely to have an incident CVD event compared to those in the decile with no reactivity (HR = 2.33, 95% CI = 1.15 – 4.69, P = 0.02). However, after adjusting for age and sex, and then also for Framingham risk score, body mass index, and education, this relationship was attenuated and not statistically significant. Diastolic BP reactivity was not associated with CVD incidence in any model. Individual differences in BP reactivity to a laboratory-induced, structured anger provocation interview may not play a major role in clinical CVD endpoints.
PMCID: PMC3296956  PMID: 22518289
13.  Prevalence, Awareness, Treatment, and Control of Hypertension in Rural Areas of Davanagere 
To study the prevalence, awareness, treatment, and control of hypertension in the rural areas of Davanagere.
Type of Study:
Cross-sectional community-based study.
Villages belonging to six sectors of the Davanagere Taluk.
Materials and Methods:
General population above 18 years.
A community-based sample was chosen by a multistage sampling technique. Subjects were screened for hypertension by a house-to-house survey. Subjects with systolic blood pressure more than 140 and diastolic blood pressure more than 90 mm of Hg, on hypertensive treatment, and history of hypertension were classified as hypertensives. The data thus obtained was compiled and analyzed.
The prevalence rate of hypertension in the study population was 18.3% (95% CI, 16.7-19.9%). Prevalence of hypertension was more in males 19.1% (95% CI, 16.7-21.5%) than in females 17.5% (95% CI, 14.9-20.1%); 11.6%, 5.6%, and 1.2% of the total subjects had Grade I, Grade II, and Grade III, respectively. Only 33.8% of them were aware of their hypertensive status. Hypertensives of 32.1% were on treatment, and 12.5% adequately controlled their BP. About 6.9% of the total hypertensives had severe hypertension.
Statistical Analysis:
Proportions, One way Analysis of Variance, Chi-square test.
PMCID: PMC2888343  PMID: 20606939
Awareness; hypertension; prevalence
14.  Antihypertensive and lipid lowering treatment in 70–74 year old individuals – predictors for treatment and blood-pressure control: a population based survey. The Hordaland Health Study (HUSK) 
BMC Geriatrics  2006;6:16.
In an elderly, community based population we aimed at investigating antihypertensive and lipid lowering medication use in relation to own and familiar cardiovascular morbidity and diabetes mellitus, as well as to lifestyle factors and general health. We also examined levels of blood pressure in untreated and treated residents, to investigate factors correlating with blood pressure control.
A health survey carried out in 1997-9 in the county of Hordaland, Norway included a self-administered questionnaire mailed to 4 338 persons born in 1925-7. Drug use the day prior to filling in the questionnaire was reported. A health check-up was carried out, where their systolic and diastolic blood pressure (SBP and DBP), body mass index (BMI), and serum-cholesterol level were recorded.
One third of respondents used one or more antihypertensive drugs, while 13% of men and women were treated with a statin. Diabetes mellitus, own or relatives'cardiovascular disease, having quit smoking, physical inactivity, and overweight correlated with antihypertensive treatment. Mean blood pressure was lower in respondents not on treatment. Among those on treatment, 38% of men and 29% of women had reached a target BP-level of lower than 140/90 mm Hg. Own cardiovascular disease and a low BMI correlated with good BP-control.
One third of 70–74 year old individuals living in the community used one or more antihypertensive drugs. Only around one third of those treated had reached a target BP-level of less than 140/90 mm Hg. Own cardiovascular disease and a low BMI correlated with good BP-control.
PMCID: PMC1624832  PMID: 17052334
15.  Relationship between hypertension, diabetes and proteinuria in rural and urban households in Yemen 
Journal of Human Hypertension  2013;27(9):572-579.
Little information is available on the meanings of proteinuria in low-resource settings. A population-based, cross-sectional survey was performed in Yemen on 10 242 subjects aged 15–69 years, stratified by age, gender and urban/rural residency. Hypertension is defined as systolic blood pressure (BP) of ⩾140 mm Hg and/or diastolic BP of ⩾90 mm Hg, and/or self-reported use of antihypertensive drugs; diabetes is diagnosed as fasting glucose of ⩾126 mg dl−1 or self-reported use of hypoglycaemic medications; proteinuria is defined as ⩾+1 at dipstick urinalysis. Odds ratios (ORs) for associations were determined by multivariable logistic regression models. Prevalence (weighted to the Yemen population aged 15–69 years) of hypertension, diabetes and proteinuria were 7.5, 3.7 and 5.1% in urban, and 7.8, 2.6 and 7.3% in rural locations, respectively. Proteinuria and hypertension were more prevalent among rural dwellers (adjusted ORs 1.56; 95% confidence limit (Cl) 1.31–1.86, and 1.23; 1.08–1.41, respectively), diabetes being less prevalent in rural areas (0.70; 0.58–0.85). Differently from hypertension and diabetes, proteinuria was inversely related with age. Most importantly, 4.6 and 6.1% of urban and rural dwellers, respectively, had proteinuria in the absence of hypertension and diabetes. The approach of considering kidney damage as a consequence of hypertension and diabetes might limit the effectiveness of prevention strategies in low-income countries.
PMCID: PMC3747332  PMID: 23514843
prevalence; proteinuria; diabetes; developing countries; epidemiology; HYDY study
16.  Prevalence, awareness, treatment, and control of hypertension: Rule of thirds in the Skaraborg project 
To describe the prevalence, awareness, and control of hypertension in a Swedish population during the early 2000s to address implications for care and prevention.
A cross-sectional population survey.
Primary health care in Skaraborg, a rural part of western Sweden.
Participants (n =2816) in a population survey of a random sample of men and women between 30 and 75 years of age in the municipalities of Vara (81% participation rate) and Skövde (70%), in western Sweden during 2001–2005.
Main outcome measures
Anthropometric measures, blood pressure, leisure-time physical activity, current smoking, fasting glucose, and cholesterol. Hypertension was defined as ongoing treatment for hypertension, or three consecutive blood pressure readings ≥140 systolic and/or ≥90 mmHg diastolic. Hypertension was considered controlled when the blood pressure was <140/90 mm Hg (both).
The prevalence of hypertension was 20% in both men and women with a steep increase by age. Among hypertensive subjects, 33% were unaware, 36% aware but uncontrolled, and 31% aware and controlled, with no statistically significant differences between men and women. Patients with diabetes had a higher awareness (87% vs. 64%, p <0.001), but the same control rate (56% vs. 44%, p =0.133), when compared with those without diabetes.
A large proportion of subjects with hypertension are still unaware of their condition, or aware but not controlled. It is important to emphasize population-based prevention to reduce the prevalence of hypertension, to perform screening to increase awareness, and to improve implementation of expert guidelines in clinical practice to improve control.
PMCID: PMC3378010  PMID: 22643153
Awareness; control; hypertension; population survey; prevention
17.  Does Reducing Physician Uncertainty Improve Hypertension Control? Rationale and Methods 
Hypertension affects nearly one-third of the U.S. population overall, and the prevalence rises sharply with age. In spite of public educational campaigns and professional education programs to encourage blood pressure measurement and control of both systolic and diastolic control to < 140/90 mmHg (or 130/80 mmHg if diabetic), 43% of treated hypertensives do not achieve the recommended JNC VII target. Among African-Americans, 48% are uncontrolled on treatment. The majority of persons classified as poorly controlled hypertensives have mild systolic blood pressure elevation (in the range of 140–160 mmHg). We hypothesized that physician uncertainty regarding the patient’s usual blood pressure, as well as uncertainty regarding the extent of medication non-adherence represent an important barrier to further reductions in the proportion of uncontrolled hypertensives in the U.S.
Using cluster randomization, ten primary care clinics (six from a public health care system and four from a private clinic system) were randomized to either the uncertainty reduction intervention condition or to usual care. An average of 68 patients per clinic were recruited to serve as units of observation. Physicians in the five intervention clinics were provided with a specially designed study form that included a graph of recent blood pressure measurements in their study patients, a check box to indicate their assessment of the adequacy of the patient’s blood pressure control, and a menu of services they could order to aid in patient management. These menu options included: 24-hour ambulatory blood pressure monitoring (ABPM); electronic bottle cap assessment of medication adherence, followed by medication adherence counseling in patients found to be non-adherent; and lifestyle assessment and counseling followed by 24-hour ABPM. Physicians in the five usual practice clinics did not have access to these services, but were informed of which patients had been enrolled in the study. Substudies carried out to further characterize the study population and interpret intervention results included ABPM and electronic bottle cap monitoring in a random subsample of patients at baseline, and audio recording of patient-physician encounters after intervention implementation.
The primary study endpoint was defined as the proportion of patients with controlled blood pressure (BP < 140/90 mmHg or < 130/80 mmHg if diabetic). Secondary endpoints include actual measured clinic systolic and diastolic blood pressure, patient physician communication patterns, physician prescribing patient self-reported lifestyle and medication adherence, physician knowledge, attitude and beliefs regarding the utility of intervention tools to achieve blood pressure control, and the cost-effectiveness of the intervention. Six-hundred eighty patients have been randomized, and 675 remain in active follow-up after 1.5 years. Patient closeout will be complete in March of 2009. Analysis of the baseline data is in progress.
Office-based blood pressure measurement error and bias, as well as physician and patient beliefs about the need for treatment intensification may be important factors that limit further progress in blood pressure control. This trial will provide data on the extent to which available technologies not widely used in primary care will change physician prescribing behavior and patient adherence to prescribed treatment.
PMCID: PMC2780342  PMID: 20031846
Hypertension Control; African-Americans; Cluster-randomized Trial; 24-hour Ambulatory Blood Pressure Monitoring; electronic bottle cap monitoring
18.  Prevalence of Cytomegalovirus Infection in a Normal Urban Population in Nova Scotia 
During 1967 and 1968 a seroepidemiological survey was conducted on the prevalence of CF antibodies to CMV in the normal population of the Halifax-Dartmouth metropolitan area of Nova Scotia. Samples of 550 sera, collected from all age groups, including newborns, were processed. At birth, 34% of infants possess antibodies, presumably of maternal origin, and there follows a decline until at 2 years of age only 4% of children exhibit evidence of infection. There is a gradual increase up to 16% by 20 years of age, and thereafter this is maintained until by 40+ years half the population possesses antibodies.
A more detailed analysis of cord sera indicated that approximately 60% of women of childbearing age possess no antibodies and are susceptible to primary CMV infection. Among these, age and gravidity are not significant factors.
These data indicate that CMV infection is fairly widespread in this community, although comparative studies suggest that it is less so than in some other areas, such as Easter Island, where a more homogeneous pattern of overcrowding and poor sacioeconomic conditions prevails.
PMCID: PMC1946419  PMID: 4311998
19.  Hypertension among adults in a deprived urban area of Peru – Undiagnosed and uncontrolled? 
BMC Research Notes  2008;1:2.
In Peru, cardiovascular disease was the second most common cause of death in those aged 65 years or more in 2000. Hypertension is a major modifiable risk factor for cardiovascular disease, and if treated can significantly reduce cardiovascular disease risk. The objectives of this study were to investigate the prevalence of hypertension and levels of awareness, treatment and control in a deprived urban area of Peru.
A cross-sectional study was completed. Blood pressure measurements were recorded in triplicate. Hypertension was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg, or self report of receiving antihypertensive medication at the time of interview.
The study sample was 584 adults (29.1% male, mean age 35.3 years). Age standardized prevalence of hypertension was 19.5% (95% CI 9.9%, 29.1%) in men, 11.4% (95% CI 3.7%, 19.1%) in women, and 13.2% (95% CI 5.0%, 21.5%) overall. Among those with hypertension 38.3% (95% CI 22.7%, 53.9%, n = 18/47) were aware of their condition with greater awareness among women than men. Of those aware, 61.1% (n = 11/18) were treated, equating to 23.4% (95% CI 10.1%, 36.7%, n = 11/47) of all adults with hypertension. Of those treated 63.6% (n = 7/11) had controlled hypertension, equating to 14.9% (95% CI 3.0%, 26.8%, n = 7/47) of all adults with hypertension.
Levels of awareness and control in this population were low. Lack of control is likely to be due to both a failure to diagnose hypertension, especially among men, and initiate or comply with treatment, especially among women. These results suggest a considerable burden of undiagnosed hypertension, and poor levels of control in those treated, in a deprived urban area of Lima, Peru.
PMCID: PMC2518278  PMID: 18710540
20.  Explaining significant differences in subjective and objective measures of cardiovascular health: evidence for the socioeconomic gradient in a population-based study 
To assess prevalence rates of subjective and objective reports of two cardiovascular disorders (hypertension and hypercholesterolemia) for the same subset of respondents in a large-scale study. To determine whether and the extent to which the socioeconomic health gradient differed in the subjective and objective reports of the two cardiovascular disorders.
Data from the first wave (2009/2011) of The Irish Longitudinal Study on Ageing were used (n = 4,179). This is a nationally representative study of community-dwelling adults aged 50+ residing in Ireland. Subjective measures were derived from self-reports of doctor-diagnosed hypertension and high cholesterol. Objective measure of hypertension was defined as: systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg and/or on antihypertensive medication. Objective measure of hypercholesterolemia was defined as: total cholesterol ≥5.2 mmol/L and/or on cholesterol-lowering medication. Objective measures of low-density-lipoprotein cholesterol and high-density-lipoprotein cholesterol were also used. Two measures of socioeconomic gradient were employed: education and wealth. Binary and multinomial logistic and linear regression analyses were used. Analyses were adjusted for an extensive battery of covariates, including demographics and measures of physical/behavioural health and health care utilization.
Prevalence of cardiovascular disorders: prevalence of hypertension and hypercholesterolemia was significantly higher when the cardiovascular disorders were measured objectively as compared to self-reports (64% and 72.1% versus 37% and 41.1%, respectively). Socioeconomic gradient in hypertension: the odds of being objectively hypertensive were significantly lower for individuals with tertiary/higher education (OR, 0.74; 95% CI, 0.60-0.92) and in the highest tertile of the wealth distribution (OR, 0.77; 95% CI, 0.62-0.95). In contrast, the associations between socioeconomic status and self-reported hypertension were not statistically significant. Socioeconomic gradient in hypercholesterolemia: wealthier individuals had higher odds of self-reporting elevated cholesterol (OR, 1.28; 95% CI, 1.03-1.58). Associations between socioeconomic status and objectively measured hypercholesterolemia and low-density-lipoprotein cholesterol were not significant. Higher education and, to a lesser extent, greater wealth were associated with higher levels of high-density-lipoprotein cholesterol.
Clear discrepancies in prevalence rates and gradients by socioeconomic status were found between subjective and objective reports of both disorders. This emphasizes the importance of objective measures when collecting population data.
PMCID: PMC3765886  PMID: 24119371
21.  Hypertension in the Parsi community of Bombay: a study on prevalence, awareness and compliance to treatment 
BMC Public Health  2003;3:1.
Uncontrolled hypertension (HT) is an established risk factor for the development of vascular diseases. Prevalence varies in different communities and no such study has been conducted in the Parsi community living in Bombay, India. The objectives of this study were to determine the prevalence, awareness, compliance to medication and control of HT in this community.
We used a 1 in 4 random selection of subjects who were ≥ 20 years of age. A questionnaire was administered and the blood pressure (BP) was measured by a doctor. HT was defined as diastolic blood pressure (DBP) ≥ 90 mm Hg ± systolic pressure (SBP) ≥ 140 mm Hg. Isolated systolic hypertension (ISH) was defined as SBP ≥ 160 mm Hg with DBP < 90 mm Hg. Subsequently, we reanalysed the data using current definition of ISH as SBP ≥ 140 mm Hg with DBP < 90 mm Hg.
2879 subjects ≥ 20 years of age were randomly selected of which 2415 (84%) participated in the study. The overall prevalence of HT in the community was 36.4%, of whom 48.5% were unaware of their hypertensive status. Of those aware of having HT, 36.4% were non-compliant with their anti-hypertensive drugs and only 13.6% had optimally controlled HT. Prevalence of ISH using the present criteria was 19.5% and 73% of hypertensives ≥ 60 years had ISH.
This study shows that prevalence of HT in the Parsi community is high and nearly half are unaware of their hypertensive status. ISH is the dominant form of HT in the elderly. Compliance to treatment is poor and optimal BP control is achieved in only a small minority. The study highlights the need for regular screening coupled with educational programs to detect and optimally treat HT in the community.
PMCID: PMC140316  PMID: 12513697
hypertension; prevalence; awareness; compliance; Parsis; India
22.  Improved Hypertension Control with the Imidazoline Agonist Moxonidine in a Multinational Metabolic Syndrome Population: Principal Results of the MERSY Study 
This study was designed to assess the effects of moxonidine on blood pressure and aspects of the metabolic syndrome in racially diverse population of patients encountered in routine medical practice. Physicians collected data on a minimum of three consecutive patients with uncontrolled essential hypertension and criteria for metabolic syndrome, eligible to receive moxonidine (0.2–0.4 mg once daily) for 6 months, either as monotherapy or as adjunct therapy to current antihypertensive treatment. Systolic and diastolic blood pressure (BP) declined by an average of 24.5 + 14.3 mmHg and 12.6 + 9.1 mmHg, respectively. BP responder rates defined as attaining BP < 140/90 mmHg were significantly (P < 0.001) and substantially higher among younger patients, nonpostmenopausal women, and patients receiving monotherapy. While potentially relevant improvements in the entire cohort were observed in regard to body weight (−2.1 ± 5.4 kg), fasting plasma glucose (from 6.8 to 6.2 mmol/L), and triglycerides (2.4 to 2.0 mmol/L), statistically significant changes in metabolic parameters could only be detected in subgroup analyses. Moxonidine therapy reduced blood pressure and improved rates of blood pressure control in this group of patients. While the observed trend towards improvement in various metabolic parameters merits further investigation, the overall effect of moxonidine treatment is consistent with a reduction of total cardiovascular risk in this hypertensive metabolic syndrome cohort.
PMCID: PMC3596898  PMID: 23533713
23.  Prevalence, awareness and risk factors of hypertension in a large cohort of Iranian adult population 
Journal of hypertension  2013;31(7):1364-1371.
There is considerable variation in hypertension prevalence and awareness, and their correlates, across different geographic locations and ethnic groups. We performed this cross-sectional analysis on data from the Golestan Cohort Study (GCS).
Enrollment in this study occurred in 2004–2008, and included 50,045 healthy subjects from Golestan Province in northeastern Iran. Hypertension was defined as a systolic blood pressure (SBP) ≥140, a diastolic blood pressure (DBP) ≥90, a prior diagnosis of hypertension, or the use of antihypertensive drugs. Potential correlates of hypertension and its awareness were analyzed by logistic regression adjusted for sex, age, BMI, place of residence, literacy, ethnicity, physical activity, smoking, black and green tea consumption and wealth score.
Of the total cohort participants, 21,350 (42.7%) were hypertensive. Age-standardized prevalence of hypertension, using the 2001 WHO standard world population, was 41.8% (95%CI: 38.3%–45.2%). Hypertension was directly associated with female sex, increased BMI, Turkmen ethnicity, and lack of physical activity, and inversely associated with drinking black tea and wealth score. Among hypertensive subjects, 46.2% were aware of their disease, 17.6% were receiving antihypertensive medication, and 32.1% of the treated subjects had controlled hypertension. Hypertension awareness was greater among women, the elderly, overweight and obese subjects, and those with a higher wealth score.
Hypertension is highly prevalent in rural Iran, many of the affected individuals are unaware of their disease, and the rate of control by antihypertensive medications is low. Increasing hypertension awareness and access to health services, especially among less privileged residents are recommended.
PMCID: PMC3766446  PMID: 23673348
hypertension; awareness; obesity; smoking; socioeconomic status
24.  Socioeconomic characteristics and controlled hypertension: Evidence from Isfahan Healthy Heart Program 
ARYA Atherosclerosis  2013;9(1):77-81.
Hypertension is a major risk factor for cardiovascular diseases. It affects approximately 18.0% of Iranian adults. This study aimed to estimate age-adjusted prevalence of hypertension and its control among Iranian persons older 19 years of age. It also tried to find and socioeconomic factors associated with hypertension control in Iranian population.
In Isfahan Healthy Heart Program (IHHP) subjects were selected by multistage random sampling. The participants completed questionnaires containing demographic information, lifestyle habits, medical history, and consumption of relevant medications, especially antihypertensive agents. Income, marital status, and educational level were considered as socioeconomic factors. Hypertension was defined as systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg, or taking antihypertensive medications. Controlled hypertension was considered as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg among hypertensive subjects.
The prevalence of hypertension and controlled hypertension was 18.9% and 20.9%, respectively. We found significant relationships between hypertension and marital status, education, and income. At age ≥ 65 years old, odds ratio (OR) was 19.09 [95% confidence interval (CI): 15.01-24.28] for hypertension. Middle family income (OR: 0.71; 95% CI: 0.58-0.87) and education level of 6-12 years (OR: 0.29; 95% CI: 0.25-0.35) were significantly associated with increased risk of hypertension (P = 0.001). Among subjects aging 65 years old or higher, the OR of controlled hypertension was 2.64 (95% CI: 1.61-4.33). Married subjects had a higher OR for controlled hypertension (OR: 2.19; 95% CI: 1.36-3.52). Obesity had no significant relationships with controlled hypertension.
The IHHP data showed significant relationships between some socioeconomic factors and controlled hypertension. Therefore, as current control rates for hypertension in Iran are clearly unacceptable, we recommend preventive measures to control hypertension in all social strata of the Iranian population.
PMCID: PMC3653252  PMID: 23696763
Socioeconomic Factor; High Blood Pressure; Control
25.  Prevalence, awareness and control of hypertension in estate workers in Malaysia 
Hypertension continues to be a major causative factor contributing to cardiovascular, cerebrovascular and renal morbidity and mortality.
The objective of this study was to assess the prevalence, awareness and control of hypertension in the estate population in Johor, Malaysia.
Patients and Methods:
A mercury sphygmomanometer was used to record systolic and diastolic blood pressures. Cross sectional population survey was carried out in the study.
The overall prevalence of hypertension in 903 subjects studied was 26.91% (243). A higher prevalence 27.65 % (133) was found in males against 26.07% (110) in females. Awareness of the disease was present in only 39% (96) of which 86.45% (83) received treatment. Among those who received treatment, control of hypertension was present in 15.66% (13).
The prevalence of hypertension among the estate population is lower than that of the general population of Malaysia, which can be attributed to their regular physical activity but the awareness, treatment, control and follow-up of patients is disappointingly low.
PMCID: PMC3271415  PMID: 22363074
Estate workers; hypertension; prevalence; physical activity

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