A 7-fold increase in mortality when high blood pressure develops in diabetic patients is more than enough reason for both doctors and patients to pay more attention to this high-risk combination. Updated guidance published in the current issue of the American Society of Hypertension’s (ASH) Journal of Clinical Hypertension addresses the urgent need for physicians to take a more integrated, individualized approach to treating hypertension (high blood pressure) in patients with diabetes by treating the intricacies of each patient profile, rather than focusing on the disease in isolation. Early initiation of medications that block the renin angiotension system (ACE inhibitors or ARBs) coupled with either thiazide-like diuretics or calcium antagonists are needed to maintain blood pressure less than 130/80 mmHg. Additionally, more frequent patient follow-up is recommended.

While the fundamentals of treatment and blood pressure goals remain unchanged, the authors emphasize that early detection of risk factors unique to each patient and earlier, more aggressive treatment be implemented. Follow-up visits after each medication adjustment should occur within 2 to 3 weeks as opposed to 4 to 8 weeks, and immediate referral to an ASH-certified clinical hypertension specialist should occur if repeated attempts to achieve blood pressure goal fails. Achieving and sustaining blood pressure goal earlier during treatment has been shown retrospectively in many clinical trials to have an impact on stroke risk. Thus, such an approach is necessary to stop the cardiovascular event rates and stroke death toll from spiraling even further out of control.

Hypertension affects more than 70 million Americans and is the most prevalent risk factor for cardiovascular and kidney disease. More than 75 percent of adults with diabetes have hypertension or are using antihypertensive medications. If implemented, this new guidance will potentially lead to better control of blood pressure, blood sugar and blood fats, all major risk factors for cardiovascular events if they are not properly managed.

“We know that mortality increases by more than 7-fold when hypertension is present in patients with diabetes,” said George Bakris, MD, president-elect of the American Society of Hypertension, co-author of the Position Paper and professor, University of Chicago School of Medicine. “Because of their increased cardiovascular risk, these patients require an integrated therapeutic intervention that, in addition to blood pressure control, should include glycemic and lipid control and antiplatelet therapy. It is imperative that we attack all risk factors simultaneously and manage the profile of each patient type more vigilantly.”

The guidance from the American Society of Hypertension is offered in a series of recommendations, accompanied by a modified treatment algorithm. Of note, the guidance draws attention to the fact that treatment of blood pressure in people with diabetes must also focus on reducing proteinuria if present. Proteinuria refers to an excessive amount of protein in the urine and may be a sign of impending kidney failure and/or a precursor to stroke and other potentially life-threatening cardiovascular events. The guidance emphasizes the importance of early identification and management of proteinuria as part of its more integrative approach to patient management.

“Diabetes is a complex disease in which blood pressure control is imperative, but it requires more than blood pressure control alone to be most effective,” explained Henry Black, MD, president of the American Society of Hypertension. “Our medical organization is providing physicians with more up-to-date guidance on how to assess and treat hypertensive patients with diabetes and we are saying ‘act globally’ to improve cardiovascular health.”

Current guidelines advise that patients start on a combination antihypertensive therapy, ideally in a single pill to improve patient adherence, if blood pressure is greater than 20/10 mmHg above recommended target levels. ASH’s new guidance reinforces this concept and provides specific data demonstrating how to initiate treatment and follow up with patients to achieve target blood pressure goals.

The authors of The Journal of Clinical Hypertension Position Paper were George L. Bakris, MD and James R. Sowers, MD, on behalf of the Hypertension Writing Group (Newswise).

Biofeedback has evolved from a fascination in the 1960s and 1970s to a mainstream methodology today for treating certain medical conditions and improving human performance. This evolution has been driven by years of scientific research demonstrating that the mind and body are connected, and that people can be taught to harness the power of this connection to change physical activity and improve health and function. Public interest in biofeedback is growing, and with it the need for a clear answer to the question, “what is biofeedback?” The leading professional organizations representing the field have answered with the following standard definition, published earlier this month.

“Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately “feed back” information to the user. The presentation of this information - often in conjunction with changes in thinking, emotions, and behavior - supports desired physiological changes. Over time, these changes can endure without continued use of an instrument.”

The Association for Applied Psychophysiology and Biofeedback (AAPB), the Biofeedback Certification Institute of America (BCIA), and the International Society for Neurofeedback and Research (ISNR) convened a task force of renowned scientists and clinicians in late 2007 who worked together to craft the standard definition. “It is important for people to have good information from sources they can trust when making decisions about what health care and performance improving methods to choose,” commented AAPB President, Aubrey Ewing, Ph.D. “We felt strongly that with more about biofeedback and its efficacy appearing in the media, and the potential for confusion arising from inaccurate use of the term, that a standard definition was necessary,” he added.

Biofeedback has been shown to be an effective treatment for migraine and tension type headache, urinary incontinence, high blood pressure, anxiety, and a number of other conditions. A growing body of research indicates that neurofeedback, (also known as EEG biofeedback) is an effective treatment for attention deficit hyperactivity disorder (ADHD) and can help manage the symptoms of autistic spectrum disorders, brain injury, posttraumatic stress, seizures, and depression. Corporate executives, musicians, artists, and athletes, including some of the medal winners in this year’s Beijing Olympics, use biofeedback and neurofeedback to reach their peaks in competition and performance.

The mainstream of biofeedback and neurofeedback practitioners, as represented by AAPB, BCIA, and ISNR, follow a standard of care based on scientific evidence that supports the use of particular biofeedback and neurofeedback methods, instruments, and claims of efficacy. The standard definition is intended to help consumers and the media in recognizing legitimate practitioners and methods, and insurance companies and government agencies in making decisions about biofeedback and neurofeedback coverage and regulation.

The Association for Applied Psychophysiology and Biofeedback (AAPB) web site provides consumer information as well as being a professional resource (Newswise).

MUSC.edu - Millions of patients with treatment-resistant clinical depression, who have struggled for years with disability and how to cope with their condition, now have an alternative treatment option that could help them lead more productive and successful lives.

The NeuroStar TMS (Transcranial Magnetic Stimulation) Therapy system, developed by Neuronetics, Inc. and initiated by research at the Medical University of South Carolina (MUSC), is the first and only approved TMS Therapy® device cleared by the Food and Drug Administration for the treatment of severe depression (October 7, 2008). Patients must be adults with major depressive disorder, commonly known as treatment-resistant depression, who have failed to improve their condition with other treatments or medication.

MUSC currently is the only location in South Carolina, North Carolina, Virginia, and Florida with this treatment option for depression. Patients will have access to the therapy at MUSC within two months.

MUSC Distinguished University Professor of Psychiatry and Brain Stimulation Laboratory Director Mark George, M.D., played a major role in developing this technology since its beginnings in the late 1980s.

“Everyone in the Brain Stimulation Laboratory has worked so hard for so many years on these studies,” he said. “They all deserve credit, as well as many other colleagues who helped to develop the necessary medical equipment to make this therapy a reality. Despite the gloom and doom that seems to surround us, the world is slightly better today than yesterday, as patients with depression have another option to try and relieve their pain and suffering.”

George also credited NARSAD (the world’s leading charity dedicated to mental health research) with a large role in advancing the new treatment by providing funding and continued support for the first trials involving this kind of treatment.

In addition to this trial that resulted in FDA approval, MUSC is conducting an NIMH (National Mental Institutes of Health) sponsored, double-blind clinical trial for TMS that will conclude in December. For more information, visit http://clinicaltrials.gov/ct2/show/NCT00149838.

How Transcranial Magnetic Stimulation works

TMS Therapy is a non-systemic (does not circulate in the bloodstream) and non-invasive (no surgery) form of neuromodulation which stimulates nerve cells in an area of the brain that is linked to depression, by delivering highly focused MRI-strength magnetic pulses. Patients treated with NeuroStar TMS Therapy do not require anesthesia or sedation and remain awake and alert. It is a 40-minute outpatient procedure that is prescribed by a psychiatrist and performed in a psychiatrist’s office. The treatment is typically administered daily for 4-6 weeks. Cost of the treatment is approximately $200-300 per session.

In the randomized controlled trial conducted for the FDA, the therapy showed significant treatment effects without systemic side effects such as weight gain or sexual dysfunction.

Throughout the NeuroStar TMS Therapy studies, more than 10,000 active TMS treatments were safely performed with:
• No systemic side effects, such as sedation, nausea, or dry mouth
• No adverse effects on concentration or memory
• No seizures
• No device-drug interactions
• Mild to moderate scalp pain or discomfort at the treatment area during treatment, which declined after the first week of treatment
• A less than 5 percent discontinuation rate due to adverse events
• There were no new safety observations compared to those seen during acute treatment during a 6 month follow-up period

NeuroStar TMS Therapy is contraindicated in patients with implanted metallic devices or non-removable metallic objects in or around the head. As with any antidepressant treatment, patients should be monitored for symptoms of worsening depression. NeuroStar TMS Therapy has not been studied in patients who have not received prior antidepressant treatment. Efficacy has not been established in patients who have failed to receive benefit from two or more prior antidepressant treatments at minimal effective dose and duration in the current episode.

About Neuronetics
Neuronetics, Inc. is a privately-held medical device company focused on developing non-invasive therapies for psychiatric and neurological disorders using MRI-strength magnetic field pulses. Based in Malvern, PA., Neuronetics is the leader in the development of TMS Therapy, a non-invasive form of neuromodulation. For more information, please visit www.neuronetics.com.

HopkinsMedicine.org - Working with genetically engineered mice, researchers at Johns Hopkins have shown that daily doses of a standardized extract from the leaves of the ginkgo tree can prevent or reduce brain damage after an induced stroke.

The scientists, in a report published in Stroke, say their work lends support to other evidence that ginkgo biloba triggers a cascade of events that neutralizes free radicals known to cause cell death.

“It’s still a large leap from rodent brains to human brains but these results strongly suggest that further research into the protective effects of ginkgo is warranted,” says lead researcher Sylvain Doré, Ph.D., an associate professor in the Department of Anesthesiology and Critical Care Medicine. “If further work confirms what we’ve seen, we could theoretically recommend a daily regimen of ginkgo to people at high risk of stroke as a preventive measure against brain damage.”

In the study, researchers gave ginkgo biloba EGb 761 - a lab-quality form of the extract - to normal mice and HO-1 knockout mice, mice lacking the gene that produces the enzyme heme oxygenase-1(HO-1). The EGb 761 ginkgo biloba extract is available in the US as a dietary supplement, made available by Nature’s Way in their Ginkgold brand supplement. HO-1 breaks down heme, a common iron molecule found in blood, into carbon monoxide, iron and biliverdin. HO-1 has been shown to act as an antioxidant and have a protective effect against inflammation in animal models.

Doré and his team gave 100 milligrams per kilogram of EGb 761 extract orally once daily for seven days before inducing stroke in the mice by briefly blocking an artery to one side of the brain. (A bioequivalent dose in humans would probably cause an increased risk of bleeds or hemorrhagic stroke - ed).

After stroke induction, the mice were tested for brain function and brain damage. One such test, for example, involves running patterns, another tests reaction to an external stimulus. Similar tests were conducted on mice that did not receive the ginkgo extract.

Neurobehavioral function was evaluated before the study and at 1, 2 and 22 hours after stroke using a four-point scale: (1) no deficit, (2) forelimb weakness, (3) inability to bear weight on the affected side, (4) no spontaneous motor activity.

Results showed that normal mice that were pretreated had 50.9 percent less neurological dysfunction and 48.2 percent smaller areas of brain damage than untreated mice. These positive effects did not exist in the HO-1 knockout mice.

“Our results suggest that some element or elements in ginkgo actually protect brain cells during stroke,” says Doré.

Roughly 700,000 people experience a stroke in the United States annually. Of those, 87 percent have an ischemic stroke, which is caused by a blocked artery in the brain. Some brain damage occurs simply from the lack of blood getting to brain cells; however, it is known that an increase in the presence of free radicals at the site of an ischemic stroke - once the clot is cleared and the blood supply returns - is also a major cause of resulting brain cell damage. Free radicals are toxic oxygen molecules that are produced when cells die. According to Doré and his team, ginkgo increases HO-1 levels, and the antioxidant properties of this enzyme eliminate free radicals at the surrounding regions of the stroke site.

The only current treatment for ischemic stroke is to clear the clot with tissue plasminogen activator (tPA) or other means. This, however, offers no real protection against the cell damage that occurs when blood flow is restored.

“Ginkgo has long been touted for its positive effects on the brain and is even prescribed in Europe and Asia for memory loss,” says Doré. “Now we have a possible understanding for how ginkgo actually works to protect neurons from damage.”

Native to China, the ginkgo tree is grown as an ornamental shade tree in Australia, Southeast Asia, Europe, Japan and North America. It is commercially cultivated in France and the United States. It has a grey bark, reaches a height of 35 meters and a diameter of 3 to 4 meters. The ginkgo biloba tree has deciduous, fan-like leaves that are green, grey-yellow, brown or blackish. Only purified extracts of phytochemicals in the leaves can be ingested, as the leaves do contain a toxic component that needs to be purified out.

Editorial note - The study is interesting as another in a series of polyphenol and phytochemical studies showing great promise for treating vascular problems, but gingko extracts are not recommended in higher dose ranges because of the bleeding risk. I would like to see NIH carry out a series of studies comparing polyphenols from different sources - pomegranate, blueberry, cocoa, gingko, etc. - to find out which polyphenols or polyphenol combinations have such potential benefits. It would advance not only our basic knowledge of gene induction by phytochemicals, but also our nutritional knowledge for better preventive medicine prescriptions - Dr. Z.

MayoClinic.org - Many women - especially multitasking working mothers - know the overwhelmed feeling and stress caused by too much to do and too little time. Better time management can help you do more. And it has health benefits, such as less stress and a better quality of life.

The October 2008 issue of Mayo Clinic Women’s HealthSource offers tips to improve time management. The recommendation is to try one strategy for two to four weeks to see if it helps. If it does, add another. If not, try a different one.

Ten time management tips:

1. Plan each day. A schedule minimizes conflicts and last-minute rushes. Write a to-do list with the most important tasks at the top. Even if you don’t get through the list, you’ll know time was spent constructively.

2. Say no to nonessential tasks. Let priorities determine your schedule rather than letting guilt have the final say.

3. Delegate. Consider what you can eliminate or delegate from your to-do list. Be willing to let others do tasks differently from how you do them.

4. Take time to do a quality job. Doing something right the first time may take more time up front, but errors caused by rushing may require longer to correct.

5. Practice the 10-minute rule. Work on dreaded tasks for 10 minutes each day. Once a task is started, you may be able to finish it.

6. Evaluate how you are spending your time. Keep a diary for three days to track tasks. Look for time that could be used more wisely, freeing up time to spend exercising or with family and friends.

7. Get plenty of exercise and sleep. Improved focus and concentration help increase efficiency, so you can complete tasks in less time.

8. Take a time management course. Employers, community colleges and community education programs often offer these classes.

9. Take a break when needed. Too much stress can derail attempts at getting organized. When you need a break, take one. Take a walk. Do some quick stretches. Take time for a day of relaxation when you need it.

10. If you are too frazzled to manage your time better, and life feels out of control, ask for help. Consider discussing your situation with a doctor or mental health professional.

Rising unemployment rates, the worst Wall Street crises since the end of World War II, record home foreclosures. There is plenty of stress to go around. What effect is stress having on our health and what can we do about it?

“Prolonged stress, both emotional and physical, impacts the overall cardiovascular status of our patients, particularly their blood pressure,” said Keith Churchwell, M.D., executive medical director of the Vanderbilt Heart and Vascular Institute.

American and global stock markets on a daily rollercoaster ride, anxiety over the burden of the government’s bailout of Wall Street, and the added stress placed on all Americans by increased financial instability could be taking its toll.

Stress can cause increasing physical demands on the body, constriction of the coronary blood vessels and heightened electrical instability in the heart.

Emotional stress can lead to decreased heart rate variability and elevated blood pressure, making the heart work harder by putting even greater stress on the whole cardiovascular system. The long-term elevation of blood pressure can have a harmful effect on the heart and the entire vascular system. Stress hormones called catecholamines, including adrenaline, can have damaging effects on the heart muscle if exposed to elevated levels for a long time, Churchwell said.

A study of more than 10,300 civil servants found that employees under 50 who suffered chronic stress had a 68 percent higher risk of heart disease than those who were not stressed at work. The findings were reported in the European Heart Journal in January 2008 by researchers from University College in London.

This study demonstrates that stress at work can lead to coronary heart disease through direct activation of neuroendocrine stress pathways and indirectly through health behaviors, according to the report.

“It’s almost always multifactorial,” Churchwell said. “It’s not just the stress, but also how people adapt to stress.”

Many people react to stress by eating poorly, stopping exercise, smoking, drinking and missing medications.

If someone comes in to the Emergency Department complaining of chest pain, doctors will ask about emotional related stress, in addition to performing a medical evaluation to find the cause of the chest pain.

“We will see a number of people come through the Vanderbilt Heart and Vascular Clinic for an evaluation of chest pain, elevated blood pressure, and shortness of breath that are outward manifestations of the emotional currents going on in their work lives,” Churchwell said. “They will either be dragged in by a family member who is worried about them or by a co-worker.”

Churchwell added that he has not seen anyone whose heart troubles are caused by the recent stock market problems, but he wouldn’t rule it out as a possibility.

“We do see stress-related chest pain in people affiliated with the music business. They have been on the road doing 50 shows in 52 nights. They call from the road and ask if they can be seen this week, and they pull the tour bus up in front of the hospital.”

Churchwell offers these tips to avoid letting stress get the better of you:

• If you have a positive routine in terms of stress relief, such as exercise, stay on it.
• If you have to work 12 to 14 hours a day, take the time to eat healthy. Avoid junk food.
• Continue to take your medications as prescribed.
• Don’t resort to smoking and drinking alcohol as “stress relievers.”
• If you experience chest pain, seek the care of a health care professional (Newswise).