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High blood pressure (Hypertension)
Contents of this page:
Illustrations
Alternative Names
Definition
Causes
Symptoms
Exams and Tests
Treatment
Outlook (Prognosis)
Possible Complications
When to Contact a Medical Professional
Prevention
References
Illustrations
Monitoring blood pressure
Untreated hypertension
Lifestyle changes
DASH diet
High blood pressure tests
Exercise can lower blood pressure
Blood pressure check
Blood pressure
Alternative Names
Hypertension; HBP; Blood pressure - high
Definition Return to top
Hypertension is the term doctors use for high blood pressure.
Blood pressure readings are measured in millimeters of mercury (mmHg) and usually given as 2 numbers. For example, 140 over 90 (written as 140/90).
The top number is your systolic pressure, the pressure created when your heart beats. I
t is considered high if it is consistently over 140.
The bottom number is your diastolic pressure, the pressure inside blood vessels when the heart is at rest. It is considered high if it is consistently over 90.
Either or both of these numbers may be too high.
Pre-hypertension is when your systolic blood pressure is between 120 and 139 or your diastolic blood pressure is between 80 and 89 on multiple readings. If you have pre-hypertension, you are more likely to develop high blood pressure at some point.
See also: Blood pressure
Causes
Blood pressure measurements are the result of the force of the blood produced by the heart and the size and condition of the arteries.
Many factors can affect blood pressure, including how much water and salt you have in your body, the condition of your kidneys, nervous system, or blood vessels, and the levels of different body hormones.
High blood pressure can affect all types of people. You have a higher risk of high blood pressure if you have a family history of the disease. High blood pressure is more common in African Americans than Caucasians.
Most of the time, no cause is identified. This is called essential hypertension. High blood pressure that results from a specific condition, habit, or medication is called secondary hypertension.
Too much salt in your diet can lead to high blood pressure. Secondary hypertension may also be due to:
Adrenal gland tumor
Alcohol poisoning
Anxiety and stress
Appetite suppressants
Arteriosclerosis
Birth control pills
Certain cold medicines
Coarctation of the aorta
Cocaine use
Cushing syndrome
Diabetes
Kidney disease, including:
Glomerulonephritis (inflammation of kidneys)
Kidney failure
Renal artery stenosis
Renal vascular obstruction or narrowing
Migraine medicines
Hemolytic-uremic syndrome
Henoch-Schonlein purpura
Obesity
Pain
Periarteritis nodosa
Pregnancy (called gestational hypertension)
Radiation enteritis
Renal artery stenosis
Retroperitoneal fibrosis
Wilms' tumor
Symptoms Return to top
Most of the time, there are no symptoms. Symptoms that may occur include:
Confusion
Chest pain
Ear noise or buzzing
Irregular heartbeat
Nosebleed
Tiredness
Vision changes
If you have a severe headache or any of the symptoms above, see your doctor right away. This may be a signs of a complication or dangerously high blood pressure called malignant hypertension.
Exams and Tests
Your health care provider will perform a physical exam and check your blood pressure. If the measurement is high, your doctor may think you have high blood pressure. The measurements need to be repeated over time, so that the diagnosis can be confirmed.
If you monitor your blood pressure at home, you may be asked the following questions:
What was your most recent blood pressure reading?
What was the previous blood pressure reading?
What is the average systolic (top number) and diastolic (bottom number)?
Has your blood pressure increased recently?
Other tests may be done to look for blood in urine or heart failure. Your doctor will look for signs of complications to your heart, kidneys, eyes, and other organs in your body.
These tests may include:
Chem-20
Echocardiogram
Urinalysis
X-ray of the kidneys
Treatment Return to top
The goal of treatment is to reduce blood pressure so that you have a lower risk of complications.
There are many different medicines that can be used to treat high blood pressure. Such medicines include:
Alpha blockers
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin receptor blockers (ARBs)
Beta-blockers
Calcium channel blockers
Central alpha agonists
Diuretics
Renin inhibitors, including aliskiren (Tekturna)
Vasodilators
Medicines used if the blood pressure is very high may include:
Clonidine
Diazoxide
Furosemide
Hydralazine
Minoxidil
Nitroprusside
Your doctor may also tell you to exercise, lose weight, and follow a healthier diet. If you have pre-hypertension, your doctor will recommend the same lifestyle changes to bring your blood pressure down to normal range.
Outlook (Prognosis) Return to top
Most of the time, high blood pressure can be controlled with medicine and lifestyle changes.
Possible Complications Return to top
Aortic dissection
Blood vessel damage (arteriosclerosis)
Brain damage
Congestive heart failure
Kidney damage
Kidney failure
Heart attack
Hypertensive heart disease
Stroke
Vision loss
When to Contact a Medical Professional Return to top
If you have high blood pressure, you will have regularly scheduled appointments with your doctor.
Even if you have not been diagnosed with high blood pressure, it is important to have your blood pressure checked during your yearly check-up, especially if someone in your family has or had high blood pressure.
Call your health care provider right away if home monitoring shows that your blood pressure remains high or you have any of the following symptoms:
Chest pain
Confusion
Excessive tiredness
Nausea and vomiting
Severe headache
Shortness of breath
Significant sweating
Vision changes
Prevention Return to top
Lifestyle changes may help control your blood pressure:
Lose weight if you are overweight. Excess weight adds to strain on the heart. In some cases, weight loss may be the only treatment needed.
Exercise regularly.
Eat a healthy diet. Eat less fat and sodium. Salt, MSG, and baking soda all contain sodium. Eat more fruits, vegetables, and fiber.
Avoid smoking.
If you have diabetes, keep your blood sugar under control.
Follow your health care provider's recommendations to modify, treat, or control possible causes of secondary hypertension.
References
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Rockville, Md. National Heart, Lung, and Blood Institute, US Department of Health and Human Services; August 2004. National Institutes of Health Publication No. 04-5230.
Wang Y, Wang QJ. The prevalence of prehypertension and hypertension among US adults according to the new joint national committee guidelines: new challenges of the old problem. Arch Intern Med. 2004;164(19):2126-34.
Eyre H, Kahn R, Robertson RM, et al. Preventing cancer, cardiovascular disease, and diabetes: A common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109(25):3244-55.
Berg AO. Screening for High Blood Pressure Recommendations and Rationale U.S. Preventive Services Task Force. USPSTF Guide to Clin Preventive Services. June 1, 2003; 1.
Whelton PK, He J, Appel LJ, et al. Primary prevention of hypertension: Clinical and public health advisory from The National High Blood Pressure Education Program. JAMA. 2002;288(15):1882-8.
Update Date: 6/4/2007
Updated by: Larry A. Weinrauch, MD, Assistant Professor of Medicine, Harvard Medical School, and Private practice specializing in Cardiovascular Disease,Watertown, MA. Review provided by VeriMed Healthcare Network.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).
URAC's accreditation program is the first of its kind, requiring compliance with 53 standards of quality and accountability, verified by independent audit.
A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial process. A.D.A.M. is also a founding member of Hi-Ethics (www.hiethics.com) and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition
. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. Copyright 1997-2008, A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
Source:
U.S. National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894
National Institutes of Health | Department of Health & Human Services Page last updated: 25 September 2008
Tuesday, October 07, 2008
New research in Hypertension Control
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Hypertension Highlights
Assessing Guidelines, Strategies, and New Drugs to Get Patients to Target
Linda Brookes, MSc
Medscape Cardiology. 2007; ©2007 Medscape
Posted 02/22/2007
Introduction
New data highlighted this month reveal that hypertension control appears to be better in the United States than in Western Europe -- but unfortunately the latest US hypertension guidelines fail to substantially affect blood pressure control in diabetic patients, whereas the new Canadian hypertension guidelines highlight for the first time the dangers of "high normal" blood pressure.
Two new reports further confirm that there is a higher rate of incident diabetes with diuretics and beta-blockers, and beta-blockers are less effective than diuretics, calcium channel blockers, or angiotensin blockers as first-line therapy for elevated blood pressure control.
Finally, the first clinical trials with new second-generation renin inhibitors and a small catalog of new combination antihypertensive pills coming soon in Europe, the United States, and, as a polypill, in India are reported.
Hypertension Control Appears Better in the United States Than in Western Europe
An analysis of survey data appears to confirm previous population-based studies showing that patients with diagnosed hypertension in the United States have lower blood pressure levels and better hypertension control than patients in Western European countries.
The results of the analysis are published in the January 22 issue of Archives of Internal Medicine.[1] The US investigators attribute the difference to lower treatment thresholds and more intensive treatment set out in the most recent US hypertension management guidelines.
However, in their analysis, almost half the US patients did not achieve their goal blood pressure as recommended in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),[2] so "better blood pressure control in the United States should not be too quickly praised," they caution.
The study, which was supported by the MacLean Center for Clinical Medical Ethics, the National Institute of Aging, and the Agency for Healthcare Research and Quality, used patient data collected from surveys conducted in 2004 in France, Germany, Italy, Spain, and the United Kingdom, as well as the United States.
The surveys were part of Cardiomonitor, an ongoing survey of physician visits by ambulatory adult patients with cardiovascular diseases in selected countries carried out since 1980 by an international market research company (Taylor Nelson Sofres Healthcare, London).
In 2004, the physicians in the survey were randomly selected, and those who agreed to participate completed 2-page diaries for 15 cardiovascular patients. Information collected included patient characteristics, initial blood pressure level before treatment, any co-occurring diseases, and the use of 7 types of antihypertensive drugs.
Investigators led by Y. Richard Wang, MD, PhD, of Temple University Hospital and University of Pennsylvania, Philadelphia, identified a total of 21,053 patients with a primary or secondary diagnosis of hypertension in all 6 countries.
These patients had visited a total of 291 cardiologists and 1284 primary care physicians. The patients were 53% male, mean age was 65 years, and 23% had diabetes mellitus.
At least 92% of patients with hypertension in each country were receiving antihypertensive drug therapy.
Use of thiazide-type diuretics was similar across all countries (29% to 13%), but use of other antihypertensive drug classes -- beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) -- varied considerably. Use of combination therapy (≥ 2 drugs) was highest in the United States (64% vs 44% to 59% in European countries).
Initial blood pressure measurements before treatment were available for 61% to 80% of patients per country and were lowest in the United States (average of 161/94 mm Hg, vs an average of 167-173/96-99 mm Hg in Europe).
The most recent blood pressure reading was also lower in the United States than in any other country (average of 134/79 mm Hg, vs an average of 139-144/80-84 mm Hg in Europe).
Only 65% of US patients had an initial pretreatment blood pressure level ≥ 160/100 mm Hg, compared with 81% to 90% of patients in the European countries.
The rate of hypertension control was found to be highest among the US patients, whether control was defined as < 140/90 mm Hg for all patients or as < 130/80 mm Hg in patients with diabetes and < 140/90 mm Hg in all others. By the later definition, 53% of US patients achieved hypertension control compared with 27% to 40% of European patients.
Multivariate analyses controlling for age, sex, current smoking, and physician specialty showed that, compared with US patients, European patients had higher latest systolic blood pressure (SBP) levels (by 5.3-10.2 mm Hg across countries examined) and diastolic blood pressure (DBP) levels (by 1.9-5.3 mm Hg; all P < .001).
These differences remained significant (P < .01) after controlling for comorbidities and concurrent drug treatment.
European patients were less likely than US patients to have hypertension control or a medication increase for inadequately controlled hypertension (P < .001).
The researchers found that initial pretreatment blood pressure levels accounted for most of the cross-national differences in latest SBP and DBP levels and the likelihood of hypertension control.
Dr. Yang and his colleagues suggest that aggressive treatment in the United States means that some patients may be receiving drug treatment they do not need, involving extra cost. However, these costs are small compared with those that would result from a future cardiovascular event that occurred due to inadequate blood pressure control.
US Hypertension Guidelines Fail to Substantially Affect Blood Pressure Control in Diabetic Patients
Despite the publication of increasingly aggressive guidelines for lowering blood pressure and the superior rate of hypertension control in the United States compared with Europe, another study by Y. Richard Wang, MD, PhD, suggests that the guidelines have had little effect on hypertension control in diabetic patients.
The study is published in the January issue of Diabetes Care.[3] The findings appear to be consistent with previous studies that reported a lack of hypertension control in diabetic patients, despite the higher risk of cardiovascular disease that they have and despite recommendations by diabetes and family physician organizations, as well as those of the JNC.
Dr. Yang compared the effects of the JNC 7 guidelines on blood pressure control in patients with diabetes vs that in nondiabetic patients between 1995 and 2005.
The JNC VI guidelines, published in 1997, lowered blood pressure goals for diabetic patients to < 130/85 mm Hg.[4] This goal was subsequently lowered in 2003, in the JNC 7 guidelines, to 130/80 mm Hg.[2] Goal blood pressure for nondiabetic patients was < 140/90 mm Hg in both JNC VI and JNC 7.
Dr. Yang used data from the National Disease and Therapeutic Index, a nationally representative survey of outpatient visits in the United States carried out by IMS Health (Plymouth Meeting, Pennsylvania). Data were available for 19,616 diabetic and 162,672 nondiabetic adult patients diagnosed with hypertension, representing about 76 million diabetic and 638 million nondiabetic physician visits in the United States.
Defining blood pressure control as blood pressure < 140/90 mm Hg, an improvement in control was seen during the entire period in all diabetic and nondiabetic patients, but percent control was greater in the nondiabetic patients compared with the diabetic patients.
The rate of hypertension control improved for both diabetic and nondiabetic patients by between 1.5% and 2.5% between 1995 and 2005.
"However, the more aggressive goal blood pressure set in the JNC VI and JNC 7 guidelines for patients did not lead to substantially better hypertension control for diabetic subjects compared with nondiabetic subjects, for whom the goal blood pressure remained the same,"
Dr. Yang reports. After publication of JNC VI, there was no immediate change in rate of control (blood pressure < 130/85 mm Hg) in diabetic patients and only a nonsignificant 1.7% increase after 3 years.
A widening gap in blood pressure control was apparent after 2001 that continued after 2003, when JNC 7 was published. By 2005, the rate of blood pressure control in nondiabetic patients (< 140/90 mm Hg) was 20% higher than control (< 130/85 mm Hg) in diabetic patients.
Dr. Yang comments that the findings of his study are "somewhat surprising considering the recognition of JNC guidelines as the gold standard for hypertension treatment, similar recommendations from other organizations such as American Diabetes Association, American College of Physicians, and American Academy of Family Physicians, and public health efforts to promote comprehensive diabetes care.
" He suggests that the reasons for this lack of improvement in blood pressure control in hypertensive patients with diabetes may be due to patient noncompliance with lifestyle recommendations and drug treatment, physician inertia to initiate and intensify treatment, and inadequate access to medical care.
"The continued lack of hypertension control for patients with diabetes in the US despite the publication of more aggressive guidelines has significant long-term cost implications for the health care system," he writes. Identifying effective interventions to deal with the challenge of lowering blood pressure in people with diabetes should be a top priority for future research, he concludes.
New Canadian Hypertension Guidelines Highlight Dangers of High Normal Blood Pressure
New guidelines for hypertension management were released to the public in Canada in January.
The Hypertension: 2007 Public Recommendations,[5] the second public version of the guidelines, has been adapted from the latest professional recommendations by Blood Pressure Canada, the Heart and Stroke Foundation of Canada, the Canadian Hypertension Education Program (CHEP), and the Canadian Hypertension Society.
For the first time, the Canadian guidelines focus on prevention of hypertension and the importance of recognizing "high normal" blood pressure (ie, 130-139/85-89 mm Hg). "More than one half of people with high normal blood pressure develop hypertension within 4 years unless they make lifestyle changes," the guidelines caution.
They also warn that > 9 in 10 Canadians will develop hypertension unless they follow a healthy lifestyle. Recommended ways to lower blood pressure include:
Physical activity for 30-60 minutes most days of the week;
More vegetables, fruit, low-fat dairy products, foods low in saturated and trans fat and salt, whole grains, lean meat, fish, and poultry in the diet; less fat food and canned or prepared foods;
Reducing salt intake;
Drinking less alcohol (≤ 1-2 drinks per day);
No smoking; and
Weight loss (at least 10 lb/5 kg) if overweight.
Advice is given on how to cut down salt intake by reading food labels and restaurant menus more carefully.
The need for regular blood pressure checks is emphasized. Target blood pressures (< 140/90 mm Hg in most people and < 130/80 mm Hg in people with diabetes or kidney disease) are explained and ways of measuring blood pressure at a physician's office or at home are described, along with the possibilities of white coat or masked hypertension when blood pressure is measured by a doctor.
Patients with diabetes or with cholesterol as well as high blood pressure are urged to ask their doctors to do kidney function tests.
As to treating hypertension, the guidelines explain that in most people at least 2 medications (probably taken in a single tablet) will be necessary in addition to the lifestyle changes.
They stress the importance of adherence to treatment and the problems that can arise if patients are not honest with their doctors about forgetting to take medications (unnecessarily increased doses, etc.).
Diuretics, beta-blockers (in patients aged < 60 years), ACE inhibitors, ARBs, and calcium channel blockers (CCBs) "all reduce blood pressure by the same amount on average," say the guidelines.
They say that some patients are more likely to need specific classes of antihypertensive drugs (eg, a diuretic and an ACE inhibitor/ARB in patients with diabetes or kidney disease, and a beta-blocker and an ACE inhibitor in patients with heart disease). They stress that the full effects of antihypertensive medication may not be apparent for up to 6 weeks.
Almost one quarter of Canadian adults -- about 5 million -- are estimated to have hypertension and 2.5 million to have high normal blood pressure. Hypertension is the leading reason for visits to primary care physicians.
Speaking on behalf of the Heart and Stroke Foundation of Canada, Sheldon W. Tobe, MD, (Sunnybrook and Women's College Health Science Centre and University of Toronto) stressed the significance of high-normal blood pressure in the new guidelines.
"We believe family doctors now understand the thresholds for diagnosing high blood pressure. Now we're saying, let's prevent hypertension from occurring. It is a big step forward," he said. "It is time for doctors to take the next step: to recognize the risks of high-normal blood pressure and treat it before it develops into high blood pressure.
" People with blood pressure in the high-normal range have double the risk of heart disease and stroke compared with those with normal blood pressure, he noted. Dr. Tobe believes that lifestyle changes can be as effective in lowering blood pressure as drug therapies.
Patients are more likely to succeed in making lifestyle changes and maintaining them if a physician emphasizes the importance of prevention by arranging a follow-up visit, and the patient is more likely to agree to make lifestyle changes and comply, he says.
Patients with high-normal blood pressure should monitor their blood pressure at home and keep track of their progress and setbacks, he recommends.
Higher Rate of Incident Diabetes With Diuretics and Beta-blockers Confirmed in Analysis of Clinical Trials
An analysis of data from major trials of antihypertensive drugs, published in The Lancet,[6] has confirmed that ARBs and ACE inhibitors have the lowest association with incident diabetes and diuretics and beta-blockers the highest.
William J. Elliott, MD, and Peter M. Meyer, PhD, (Rush University Medical Center, Chicago, Illinois) conducted their analysis using a new statistical technique known as network meta-analysis.[7]
This type of analysis allows the relative effectiveness of 2 treatments to be estimated when they have not been compared with each other directly in a randomized trial, but have each been compared with other treatments.
In this way, Drs. Elliott and Meyer were able to make comparisons of antihypertensive drug classes, including ARBs and ACE inhibitors, that had never been directly compared in a randomized clinical trial. Their study was supported in part by the US National Institutes of Health.
Long-term randomized clinical trials of antihypertensive drugs that reported new cases of diabetes from 1966 to September 15, 2006, were identified from searches of MEDLINE and other medical publication databases and reference lists from all meta-analyses and all other potential sources.
A total of 22 clinical trials comprising 143,153 enrolled participants who did not have diabetes at randomization were found to be eligible for inclusion in the analysis. Seventeen trials enrolled patients with hypertension, 3 enrolled high-risk patients, and 1 enrolled those with heart failure. The trials involved a total of 48 groups of patients randomized to initial treatment with a(n):
ARB (5 groups, 14,185 patients);
ACE inhibitor (8 groups, 22,941 patients);
CCB; (9 groups, 38,607 patients);
Placebo (9 groups, 24,767 patients);
Beta-blocker (9 groups, 35,745 patients); or
Diuretic (8 groups, 18,699 patients).
Using an initial diuretic as the standard of comparison, initial treatment with an ARB, ACE inhibitor, CCB, or placebo was in all cases associated with significantly fewer cases of incident diabetes. The odds ratios were:
ARB 0.57 (95% confidence interval [CI] 0.46-0.72, P < .0001);
ACE inhibitor 0.67 (95% CI 0.56-0.80, P < .0001);
CCB 0.75 (95% CI 0.62-0.90, P = .002);
Placebo 0.77 (95% CI 0.63-0.94, P = .009); and
Beta-blocker 0.90 (95% CI 0.75-1.09, P = .30).
When placebo was used as referent agent, only the initial ARB and the initial diuretic retained significance, with the diuretic associated with a 30% increase in risk of incident diabetes. These results changed little when subjected to sensitivity analyses.
Drs. Elliot and Meyer point out that their results are consistent with those of previous meta-analyses.
The reasons for the different effects of these antihypertensive drug classes may be due to their effects on circulating kinins, pancreatic insulin release, and the peripheral effects of insulin, they suggest, noting that animal studies have also implicated the peroxisome proliferator-activated receptor gamma (PPAR-gamma) receptor. "Which of these is mort important in human beings remains a topic for future research," they say.
They add that the implications of their findings for clinical practice are uncertain, given the approaches of different national hypertension guidelines to diuretics and beta-blockers and the lack of data about the increased cardiovascular risk associated with incident diabetes over the long term.
More high quality data can be expected from current clinical trials such as the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial, the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET), and the Telmisartan Randomized Assessment Study in ACE-Intolerant Subjects With Cardiovascular Disease (TRANSCEND), each of which includes incident diabetes as a primary or secondary end point.
They may also help to determine whether ARBs and ACE inhibitors have significantly different effects on incident diabetes.
First-line Beta-blockers Less Effective Than Diuretics, CCBs, or Angiotensin Blockers for Elevated Blood Pressure
An analysis of clinical trials of beta-blockers by a group of researchers based in South Africa confirm previous reports that beta-blockers are "inferior first-line choices" for the treatment of hypertension compared with diuretics, ACE inhibitors/ARBs, or CCBs.
The analysis, which was funded by the Medical Research Council of South Africa, first appeared in the Journal of Hypertension[8] and has now been published by the Cochrane Collaboration.[9] Its conclusion, which was the same in both publications, was based on the relatively weak effect of beta-blockers in preventing stroke and the absence of an effect on coronary heart disease (CHD) compared with placebo or no treatment.
More importantly, say the authors, they based it on the trend toward worse outcomes compared with CCBs, angiotensin blockers, and thiazide-type diuretics.
The analysis was undertaken because previous meta-analyses compared beta-blockers with all other antihypertensive drugs taken together, whereas the South African group points out that they might be better or worse than a specific class of drugs for a particular outcome measure.
In addition, previous reviews did not examine the tolerability of beta-blockers relative to other antihypertensive medications.
Lead authors Charles Shey Wiysonge, MD, (University of Cape Town, Groote Schuur Hospital) and Hazel A Bradley, MPH, (University of the Western Cape, Bellville) described how they identified eligible clinical trials published through June 2006 by searching the Cochrane Controlled Trials Register, MEDLINE, EMBASE, reference lists of previous reviews, and by contacting researchers.
They were looking for randomized, controlled trials that assessed the effectiveness of beta-blockers compared with placebo, no therapy, or other drug classes, as monotherapy or first-line therapy for hypertension, on mortality and morbidity end points in men and nonpregnant women aged ≥ 18 years.
Thirteen trials, involving 91,561 participants, that met the inclusion criteria were identified. These trials compared beta-blockers with placebo or no treatment (4 trials with 23,613 participants), diuretics (5 trials with 18,241 participants), CCBs (4 trials with 44,825 participants), or ACE inhibitors or ARBs, which were grouped together as renin-angiotensin system (RAS) inhibitors because of small numbers (3 trials with 10,828 participants).
Trial participants were analyzed according to the groups to which they were randomized, regardless of subsequent treatment they actually received.
The researchers found that the effect of beta-blockers on all-cause mortality did not differ from that of placebo, diuretics, or RAS inhibitors, but was significantly higher for beta-blockers compared with CCBs (relative risk [RR] 1.07, 95% CI 1.00-1.14, P = .04), corresponding to an absolute increase of 0.5%. Patients on beta-blockers had a markedly reduced risk of total cardiovascular disease (fatal and nonfatal CHD and stroke, plus congestive heart failure and transient ischemic attack, when reported) compared with placebo (RR 0.88, 95% CI 0.79-0.97).
This was primarily a reflection of the significantly lower risk of stroke with beta-blockers (RR 0.80, 95% CI 0.66-0.96), calculated as an absolute risk reduction of 0.5% compared with placebo.
The effect of beta-blockers on cardiovascular disease was significantly worse than that of CCBs (RR 1.18, 95% CI 1.08-1.29) but did not differ from that of diuretics or RAS inhibitors. Increased total cardiovascular disease was due to an increase in stroke compared with CCBs (RR 1.24, 95% CI 1.11-1.40), an increase in absolute risk of 0.5%.
There was also an increase in stroke with beta-blockers compared with RAS inhibitors (RR 1.30, 95% CI 1.11-1.53), an increase in absolute risk of 1.5%. The effect of beta-blockers on CHD was not significantly different from that of placebo, diuretics, CCBs, or RAS inhibitors.
Patients on beta-blockers were more likely than those on diuretics or RAS inhibitors to discontinue treatment due to side effects, but there was no difference compared with placebo or CCBs.
There were no differences in depressive symptoms among the different treatment groups, but patients on beta-blockers appeared more likely than those on diuretics, CCBs, or RAS inhibitors to develop fatigue.
The risk of sexual dysfunction appeared lower than with diuretics, but higher than with CCBs or RAS inhibitors. Blood pressures (SBP and DBP) in the beta-blocker arms of the trials were 0-2 mm Hg higher than on the other treatment arms.
This study was able to confirm the finding of a previous meta-analysis carried out by Swedish researchers, which found beta-blockers are less effective than other antihypertensive drugs at preventing strokes.[10] However, because of lack of data, Dr. Wiysonge and colleagues were unable to confirm whether the disadvantages of beta-blockers as first-line antihypertensive therapy are limited to elderly patients, as suggested by Canadian researchers Nadia Khan, MD, and Finlay A McAlister, MD, in a previous review.[11]
They also could not draw any conclusions about whether cardioselective and nonselective beta-blockers have different effects, since most of the beta-blocker trials in the analysis used atenolol (75% of participants on beta-blockers). These questions should be addressed in new randomized clinical trials, the researchers recommend.
Clinical Trials Begun With New Second-Generation Renin Inhibitor
Another second-generation oral renin inhibitor has entered clinical trials in development for the treatment of hypertension. Speedel (Basel, Switzerland), the company that licensed and originally developed the first oral renin inhibitor likely to receive regulatory approval, announced in January that a phase 1 trial of SPP1148 had begun to test the safety and tolerability of single and multiple oral doses in healthy volunteers. First results are expected in during the last quarter of 2007.[12]
SPP1148 was selected for clinical trials following the preclinical evaluation of 2 potential candidates from the SPP1100 series on the basis of its superior animal bioavailability, positive effects on renal failure models in animals, and its suitability for manufacturing, Speedel says.
The SPP1100 series is one of several new series of renin inhibitors in development by Speedel Experimenta, the company's late-stage research unit, and is based on a new chemical entity. Speedel is developing a number of series of second-generation renin inhibitors, including the SPP600 series (under license from Roche), the SPP800 series (developed with Locus Pharmaceuticals), and the SPP1100 series.
A member of the SPP600 series, SPP635, progressed to a phase 2a proof-of-concept trial in October 2006. This trial is treating 35 hypertensive patients with SPP635 and is expected to finish during the third quarter of 2007.
Aliskiren (SPP100), the first-in-class renin inhibitor, expected to be on the market in the United States and Europe this year, is partnered with Novartis (Basel) for development and commercialization in hypertension.
Novartis filed for regulatory approval for aliskiren in the United States and Europe in 2006, and the US regulatory review process, which was extended in December by up to 3 months, is expected to be completed during the first quarter of 2007. Novartis predicts that it will launch aliskiren for the treatment of hypertension during the first half of 2007 in the United States and during the first half of 2007 in Europe.
The company presented extensive phase 3 clinical data at cardiology and hypertension conferences, including the World Congress of Cardiology, throughout 2006, and has an ongoing cardiovascular outcome program investigating aliskiren in primary and secondary prevention as well as in heart failure.
Speedel believes that "renin inhibition may be the new gold standard for the treatment of hypertension and related disorders in the next decade." Although renin inhibitors have been described as "a breakthrough," and it has been suggested that renin inhibitors would be expected to have fewer side effects than ACE inhibitors, they might be less powerful in reducing blood pressure because they do not block the degradation of bradykinin.[13]
Other companies reported to be developing renin inhibitors, some of which have moved into early clinical trials, include Actelion, Merck, GlaxoSmithKline/Vita, and Pfizer.
New Combination Antihypertensive Pills Coming Soon in Europe, the United States, and, as a Polypill, in India
Three new pills containing fixed doses of 2 antihypertensive drugs are expected to come on the market within the next 2 years. Two of these pills will contain only blood pressure lowering drugs, but 1 is being touted as the first commercially available "polypill" developed especially with less affluent countries in mind.
The 2-drug pills comprise a CCB and ACE inhibitor or ARB. This combination is becoming increasingly popular as antihypertensive treatment, with or without a thiazide-type diuretic, as demonstrated recently in the blood pressure-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-BPLA),[14] and as recommended in the latest UK hypertension guidelines.[15]
Fixed Combination of a CCB and a RAS Blocker
Exforge. A combination of the CCB, amlodipine, and the ARB, valsartan, 2 of the world's most prescribed antihypertensive drugs, was approved for the treatment of hypertension by the Food and Drug Administration (FDA) in the United States (December 2006)[16] and the European Union (EU; January 2007).[17]
Novartis, the company that will market the combination pill worldwide as Exforge, announced that it will become commercially available in both regions this year. Both approvals were based on clinical trials in > 5000 patients.
In the EU, Exforge is indicated for the treatment of hypertension in patients whose blood pressure is not adequately controlled by amlodipine or valsartan alone.
It will be launched shortly in Germany followed by launches in most other EU countries throughout the year, pending expiration of the patent protection for amlodipine (held by Pfizer).
The EU decision applies in all 27 EU member states plus Iceland and Norway; Exforge has also been approved in Switzerland. In the United States the FDA issued a tentative approval, pending expiration of market exclusivity and patent protection for amlodipine besylate in September 2007.
Exforge was deemed to have met all the required standards for safety, efficacy, and manufacturing quality and is expected to become available to patients in the US in late September 2007.
Novartis says that clinical trials with Exforge have demonstrated that it helps up to 9 out of 10 patients to reach their blood pressure goal (ie, DBP < 90 mm Hg or a > 10 mm Hg reduction from baseline).[18,19] The combination pill has been shown in trials to deliver reductions in blood pressure of 36 mm Hg and up to 43 mm Hg in some patient populations.[20]
Overall, the pill is well tolerated, with an improved side effect profile over amlodipine alone. In particular, it is associated with a lower incidence of peripheral edema compared with amlodipine monotherapy.
Zaneril. Another new fixed combination of a CCB and a RAS blocker due to be marketed for the first time in 2007 is lercanidipine plus the ACE inhibitor enalapril, which will be launched as Zaneril in Germany in April by Meda (Solna, Sweden) under license from Recordati (Milan, Italy).[21]
The new fixed combination was first approved in Germany in July 2007. Germany will act as Reference Member State in the mutual recognition process for the rest of Europe, which is expected to be completed during 2007. Recordati has licensed Zaneril to Sigma Tau (Rome) for its next launch, in Italy, expected to take place at the beginning of 2008.[22]
Other agreements have been made to market Zaneril in Europe, Korea, Australia, Taiwan, the Middle East, and South Africa.
The "Polypill"
The second half of 2007 may also see the launch of a combination pill including 2 antihypertensive drugs (lisinopril and atenolol) in India, but this pill will also contain a statin (simvastatin) and aspirin, and will be launched as the first "polypill" by Indian pharmaceutical company Dr. Reddy's Laboratories (Hyderabad).[23]
The polypill will become available after the completion of clinical trials carried out at 10 Indian medical centers. This polypill is meant only for individuals at high risk of heart disease and stroke and not as a mass prescription for everyone over age 55 years, which was the polypill originally proposed by UK researchers Prof Nicholas Wald, DSc, and Prof Malcolm Law, MBBS, (University of London) in 2003.[24] Future launches of the Indian polypill are being planned for 2008-2009 in Russia, Brazil, and Australia.
The pill has been developed in partnership with researchers at the University of Auckland, New Zealand. The formulation is expected to comprise 75 mg of aspirin; 10, 20, or 40 mg of simvastatin; 5-10 mg of lisinopril; and 25 mg of atenolol.
The once-daily pill will be available in 3 strengths, according to the company. Commenting on the constituents of the polypill, Prof Anthony Rodgers, MBChB, PhD (University of Auckland), who has led research into the polypill in New Zealand, said that 2 antihypertensive agents should "be adequate in many cases to treat to goal and also adhere to guidelines.
It may also be easier to find acceptance of a 2-antihypertensive combination by doctors, rather than 3, particularly in cases of mild to moderate hypertension." All the drugs contained in the pill are off patent, making it especially cheap to produce.
A global trial of the polypill will begin in 2007. The Health Research Council of New Zealand has invested NZ$350,000 to support the overall coordination of the trial and recruitment in New Zealand, and Dr. Reddy's will invest NZ$7.5 million in developing the polypill and providing supplies for global clinical trials.
The trial investigators, led by Prof. Rodgers, will recruit about 600 people at high risk of myocardial infarction or stroke in Australia, Brazil, China, South Africa, the United States, and the United Kingdom, as well as India and New Zealand.
If this is successful, a larger trial will be carried out in up to 5000 people at moderate risk of heart disease. A separate trial in New Zealand, funded by the Health Care Research Council, will compare the benefits of the polypill with those of existing medication in 300 Maori and 300 non-Maori participants.
A 3- or 4-drug polypill for developing countries has long been supported by the World Health Organization.
Recently researchers calculated that a 4-drug polypill, like the one being tested by Dr. Reddy's, could halve the risk of death from cardiovascular disease in high-risk patients.[25] However, writing in the January 18 issue of The New England Journal of Medicine, Prof. K. Srinath Reddy, MD, DM (All India Institute of Medical Sciences, New Delhi), a long-time proponent of the polypill for prevention of cardiovascular disease, cautions that the value of such a pill must be "clearly demonstrated, rather then simply assumed."[26]
According to Prof. Reddy, a second Indian pharmaceutical company also has a 4-drug polypill about to enter clinical trials.
Another plan to develop a polypill was revealed at last year's World Congress of Cardiology in Barcelona.
Valentin Fuster, MD, Chairman of the Scientific Advisory and External Evaluation Committee of the Centro Nacional de Investigaciones Cardiovasculares and current president of the World Heart Federation, announced an intended collaboration with the Spanish pharmaceutical industry to develop a polypill for secondary prevention in low- and middle-income countries.
The pill would likely contain an ACE inhibitor, a statin, and aspirin, and first be tested in Spain and larger countries such as China. It should become available by 2010, according to Dr. Fuster.
References
Wang YR, Alexander GC, Stafford RS. Outpatient hypertension treatment, treatment intensification, and control in Western Europe and the United States. Arch Intern Med. 2007;167:141-147.
Abstract
Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.
Abstract
Wang YR. Lack of effect of guideline changes on hypertension control for patients with diabetes in the U.S., 1995-2005. Diabetes Care. 2007;30:49-52. Abstract
Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med. 1997;157:2413-2446.
Abstract
Blood Pressure Canada, Heart and Stroke Foundation of Canada, Canadian Hypertension Education Program (CHEP), Canadian Hypertension Society. Hypertension: 2007 public recommendations. Available at: http://www.hypertension.ca/chep/docs/chep2007-recommendations-english.pdf and http://ww2.heartandstroke.ca/images/english/CHEP-EN-2007.pdf. Accessed February 21, 2007.
Elliott WJ, Meyer PM. Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet. 2007;369:201-207. Abstract
Lumley T. Network meta-analysis for indirect treatment comparisons. Stat Med. 2002;21:2313-2324.
Abstract
Bradley HA, Wiysonge CS, Volmink JA, et al. How strong is the evidence for use of beta-blockers as first-line therapy for hypertension? Systematic review and meta-analysis. J Hypertens. 2006;24:2131-2141. Abstract
Wiysonge CS, Bradley H, Mayosi BM, et al. Beta-blockers for hypertension. Cochrane Database Syst Rev. 2007;(1):CD002003.
Lindholm LH, Carlberg B, Samuelsson O. Should beta blockers remain first choice in the treatment of primary hypertension? A metaanalysis. Lancet. 2005;366:1545-1553. [See Related Links]
Khan N, McAlister FA. Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis. CMAJ. 2006;174:1737-1742. [See Related Links]
Speedel (Basel, Switzerland and Bridgewater, New Jersey). Speedel initiates Phase I safety and tolerability testing of SPP1148 in healthy volunteers: Second new series of renin inhibitors for treatment of hypertension to enter clinical trials. January 12, 2007. Available at: http://www.speedel.com. Accessed February 21, 2007.
Staessen JA, Li Y, Richart R. Oral renin inhibitors. Lancet. 2006;368:1449-1456. Abstract
Dahlof B, Sever PS, Poulter NR; for the ASCOT investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895-506. Abstract
The National Collaborating Centre for Chronic Conditions. Hypertension: Management of Hypertension in Adults in Primary Care: Partial Update. London, UK: Royal College of Physicians; 2006.
Novartis Pharmaceuticals Corporation. Exforge(R) receives US regulatory approval as a new and highly effective treatment option for patients with high blood pressure. December 22, 2006. Available at: http://www.novartis.com. Accessed February 21, 2007.
Novartis. Exforge(R) approved in Europe as powerful new blood pressure therapy combining two leading medications in a single pill. January 18, 2007. Available at: http://www.novartis.com. Accessed February 21, 2007.
Data on file (Study VAA489A2201 and Study VAA489A2307). Novartis Pharmaceuticals Corporation. East Hanover, New Jersey. 07936. Available at: http://www.novartis.com. Accessed February 21, 2007.
Data on file (Exforge Summary Clinical Efficacy). Novartis Pharmaceuticals Corporation. East Hanover, New Jersey. 07936. Available at: http://www.novartis.com. Accessed February 21, 2007.
Poldermans D, Gamboa R, Fomina I, et al. Comparative safety and blood pressure (BP)-lowering efficacy of a combination of amlodipine + valsartan and lisinopril + hydrochlorothiazide in patients with stage 2 hypertension. Program and abstracts of ASH 2006: 21st Annual Scientific Meeting; May 16-20, 2006; New York, NY. Abstract P217.
Recordati. Recordati signs agreement with Meda for the co-marketing of its new antihypertension product in Germany. February 7, 2007. Available at: http://www.recordati.com. Accessed February 21, 2007.
Recordati. Recordati signs co-marketing agreement with Sigma-Tau in Italy for its new antihypertension product. December 21, 2006. Available at: http://www.recordati.com. Accessed February 21, 2007.
Dr Reddy's. World's first polypill trial. December 7, 2006. Available at: http://www.drreddys.com. Accessed February 21, 2007.
Wald, NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326:1419.
Gaziano TA, Opie LH, Weinstein MC. Cardiovascular disease prevention with a multidrug regimen in the developing world: a cost-effectiveness analysis. Lancet. 2006;368:679-686. Abstract
Reddy KS. The preventive polypill--much promise, insufficient evidence. N Engl J Med. 2007;356:212.
Funding Information
Supported by an independent educational grant from Pfizer.
Linda Brookes, MSc, freelance medical writer based in London and New York
Disclosure: Linda Brookes, MSc, has disclosed no relevant financial relationships.
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Hypertension Highlights
Assessing Guidelines, Strategies, and New Drugs to Get Patients to Target
Linda Brookes, MSc
Medscape Cardiology. 2007; ©2007 Medscape
Posted 02/22/2007
Introduction
New data highlighted this month reveal that hypertension control appears to be better in the United States than in Western Europe -- but unfortunately the latest US hypertension guidelines fail to substantially affect blood pressure control in diabetic patients, whereas the new Canadian hypertension guidelines highlight for the first time the dangers of "high normal" blood pressure.
Two new reports further confirm that there is a higher rate of incident diabetes with diuretics and beta-blockers, and beta-blockers are less effective than diuretics, calcium channel blockers, or angiotensin blockers as first-line therapy for elevated blood pressure control.
Finally, the first clinical trials with new second-generation renin inhibitors and a small catalog of new combination antihypertensive pills coming soon in Europe, the United States, and, as a polypill, in India are reported.
Hypertension Control Appears Better in the United States Than in Western Europe
An analysis of survey data appears to confirm previous population-based studies showing that patients with diagnosed hypertension in the United States have lower blood pressure levels and better hypertension control than patients in Western European countries.
The results of the analysis are published in the January 22 issue of Archives of Internal Medicine.[1] The US investigators attribute the difference to lower treatment thresholds and more intensive treatment set out in the most recent US hypertension management guidelines.
However, in their analysis, almost half the US patients did not achieve their goal blood pressure as recommended in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),[2] so "better blood pressure control in the United States should not be too quickly praised," they caution.
The study, which was supported by the MacLean Center for Clinical Medical Ethics, the National Institute of Aging, and the Agency for Healthcare Research and Quality, used patient data collected from surveys conducted in 2004 in France, Germany, Italy, Spain, and the United Kingdom, as well as the United States.
The surveys were part of Cardiomonitor, an ongoing survey of physician visits by ambulatory adult patients with cardiovascular diseases in selected countries carried out since 1980 by an international market research company (Taylor Nelson Sofres Healthcare, London).
In 2004, the physicians in the survey were randomly selected, and those who agreed to participate completed 2-page diaries for 15 cardiovascular patients. Information collected included patient characteristics, initial blood pressure level before treatment, any co-occurring diseases, and the use of 7 types of antihypertensive drugs.
Investigators led by Y. Richard Wang, MD, PhD, of Temple University Hospital and University of Pennsylvania, Philadelphia, identified a total of 21,053 patients with a primary or secondary diagnosis of hypertension in all 6 countries.
These patients had visited a total of 291 cardiologists and 1284 primary care physicians. The patients were 53% male, mean age was 65 years, and 23% had diabetes mellitus.
At least 92% of patients with hypertension in each country were receiving antihypertensive drug therapy.
Use of thiazide-type diuretics was similar across all countries (29% to 13%), but use of other antihypertensive drug classes -- beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) -- varied considerably. Use of combination therapy (≥ 2 drugs) was highest in the United States (64% vs 44% to 59% in European countries).
Initial blood pressure measurements before treatment were available for 61% to 80% of patients per country and were lowest in the United States (average of 161/94 mm Hg, vs an average of 167-173/96-99 mm Hg in Europe).
The most recent blood pressure reading was also lower in the United States than in any other country (average of 134/79 mm Hg, vs an average of 139-144/80-84 mm Hg in Europe).
Only 65% of US patients had an initial pretreatment blood pressure level ≥ 160/100 mm Hg, compared with 81% to 90% of patients in the European countries.
The rate of hypertension control was found to be highest among the US patients, whether control was defined as < 140/90 mm Hg for all patients or as < 130/80 mm Hg in patients with diabetes and < 140/90 mm Hg in all others. By the later definition, 53% of US patients achieved hypertension control compared with 27% to 40% of European patients.
Multivariate analyses controlling for age, sex, current smoking, and physician specialty showed that, compared with US patients, European patients had higher latest systolic blood pressure (SBP) levels (by 5.3-10.2 mm Hg across countries examined) and diastolic blood pressure (DBP) levels (by 1.9-5.3 mm Hg; all P < .001).
These differences remained significant (P < .01) after controlling for comorbidities and concurrent drug treatment.
European patients were less likely than US patients to have hypertension control or a medication increase for inadequately controlled hypertension (P < .001).
The researchers found that initial pretreatment blood pressure levels accounted for most of the cross-national differences in latest SBP and DBP levels and the likelihood of hypertension control.
Dr. Yang and his colleagues suggest that aggressive treatment in the United States means that some patients may be receiving drug treatment they do not need, involving extra cost. However, these costs are small compared with those that would result from a future cardiovascular event that occurred due to inadequate blood pressure control.
US Hypertension Guidelines Fail to Substantially Affect Blood Pressure Control in Diabetic Patients
Despite the publication of increasingly aggressive guidelines for lowering blood pressure and the superior rate of hypertension control in the United States compared with Europe, another study by Y. Richard Wang, MD, PhD, suggests that the guidelines have had little effect on hypertension control in diabetic patients.
The study is published in the January issue of Diabetes Care.[3] The findings appear to be consistent with previous studies that reported a lack of hypertension control in diabetic patients, despite the higher risk of cardiovascular disease that they have and despite recommendations by diabetes and family physician organizations, as well as those of the JNC.
Dr. Yang compared the effects of the JNC 7 guidelines on blood pressure control in patients with diabetes vs that in nondiabetic patients between 1995 and 2005.
The JNC VI guidelines, published in 1997, lowered blood pressure goals for diabetic patients to < 130/85 mm Hg.[4] This goal was subsequently lowered in 2003, in the JNC 7 guidelines, to 130/80 mm Hg.[2] Goal blood pressure for nondiabetic patients was < 140/90 mm Hg in both JNC VI and JNC 7.
Dr. Yang used data from the National Disease and Therapeutic Index, a nationally representative survey of outpatient visits in the United States carried out by IMS Health (Plymouth Meeting, Pennsylvania). Data were available for 19,616 diabetic and 162,672 nondiabetic adult patients diagnosed with hypertension, representing about 76 million diabetic and 638 million nondiabetic physician visits in the United States.
Defining blood pressure control as blood pressure < 140/90 mm Hg, an improvement in control was seen during the entire period in all diabetic and nondiabetic patients, but percent control was greater in the nondiabetic patients compared with the diabetic patients.
The rate of hypertension control improved for both diabetic and nondiabetic patients by between 1.5% and 2.5% between 1995 and 2005.
"However, the more aggressive goal blood pressure set in the JNC VI and JNC 7 guidelines for patients did not lead to substantially better hypertension control for diabetic subjects compared with nondiabetic subjects, for whom the goal blood pressure remained the same,"
Dr. Yang reports. After publication of JNC VI, there was no immediate change in rate of control (blood pressure < 130/85 mm Hg) in diabetic patients and only a nonsignificant 1.7% increase after 3 years.
A widening gap in blood pressure control was apparent after 2001 that continued after 2003, when JNC 7 was published. By 2005, the rate of blood pressure control in nondiabetic patients (< 140/90 mm Hg) was 20% higher than control (< 130/85 mm Hg) in diabetic patients.
Dr. Yang comments that the findings of his study are "somewhat surprising considering the recognition of JNC guidelines as the gold standard for hypertension treatment, similar recommendations from other organizations such as American Diabetes Association, American College of Physicians, and American Academy of Family Physicians, and public health efforts to promote comprehensive diabetes care.
" He suggests that the reasons for this lack of improvement in blood pressure control in hypertensive patients with diabetes may be due to patient noncompliance with lifestyle recommendations and drug treatment, physician inertia to initiate and intensify treatment, and inadequate access to medical care.
"The continued lack of hypertension control for patients with diabetes in the US despite the publication of more aggressive guidelines has significant long-term cost implications for the health care system," he writes. Identifying effective interventions to deal with the challenge of lowering blood pressure in people with diabetes should be a top priority for future research, he concludes.
New Canadian Hypertension Guidelines Highlight Dangers of High Normal Blood Pressure
New guidelines for hypertension management were released to the public in Canada in January.
The Hypertension: 2007 Public Recommendations,[5] the second public version of the guidelines, has been adapted from the latest professional recommendations by Blood Pressure Canada, the Heart and Stroke Foundation of Canada, the Canadian Hypertension Education Program (CHEP), and the Canadian Hypertension Society.
For the first time, the Canadian guidelines focus on prevention of hypertension and the importance of recognizing "high normal" blood pressure (ie, 130-139/85-89 mm Hg). "More than one half of people with high normal blood pressure develop hypertension within 4 years unless they make lifestyle changes," the guidelines caution.
They also warn that > 9 in 10 Canadians will develop hypertension unless they follow a healthy lifestyle. Recommended ways to lower blood pressure include:
Physical activity for 30-60 minutes most days of the week;
More vegetables, fruit, low-fat dairy products, foods low in saturated and trans fat and salt, whole grains, lean meat, fish, and poultry in the diet; less fat food and canned or prepared foods;
Reducing salt intake;
Drinking less alcohol (≤ 1-2 drinks per day);
No smoking; and
Weight loss (at least 10 lb/5 kg) if overweight.
Advice is given on how to cut down salt intake by reading food labels and restaurant menus more carefully.
The need for regular blood pressure checks is emphasized. Target blood pressures (< 140/90 mm Hg in most people and < 130/80 mm Hg in people with diabetes or kidney disease) are explained and ways of measuring blood pressure at a physician's office or at home are described, along with the possibilities of white coat or masked hypertension when blood pressure is measured by a doctor.
Patients with diabetes or with cholesterol as well as high blood pressure are urged to ask their doctors to do kidney function tests.
As to treating hypertension, the guidelines explain that in most people at least 2 medications (probably taken in a single tablet) will be necessary in addition to the lifestyle changes.
They stress the importance of adherence to treatment and the problems that can arise if patients are not honest with their doctors about forgetting to take medications (unnecessarily increased doses, etc.).
Diuretics, beta-blockers (in patients aged < 60 years), ACE inhibitors, ARBs, and calcium channel blockers (CCBs) "all reduce blood pressure by the same amount on average," say the guidelines.
They say that some patients are more likely to need specific classes of antihypertensive drugs (eg, a diuretic and an ACE inhibitor/ARB in patients with diabetes or kidney disease, and a beta-blocker and an ACE inhibitor in patients with heart disease). They stress that the full effects of antihypertensive medication may not be apparent for up to 6 weeks.
Almost one quarter of Canadian adults -- about 5 million -- are estimated to have hypertension and 2.5 million to have high normal blood pressure. Hypertension is the leading reason for visits to primary care physicians.
Speaking on behalf of the Heart and Stroke Foundation of Canada, Sheldon W. Tobe, MD, (Sunnybrook and Women's College Health Science Centre and University of Toronto) stressed the significance of high-normal blood pressure in the new guidelines.
"We believe family doctors now understand the thresholds for diagnosing high blood pressure. Now we're saying, let's prevent hypertension from occurring. It is a big step forward," he said. "It is time for doctors to take the next step: to recognize the risks of high-normal blood pressure and treat it before it develops into high blood pressure.
" People with blood pressure in the high-normal range have double the risk of heart disease and stroke compared with those with normal blood pressure, he noted. Dr. Tobe believes that lifestyle changes can be as effective in lowering blood pressure as drug therapies.
Patients are more likely to succeed in making lifestyle changes and maintaining them if a physician emphasizes the importance of prevention by arranging a follow-up visit, and the patient is more likely to agree to make lifestyle changes and comply, he says.
Patients with high-normal blood pressure should monitor their blood pressure at home and keep track of their progress and setbacks, he recommends.
Higher Rate of Incident Diabetes With Diuretics and Beta-blockers Confirmed in Analysis of Clinical Trials
An analysis of data from major trials of antihypertensive drugs, published in The Lancet,[6] has confirmed that ARBs and ACE inhibitors have the lowest association with incident diabetes and diuretics and beta-blockers the highest.
William J. Elliott, MD, and Peter M. Meyer, PhD, (Rush University Medical Center, Chicago, Illinois) conducted their analysis using a new statistical technique known as network meta-analysis.[7]
This type of analysis allows the relative effectiveness of 2 treatments to be estimated when they have not been compared with each other directly in a randomized trial, but have each been compared with other treatments.
In this way, Drs. Elliott and Meyer were able to make comparisons of antihypertensive drug classes, including ARBs and ACE inhibitors, that had never been directly compared in a randomized clinical trial. Their study was supported in part by the US National Institutes of Health.
Long-term randomized clinical trials of antihypertensive drugs that reported new cases of diabetes from 1966 to September 15, 2006, were identified from searches of MEDLINE and other medical publication databases and reference lists from all meta-analyses and all other potential sources.
A total of 22 clinical trials comprising 143,153 enrolled participants who did not have diabetes at randomization were found to be eligible for inclusion in the analysis. Seventeen trials enrolled patients with hypertension, 3 enrolled high-risk patients, and 1 enrolled those with heart failure. The trials involved a total of 48 groups of patients randomized to initial treatment with a(n):
ARB (5 groups, 14,185 patients);
ACE inhibitor (8 groups, 22,941 patients);
CCB; (9 groups, 38,607 patients);
Placebo (9 groups, 24,767 patients);
Beta-blocker (9 groups, 35,745 patients); or
Diuretic (8 groups, 18,699 patients).
Using an initial diuretic as the standard of comparison, initial treatment with an ARB, ACE inhibitor, CCB, or placebo was in all cases associated with significantly fewer cases of incident diabetes. The odds ratios were:
ARB 0.57 (95% confidence interval [CI] 0.46-0.72, P < .0001);
ACE inhibitor 0.67 (95% CI 0.56-0.80, P < .0001);
CCB 0.75 (95% CI 0.62-0.90, P = .002);
Placebo 0.77 (95% CI 0.63-0.94, P = .009); and
Beta-blocker 0.90 (95% CI 0.75-1.09, P = .30).
When placebo was used as referent agent, only the initial ARB and the initial diuretic retained significance, with the diuretic associated with a 30% increase in risk of incident diabetes. These results changed little when subjected to sensitivity analyses.
Drs. Elliot and Meyer point out that their results are consistent with those of previous meta-analyses.
The reasons for the different effects of these antihypertensive drug classes may be due to their effects on circulating kinins, pancreatic insulin release, and the peripheral effects of insulin, they suggest, noting that animal studies have also implicated the peroxisome proliferator-activated receptor gamma (PPAR-gamma) receptor. "Which of these is mort important in human beings remains a topic for future research," they say.
They add that the implications of their findings for clinical practice are uncertain, given the approaches of different national hypertension guidelines to diuretics and beta-blockers and the lack of data about the increased cardiovascular risk associated with incident diabetes over the long term.
More high quality data can be expected from current clinical trials such as the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial, the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET), and the Telmisartan Randomized Assessment Study in ACE-Intolerant Subjects With Cardiovascular Disease (TRANSCEND), each of which includes incident diabetes as a primary or secondary end point.
They may also help to determine whether ARBs and ACE inhibitors have significantly different effects on incident diabetes.
First-line Beta-blockers Less Effective Than Diuretics, CCBs, or Angiotensin Blockers for Elevated Blood Pressure
An analysis of clinical trials of beta-blockers by a group of researchers based in South Africa confirm previous reports that beta-blockers are "inferior first-line choices" for the treatment of hypertension compared with diuretics, ACE inhibitors/ARBs, or CCBs.
The analysis, which was funded by the Medical Research Council of South Africa, first appeared in the Journal of Hypertension[8] and has now been published by the Cochrane Collaboration.[9] Its conclusion, which was the same in both publications, was based on the relatively weak effect of beta-blockers in preventing stroke and the absence of an effect on coronary heart disease (CHD) compared with placebo or no treatment.
More importantly, say the authors, they based it on the trend toward worse outcomes compared with CCBs, angiotensin blockers, and thiazide-type diuretics.
The analysis was undertaken because previous meta-analyses compared beta-blockers with all other antihypertensive drugs taken together, whereas the South African group points out that they might be better or worse than a specific class of drugs for a particular outcome measure.
In addition, previous reviews did not examine the tolerability of beta-blockers relative to other antihypertensive medications.
Lead authors Charles Shey Wiysonge, MD, (University of Cape Town, Groote Schuur Hospital) and Hazel A Bradley, MPH, (University of the Western Cape, Bellville) described how they identified eligible clinical trials published through June 2006 by searching the Cochrane Controlled Trials Register, MEDLINE, EMBASE, reference lists of previous reviews, and by contacting researchers.
They were looking for randomized, controlled trials that assessed the effectiveness of beta-blockers compared with placebo, no therapy, or other drug classes, as monotherapy or first-line therapy for hypertension, on mortality and morbidity end points in men and nonpregnant women aged ≥ 18 years.
Thirteen trials, involving 91,561 participants, that met the inclusion criteria were identified. These trials compared beta-blockers with placebo or no treatment (4 trials with 23,613 participants), diuretics (5 trials with 18,241 participants), CCBs (4 trials with 44,825 participants), or ACE inhibitors or ARBs, which were grouped together as renin-angiotensin system (RAS) inhibitors because of small numbers (3 trials with 10,828 participants).
Trial participants were analyzed according to the groups to which they were randomized, regardless of subsequent treatment they actually received.
The researchers found that the effect of beta-blockers on all-cause mortality did not differ from that of placebo, diuretics, or RAS inhibitors, but was significantly higher for beta-blockers compared with CCBs (relative risk [RR] 1.07, 95% CI 1.00-1.14, P = .04), corresponding to an absolute increase of 0.5%. Patients on beta-blockers had a markedly reduced risk of total cardiovascular disease (fatal and nonfatal CHD and stroke, plus congestive heart failure and transient ischemic attack, when reported) compared with placebo (RR 0.88, 95% CI 0.79-0.97).
This was primarily a reflection of the significantly lower risk of stroke with beta-blockers (RR 0.80, 95% CI 0.66-0.96), calculated as an absolute risk reduction of 0.5% compared with placebo.
The effect of beta-blockers on cardiovascular disease was significantly worse than that of CCBs (RR 1.18, 95% CI 1.08-1.29) but did not differ from that of diuretics or RAS inhibitors. Increased total cardiovascular disease was due to an increase in stroke compared with CCBs (RR 1.24, 95% CI 1.11-1.40), an increase in absolute risk of 0.5%.
There was also an increase in stroke with beta-blockers compared with RAS inhibitors (RR 1.30, 95% CI 1.11-1.53), an increase in absolute risk of 1.5%. The effect of beta-blockers on CHD was not significantly different from that of placebo, diuretics, CCBs, or RAS inhibitors.
Patients on beta-blockers were more likely than those on diuretics or RAS inhibitors to discontinue treatment due to side effects, but there was no difference compared with placebo or CCBs.
There were no differences in depressive symptoms among the different treatment groups, but patients on beta-blockers appeared more likely than those on diuretics, CCBs, or RAS inhibitors to develop fatigue.
The risk of sexual dysfunction appeared lower than with diuretics, but higher than with CCBs or RAS inhibitors. Blood pressures (SBP and DBP) in the beta-blocker arms of the trials were 0-2 mm Hg higher than on the other treatment arms.
This study was able to confirm the finding of a previous meta-analysis carried out by Swedish researchers, which found beta-blockers are less effective than other antihypertensive drugs at preventing strokes.[10] However, because of lack of data, Dr. Wiysonge and colleagues were unable to confirm whether the disadvantages of beta-blockers as first-line antihypertensive therapy are limited to elderly patients, as suggested by Canadian researchers Nadia Khan, MD, and Finlay A McAlister, MD, in a previous review.[11]
They also could not draw any conclusions about whether cardioselective and nonselective beta-blockers have different effects, since most of the beta-blocker trials in the analysis used atenolol (75% of participants on beta-blockers). These questions should be addressed in new randomized clinical trials, the researchers recommend.
Clinical Trials Begun With New Second-Generation Renin Inhibitor
Another second-generation oral renin inhibitor has entered clinical trials in development for the treatment of hypertension. Speedel (Basel, Switzerland), the company that licensed and originally developed the first oral renin inhibitor likely to receive regulatory approval, announced in January that a phase 1 trial of SPP1148 had begun to test the safety and tolerability of single and multiple oral doses in healthy volunteers. First results are expected in during the last quarter of 2007.[12]
SPP1148 was selected for clinical trials following the preclinical evaluation of 2 potential candidates from the SPP1100 series on the basis of its superior animal bioavailability, positive effects on renal failure models in animals, and its suitability for manufacturing, Speedel says.
The SPP1100 series is one of several new series of renin inhibitors in development by Speedel Experimenta, the company's late-stage research unit, and is based on a new chemical entity. Speedel is developing a number of series of second-generation renin inhibitors, including the SPP600 series (under license from Roche), the SPP800 series (developed with Locus Pharmaceuticals), and the SPP1100 series.
A member of the SPP600 series, SPP635, progressed to a phase 2a proof-of-concept trial in October 2006. This trial is treating 35 hypertensive patients with SPP635 and is expected to finish during the third quarter of 2007.
Aliskiren (SPP100), the first-in-class renin inhibitor, expected to be on the market in the United States and Europe this year, is partnered with Novartis (Basel) for development and commercialization in hypertension.
Novartis filed for regulatory approval for aliskiren in the United States and Europe in 2006, and the US regulatory review process, which was extended in December by up to 3 months, is expected to be completed during the first quarter of 2007. Novartis predicts that it will launch aliskiren for the treatment of hypertension during the first half of 2007 in the United States and during the first half of 2007 in Europe.
The company presented extensive phase 3 clinical data at cardiology and hypertension conferences, including the World Congress of Cardiology, throughout 2006, and has an ongoing cardiovascular outcome program investigating aliskiren in primary and secondary prevention as well as in heart failure.
Speedel believes that "renin inhibition may be the new gold standard for the treatment of hypertension and related disorders in the next decade." Although renin inhibitors have been described as "a breakthrough," and it has been suggested that renin inhibitors would be expected to have fewer side effects than ACE inhibitors, they might be less powerful in reducing blood pressure because they do not block the degradation of bradykinin.[13]
Other companies reported to be developing renin inhibitors, some of which have moved into early clinical trials, include Actelion, Merck, GlaxoSmithKline/Vita, and Pfizer.
New Combination Antihypertensive Pills Coming Soon in Europe, the United States, and, as a Polypill, in India
Three new pills containing fixed doses of 2 antihypertensive drugs are expected to come on the market within the next 2 years. Two of these pills will contain only blood pressure lowering drugs, but 1 is being touted as the first commercially available "polypill" developed especially with less affluent countries in mind.
The 2-drug pills comprise a CCB and ACE inhibitor or ARB. This combination is becoming increasingly popular as antihypertensive treatment, with or without a thiazide-type diuretic, as demonstrated recently in the blood pressure-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-BPLA),[14] and as recommended in the latest UK hypertension guidelines.[15]
Fixed Combination of a CCB and a RAS Blocker
Exforge. A combination of the CCB, amlodipine, and the ARB, valsartan, 2 of the world's most prescribed antihypertensive drugs, was approved for the treatment of hypertension by the Food and Drug Administration (FDA) in the United States (December 2006)[16] and the European Union (EU; January 2007).[17]
Novartis, the company that will market the combination pill worldwide as Exforge, announced that it will become commercially available in both regions this year. Both approvals were based on clinical trials in > 5000 patients.
In the EU, Exforge is indicated for the treatment of hypertension in patients whose blood pressure is not adequately controlled by amlodipine or valsartan alone.
It will be launched shortly in Germany followed by launches in most other EU countries throughout the year, pending expiration of the patent protection for amlodipine (held by Pfizer).
The EU decision applies in all 27 EU member states plus Iceland and Norway; Exforge has also been approved in Switzerland. In the United States the FDA issued a tentative approval, pending expiration of market exclusivity and patent protection for amlodipine besylate in September 2007.
Exforge was deemed to have met all the required standards for safety, efficacy, and manufacturing quality and is expected to become available to patients in the US in late September 2007.
Novartis says that clinical trials with Exforge have demonstrated that it helps up to 9 out of 10 patients to reach their blood pressure goal (ie, DBP < 90 mm Hg or a > 10 mm Hg reduction from baseline).[18,19] The combination pill has been shown in trials to deliver reductions in blood pressure of 36 mm Hg and up to 43 mm Hg in some patient populations.[20]
Overall, the pill is well tolerated, with an improved side effect profile over amlodipine alone. In particular, it is associated with a lower incidence of peripheral edema compared with amlodipine monotherapy.
Zaneril. Another new fixed combination of a CCB and a RAS blocker due to be marketed for the first time in 2007 is lercanidipine plus the ACE inhibitor enalapril, which will be launched as Zaneril in Germany in April by Meda (Solna, Sweden) under license from Recordati (Milan, Italy).[21]
The new fixed combination was first approved in Germany in July 2007. Germany will act as Reference Member State in the mutual recognition process for the rest of Europe, which is expected to be completed during 2007. Recordati has licensed Zaneril to Sigma Tau (Rome) for its next launch, in Italy, expected to take place at the beginning of 2008.[22]
Other agreements have been made to market Zaneril in Europe, Korea, Australia, Taiwan, the Middle East, and South Africa.
The "Polypill"
The second half of 2007 may also see the launch of a combination pill including 2 antihypertensive drugs (lisinopril and atenolol) in India, but this pill will also contain a statin (simvastatin) and aspirin, and will be launched as the first "polypill" by Indian pharmaceutical company Dr. Reddy's Laboratories (Hyderabad).[23]
The polypill will become available after the completion of clinical trials carried out at 10 Indian medical centers. This polypill is meant only for individuals at high risk of heart disease and stroke and not as a mass prescription for everyone over age 55 years, which was the polypill originally proposed by UK researchers Prof Nicholas Wald, DSc, and Prof Malcolm Law, MBBS, (University of London) in 2003.[24] Future launches of the Indian polypill are being planned for 2008-2009 in Russia, Brazil, and Australia.
The pill has been developed in partnership with researchers at the University of Auckland, New Zealand. The formulation is expected to comprise 75 mg of aspirin; 10, 20, or 40 mg of simvastatin; 5-10 mg of lisinopril; and 25 mg of atenolol.
The once-daily pill will be available in 3 strengths, according to the company. Commenting on the constituents of the polypill, Prof Anthony Rodgers, MBChB, PhD (University of Auckland), who has led research into the polypill in New Zealand, said that 2 antihypertensive agents should "be adequate in many cases to treat to goal and also adhere to guidelines.
It may also be easier to find acceptance of a 2-antihypertensive combination by doctors, rather than 3, particularly in cases of mild to moderate hypertension." All the drugs contained in the pill are off patent, making it especially cheap to produce.
A global trial of the polypill will begin in 2007. The Health Research Council of New Zealand has invested NZ$350,000 to support the overall coordination of the trial and recruitment in New Zealand, and Dr. Reddy's will invest NZ$7.5 million in developing the polypill and providing supplies for global clinical trials.
The trial investigators, led by Prof. Rodgers, will recruit about 600 people at high risk of myocardial infarction or stroke in Australia, Brazil, China, South Africa, the United States, and the United Kingdom, as well as India and New Zealand.
If this is successful, a larger trial will be carried out in up to 5000 people at moderate risk of heart disease. A separate trial in New Zealand, funded by the Health Care Research Council, will compare the benefits of the polypill with those of existing medication in 300 Maori and 300 non-Maori participants.
A 3- or 4-drug polypill for developing countries has long been supported by the World Health Organization.
Recently researchers calculated that a 4-drug polypill, like the one being tested by Dr. Reddy's, could halve the risk of death from cardiovascular disease in high-risk patients.[25] However, writing in the January 18 issue of The New England Journal of Medicine, Prof. K. Srinath Reddy, MD, DM (All India Institute of Medical Sciences, New Delhi), a long-time proponent of the polypill for prevention of cardiovascular disease, cautions that the value of such a pill must be "clearly demonstrated, rather then simply assumed."[26]
According to Prof. Reddy, a second Indian pharmaceutical company also has a 4-drug polypill about to enter clinical trials.
Another plan to develop a polypill was revealed at last year's World Congress of Cardiology in Barcelona.
Valentin Fuster, MD, Chairman of the Scientific Advisory and External Evaluation Committee of the Centro Nacional de Investigaciones Cardiovasculares and current president of the World Heart Federation, announced an intended collaboration with the Spanish pharmaceutical industry to develop a polypill for secondary prevention in low- and middle-income countries.
The pill would likely contain an ACE inhibitor, a statin, and aspirin, and first be tested in Spain and larger countries such as China. It should become available by 2010, according to Dr. Fuster.
References
Wang YR, Alexander GC, Stafford RS. Outpatient hypertension treatment, treatment intensification, and control in Western Europe and the United States. Arch Intern Med. 2007;167:141-147.
Abstract
Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.
Abstract
Wang YR. Lack of effect of guideline changes on hypertension control for patients with diabetes in the U.S., 1995-2005. Diabetes Care. 2007;30:49-52. Abstract
Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med. 1997;157:2413-2446.
Abstract
Blood Pressure Canada, Heart and Stroke Foundation of Canada, Canadian Hypertension Education Program (CHEP), Canadian Hypertension Society. Hypertension: 2007 public recommendations. Available at: http://www.hypertension.ca/chep/docs/chep2007-recommendations-english.pdf and http://ww2.heartandstroke.ca/images/english/CHEP-EN-2007.pdf. Accessed February 21, 2007.
Elliott WJ, Meyer PM. Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet. 2007;369:201-207. Abstract
Lumley T. Network meta-analysis for indirect treatment comparisons. Stat Med. 2002;21:2313-2324.
Abstract
Bradley HA, Wiysonge CS, Volmink JA, et al. How strong is the evidence for use of beta-blockers as first-line therapy for hypertension? Systematic review and meta-analysis. J Hypertens. 2006;24:2131-2141. Abstract
Wiysonge CS, Bradley H, Mayosi BM, et al. Beta-blockers for hypertension. Cochrane Database Syst Rev. 2007;(1):CD002003.
Lindholm LH, Carlberg B, Samuelsson O. Should beta blockers remain first choice in the treatment of primary hypertension? A metaanalysis. Lancet. 2005;366:1545-1553. [See Related Links]
Khan N, McAlister FA. Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis. CMAJ. 2006;174:1737-1742. [See Related Links]
Speedel (Basel, Switzerland and Bridgewater, New Jersey). Speedel initiates Phase I safety and tolerability testing of SPP1148 in healthy volunteers: Second new series of renin inhibitors for treatment of hypertension to enter clinical trials. January 12, 2007. Available at: http://www.speedel.com. Accessed February 21, 2007.
Staessen JA, Li Y, Richart R. Oral renin inhibitors. Lancet. 2006;368:1449-1456. Abstract
Dahlof B, Sever PS, Poulter NR; for the ASCOT investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895-506. Abstract
The National Collaborating Centre for Chronic Conditions. Hypertension: Management of Hypertension in Adults in Primary Care: Partial Update. London, UK: Royal College of Physicians; 2006.
Novartis Pharmaceuticals Corporation. Exforge(R) receives US regulatory approval as a new and highly effective treatment option for patients with high blood pressure. December 22, 2006. Available at: http://www.novartis.com. Accessed February 21, 2007.
Novartis. Exforge(R) approved in Europe as powerful new blood pressure therapy combining two leading medications in a single pill. January 18, 2007. Available at: http://www.novartis.com. Accessed February 21, 2007.
Data on file (Study VAA489A2201 and Study VAA489A2307). Novartis Pharmaceuticals Corporation. East Hanover, New Jersey. 07936. Available at: http://www.novartis.com. Accessed February 21, 2007.
Data on file (Exforge Summary Clinical Efficacy). Novartis Pharmaceuticals Corporation. East Hanover, New Jersey. 07936. Available at: http://www.novartis.com. Accessed February 21, 2007.
Poldermans D, Gamboa R, Fomina I, et al. Comparative safety and blood pressure (BP)-lowering efficacy of a combination of amlodipine + valsartan and lisinopril + hydrochlorothiazide in patients with stage 2 hypertension. Program and abstracts of ASH 2006: 21st Annual Scientific Meeting; May 16-20, 2006; New York, NY. Abstract P217.
Recordati. Recordati signs agreement with Meda for the co-marketing of its new antihypertension product in Germany. February 7, 2007. Available at: http://www.recordati.com. Accessed February 21, 2007.
Recordati. Recordati signs co-marketing agreement with Sigma-Tau in Italy for its new antihypertension product. December 21, 2006. Available at: http://www.recordati.com. Accessed February 21, 2007.
Dr Reddy's. World's first polypill trial. December 7, 2006. Available at: http://www.drreddys.com. Accessed February 21, 2007.
Wald, NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326:1419.
Gaziano TA, Opie LH, Weinstein MC. Cardiovascular disease prevention with a multidrug regimen in the developing world: a cost-effectiveness analysis. Lancet. 2006;368:679-686. Abstract
Reddy KS. The preventive polypill--much promise, insufficient evidence. N Engl J Med. 2007;356:212.
Funding Information
Supported by an independent educational grant from Pfizer.
Linda Brookes, MSc, freelance medical writer based in London and New York
Disclosure: Linda Brookes, MSc, has disclosed no relevant financial relationships.
Quarks: the source of protons and neutrons in atoms get recognition from the Nobel Commitee for Physics in 2008
Global7 the new Millennial Renaissance Vision for the Globe
Particle physics celebrates Nobel
The protons and neutrons in atoms are made up of quarks
The Nobel Prize in physics is to be shared by two Japanese citizens and an American, the Royal Swedish Academy of Sciences has announced.
Yoichiro Nambu, Makoto Kobayashi and Toshihide Maskawa provided new insights into the building blocks of matter.
Nambu described a mechanism called spontaneous broken symmetry in subatomic physics.
The work of Kobayashi and Maskawa predicted the existence of three families of particles known as quarks.
According to the Standard Model in particle physics - which ties together the smallest known building blocks of matter and three of nature's forces - quarks are the elementary sub-units of protons and neutrons, which together make up the nuclei of atoms.
The scientists' investigations explain anomalies that exist in the very fabric of the Universe.
According to the Nobel jury, "spontaneous broken symmetry is said to conceal nature's order under an apparently jumbled surface".
One analogy is to consider a pencil balancing on its point that then suddenly falls over. Prior to falling, the pencil is in perfect symmetry and has no preferred direction in which to topple; but in moving to the lower energy position of resting lengthways on the surface, the pencil suddenly defines a direction and the symmetry is broken.
What Nambu did was to formulate a mathematical description for this phenomenon in particle physics. The work is highly relevant in relation to upcoming experiments on the Large Hadron Collider (LHC), the recently completed giant accelerator at Cern on the Swiss-French border.
The LHC will search for an explanation for why the Universe has mass - with the leading candidate being the so-called Higgs field.
At the extremely high energies that existed in the very early Universe, symmetries would have existed that were then suddenly broken as the cosmos cooled and expanded. Theory suggests the mass resulted when the Higgs lost its symmetry.
Professor Sir Chris Llewellyn Smith, who was director general at Cern in the 1990s, said Nobel recognition for Nambu was long overdue.
"Hidden symmetries allow simple, economical laws to give rise to very diverse, apparently unrelated, phenomena," he commented.
"They play a key role in the unification of different forces in the successful Standard Model of particle physics."
The symmetries Nambu described are subtlety different to those studied by Kobayashi and Maskawa. Their work helps explain violations that occur in certain conservation laws at the particle level.
One key violation occurred immediately after the Big Bang, when just a small amount more matter than antimatter was created. Because these two kinds of particles annihilate each other when they meet, that excess of matter was responsible for seeding the Universe.
Kobayashi and Maskawa prevented a crisis in the Standard Model by showing the asymmetries could be accounted for if the numbers of recognised quarks was increased from three to six.
Observations subsequently confirmed their predictions.
Professor Nambu, 87, from the University of Chicago, is a US citizen but was born in Japan.
Professor Kobayashi, 64, works at the KEK Laboratory, Tsukuba, Japan; while Professor Toshihide Maskawa, 68, is affiliated to the University of Kyoto, Japan.
The Nobel Prizes - which also cover chemistry, medicine, literature, peace and economics (more properly called the Sveriges Riksbank Prize) - are valued at 10m Swedish Kronor (£8m/$14m).
Nambu will receive 5m Kronor; Kobayashi and Maskawa will share the other half.
Laureates also receive a medal and a diploma.
Last year's winners in physics were France's Albert Fert and Germany's Peter Gruenberg for work on the discovery of giant magnetoresistance.
Their breakthrough paved the way for much of modern gadgetry by allowing industry to develop sensitive reading tools to pull data off hard drives in computers, iPods and other digital devices.
Particle physics celebrates Nobel
The protons and neutrons in atoms are made up of quarks
The Nobel Prize in physics is to be shared by two Japanese citizens and an American, the Royal Swedish Academy of Sciences has announced.
Yoichiro Nambu, Makoto Kobayashi and Toshihide Maskawa provided new insights into the building blocks of matter.
Nambu described a mechanism called spontaneous broken symmetry in subatomic physics.
The work of Kobayashi and Maskawa predicted the existence of three families of particles known as quarks.
According to the Standard Model in particle physics - which ties together the smallest known building blocks of matter and three of nature's forces - quarks are the elementary sub-units of protons and neutrons, which together make up the nuclei of atoms.
The scientists' investigations explain anomalies that exist in the very fabric of the Universe.
According to the Nobel jury, "spontaneous broken symmetry is said to conceal nature's order under an apparently jumbled surface".
One analogy is to consider a pencil balancing on its point that then suddenly falls over. Prior to falling, the pencil is in perfect symmetry and has no preferred direction in which to topple; but in moving to the lower energy position of resting lengthways on the surface, the pencil suddenly defines a direction and the symmetry is broken.
What Nambu did was to formulate a mathematical description for this phenomenon in particle physics. The work is highly relevant in relation to upcoming experiments on the Large Hadron Collider (LHC), the recently completed giant accelerator at Cern on the Swiss-French border.
The LHC will search for an explanation for why the Universe has mass - with the leading candidate being the so-called Higgs field.
At the extremely high energies that existed in the very early Universe, symmetries would have existed that were then suddenly broken as the cosmos cooled and expanded. Theory suggests the mass resulted when the Higgs lost its symmetry.
Professor Sir Chris Llewellyn Smith, who was director general at Cern in the 1990s, said Nobel recognition for Nambu was long overdue.
"Hidden symmetries allow simple, economical laws to give rise to very diverse, apparently unrelated, phenomena," he commented.
"They play a key role in the unification of different forces in the successful Standard Model of particle physics."
The symmetries Nambu described are subtlety different to those studied by Kobayashi and Maskawa. Their work helps explain violations that occur in certain conservation laws at the particle level.
One key violation occurred immediately after the Big Bang, when just a small amount more matter than antimatter was created. Because these two kinds of particles annihilate each other when they meet, that excess of matter was responsible for seeding the Universe.
Kobayashi and Maskawa prevented a crisis in the Standard Model by showing the asymmetries could be accounted for if the numbers of recognised quarks was increased from three to six.
Observations subsequently confirmed their predictions.
Professor Nambu, 87, from the University of Chicago, is a US citizen but was born in Japan.
Professor Kobayashi, 64, works at the KEK Laboratory, Tsukuba, Japan; while Professor Toshihide Maskawa, 68, is affiliated to the University of Kyoto, Japan.
The Nobel Prizes - which also cover chemistry, medicine, literature, peace and economics (more properly called the Sveriges Riksbank Prize) - are valued at 10m Swedish Kronor (£8m/$14m).
Nambu will receive 5m Kronor; Kobayashi and Maskawa will share the other half.
Laureates also receive a medal and a diploma.
Last year's winners in physics were France's Albert Fert and Germany's Peter Gruenberg for work on the discovery of giant magnetoresistance.
Their breakthrough paved the way for much of modern gadgetry by allowing industry to develop sensitive reading tools to pull data off hard drives in computers, iPods and other digital devices.
Monday, October 06, 2008
Aids Pioneers and Cancer Sceintist win Nobel Prize
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AIDS pioneers and cancer scientist win Nobel prize
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By Niklas PollardPosted 2008/10/06 at 1:53 pm EDT
STOCKHOLM, Oct. 6, 2008 (Reuters) — Two French scientists who discovered the AIDS virus and a German who bucked conventional wisdom to find a virus that causes cervical cancer were awarded the 2008 Nobel prize for medicine on Monday.
Professor Harald zur Hausen joint Nobel Prize winner in Physiology or Medicine 2008, poses in a laboratory at the cancer research center of the university in Heidelberg October 6, 2008. REUTERS/Alex Grimm
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Sexually Transmitted Diseases
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www.Voice88.comLuc Montagnier, director of the World Foundation for AIDS Research and Prevention, and Francoise Barre-Sinoussi of the Institut Pasteur won half the prize of 10 million Swedish crowns ($1.4 million) for discovering the virus that has killed 25 million people since it was identified in the 1980s.
Dr. Harald zur Hausen of the University of Duesseldorf and a former director of the German Cancer Research Center shared the other half of the prize for work that went against the established opinion about the cause of cervical cancer.
"The three laureates have discovered two new viruses of great importance and the result of that has led to an improved global health," said Jan Andersson, a member of the Nobel Assembly at Sweden's Karolinska Institute.
The discoveries made it possible to diagnose both infections, and led to the development of two vaccines that prevent cervical cancer, and more than 20 drugs that can keep HIV patients healthy.
But Montagnier said those who most need the diagnosis and treatments for AIDS are not getting either.
"It's Africa which is carrying the weight of the epidemic at this moment. Out of millions of people infected, a large number are not being treated, either because they don't have access to treatment or because they don't know they are infected," Montagnier told Reuters in Abidjan, Ivory Coast, where he was giving a lecture.
The award is a decisive vote for Montagnier in a long-running dispute over who discovered and identified the virus, Montagnier or Dr. Robert Gallo, then of the U.S. National Cancer Institute.
"There was no doubt as to who made the fundamental discoveries," Nobel Assembly member Maria Masucci told Reuters.
CANCER DISCOVERY
Zur Hausen was recognized for finding that the human papilloma virus, or HPV, caused cervical cancer.
"More than 5 percent of all cancers worldwide are caused by persistent infection with this virus," the Nobel committee said. The virus, which infects at least half of all sexually active adults, can also cause genital warts, cancer of the penis and other genitalia.
The German scientist, who began his research in the 1970s, searched for different HPV types, detecting them in 70 percent of cervical tumor samples from around the world.
An estimated 500,000 women are diagnosed with the disease each year and about 300,000 die from it, mostly in the developing world.
Zur Hausen said he thought more cancers would be linked to viruses. "I suspect there will be more in the future," he said in a telephone interview.
GlaxoSmithKline and Merck and Co. have developed vaccines against HPV -- which are controversial because to be effective the series of costly shots must be given to girls before they begin sexual activity.
Medicine is traditionally the first of the Nobel prizes awarded each year. The prizes for achievement in science, literature and peace were first awarded in 1901 in accordance with the will of dynamite inventor Alfred Nobel.
The Nobel laureate for physics will be announced on Tuesday, chemistry on Wednesday, literature on Thursday and the Nobel Peace Prize on Friday in Oslo.
(Additional reporting by Adam Cox, Elinor Schang and Anna Ringstrom in Stockholm, Maggie Fox in Washington, Michael Kahn in London; Brian Rohan in Paris, and Loucoumane Coulibaly in Abidjan)
(Editing by Maggie Fox and Eric Walsh)
TOP NEWS Share Blog Subscribe Print Email Bookmark
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AIDS pioneers and cancer scientist win Nobel prize
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By Niklas PollardPosted 2008/10/06 at 1:53 pm EDT
STOCKHOLM, Oct. 6, 2008 (Reuters) — Two French scientists who discovered the AIDS virus and a German who bucked conventional wisdom to find a virus that causes cervical cancer were awarded the 2008 Nobel prize for medicine on Monday.
Professor Harald zur Hausen joint Nobel Prize winner in Physiology or Medicine 2008, poses in a laboratory at the cancer research center of the university in Heidelberg October 6, 2008. REUTERS/Alex Grimm
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HIV and AIDS
Science and Technology
Sexual and Reproductive Health
Sexually Transmitted Diseases
Vaccines
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www.Voice88.comLuc Montagnier, director of the World Foundation for AIDS Research and Prevention, and Francoise Barre-Sinoussi of the Institut Pasteur won half the prize of 10 million Swedish crowns ($1.4 million) for discovering the virus that has killed 25 million people since it was identified in the 1980s.
Dr. Harald zur Hausen of the University of Duesseldorf and a former director of the German Cancer Research Center shared the other half of the prize for work that went against the established opinion about the cause of cervical cancer.
"The three laureates have discovered two new viruses of great importance and the result of that has led to an improved global health," said Jan Andersson, a member of the Nobel Assembly at Sweden's Karolinska Institute.
The discoveries made it possible to diagnose both infections, and led to the development of two vaccines that prevent cervical cancer, and more than 20 drugs that can keep HIV patients healthy.
But Montagnier said those who most need the diagnosis and treatments for AIDS are not getting either.
"It's Africa which is carrying the weight of the epidemic at this moment. Out of millions of people infected, a large number are not being treated, either because they don't have access to treatment or because they don't know they are infected," Montagnier told Reuters in Abidjan, Ivory Coast, where he was giving a lecture.
The award is a decisive vote for Montagnier in a long-running dispute over who discovered and identified the virus, Montagnier or Dr. Robert Gallo, then of the U.S. National Cancer Institute.
"There was no doubt as to who made the fundamental discoveries," Nobel Assembly member Maria Masucci told Reuters.
CANCER DISCOVERY
Zur Hausen was recognized for finding that the human papilloma virus, or HPV, caused cervical cancer.
"More than 5 percent of all cancers worldwide are caused by persistent infection with this virus," the Nobel committee said. The virus, which infects at least half of all sexually active adults, can also cause genital warts, cancer of the penis and other genitalia.
The German scientist, who began his research in the 1970s, searched for different HPV types, detecting them in 70 percent of cervical tumor samples from around the world.
An estimated 500,000 women are diagnosed with the disease each year and about 300,000 die from it, mostly in the developing world.
Zur Hausen said he thought more cancers would be linked to viruses. "I suspect there will be more in the future," he said in a telephone interview.
GlaxoSmithKline and Merck and Co. have developed vaccines against HPV -- which are controversial because to be effective the series of costly shots must be given to girls before they begin sexual activity.
Medicine is traditionally the first of the Nobel prizes awarded each year. The prizes for achievement in science, literature and peace were first awarded in 1901 in accordance with the will of dynamite inventor Alfred Nobel.
The Nobel laureate for physics will be announced on Tuesday, chemistry on Wednesday, literature on Thursday and the Nobel Peace Prize on Friday in Oslo.
(Additional reporting by Adam Cox, Elinor Schang and Anna Ringstrom in Stockholm, Maggie Fox in Washington, Michael Kahn in London; Brian Rohan in Paris, and Loucoumane Coulibaly in Abidjan)
(Editing by Maggie Fox and Eric Walsh)
Papiloma Virus and HIV as causes of Cervical Cancer and AIDS Disease recongnized by Noble committee 2008
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Human Papilloma Virus And Cancer, HIV Discoveries Recognized In 2008 Nobel Prize In Physiology Or Medicine
ScienceDaily (Oct. 6, 2008) — The Nobel Assembly at Karolinska Institutet has today decided to award The Nobel Prize in Physiology or Medicine for 2008 with one half to: Harald zur Hausen for his discovery of "human papilloma viruses causing cervical cancer" and the other half jointly to Françoise Barré-Sinoussi and Luc Montagnier for their discovery of "human immunodeficiency virus."
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See also:
Health & Medicine
HIV and AIDS
Viruses
Infectious Diseases
Cancer
Lymphoma
Brain Tumor
Reference
HPV vaccine
HPV
Pap smear
Sexually transmitted disease
This year's Nobel Prize awards discoveries of two viruses causing severe human diseases.
Harald zur Hausen went against current dogma and postulated that oncogenic human papilloma virus (HPV) caused cervical cancer, the second most common cancer among women.
He realized that HPV-DNA could exist in a non-productive state in the tumours, and should be detectable by specific searches for viral DNA.
He found HPV to be a heterogeneous family of viruses. Only some HPV types cause cancer. His discovery has led to characterization of the natural history of HPV infection, an understanding of mechanisms of HPV-induced carcinogenesis and the development of prophylactic vaccines against HPV acquisition.
Françoise Barré-Sinoussi and Luc Montagnier discovered human immunodeficiency virus (HIV).
Virus production was identified in lymphocytes from patients with enlarged lymph nodes in early stages of acquired immunodeficiency, and in blood from patients with late stage disease.
They characterized this retrovirus as the first known human lentivirus based on its morphological, biochemical and immunological properties. HIV impaired the immune system because of massive virus replication and cell damage to lymphocytes.
The discovery was one prerequisite for the current understanding of the biology of the disease and its antiretroviral treatment.
Discovery of human papilloma virus causing cervical cancer
Against the prevailing view during the 1970s, Harald zur Hausen postulated a role for human papilloma virus (HPV) in cervical cancer.
He assumed that the tumour cells, if they contained an oncogenic virus, should harbour viral DNA integrated into their genomes.
The HPV genes promoting cell proliferation should therefore be detectable by specifically searching tumour cells for such viral DNA.
Harald zur Hausen pursued this idea for over 10 years by searching for different HPV types, a search made difficult by the fact that only parts of the viral DNA were integrated into the host genome.
He found novel HPV-DNA in cervix cancer biopsies, and thus discovered the new, tumourigenic HPV16 type in 1983.
In 1984, he cloned HPV16 and 18 from patients with cervical cancer. The HPV types 16 and 18 were consistently found in about 70% of cervical cancer biopsies throughout the world.
Importance of the HPV discovery
The global public health burden attributable to human papilloma viruses is considerable. More than 5% of all cancers worldwide are caused by persistent infection with this virus.
Infection by the human papilloma virus is the most common sexually transmitted agent, afflicting 50-80% of the population. Of the more than 100 HPV types known, about 40 infect the genital tract, and 15 of these put women at high risk for cervical cancer.
In addition, HPV is found in some vulval, penile, oral and other cancers. Human papilloma virus can be detected in 99.7% of women with histologically confirmed cervical cancer, affecting some 500,000 women per year.
Harald zur Hausen demonstrated novel properties of HPV that have led to an understanding of mechanisms for papilloma virus-induced carcinogenesis and the predisposing factors for viral persistence and cellular transformation.
He made HPV16 and 18 available to the scientific community. Vaccines were ultimately developed that provide =95 % protection from infection by the high risk HPV16 and 18 types.
The vaccines may also reduce the need for surgery and the global burden of cervical cancer.
Discovery of HIV
Following medical reports of a novel immunodeficiency syndrome in 1981, the search for a causative agent was on.
Françoise Barré-Sinoussi and Luc Montagnier isolated and cultured lymph node cells from patients that had swollen lymph nodes characteristic of the early stage of acquired immune deficiency.
They detected activity of the retroviral enzyme reverse transcriptase, a direct sign of retrovirus replication.
They also found retroviral particles budding from the infected cells. Isolated virus infected and killed lymphocytes from both diseased and healthy donors, and reacted with antibodies from infected patients.
In contrast to previously characterized human oncogenic retroviruses, the novel retrovirus they had discovered, now known as human immunodeficiency virus (HIV), did not induce uncontrolled cell growth.
Instead, the virus required cell activation for replication and mediated cell fusion of T lymphocytes.
This partly explained how HIV impairs the immune system since the T cells are essential for immune defence.
By 1984, Barré-Sinoussi and Montagnier had obtained several isolates of the novel human retrovirus, which they identified as a lentivirus, from sexually infected individuals, haemophiliacs, mother to infant transmissions and transfused patients. The significance of their achievements should be viewed in the context of a global ubiquitous epidemic affecting close to 1% of the population.
Importance of the HIV discovery
Soon after the discovery of the virus, several groups contributed to the definitive demonstration of HIV as the cause of acquired human immunodeficiency syndrome (AIDS). Barré-Sinoussi and Montagnier's discovery made rapid cloning of the HIV-1 genome possible.
This has allowed identification of important details in its replication cycle and how the virus interacts with its host. Furthermore, it led to development of methods to diagnose infected patients and to screen blood
products, which has limited the spread of the pandemic. The unprecedented development of several classes of new antiviral drugs is also a result of knowledge of the details of the viral replication cycle.
The combination of prevention and treatment has substantially decreased spread of the disease and dramatically increased life expectancy among treated patients. The cloning of HIV enabled studies of its origin and evolution.
The virus was probably passed to humans from chimpanzees in West Africa early in the 20th century, but it is still unclear why the epidemic spread so dramatically from 1970 and onwards.
Identification of virus-host interactions has provided information on how HIV evades the host’s immune system by impairing lymphocyte function, by constantly changing and by hiding its genome in the host lymphocyte DNA, making its eradication in the infected host difficult even after long-term antiviral treatment.
Extensive knowledge about these unique viral host interactions has, however, generated results that can provide ideas for future vaccine development as well as for therapeutic approaches targeting viral latency.
HIV has generated a novel pandemic. Never before has science and medicine been so quick to discover, identify the origin and provide treatment for a new disease entity. Successful anti-retroviral therapy results in life expectancies for persons with HIV infection now reaching levels similar to those of uninfected people.
Harald zur Hausen, born 1936 in Germany, German citizen, MD at University of Düsseldorf, Germany. Professor emeritus and former Chairman and Scientific Director, German Cancer Research Centre, Heidelberg, Germany.
Françoise Barré-Sinoussi, born 1947 in France, French citizen, PhD in virology, Institut Pasteur, Garches, France. Professor and Director, Regulation of Retroviral Infections Unit, Virology Department, Institut Pasteur, Paris, France.
Luc Montagnier, born 1932 in France, French citizen, PhD in virology, University of Paris, Paris, France. Professor emeritus and Director, World Foundation for AIDS Research and Prevention, Paris, France.
--------------------------------------------------------------------------------
Adapted from materials provided by Nobel Web/ Nobelprize.org.
Need to cite this story in your essay, paper, or report? Use one of the following formats:
APA
MLA Nobel Web/ Nobelprize.org (2008, October 6). Human Papilloma Virus And Cancer, HIV Discoveries Recognized In 2008 Nobel Prize In Physiology Or Medicine. ScienceDaily. Retrieved October 6, 2008, from http://www.sciencedaily.com /releases/2008/10/081006093031.htmenlarge
Illustrations of human papilloma viruses causing cervical cancer and human immunodeficiency virus. (Credit: Copyright The Nobel Committee for Physiology or Medicine 2008 / Illustration by Annika Röhl)
Ads by GoogleAdvertise here
--------------------------------------------------------------------------------
1 flat stomach rule: obey
I cut out 2 lbs of stomach fat each week by obeying this 1 old rule.
Wu-YiSource.comHuman Papilloma Virus
Looking for Human Papilloma Virus? See Human Papilloma Virus.
Spectrum-Health.orgAll-new Ford F-450 Pickup
Team Tough tested to show you what it can accomplish in your world.
fordvehicles.comThe Bakken Oil Formation
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Related Stories
--------------------------------------------------------------------------------
Early Detection Of Human Papilloma And Other Viral Infections (Oct. 16, 2007) — Scientists have developed a new, amazingly sensitive method for identifying the earliest stages of infection with human papilloma virus (HPV), a common virus that can increase the risk of cervical ... > read more
Viruses May Play A Role In Lung Cancer Development (Apr. 25, 2008) — New research highlights emerging evidence that common viruses may contribute to the development of lung cancer. Experts agree that smoking is by far the most important factor that contributes to lung ... > read more
Link Between Nationality And Cervical Cancer In Sweden (Sep. 3, 2008) — Gynaecological screening tests for cervical cancer have been available to all women in Sweden for almost four decades. Despite this, many immigrant women have a higher risk of developing the disease ... > read more
Texas Scientists Discover How A Hepatitis C Protein Promotes Liver Cancer (Dec. 6, 2005) — Scientists at the University of Texas Medical Branch at Galveston have identified a key biochemical connection between the hepatitis C virus and liver ... > read more
Winning A Nobel Prize Adds Nearly 2 Years To Your Lifespan, New Research Says (Jan. 18, 2007) — New research by the University of Warwick reveals that a Nobel Prize brings more than just cash and kudos -- it can also add nearly two years to your ... > read more
Hepatitis C: Identification Of A Protein That Inhibits The Virus (Apr. 17, 2008) — Scientists have provided evidence of a protein that inhibits the hepatitis C virus at an early stage of its infective cycle. This research suggests possible new perspectives for the development of ... > read more
Cancer Risk In HIV, Transplant Patients (July 10, 2007) — HIV/AIDS and kidney transplant patients are at much greater risk of contracting 20 different types of cancer than the general population, according to a recent article. HIV/AIDS patients are 11 times ... > read more
HIV Drug Could Be Used To Prevent Cervical Cancer (Aug. 29, 2006) — Researchers at the University of Manchester are developing a topical treatment against the human papilloma virus (HPV) which is responsible for pre-cancerous and cancerous disease of the cervix as ... > read more
ence News Share Blog Cite Print Email Bookmark
Human Papilloma Virus And Cancer, HIV Discoveries Recognized In 2008 Nobel Prize In Physiology Or Medicine
ScienceDaily (Oct. 6, 2008) — The Nobel Assembly at Karolinska Institutet has today decided to award The Nobel Prize in Physiology or Medicine for 2008 with one half to: Harald zur Hausen for his discovery of "human papilloma viruses causing cervical cancer" and the other half jointly to Françoise Barré-Sinoussi and Luc Montagnier for their discovery of "human immunodeficiency virus."
--------------------------------------------------------------------------------
See also:
Health & Medicine
HIV and AIDS
Viruses
Infectious Diseases
Cancer
Lymphoma
Brain Tumor
Reference
HPV vaccine
HPV
Pap smear
Sexually transmitted disease
This year's Nobel Prize awards discoveries of two viruses causing severe human diseases.
Harald zur Hausen went against current dogma and postulated that oncogenic human papilloma virus (HPV) caused cervical cancer, the second most common cancer among women.
He realized that HPV-DNA could exist in a non-productive state in the tumours, and should be detectable by specific searches for viral DNA.
He found HPV to be a heterogeneous family of viruses. Only some HPV types cause cancer. His discovery has led to characterization of the natural history of HPV infection, an understanding of mechanisms of HPV-induced carcinogenesis and the development of prophylactic vaccines against HPV acquisition.
Françoise Barré-Sinoussi and Luc Montagnier discovered human immunodeficiency virus (HIV).
Virus production was identified in lymphocytes from patients with enlarged lymph nodes in early stages of acquired immunodeficiency, and in blood from patients with late stage disease.
They characterized this retrovirus as the first known human lentivirus based on its morphological, biochemical and immunological properties. HIV impaired the immune system because of massive virus replication and cell damage to lymphocytes.
The discovery was one prerequisite for the current understanding of the biology of the disease and its antiretroviral treatment.
Discovery of human papilloma virus causing cervical cancer
Against the prevailing view during the 1970s, Harald zur Hausen postulated a role for human papilloma virus (HPV) in cervical cancer.
He assumed that the tumour cells, if they contained an oncogenic virus, should harbour viral DNA integrated into their genomes.
The HPV genes promoting cell proliferation should therefore be detectable by specifically searching tumour cells for such viral DNA.
Harald zur Hausen pursued this idea for over 10 years by searching for different HPV types, a search made difficult by the fact that only parts of the viral DNA were integrated into the host genome.
He found novel HPV-DNA in cervix cancer biopsies, and thus discovered the new, tumourigenic HPV16 type in 1983.
In 1984, he cloned HPV16 and 18 from patients with cervical cancer. The HPV types 16 and 18 were consistently found in about 70% of cervical cancer biopsies throughout the world.
Importance of the HPV discovery
The global public health burden attributable to human papilloma viruses is considerable. More than 5% of all cancers worldwide are caused by persistent infection with this virus.
Infection by the human papilloma virus is the most common sexually transmitted agent, afflicting 50-80% of the population. Of the more than 100 HPV types known, about 40 infect the genital tract, and 15 of these put women at high risk for cervical cancer.
In addition, HPV is found in some vulval, penile, oral and other cancers. Human papilloma virus can be detected in 99.7% of women with histologically confirmed cervical cancer, affecting some 500,000 women per year.
Harald zur Hausen demonstrated novel properties of HPV that have led to an understanding of mechanisms for papilloma virus-induced carcinogenesis and the predisposing factors for viral persistence and cellular transformation.
He made HPV16 and 18 available to the scientific community. Vaccines were ultimately developed that provide =95 % protection from infection by the high risk HPV16 and 18 types.
The vaccines may also reduce the need for surgery and the global burden of cervical cancer.
Discovery of HIV
Following medical reports of a novel immunodeficiency syndrome in 1981, the search for a causative agent was on.
Françoise Barré-Sinoussi and Luc Montagnier isolated and cultured lymph node cells from patients that had swollen lymph nodes characteristic of the early stage of acquired immune deficiency.
They detected activity of the retroviral enzyme reverse transcriptase, a direct sign of retrovirus replication.
They also found retroviral particles budding from the infected cells. Isolated virus infected and killed lymphocytes from both diseased and healthy donors, and reacted with antibodies from infected patients.
In contrast to previously characterized human oncogenic retroviruses, the novel retrovirus they had discovered, now known as human immunodeficiency virus (HIV), did not induce uncontrolled cell growth.
Instead, the virus required cell activation for replication and mediated cell fusion of T lymphocytes.
This partly explained how HIV impairs the immune system since the T cells are essential for immune defence.
By 1984, Barré-Sinoussi and Montagnier had obtained several isolates of the novel human retrovirus, which they identified as a lentivirus, from sexually infected individuals, haemophiliacs, mother to infant transmissions and transfused patients. The significance of their achievements should be viewed in the context of a global ubiquitous epidemic affecting close to 1% of the population.
Importance of the HIV discovery
Soon after the discovery of the virus, several groups contributed to the definitive demonstration of HIV as the cause of acquired human immunodeficiency syndrome (AIDS). Barré-Sinoussi and Montagnier's discovery made rapid cloning of the HIV-1 genome possible.
This has allowed identification of important details in its replication cycle and how the virus interacts with its host. Furthermore, it led to development of methods to diagnose infected patients and to screen blood
products, which has limited the spread of the pandemic. The unprecedented development of several classes of new antiviral drugs is also a result of knowledge of the details of the viral replication cycle.
The combination of prevention and treatment has substantially decreased spread of the disease and dramatically increased life expectancy among treated patients. The cloning of HIV enabled studies of its origin and evolution.
The virus was probably passed to humans from chimpanzees in West Africa early in the 20th century, but it is still unclear why the epidemic spread so dramatically from 1970 and onwards.
Identification of virus-host interactions has provided information on how HIV evades the host’s immune system by impairing lymphocyte function, by constantly changing and by hiding its genome in the host lymphocyte DNA, making its eradication in the infected host difficult even after long-term antiviral treatment.
Extensive knowledge about these unique viral host interactions has, however, generated results that can provide ideas for future vaccine development as well as for therapeutic approaches targeting viral latency.
HIV has generated a novel pandemic. Never before has science and medicine been so quick to discover, identify the origin and provide treatment for a new disease entity. Successful anti-retroviral therapy results in life expectancies for persons with HIV infection now reaching levels similar to those of uninfected people.
Harald zur Hausen, born 1936 in Germany, German citizen, MD at University of Düsseldorf, Germany. Professor emeritus and former Chairman and Scientific Director, German Cancer Research Centre, Heidelberg, Germany.
Françoise Barré-Sinoussi, born 1947 in France, French citizen, PhD in virology, Institut Pasteur, Garches, France. Professor and Director, Regulation of Retroviral Infections Unit, Virology Department, Institut Pasteur, Paris, France.
Luc Montagnier, born 1932 in France, French citizen, PhD in virology, University of Paris, Paris, France. Professor emeritus and Director, World Foundation for AIDS Research and Prevention, Paris, France.
--------------------------------------------------------------------------------
Adapted from materials provided by Nobel Web/ Nobelprize.org.
Need to cite this story in your essay, paper, or report? Use one of the following formats:
APA
MLA Nobel Web/ Nobelprize.org (2008, October 6). Human Papilloma Virus And Cancer, HIV Discoveries Recognized In 2008 Nobel Prize In Physiology Or Medicine. ScienceDaily. Retrieved October 6, 2008, from http://www.sciencedaily.com /releases/2008/10/081006093031.htmenlarge
Illustrations of human papilloma viruses causing cervical cancer and human immunodeficiency virus. (Credit: Copyright The Nobel Committee for Physiology or Medicine 2008 / Illustration by Annika Röhl)
Ads by GoogleAdvertise here
--------------------------------------------------------------------------------
1 flat stomach rule: obey
I cut out 2 lbs of stomach fat each week by obeying this 1 old rule.
Wu-YiSource.comHuman Papilloma Virus
Looking for Human Papilloma Virus? See Human Papilloma Virus.
Spectrum-Health.orgAll-new Ford F-450 Pickup
Team Tough tested to show you what it can accomplish in your world.
fordvehicles.comThe Bakken Oil Formation
Forget the Oil Sands: The New Oil Boom Is In 'The Bakken.' New Rpt.
www.EnergyAndCapital.com/Bakken_OilNew & Used Cars
Find Low car prices in your area Get the Car of your dreams today
carworks.com
Related Stories
--------------------------------------------------------------------------------
Early Detection Of Human Papilloma And Other Viral Infections (Oct. 16, 2007) — Scientists have developed a new, amazingly sensitive method for identifying the earliest stages of infection with human papilloma virus (HPV), a common virus that can increase the risk of cervical ... > read more
Viruses May Play A Role In Lung Cancer Development (Apr. 25, 2008) — New research highlights emerging evidence that common viruses may contribute to the development of lung cancer. Experts agree that smoking is by far the most important factor that contributes to lung ... > read more
Link Between Nationality And Cervical Cancer In Sweden (Sep. 3, 2008) — Gynaecological screening tests for cervical cancer have been available to all women in Sweden for almost four decades. Despite this, many immigrant women have a higher risk of developing the disease ... > read more
Texas Scientists Discover How A Hepatitis C Protein Promotes Liver Cancer (Dec. 6, 2005) — Scientists at the University of Texas Medical Branch at Galveston have identified a key biochemical connection between the hepatitis C virus and liver ... > read more
Winning A Nobel Prize Adds Nearly 2 Years To Your Lifespan, New Research Says (Jan. 18, 2007) — New research by the University of Warwick reveals that a Nobel Prize brings more than just cash and kudos -- it can also add nearly two years to your ... > read more
Hepatitis C: Identification Of A Protein That Inhibits The Virus (Apr. 17, 2008) — Scientists have provided evidence of a protein that inhibits the hepatitis C virus at an early stage of its infective cycle. This research suggests possible new perspectives for the development of ... > read more
Cancer Risk In HIV, Transplant Patients (July 10, 2007) — HIV/AIDS and kidney transplant patients are at much greater risk of contracting 20 different types of cancer than the general population, according to a recent article. HIV/AIDS patients are 11 times ... > read more
HIV Drug Could Be Used To Prevent Cervical Cancer (Aug. 29, 2006) — Researchers at the University of Manchester are developing a topical treatment against the human papilloma virus (HPV) which is responsible for pre-cancerous and cancerous disease of the cervix as ... > read more
Friday, September 12, 2008
Renaissance of Primary Health Care? Fact or Fiction?
A renaissance in primary health care
30 years ago, in the midst of the Cold War, health experts and policy makers from 134 WHO member states convened in the former USSR to attend a conference on international primary health care. On Sept 12, 1978, the Alma-Ata Declaration was signed, with the ambitious target of achieving “Health for All by 2000”.
In 1978, 2000 million people were estimated to have no access to adequate health care. There were vast inequalities between rich and poor countries, and between rich and poor populations within countries. The Alma-Ata Declaration revolutionised the world's interpretation of health.
Its message was that inadequate and unequal health care was unacceptable: economically, socially, and politically. Unfortunately, the goal of “health for all”, while a rallying call to action, was not met.
Theories for this failure abound: the vision for primary health care was politically unacceptable to some nations and so was marginalised; emerging health threats took precedence (no one imagined the global disease burden that HIV/AIDS would bring); and health priorities shifted (to the Millennium Development Goals [MDGs]).
30 years on, what is the relevance of the Alma-Ata Declaration in 2008? In short, primary health care is now offering global health a lifeline. Progress towards the MDGs has stalled. Weak health systems have restricted the success of efforts to improve maternal, newborn, and child health, and to reduce the disease burden from malaria and tuberculosis.
New epidemics of chronic disease threaten to reverse what small gains have been achieved. To get back on track, and to meet the MDGs by 2015, countries need to strengthen their health systems through the implementation of effective primary health care.
Now is the right moment to proclaim the urgent need for a renaissance in primary health care.
The continuing relevance of this 30-year-old Declaration is remarkable. Many of the challenges faced in 1978 remain, such as infectious diseases (eg, the ongoing threat of H5N1 avian influenza and HIV/AIDS), political instability and conflict (most recently seen in Iraq and Zimbabwe), and worsening poverty (the World Bank last month estimated that 1·4 billion people now live in poverty).
In recognition of this timely reawakening of interest in primary health care, this week's Lancet revisits, updates, and relaunches the key messages from Alma-Ata.
A series of eight papers begins with an analysis of modern primary health care, and issues such as implementing cost-effective interventions in low-resource settings and tackling the growing burden of chronic diseases. We publish an analysis of individual country progress since 1978, with possible lessons for those who have shown the least advance.
Involvement of communities in planning and implementation of health care (one of the main tenets of the Alma-Ata Declaration) is explored in the context of maternal, newborn, and child health, as are the roles of national policies and effective service integration, all foundations of a successful primary health care service. The final paper in the series looks to the future and provides a series of action points to revitalise primary health care,both nationally and globally.
WHO's vision for health—complete physical, mental, and social wellbeing—is the key to achieving Alma-Ata's prime goal of “health for all”. This week's research articles also focus on these three principles.
Stephen Tollman and colleagues discuss the challenges in managing chronic diseases in primary health care and the importance of providing adequate services to ensure physical wellbeing.
Atif Rahman and co-workers tackle mental health in Bangladesh, with a psychological intervention that can be delivered within communities to treat mothers with perinatal depression. And the importance of social development is shown by Luis Huicho and authors who present data from four countries highlighting the importance of health workers with shorter durations of training in providing vital care to people in low-resource settings.
Importantly, WHO, under Margaret Chan's effective leadership and together with her regional directors, has reaffirmed its commitment to primary health care. This revisioning of the principles of Alma-Ata is welcome and illustrates a new unity of purpose across global health institutions.
Political progress is also encouraging. Following the G8 meeting earlier this year, Japan has announced its own commitment to lead international initiatives to strengthen health systems.
Such renewed global interest in primary health care is promising. The need remains great and there are no shortcuts to success. But with refined international relationships, new and emerging technologies, and 30 years of experience, “health for all” need not be a dream buried in the past.
The right to the highest attainable standard of health can be a reality within our grasp.
The Lancet
30 years ago, in the midst of the Cold War, health experts and policy makers from 134 WHO member states convened in the former USSR to attend a conference on international primary health care. On Sept 12, 1978, the Alma-Ata Declaration was signed, with the ambitious target of achieving “Health for All by 2000”.
In 1978, 2000 million people were estimated to have no access to adequate health care. There were vast inequalities between rich and poor countries, and between rich and poor populations within countries. The Alma-Ata Declaration revolutionised the world's interpretation of health.
Its message was that inadequate and unequal health care was unacceptable: economically, socially, and politically. Unfortunately, the goal of “health for all”, while a rallying call to action, was not met.
Theories for this failure abound: the vision for primary health care was politically unacceptable to some nations and so was marginalised; emerging health threats took precedence (no one imagined the global disease burden that HIV/AIDS would bring); and health priorities shifted (to the Millennium Development Goals [MDGs]).
30 years on, what is the relevance of the Alma-Ata Declaration in 2008? In short, primary health care is now offering global health a lifeline. Progress towards the MDGs has stalled. Weak health systems have restricted the success of efforts to improve maternal, newborn, and child health, and to reduce the disease burden from malaria and tuberculosis.
New epidemics of chronic disease threaten to reverse what small gains have been achieved. To get back on track, and to meet the MDGs by 2015, countries need to strengthen their health systems through the implementation of effective primary health care.
Now is the right moment to proclaim the urgent need for a renaissance in primary health care.
The continuing relevance of this 30-year-old Declaration is remarkable. Many of the challenges faced in 1978 remain, such as infectious diseases (eg, the ongoing threat of H5N1 avian influenza and HIV/AIDS), political instability and conflict (most recently seen in Iraq and Zimbabwe), and worsening poverty (the World Bank last month estimated that 1·4 billion people now live in poverty).
In recognition of this timely reawakening of interest in primary health care, this week's Lancet revisits, updates, and relaunches the key messages from Alma-Ata.
A series of eight papers begins with an analysis of modern primary health care, and issues such as implementing cost-effective interventions in low-resource settings and tackling the growing burden of chronic diseases. We publish an analysis of individual country progress since 1978, with possible lessons for those who have shown the least advance.
Involvement of communities in planning and implementation of health care (one of the main tenets of the Alma-Ata Declaration) is explored in the context of maternal, newborn, and child health, as are the roles of national policies and effective service integration, all foundations of a successful primary health care service. The final paper in the series looks to the future and provides a series of action points to revitalise primary health care,both nationally and globally.
WHO's vision for health—complete physical, mental, and social wellbeing—is the key to achieving Alma-Ata's prime goal of “health for all”. This week's research articles also focus on these three principles.
Stephen Tollman and colleagues discuss the challenges in managing chronic diseases in primary health care and the importance of providing adequate services to ensure physical wellbeing.
Atif Rahman and co-workers tackle mental health in Bangladesh, with a psychological intervention that can be delivered within communities to treat mothers with perinatal depression. And the importance of social development is shown by Luis Huicho and authors who present data from four countries highlighting the importance of health workers with shorter durations of training in providing vital care to people in low-resource settings.
Importantly, WHO, under Margaret Chan's effective leadership and together with her regional directors, has reaffirmed its commitment to primary health care. This revisioning of the principles of Alma-Ata is welcome and illustrates a new unity of purpose across global health institutions.
Political progress is also encouraging. Following the G8 meeting earlier this year, Japan has announced its own commitment to lead international initiatives to strengthen health systems.
Such renewed global interest in primary health care is promising. The need remains great and there are no shortcuts to success. But with refined international relationships, new and emerging technologies, and 30 years of experience, “health for all” need not be a dream buried in the past.
The right to the highest attainable standard of health can be a reality within our grasp.
The Lancet
Thursday, September 11, 2008
Tied like a knot a 14 year old song
"Tied Like A Knot" By: Abigail Belai
We were swingin' in the playground
that day after school
when you said the words
that helped me get through the hard times
you held on so tight
I was sitting on your bed
when I got the news
we didn't even move
all you heard were soft cries
we held on so tight
I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we'd never break apart
cuz were tied like a knot
We were stayin' up on a late night
talking on the phone
you fekt so alone
like a part of you was out in the cold
we should have known
that we'd be in different places
at different times
but being seperated dosen't mean we gotta cry
we held on so tight
I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we'd never break apart
cuz were tied like a knot
After all these years
you kept your word
we never broke apart
how 'bout we add a double knot
cuz love never breakes apart
I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we never broke apart
cuz were still tied like a knot
♥
We were swingin' in the playground
that day after school
when you said the words
that helped me get through the hard times
you held on so tight
I was sitting on your bed
when I got the news
we didn't even move
all you heard were soft cries
we held on so tight
I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we'd never break apart
cuz were tied like a knot
We were stayin' up on a late night
talking on the phone
you fekt so alone
like a part of you was out in the cold
we should have known
that we'd be in different places
at different times
but being seperated dosen't mean we gotta cry
we held on so tight
I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we'd never break apart
cuz were tied like a knot
After all these years
you kept your word
we never broke apart
how 'bout we add a double knot
cuz love never breakes apart
I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we never broke apart
cuz were still tied like a knot
♥
Tuesday, September 09, 2008
The Infinite Human Memory Discovered?
Humans Have Astonishing Memories, Study Finds Clara Moskowitz
LiveScience Staff Writer
LiveScience.com
Tue Sep 9, 12:02 AM ET
If human memory were truly digital, it would have just received an upgrade from something like the capacity of a floppy disk to that of a flash drive. A new study found the brain can remember a lot more than previously believed.
In a recent experiment, people who viewed pictures of thousands of objects over five hours were able to remember astonishing details afterward about most of the objects.
Though previous studies have never measured such astounding feats of memory, it may be simply because no one really tried.
"People had never tested whether people could remember this much detail about this many objects," said researcher Timothy Brady, a cognitive neuroscientist at MIT. "Nobody actually pushed it this far."
When they did push the human brain to its limits, the scientists found that under the right circumstances, it can store minute visual details far beyond what had been imagined.
Those circumstances include looking at images of objects that are familiar, such as remote controls, dollar bills and loaves of bread, as opposed to abstract artworks.
Another factor that seemed to help was motivation to do well: The participant who scored highest won a small prize of money (the researchers refused to say exactly how much).
"You have to try," said MIT co-author Talia Konkle. "You have to want to do it."
The study, funded by the National Science Foundation, National Institutes of Health, a National Defense Science and Engineering Graduate Fellowship, and a National Research Service Award, was detailed in the Sept. 8 issue of the journal Proceedings of the National Academy of Sciences.
In the experiment, 14 people ranging from age 18 to 40 viewed nearly 3,000 images, one at a time, for three seconds each. Afterwards, they were shown pairs of images and asked to select the exact image they had seen earlier.
The test pairs fell into three categories: two completely different objects, an object and a different example of the same type of object (such as two different remote controls), and an object along with a slightly altered version of the same object (such as a cup full and another cup half-full).
Stunningly, participants on average chose the correct image 92 percent, 88 percent and 87 percent of the time, in each of the three pairing categories respectively. Though 14 subjects may not sound like a huge sample, the fact that they each recalled the objects with very similar rates of success suggests the results are not a fluke.
"To give just one example, this means that after having seen thousands of objects, subjects didn't just remember which cabinet they had seen, but also that the cabinet door was slightly open," Brady said.
Even the researchers didn't expect quite such high recall rates.
"We had the intuition that it might be possible, but we were surprised by the magnitude of the effect," said study leader Aude Oliva, also of MIT. "These numbers, higher than 85 and 90 percent, impressed us and also impressed a lot of people who heard about the work."
So now that we know the brain's memory is so fantastic, are we all out of excuses for forgetting friends' birthdays?
Luckily not, Brady said.
"To some extent it's about attention, actively encoding specific details into memory," he told LiveScience. "If we tried really hard we actually could remember when someone's birthday was: if you say to yourself, 'The birthday is on this day and that relates to these other things that I remember.'"
Basically, he said, we can remember most things we put our minds to, if we invest enough attention and effort into trying to store them in the first place.
Video: Attention Training Video: A Turn-off Switch for Alzheimer's Top 10 Mysteries of the Mind Original Story: Humans Have Astonishing Memories, Study Finds LiveScience.com chronicles the daily advances and innovations made in science and technology.
We take on the misconceptions that often pop up around scientific discoveries and deliver short, provocative explanations with a certain wit and style. Check out our science videos, Trivia & Quizzes and Top 10s.
Join our community to debate hot-button issues like stem cells, climate change and evolution. You can also sign up for free newsletters, register for RSS feeds and get cool gadgets at the LiveScience Store.
Copyright © 2008 Yahoo! Inc. All rights reserved.
Questions or Comments
Privacy Policy -Terms of Service - Copyright/IP Policy
LiveScience Staff Writer
LiveScience.com
Tue Sep 9, 12:02 AM ET
If human memory were truly digital, it would have just received an upgrade from something like the capacity of a floppy disk to that of a flash drive. A new study found the brain can remember a lot more than previously believed.
In a recent experiment, people who viewed pictures of thousands of objects over five hours were able to remember astonishing details afterward about most of the objects.
Though previous studies have never measured such astounding feats of memory, it may be simply because no one really tried.
"People had never tested whether people could remember this much detail about this many objects," said researcher Timothy Brady, a cognitive neuroscientist at MIT. "Nobody actually pushed it this far."
When they did push the human brain to its limits, the scientists found that under the right circumstances, it can store minute visual details far beyond what had been imagined.
Those circumstances include looking at images of objects that are familiar, such as remote controls, dollar bills and loaves of bread, as opposed to abstract artworks.
Another factor that seemed to help was motivation to do well: The participant who scored highest won a small prize of money (the researchers refused to say exactly how much).
"You have to try," said MIT co-author Talia Konkle. "You have to want to do it."
The study, funded by the National Science Foundation, National Institutes of Health, a National Defense Science and Engineering Graduate Fellowship, and a National Research Service Award, was detailed in the Sept. 8 issue of the journal Proceedings of the National Academy of Sciences.
In the experiment, 14 people ranging from age 18 to 40 viewed nearly 3,000 images, one at a time, for three seconds each. Afterwards, they were shown pairs of images and asked to select the exact image they had seen earlier.
The test pairs fell into three categories: two completely different objects, an object and a different example of the same type of object (such as two different remote controls), and an object along with a slightly altered version of the same object (such as a cup full and another cup half-full).
Stunningly, participants on average chose the correct image 92 percent, 88 percent and 87 percent of the time, in each of the three pairing categories respectively. Though 14 subjects may not sound like a huge sample, the fact that they each recalled the objects with very similar rates of success suggests the results are not a fluke.
"To give just one example, this means that after having seen thousands of objects, subjects didn't just remember which cabinet they had seen, but also that the cabinet door was slightly open," Brady said.
Even the researchers didn't expect quite such high recall rates.
"We had the intuition that it might be possible, but we were surprised by the magnitude of the effect," said study leader Aude Oliva, also of MIT. "These numbers, higher than 85 and 90 percent, impressed us and also impressed a lot of people who heard about the work."
So now that we know the brain's memory is so fantastic, are we all out of excuses for forgetting friends' birthdays?
Luckily not, Brady said.
"To some extent it's about attention, actively encoding specific details into memory," he told LiveScience. "If we tried really hard we actually could remember when someone's birthday was: if you say to yourself, 'The birthday is on this day and that relates to these other things that I remember.'"
Basically, he said, we can remember most things we put our minds to, if we invest enough attention and effort into trying to store them in the first place.
Video: Attention Training Video: A Turn-off Switch for Alzheimer's Top 10 Mysteries of the Mind Original Story: Humans Have Astonishing Memories, Study Finds LiveScience.com chronicles the daily advances and innovations made in science and technology.
We take on the misconceptions that often pop up around scientific discoveries and deliver short, provocative explanations with a certain wit and style. Check out our science videos, Trivia & Quizzes and Top 10s.
Join our community to debate hot-button issues like stem cells, climate change and evolution. You can also sign up for free newsletters, register for RSS feeds and get cool gadgets at the LiveScience Store.
Copyright © 2008 Yahoo! Inc. All rights reserved.
Questions or Comments
Privacy Policy -Terms of Service - Copyright/IP Policy
Friday, September 05, 2008
Francis Falceto's Ethiopique Compilation
September 05, 2008
Ethiopia: Swinging Addis Comes Back
Mahmoud Ahmed, back in the day.
Photo: blogs.guardian.co.uk by John Oseid
Get your streamers ready. Enqutatash, the Ethiopian New Year, arrives September 11; it will be the year 2001 in the Orthodox calendar. Now's your chance to get hooked--like me--on one of the coolest, most beguiling, and most unlikely musical revivals in years.
At a French embassy soirée in Addis Ababa some years ago, I was told that Ethiopian jazz was all the rage in the waning years of Haile Selassie's long reign, and that the swell society used to gather in posh hotels and party away to the music. "Swinging Addis," they called it. Then came the Mengistu regime in the mid-seventies and the fun door was slammed shut for 18 years.
The Golden Era stars, now septuagenarians, have made an improbable comeback, and their R&B- and soul-inflected jazz is a huge hit both on disc and in concert. A number of them recently gave a smashing Lincoln Center performance.
Here's an enthusiastic review of the packed spectacle I caught in late August at Lincoln Center's Damrosch Park bandshell. Ethiopians of all ages were there, and so was the porkpie-hatted, goateed Brooklyn hipster crowd. Among the audience members, I stumbled upon Saturday Night Live's ridiculously talented Fred Armisen, who said he was mesmerized by the show.
Elegant singer Mahmoud Ahmed, dressed in a white tunic with a red sash, had the crowd on its feet with his shimmying and clapping. Alemayehu Eshete, a singer known for his James Brown-like persona, joined him on stage. They were backed by the Massachusetts-based jazz group Either/Orchestra, which some years ago latched on to the Ethio pentatonic sound and now plays regularly with these guys. Saxophonist Getatchew Mekurya fronted a hard driving set with Dutch punk band The Ex. Here's a fun amateur video.
The Horn of Africa musical explosion can be traced to one man's labor of love. A decade ago, Frenchman Francis Falceto began compiling Golden Era music. By now, his Paris-based label Buda Musique has released well over 20 volumes in the Ethiopique series. Not only have European and American hipsters caught on, but also director Jim Jarmusch employed the dean of Ethio-jazz, arranger and vibraphone player Mulatu Astatke, for the sound track of his film Broken Flowers.
For Ethiopian New Years, I will be partying at New York City's popular downtown nightclub SOB's on Friday, September 12, where the young singer Zeritu Kebede is coming directly from Ethiopia. Here's a clip of her in action. America's larger cities now all have vibrant Habesha (as Ethiopians call themselves) communities. Keep your eyes open for shows and get ready for an awesome new experience.
Further reading:
* Britain's Independent newspaper profiles Francis Falceto's Ethiopique compilations and previews a UK performance.
* In an NPR interview, Falceto discusses the history of his Ethiopique series.
* Falceto's Abyssinie Swing is a coffee table book of black and white photographs.
Posted at 02:00 PM in BOOM BOX | Permalink | Email this post | Reddit It | Digg This | Add to del.icio.us
Ethiopia: Swinging Addis Comes Back
Mahmoud Ahmed, back in the day.
Photo: blogs.guardian.co.uk by John Oseid
Get your streamers ready. Enqutatash, the Ethiopian New Year, arrives September 11; it will be the year 2001 in the Orthodox calendar. Now's your chance to get hooked--like me--on one of the coolest, most beguiling, and most unlikely musical revivals in years.
At a French embassy soirée in Addis Ababa some years ago, I was told that Ethiopian jazz was all the rage in the waning years of Haile Selassie's long reign, and that the swell society used to gather in posh hotels and party away to the music. "Swinging Addis," they called it. Then came the Mengistu regime in the mid-seventies and the fun door was slammed shut for 18 years.
The Golden Era stars, now septuagenarians, have made an improbable comeback, and their R&B- and soul-inflected jazz is a huge hit both on disc and in concert. A number of them recently gave a smashing Lincoln Center performance.
Here's an enthusiastic review of the packed spectacle I caught in late August at Lincoln Center's Damrosch Park bandshell. Ethiopians of all ages were there, and so was the porkpie-hatted, goateed Brooklyn hipster crowd. Among the audience members, I stumbled upon Saturday Night Live's ridiculously talented Fred Armisen, who said he was mesmerized by the show.
Elegant singer Mahmoud Ahmed, dressed in a white tunic with a red sash, had the crowd on its feet with his shimmying and clapping. Alemayehu Eshete, a singer known for his James Brown-like persona, joined him on stage. They were backed by the Massachusetts-based jazz group Either/Orchestra, which some years ago latched on to the Ethio pentatonic sound and now plays regularly with these guys. Saxophonist Getatchew Mekurya fronted a hard driving set with Dutch punk band The Ex. Here's a fun amateur video.
The Horn of Africa musical explosion can be traced to one man's labor of love. A decade ago, Frenchman Francis Falceto began compiling Golden Era music. By now, his Paris-based label Buda Musique has released well over 20 volumes in the Ethiopique series. Not only have European and American hipsters caught on, but also director Jim Jarmusch employed the dean of Ethio-jazz, arranger and vibraphone player Mulatu Astatke, for the sound track of his film Broken Flowers.
For Ethiopian New Years, I will be partying at New York City's popular downtown nightclub SOB's on Friday, September 12, where the young singer Zeritu Kebede is coming directly from Ethiopia. Here's a clip of her in action. America's larger cities now all have vibrant Habesha (as Ethiopians call themselves) communities. Keep your eyes open for shows and get ready for an awesome new experience.
Further reading:
* Britain's Independent newspaper profiles Francis Falceto's Ethiopique compilations and previews a UK performance.
* In an NPR interview, Falceto discusses the history of his Ethiopique series.
* Falceto's Abyssinie Swing is a coffee table book of black and white photographs.
Posted at 02:00 PM in BOOM BOX | Permalink | Email this post | Reddit It | Digg This | Add to del.icio.us
Tuesday, September 02, 2008
Business Process ReEngineering a Value adding tool or a dehumanizing gadget
Business process reengineering
2008
Business process reengineering (BPR) is a management approach aiming at improvements by means of elevating efficiency and effectiveness of the processes that exist within and across organizations.
The key to BPR is for organizations to look at their business processes from a "clean slate" perspective and determine how they can best construct these processes to improve how they conduct business.
Business process reengineering is also known as BPR, Business Process Redesign, Business Transformation, or Business Process Change Management.
Contents [hide]
1 History
2 Definition of BPR
3 The role of information technology
4 Methodology
5 Successes
6 Critique
7 Development after 1995
8 See also
9 External links
10 Notes
History
In 1990, Michael Hammer, a former professor of computer science at the Massachusetts Institute of Technology (MIT), published an article in the Harvard Business Review, in which he claimed that the major challenge for managers is to obliterate non-value adding work, rather than using technology for automating it (Hammer 1990).
This statement implicitly accused managers of having focused on the wrong issues, namely that technology in general, and more specifically information technology, has been used primarily for automating existing work rather than using it as an enabler for making non-value adding work obsolete.
Hammer's claim was simple: Most of the work being done does not add any value for customers, and this work should be removed, not accelerated through automation. Instead, companies should reconsider their processes in order to maximize customer value, while minimizing the consumption of resources required for delivering their product or service.
A similar idea was advocated by Thomas H. Davenport and J. Short (1990), at that time a member of the Ernst & Young research center, in a paper published in the Sloan Management Review the same year as Hammer published his paper.
This idea, to unbiasedly review a company’s business processes, was rapidly adopted by a huge number of firms, which were striving for renewed competitiveness, which they had lost due to the market entrance of foreign competitors, their inability to satisfy customer needs, and their insufficient cost structure.
Even well established management thinkers, such as Peter Drucker and Tom Peters, were accepting and advocating BPR as a new tool for (re-)achieving success in a dynamic world. During the following years, a fast growing number of publications, books as well as journal articles, was dedicated to BPR, and many consulting firms embarked on this trend and developed BPR methods.
However, the critics were fast to claim that BPR was a way to dehumanize the work place, increase managerial control, and to justify downsizing, i.e. major reductions of the work force (Greenbaum 1995, Industry Week 1994), and a rebirth of Taylorism under a different label.
Despite this critique, reengineering was adopted at an accelerating pace and by 1993, as many as 65% of the Fortune 500 companies claimed to either have initiated reengineering efforts, or to have plans to do so. This trend was fueled by the fast adoption of BPR by the consulting industry, but also by the study Made in America, conducted by MIT, that showed how companies in many US industries had lagged behind their foreign counterparts in terms of competitiveness, time-to-market and productivity.
Definition of BPR
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Please improve the article or discuss proposed changes on the talk page.
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Different definitions can be found. This section contains the definition provided in notable publications in the field.
Hammer and Champy (1993) define BPR as
"... the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance, such as cost, quality, service, and speed."
Thomas H. Davenport (1993), another well-known BPR theorist, uses the term process innovation, which he says
”encompasses the envisioning of new work strategies, the actual process design activity, and the implementation of the change in all its complex technological, human, and organizational dimensions”.
Additionally, Davenport (ibid.) points out the major difference between BPR and other approaches to organization development (OD), especially the continuous improvement or TQM movement, when he states:
"Today firms must seek not fractional, but multiplicative levels of improvement – 10x rather than 10%."
Finally, Johansson et al. (1993) provide a description of BPR relative to other process-oriented views, such as Total Quality Management (TQM) and Just-in-time (JIT), and state:
"Business Process Reengineering, although a close relative, seeks radical rather than merely continuous improvement. It escalates the efforts of JIT and TQM to make process orientation a strategic tool and a core competence of the organization. BPR concentrates on core business processes, and uses the specific techniques within the JIT and TQM ”toolboxes” as enablers, while broadening the process vision."
In order to achieve the major improvements BPR is seeking for, the change of structural organizational variables, and other ways of managing and performing work is often considered as being insufficient.
For being able to reap the achievable benefits fully, the use of information technology (IT) is conceived as a major contributing factor. While IT traditionally has been used for supporting the existing business functions, i.e. it was used for increasing organizational efficiency, it now plays a role as enabler of new organizational forms, and patterns of collaboration within and between organizations.
BPR derives its existence from different disciplines, and four major areas can be identified as being subjected to change in BPR - organization, technology, strategy, and people - where a process view is used as common framework for considering these dimensions. The approach can be graphically depicted by a modification of "Leavitt’s diamond" (Leavitt 1965).
Business strategy is the primary driver of BPR initiatives and the other dimensions are governed by strategy's encompassing role. The organization dimension reflects the structural elements of the company, such as hierarchical levels, the composition of organizational units, and the distribution of work between them. Technology is concerned with the use of computer systems and other forms of communication technology in the business.
In BPR, information technology is generally considered as playing a role as enabler of new forms of organizing and collaborating, rather than supporting existing business functions. The people / human resources dimension deals with aspects such as education, training, motivation and reward systems. The concept of business processes - interrelated activities aiming at creating a value added output to a customer - is the basic underlying idea of BPR. These processes are characterized by a number of attributes: Process ownership, customer focus, value adding, and cross-functionality.
The role of information technology
Information technology (IT) has historically played an important role in the reengineering concept. It is considered by some as a major enabler for new forms of working and collaborating within an organization and across organizational borders.
The early BPR literature, e.g. Hammer & Champy (1993), identified several so called disruptive technologies that were supposed to challenge traditional wisdom about how work should be performed.
Shared databases, making information available at many places
Expert systems, allowing generalists to perform specialist tasks
Telecommunication networks, allowing organizations to be centralized and decentralized at the same time
Decision-support tools, allowing decision-making to be a part of everybody's job
Wireless data communication and portable computers, allowing field personnel to work office independent
Interactive videodisk, to get in immediate contact with potential buyers
Automatic identification and tracking, allowing things to tell where they are, instead of requiring to be found
High performance computing, allowing on-the-fly planning and revisioning
In the mid 1990s, especially workflow management systems were considered as a significant contributor to improved process efficiency. Also ERP (Enterprise Resource Planning) vendors, such as SAP, JD Edwards, Oracle, PeopleSoft, positioned their solutions as vehicles for business process redesign and improvement.
Methodology
Although the labels and steps differ slightly, the early methodologies that were rooted in IT-centric BPR solutions share many of the same basic principles and elements. The following outline is one such model, based on the PRLC (Process Reengineering Life Cycle) approach developed by Guha et.al. (1993).
Simplified schematic outline of using a business process approach, examplified for pharmceutical R&D:
1. Structural organization with functional units
2. Introduction of New Product Development as cross-functional process
3. Re-structuring and streamlining activities, removal of non-value adding tasksEnvision new processes
Secure management support
Identify reengineering opportunities
Identify enabling technologies
Align with corporate strategy
Initiating change
Set up reengineering team
Outline performance goals
Process diagnosis
Describe existing processes
Uncover pathologies in existing processes
Process redesign
Develop alternative process scenarios
Develop new process design
Design HR architecture
Select IT platform
Develop overall blueprint and gather feedback
Reconstruction
Develop/install IT solution
Establish process changes
Process monitoring
Performance measurement, including time, quality, cost, IT performance
Link to continuous improvement
-> Loop-back to diagnosis
Benefiting from lessons learned from the early adopters, some BPR practitioners advocated a change in emphasis to a customer-centric, as opposed to an IT-centric, methodology. One such methodology, that also incorporated a Risk and Impact Assessment to account for the impact that BPR can have on jobs and operations, was described by Lon Roberts (1994).
Roberts also stressed the use of change management tools to proactively address resistance to change—a factor linked to the demise of many reengineering initiatives that looked good on the drawing board.
Also within the management consulting industry, a significant number of methodological approaches have been developed. A set of short papers, outlining and comparing some of them can be found here, followed by some guidelines for companies considering to contract a consultancy for a BPR initiative:
Overview
Andersen Consulting (now Accenture)
Bain & Co.
Boston Consulting Group
McKinsey & Co.
Comparison
Guidelines for BPR consulting clients
Successes
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BPR, if implemented properly, can give huge returns. BPR has helped giants like Procter and Gamble Corporation and General Motors Corporation succeed after financial drawbacks due to competition.
It helped American Airlines somewhat get back on track from the bad debt that is currently haunting their business practice. BPR is about the proper method of implementation.
General Motors Corporation implemented a 3-year plan to consolidate their multiple desktop systems into one. It is known internally as "Consistent Office Environment" (Booker, 1994). This reengineering process involved replacing the numerous brands of desktop systems, network operating systems and application development tools into a more manageable number of vendors and technology platforms.
According to Donald G. Hedeen, director of desktops and deployment at GM and manager of the upgrade program, he says that the proces
s "lays the foundation for the implementation of a common business communication strategy across General Motors." (Booker, 1994).
Lotus Development Corporation and Hewlett-Packard Development Company, formerly Compaq Computer Corporation, received the single largest non-government sales ever from General Motors Corporation. GM also planned to use Novell NetWare as a security client, Microsoft Office and Hewlett-Packard printers.
According to Donald G. Hedeen, this saved GM 10% to 25% on support costs, 3% to 5% on hardware, 40% to 60% on software licensing fees, and increased efficiency by overcoming incompatibility issues by using just one platform across the entire company.
Michael Dell is the founder and CEO of DELL Incorporated, which has been in business since 1983 and has been the world's fastest growing major PC Company. Michael Dell's idea of a successful business is to keep the smallest inventory possible by having a direct link with the manufacturer.
When a customer places an order, the custom parts requested by the customer are automatically sent to the manufacturer for shipment. This reduces the cost for inventory tracking and massive warehouse maintenance. Dell's website is noted for bringing in nearly "$10 million each day in sales."(Smith, 1999).
Michael Dell mentions: "If you have a good strategy with sound economics, the real challenge is to get people excited about what you're doing. A lot of businesses get off track because they don't communicate an excitement about being part of a winning team that can achieve big goals.
If a company can't motivate its people and it doesn't have a clear compass, it will drift." (Smith, 1999) Dell's stocks have been ranked as the top stock for the decade of the 1990s, when it had a return of 57,282% (Knestout and Ramage, 1999).
Michael Dell is now concentrating more on customer service than selling computers since the PC market price has pretty much equalized. Michael Dell notes: "The new frontier in our industry is service, which is a much greater differentiator when price has been equalized.
In our industry, there's been a pretty huge gap between what customers want in service and what they can get, so they've come to expect mediocre service. We may be the best in this area, but we can still improve quite a bit—in the quality of the product, the availability of parts, service and delivery time." (Smith, 1999) Michael Dell understands the concept of BPR and really recognizes where and when to reengineer his business.
Ford reengineered their business and manufacturing process from just manufacturing cars to manufacturing quality cars, where the number one goal is quality. This helped Ford save millions on recalls and warranty repairs.
Ford has accomplished this goal by incorporating barcodes on all their parts and scanners to scan for any missing parts in a completed car coming off of the assembly line. This helped them guarantee a safe and quality car. They have also implemented Voice-over-IP (VoIP) to reduce the cost of having meetings between the branches.
A multi-billion dollar corporation like Procter and Gamble Corporation, which carries 300 brands and growing really has a strong grasp in re-engineering. Procter and Gamble Corporation's chief technology officer, G. Gil Cloyd, explains how a company which carries multiple brands has to contend with the "classic innovator's dilemma — most innovations fail, but companies that don't innovate die.
His solution, innovating innovation..." (Teresko, 2004). Cloyd has helped a company like Procter and Gamble grow to $5.1 billion by the fiscal year of 2004. According to Cloyd's scorecard, he was able to raise the volume by 17%, the organic volume by 10%, sales are at $51.4 billion up by 19%, with organic sales up 8%, earnings are at $6.5 billion up 25% and share earnings up 25%. Procter and Gamble also has a free cash flow of $7.3 billion or 113% of earnings, dividends up 13% annually with a total shareholder return of 24%. Cloyd states: "The challenge we face is the competitive need for a very rapid pace of innovation.
In the consumer products world, we estimate that the required pace of innovation has double in the last three years. Digital technology is very important in helping us to learn faster." (Teresko, 2004) G. Gil Cloyd also predicts, in the near future, "as much as 90% of P&G's R&D will be done in a virtual world with the remainder being physical validation of results and options." (Teresko, 2004).
Critique
The most frequent and harsh critique against BPR concerns the strict focus on efficiency and technology and the disregard of people in the organization that is subjected to a reengineering initiative. Very often, the label BPR was used for major workforce reductions. Thomas Davenport, an early BPR proponent, stated that
"When I wrote about "business process redesign" in 1990, I explicitly said that using it for cost reduction alone was not a sensible goal. And consultants Michael Hammer and James Champy, the two names most closely associated with reengineering, have insisted all along that layoffs shouldn't be the point. But the fact is, once out of the bottle, the reengineering genie quickly turned ugly." (Davenport, 1995)
Michael Hammer similarly admitted that
"I wasn't smart enough about that. I was reflecting my engineering background and was insufficient appreciative of the human dimension. I've learned that's critical." (White, 1996)
Other criticism brought forward against the BPR concept include
lack of management support for the initiative and thus poor acceptance in the organization.
exaggerated expectations regarding the potential benefits from a BPR initiative and consequently failure to achieve the expected results.
underestimation of the resistance to change within the organization.
implementation of generic so-called best-practice processes that do not fit specific company needs.
overtrust in technology solutions.
performing BPR as a one-off project with limited strategy alignment and long-term perspective.
poor project management.
Development after 1995
With the publication of critiques in 1995 and 1996 by some of the early BPR proponents, coupled with abuses and misuses of the concept by others, the reengineering fervor in the U.S. began to wane. Since then, considering business processes as a starting point for business analysis and redesign has become a widely accepted approach and is a standard part of the change methodology portfolio, but is typically performed in a less radical way as originally proposed.
More recently, the concept of Business Process Management (BPM) has gained major attention in the corporate world and can be considered as a successor to the BPR wave of the 1990s, as it is evenly driven by a striving for process efficiency supported by information technology. Equivalently to the critique brought forward against BPR, BPM is now accused of focusing on technology and disregarding the people aspects of change.
See also
Kaizen
Business Process Management
process improvement
workflow
Service-Oriented Modeling Framework (SOMF)
Business Process Modeling Notation (BPMN)
External links
BPR Articles
Hammering Hammer (A Critical Analysis of Michael Hammer's Process Enterprise approach.)
BPR : Decision engineering in a strained industrial and business environment
Notes
Davenport, Thomas & Short, J. (1990), The New Industrial Engineering: Information Technology and Business Process Redesign, in: Sloan Management Review, Summer 1990, pp 11-27
Davenport, Thomas (1993), Process Innovation: Reengineering work through information technology, Harvard Business School Press, Boston
Davenport, Thomas (1995), Reengineering - The Fad That Forgot People, Fast Company, November 1995.
Drucker, Peter (1972), Work and Tools, in: W. Kranzberg and W.H. Davenport (eds), Technology and Culture, New York
Greenbaum, Joan (1995), Windows on the workplace, Cornerstone
Guha, S.; Kettinger, W.J. & Teng, T.C., Business Process Reengineering: Building a Comprehensive Methodology, Information Systems Management, Summer 1993
Hammer, Michael (1990), Reengineering Work: Don’t automate, obliterate, Harvard Business Review, Jul/Aug 1990, pp 104-112
Hammer, Michael and Champy, James (1993), Reengineering the Corporation: A Manifesto for Business Revolution, Harper Business Chapter 1 excerpt
Industry Week (1994), De-engineering the corporation, Industry Week article, 4/18/94
Johansson, Henry J. et.al. (1993), Business Process Reengineering: BreakPoint Strategies for Market Dominance, John Wiley & Sons
Leavitt, H.J. (1965), Applied Organizational Change in Industry: Structural, Technological and Humanistic Approaches, in: James March (ed.), Handbook of Organizations, Rand McNally, Chicago
Loyd, Tom (1994), Giants with Feet of Clay, Financial Times, Dec 5 1994, p 8
Malhotra, Yogesh (1998), Business Process Redesign: An Overview, IEEE Engineering Management Review, vol. 26, no. 3, Fall 1998.
Roberts, Lon (1994), Process Reengineering: The Key To Achieving Breakthrough Success, Quality Press, Milwaukee.
Taylor (1911), Frederick, The principles of scientific management, Harper & Row, New York
Thompson, James D. (1969), Organizations in Action, MacGraw-Hill, New York
White, JB (1996), Wall Street Journal. New York, N.Y.: Nov 26, 1996. pg. A.1
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Reengineering Success Factors
More than half of early reengineering projects failed to be completed or did not achieve bottom-line business results, and for this reason business process reengineering "success factors" have become an important area of study. The success factors below are derived from benchmarking studies with more than 150 companies over a 24 month period.
Success factors are a collection of lessons learned from reengineering projects. Reengineering team members and consultants that have struggled to make their projects successful often say,
"If I had it to do over again, I would…" ,
and from these lessons common themes have emerged. In this module we examine these themes or success factors that lead to successful outcomes for reengineering projects. These include:
Top Management Sponsorship (strong and consistent involvement)
Strategic Alignment (with company strategic direction)
Compelling Business Case for Change (with measurable objectives)
Proven Methodology (that includes a vision process)
Effective Change Management (address cultural transformation)
Line Ownership (pair ownership with accountability)
Reengineering Team Composition (in both breadth and knowledge)
Top Management Sponsorship
Major business process change typically affects processes, technology, job roles and culture in the workplace. Significant changes to even one of these areas requires resources, money, and leadership. Changing them simultaneously is an extraordinary task. If top management does not provide strong and consistent support, most likely one of these three elements (money, resources, or leadership) will not be present over the life of the project, severely crippling your chances for success.
It may be true that consultants and reengineering managers give this topic a lot of attention. Mostly because current models of re-designing business processes use staff functions and consultants as change agents, and often the targeted organizations are not inviting the change. Without top management sponsorship, implementation efforts can be strongly resisted and ineffective.
Top management support for large companies with corporate staff organizations has another dimension. If the top management in the "line" organization and "staff" organization do not partner and become equal stakeholders in the change, AND you only have staff management support, you most likely are ill-prepared for a successful reengineering project (line management in this context are the top managers of the operation ultimately accountable for business performance -- P&L, customer service, etc.). Projects that result in major change in an organization rarely succeed without top management support in the line organization.
Strategic Alignment
You should be able to tie your reengineering project goals back to key business objectives and the overall strategic direction for the organization. This linkage should show the thread from the top down, so each person can easily connect the overall business direction with your reengineering effort. You should be able to demonstrate this alignment from the perspective of financial performance, customer service, associate (employee) value, and the vision for the organization.
Reengineering projects not in alignment with the company's strategic direction can be counterproductive. It is not unthinkable that an organization may make significant investments in an area that is not a core competency for the company, and later this capability be outsourced. Such reengineering initiatives are wasteful and steal resources from other strategic projects.
Moreover, without strategic alignment your key stakeholders and sponsors may find themselves unable to provide the level of support you need in terms of money and resources, especially if there are other projects more critical to the future of the business, and more aligned with the strategic direction.
Business Case for Change
In one page or less you must be able to communicate the business case for change. Less is preferred. If it requires more than this, you either don't understand the problem or you don't understand your customers.
You may find your first attempt at the business case is 100 pages of text, with an associated presentation of another 50 view graphs (overhead slides). After giving the business case 20 times you find out that you can articulate the need for change in 2 minutes and 3 or 4 paragraphs. Stick with the shorter version.
Why is this important? First, your project is not the center of the universe. People have other important things to do, too. Second, you must make this case over and over again throughout the project and during implementation - the simpler and shorter it is, the more understandable and compelling your case will be.
Cover the few critical points. Talk to the current state, and what impact this condition has on customers, associates and business results. State the drivers that are causing this condition to occur. State what your going to do about it (vision and plan), and make specific commitments. Keep focusing on the customer. Connect this plan to specific, measurable objectives related to customers, associates, business results, and strategic direction. Show how much time and money you need and when you expect to get it back. Don't sell past the close. No matter how long you talk, you will get resistance from some, and support from others, so you might as well keep it short.
The business case for change will remain the center piece that defines your project, and should be a living document that the reengineering team uses to demonstrate success. Financial pay back and real customer impact from major change initiatives are difficult to measure and more difficult to obtain; without a rigorous business case both are unlikely.
Proven Methodology
The previous module presented several BPR methodologies, and it is important to note that your methodology does matter. Seat-of-the-pants reengineering is just too risky given the size of the investment and impact these projects have on processes and people.
Not only should your team members understand reengineering, they should know how to go about it. In short, you need an approach that will meet the needs of your project and one that the team understands and supports.
Change Management
One of the most overlooked obstacles to successful project implementation is resistance from those whom implementers believe will benefit the most. Most projects underestimate the cultural impact of major process and structural change, and as a result do not achieve the full potential of their change effort.
Change is not an event, despite our many attempts to call folks together and have a meeting to make change happen. Change management is the discipline of managing change as a process, with due consideration that we are people, not programmable machines. It is about leadership with open, honest and frequent communication.
It must be OK to show resistance, to surface issues, and to be afraid of change. Organizations do not change. People change, one at a time. The better you manage the change, the less pain you will have during the transition, and your impact on work productivity will be minimized.
Line Ownership
Many re-design teams are the SWAT type -- senior management responding to crisis in line operations with external consultants or their own staff. It's a rescue operation. Unfortunately the ability of external consultants to implement significant change in an organization is small. The chances are only slightly better for staff groups. Ultimately the solution and results come back to those accountable for day-to-day execution.
That does not mean that consultants or staff are not valuable. What it does mean, though, is that the terms of engagement and accountability must be clear. The ownership must ultimately rest with the line operation, whether it be manufacturing, customer service, logistics, sales, etc.
This is where it gets messy. Often those closest to the problem can't even see it. They seem hardly in a position to implement radical change. They are, in a matter of speaking, the reason you're in this fix to begin with. They lack objectivity, external focus, technical re-design knowledge, and money.
On the other hand, they know today's processes, they know the gaps and issues, they have front-line, in-your-face experience. They are real. The customers work with them, not your consultants and staff personnel.
Hence your dilemma. The line operation probably cannot heal itself when it comes to major business re-design. Staff and consultants have no lasting accountability for the solution, and never succeed at forcing solutions on line organizations.
You need both. You need the line organization to have the awareness that they need help, to contribute their knowledge, and to own the solution and implementation. At the same time you need the expertise and objectivity from outside of the organization.
Building this partnership is the responsibility of the line organization, stakeholders and re-design team. No group is off the hook.
Reengineering Team Composition
The reengineering team composition should be a mixed bag. For example,
some members who don't know the process at all,
some members that know the process inside-out,
include customers if you can,
some members representing impacted organizations,
one or two technology gurus,
each person your best and brightest, passionate and committed, and
some members from outside of your company.
Moreover, keep the team under 10 players. If you are finding this difficult, give back some of the "representative" members. Not every organization should or needs to be represented on the initial core team. If you fail to keep the team a manageable size, you will find the entire process much more difficult to execute effectively.
Seven reengineering success factors have been introduced in this module. Subsequent modules in this series written by industry experts will take several of these success factors into greater depth.
Source: Prosci's 1998-1999 Reengineering Best Practices study (248 companies)
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bookstore where you can purchase reengineering toolkits, templates, checklists and reference material
research results from studies with more than 400 companies involved in major change projects
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yellow pages of vendors, consultants, and other resources for project teams
Welcome to the BPR Tutorial Series
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Purpose of this module:
Gain an understanding of what is meant by "business process".
Understand and contrast continuous process improvement and business process reengineering (BPR).
If you have ever waited in line at the grocery store, you can appreciate the need for process improvement. In this case, the "process" is called the check-out process, and the purpose of the process is to pay for and bag your groceries. The process begins with you stepping into line, and ends with you receiving your receipt and leaving the store. You are the customer (you have the money and you have come to buy food), and the store is the supplier.
The process steps are the activities that you and the store personnel do to complete the transaction. In this simple example, we have described a business process. Imagine other business processes: ordering clothes from mail order companies, requesting new telephone service from your telephone company, developing new products, administering the social security process, building a new home, etc.
Business processes are simply a set of activities that transform a set of inputs into a set of outputs (goods or services) for another person or process using people and tools. We all do them, and at one time or another play the role of customer or supplier.
You may see business processes pictured as a set of triangles as shown below. The purpose of this model is to define the supplier and process inputs, your process, and the customer and associated outputs. Also shown is the feedback loop from customers.
So why business process improvement?
Improving business processes is paramount for businesses to stay competitive in today's marketplace. Over the last 10 to 15 years companies have been forced to improve their business processes because we, as customers, are demanding better and better products and services. And if we do not receive what we want from one supplier, we have many others to choose from (hence the competitive issue for businesses). Many companies began business process improvement with a continuous improvement model. This model attempts to understand and measure the current process, and make performance improvements accordingly.
The figure below illustrates the basic steps. You begin by documenting what you do today, establish some way to measure the process based on what your customers want, do the process, measure the results, and then identify improvement opportunities based on the data you collected. You then implement process improvements, and measure the performance of the new process. This loop repeats over and over again, and is called continuous process improvement. You might also hear it called business process improvement, functional process improvement, etc.
This method for improving business processes is effective to obtain gradual, incremental improvement. However, over the last 10 years several factors have accelerated the need to improve business processes. The most obvious is technology. New technologies (like the Internet) are rapidly bringing new capabilities to businesses, thereby raising the competitive bar and the need to improve business processes dramatically.
Another apparent trend is the opening of world markets and increased free trade. Such changes bring more companies into the marketplace, and competing becomes harder and harder. In today's marketplace, major changes are required to just stay even. It has become a matter of survival for most companies.
As a result, companies have sought out methods for faster business process improvement. Moreover, companies want breakthrough performance changes, not just incremental changes, and they want it now. Because the rate of change has increased for everyone, few businesses can afford a slow change process. One approach for rapid change and dramatic improvement that has emerged is Business Process Reengineering (BPR).
Business Process Reengineering (BPR)
BPR relies on a different school of thought than continuous process improvement. In the extreme, reengineering assumes the current process is irrelevant - it doesn't work, it's broke, forget it. Start over. Such a clean slate perspective enables the designers of business processes to disassociate themselves from today's process, and focus on a new process. In a manner of speaking, it is like projecting yourself into the future and asking yourself: what should the process look like? What do my customers want it to look like? What do other employees want it to look like? How do best-in-class companies do it? What might we be able to do with new technology?
Such an approach is pictured below. It begins with defining the scope and objectives of your reengineering project, then going through a learning process (with your customers, your employees, your competitors and non-competitors, and with new technology). Given this knowledge base, you can create a vision for the future and design new business processes. Given the definition of the "to be" state, you can then create a plan of action based on the gap between your current processes, technologies and structures, and where you want to go. It is then a matter of implementing your solution.
In summary, the extreme contrast between continuous process improvement and business process reengineering lies in where you start (with today's process, or with a clean slate), and with the magnitude and rate of resulting changes.
Over time many derivatives of radical, breakthrough improvement and continuous improvement have emerged that attempt to address the difficulties of implementing major change in corporations. It is difficult to find a single approach exactly matched to a particular company's needs, and the challenge is to know what method to use when, and how to pull it off successfully such that bottom-line business results are achieved. Such are the topics for this module series.
The BPR Online Learning Center offers several sources to help with reengineering and business process design projects:
free tutorials (provided in this series)
bookstore where you can purchase reengineering toolkits, templates, checklists and reference material
research results from studies with more than 400 companies involved in major change projects
article indexes of online material from other sources
yellow pages of vendors, consultants, and other resources for project teams
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2008
Business process reengineering (BPR) is a management approach aiming at improvements by means of elevating efficiency and effectiveness of the processes that exist within and across organizations.
The key to BPR is for organizations to look at their business processes from a "clean slate" perspective and determine how they can best construct these processes to improve how they conduct business.
Business process reengineering is also known as BPR, Business Process Redesign, Business Transformation, or Business Process Change Management.
Contents [hide]
1 History
2 Definition of BPR
3 The role of information technology
4 Methodology
5 Successes
6 Critique
7 Development after 1995
8 See also
9 External links
10 Notes
History
In 1990, Michael Hammer, a former professor of computer science at the Massachusetts Institute of Technology (MIT), published an article in the Harvard Business Review, in which he claimed that the major challenge for managers is to obliterate non-value adding work, rather than using technology for automating it (Hammer 1990).
This statement implicitly accused managers of having focused on the wrong issues, namely that technology in general, and more specifically information technology, has been used primarily for automating existing work rather than using it as an enabler for making non-value adding work obsolete.
Hammer's claim was simple: Most of the work being done does not add any value for customers, and this work should be removed, not accelerated through automation. Instead, companies should reconsider their processes in order to maximize customer value, while minimizing the consumption of resources required for delivering their product or service.
A similar idea was advocated by Thomas H. Davenport and J. Short (1990), at that time a member of the Ernst & Young research center, in a paper published in the Sloan Management Review the same year as Hammer published his paper.
This idea, to unbiasedly review a company’s business processes, was rapidly adopted by a huge number of firms, which were striving for renewed competitiveness, which they had lost due to the market entrance of foreign competitors, their inability to satisfy customer needs, and their insufficient cost structure.
Even well established management thinkers, such as Peter Drucker and Tom Peters, were accepting and advocating BPR as a new tool for (re-)achieving success in a dynamic world. During the following years, a fast growing number of publications, books as well as journal articles, was dedicated to BPR, and many consulting firms embarked on this trend and developed BPR methods.
However, the critics were fast to claim that BPR was a way to dehumanize the work place, increase managerial control, and to justify downsizing, i.e. major reductions of the work force (Greenbaum 1995, Industry Week 1994), and a rebirth of Taylorism under a different label.
Despite this critique, reengineering was adopted at an accelerating pace and by 1993, as many as 65% of the Fortune 500 companies claimed to either have initiated reengineering efforts, or to have plans to do so. This trend was fueled by the fast adoption of BPR by the consulting industry, but also by the study Made in America, conducted by MIT, that showed how companies in many US industries had lagged behind their foreign counterparts in terms of competitiveness, time-to-market and productivity.
Definition of BPR
This article or section contains too many quotations for an encyclopedic entry.
Please improve the article or discuss proposed changes on the talk page.
You can edit the article to add more encyclopedic text or link the article to a page of quotations, possibly one of the same name, on Wikiquote. See Wikipedia's guide to writing better articles for further suggestions. (April 2008)
Different definitions can be found. This section contains the definition provided in notable publications in the field.
Hammer and Champy (1993) define BPR as
"... the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance, such as cost, quality, service, and speed."
Thomas H. Davenport (1993), another well-known BPR theorist, uses the term process innovation, which he says
”encompasses the envisioning of new work strategies, the actual process design activity, and the implementation of the change in all its complex technological, human, and organizational dimensions”.
Additionally, Davenport (ibid.) points out the major difference between BPR and other approaches to organization development (OD), especially the continuous improvement or TQM movement, when he states:
"Today firms must seek not fractional, but multiplicative levels of improvement – 10x rather than 10%."
Finally, Johansson et al. (1993) provide a description of BPR relative to other process-oriented views, such as Total Quality Management (TQM) and Just-in-time (JIT), and state:
"Business Process Reengineering, although a close relative, seeks radical rather than merely continuous improvement. It escalates the efforts of JIT and TQM to make process orientation a strategic tool and a core competence of the organization. BPR concentrates on core business processes, and uses the specific techniques within the JIT and TQM ”toolboxes” as enablers, while broadening the process vision."
In order to achieve the major improvements BPR is seeking for, the change of structural organizational variables, and other ways of managing and performing work is often considered as being insufficient.
For being able to reap the achievable benefits fully, the use of information technology (IT) is conceived as a major contributing factor. While IT traditionally has been used for supporting the existing business functions, i.e. it was used for increasing organizational efficiency, it now plays a role as enabler of new organizational forms, and patterns of collaboration within and between organizations.
BPR derives its existence from different disciplines, and four major areas can be identified as being subjected to change in BPR - organization, technology, strategy, and people - where a process view is used as common framework for considering these dimensions. The approach can be graphically depicted by a modification of "Leavitt’s diamond" (Leavitt 1965).
Business strategy is the primary driver of BPR initiatives and the other dimensions are governed by strategy's encompassing role. The organization dimension reflects the structural elements of the company, such as hierarchical levels, the composition of organizational units, and the distribution of work between them. Technology is concerned with the use of computer systems and other forms of communication technology in the business.
In BPR, information technology is generally considered as playing a role as enabler of new forms of organizing and collaborating, rather than supporting existing business functions. The people / human resources dimension deals with aspects such as education, training, motivation and reward systems. The concept of business processes - interrelated activities aiming at creating a value added output to a customer - is the basic underlying idea of BPR. These processes are characterized by a number of attributes: Process ownership, customer focus, value adding, and cross-functionality.
The role of information technology
Information technology (IT) has historically played an important role in the reengineering concept. It is considered by some as a major enabler for new forms of working and collaborating within an organization and across organizational borders.
The early BPR literature, e.g. Hammer & Champy (1993), identified several so called disruptive technologies that were supposed to challenge traditional wisdom about how work should be performed.
Shared databases, making information available at many places
Expert systems, allowing generalists to perform specialist tasks
Telecommunication networks, allowing organizations to be centralized and decentralized at the same time
Decision-support tools, allowing decision-making to be a part of everybody's job
Wireless data communication and portable computers, allowing field personnel to work office independent
Interactive videodisk, to get in immediate contact with potential buyers
Automatic identification and tracking, allowing things to tell where they are, instead of requiring to be found
High performance computing, allowing on-the-fly planning and revisioning
In the mid 1990s, especially workflow management systems were considered as a significant contributor to improved process efficiency. Also ERP (Enterprise Resource Planning) vendors, such as SAP, JD Edwards, Oracle, PeopleSoft, positioned their solutions as vehicles for business process redesign and improvement.
Methodology
Although the labels and steps differ slightly, the early methodologies that were rooted in IT-centric BPR solutions share many of the same basic principles and elements. The following outline is one such model, based on the PRLC (Process Reengineering Life Cycle) approach developed by Guha et.al. (1993).
Simplified schematic outline of using a business process approach, examplified for pharmceutical R&D:
1. Structural organization with functional units
2. Introduction of New Product Development as cross-functional process
3. Re-structuring and streamlining activities, removal of non-value adding tasksEnvision new processes
Secure management support
Identify reengineering opportunities
Identify enabling technologies
Align with corporate strategy
Initiating change
Set up reengineering team
Outline performance goals
Process diagnosis
Describe existing processes
Uncover pathologies in existing processes
Process redesign
Develop alternative process scenarios
Develop new process design
Design HR architecture
Select IT platform
Develop overall blueprint and gather feedback
Reconstruction
Develop/install IT solution
Establish process changes
Process monitoring
Performance measurement, including time, quality, cost, IT performance
Link to continuous improvement
-> Loop-back to diagnosis
Benefiting from lessons learned from the early adopters, some BPR practitioners advocated a change in emphasis to a customer-centric, as opposed to an IT-centric, methodology. One such methodology, that also incorporated a Risk and Impact Assessment to account for the impact that BPR can have on jobs and operations, was described by Lon Roberts (1994).
Roberts also stressed the use of change management tools to proactively address resistance to change—a factor linked to the demise of many reengineering initiatives that looked good on the drawing board.
Also within the management consulting industry, a significant number of methodological approaches have been developed. A set of short papers, outlining and comparing some of them can be found here, followed by some guidelines for companies considering to contract a consultancy for a BPR initiative:
Overview
Andersen Consulting (now Accenture)
Bain & Co.
Boston Consulting Group
McKinsey & Co.
Comparison
Guidelines for BPR consulting clients
Successes
This article or section is written like an advertisement.
Please help rewrite this article from a neutral point of view.
For blatant advertising that would require a fundamental rewrite to become encyclopedic, use {{db-spam}} to mark for speedy deletion. (April 2008)
BPR, if implemented properly, can give huge returns. BPR has helped giants like Procter and Gamble Corporation and General Motors Corporation succeed after financial drawbacks due to competition.
It helped American Airlines somewhat get back on track from the bad debt that is currently haunting their business practice. BPR is about the proper method of implementation.
General Motors Corporation implemented a 3-year plan to consolidate their multiple desktop systems into one. It is known internally as "Consistent Office Environment" (Booker, 1994). This reengineering process involved replacing the numerous brands of desktop systems, network operating systems and application development tools into a more manageable number of vendors and technology platforms.
According to Donald G. Hedeen, director of desktops and deployment at GM and manager of the upgrade program, he says that the proces
s "lays the foundation for the implementation of a common business communication strategy across General Motors." (Booker, 1994).
Lotus Development Corporation and Hewlett-Packard Development Company, formerly Compaq Computer Corporation, received the single largest non-government sales ever from General Motors Corporation. GM also planned to use Novell NetWare as a security client, Microsoft Office and Hewlett-Packard printers.
According to Donald G. Hedeen, this saved GM 10% to 25% on support costs, 3% to 5% on hardware, 40% to 60% on software licensing fees, and increased efficiency by overcoming incompatibility issues by using just one platform across the entire company.
Michael Dell is the founder and CEO of DELL Incorporated, which has been in business since 1983 and has been the world's fastest growing major PC Company. Michael Dell's idea of a successful business is to keep the smallest inventory possible by having a direct link with the manufacturer.
When a customer places an order, the custom parts requested by the customer are automatically sent to the manufacturer for shipment. This reduces the cost for inventory tracking and massive warehouse maintenance. Dell's website is noted for bringing in nearly "$10 million each day in sales."(Smith, 1999).
Michael Dell mentions: "If you have a good strategy with sound economics, the real challenge is to get people excited about what you're doing. A lot of businesses get off track because they don't communicate an excitement about being part of a winning team that can achieve big goals.
If a company can't motivate its people and it doesn't have a clear compass, it will drift." (Smith, 1999) Dell's stocks have been ranked as the top stock for the decade of the 1990s, when it had a return of 57,282% (Knestout and Ramage, 1999).
Michael Dell is now concentrating more on customer service than selling computers since the PC market price has pretty much equalized. Michael Dell notes: "The new frontier in our industry is service, which is a much greater differentiator when price has been equalized.
In our industry, there's been a pretty huge gap between what customers want in service and what they can get, so they've come to expect mediocre service. We may be the best in this area, but we can still improve quite a bit—in the quality of the product, the availability of parts, service and delivery time." (Smith, 1999) Michael Dell understands the concept of BPR and really recognizes where and when to reengineer his business.
Ford reengineered their business and manufacturing process from just manufacturing cars to manufacturing quality cars, where the number one goal is quality. This helped Ford save millions on recalls and warranty repairs.
Ford has accomplished this goal by incorporating barcodes on all their parts and scanners to scan for any missing parts in a completed car coming off of the assembly line. This helped them guarantee a safe and quality car. They have also implemented Voice-over-IP (VoIP) to reduce the cost of having meetings between the branches.
A multi-billion dollar corporation like Procter and Gamble Corporation, which carries 300 brands and growing really has a strong grasp in re-engineering. Procter and Gamble Corporation's chief technology officer, G. Gil Cloyd, explains how a company which carries multiple brands has to contend with the "classic innovator's dilemma — most innovations fail, but companies that don't innovate die.
His solution, innovating innovation..." (Teresko, 2004). Cloyd has helped a company like Procter and Gamble grow to $5.1 billion by the fiscal year of 2004. According to Cloyd's scorecard, he was able to raise the volume by 17%, the organic volume by 10%, sales are at $51.4 billion up by 19%, with organic sales up 8%, earnings are at $6.5 billion up 25% and share earnings up 25%. Procter and Gamble also has a free cash flow of $7.3 billion or 113% of earnings, dividends up 13% annually with a total shareholder return of 24%. Cloyd states: "The challenge we face is the competitive need for a very rapid pace of innovation.
In the consumer products world, we estimate that the required pace of innovation has double in the last three years. Digital technology is very important in helping us to learn faster." (Teresko, 2004) G. Gil Cloyd also predicts, in the near future, "as much as 90% of P&G's R&D will be done in a virtual world with the remainder being physical validation of results and options." (Teresko, 2004).
Critique
The most frequent and harsh critique against BPR concerns the strict focus on efficiency and technology and the disregard of people in the organization that is subjected to a reengineering initiative. Very often, the label BPR was used for major workforce reductions. Thomas Davenport, an early BPR proponent, stated that
"When I wrote about "business process redesign" in 1990, I explicitly said that using it for cost reduction alone was not a sensible goal. And consultants Michael Hammer and James Champy, the two names most closely associated with reengineering, have insisted all along that layoffs shouldn't be the point. But the fact is, once out of the bottle, the reengineering genie quickly turned ugly." (Davenport, 1995)
Michael Hammer similarly admitted that
"I wasn't smart enough about that. I was reflecting my engineering background and was insufficient appreciative of the human dimension. I've learned that's critical." (White, 1996)
Other criticism brought forward against the BPR concept include
lack of management support for the initiative and thus poor acceptance in the organization.
exaggerated expectations regarding the potential benefits from a BPR initiative and consequently failure to achieve the expected results.
underestimation of the resistance to change within the organization.
implementation of generic so-called best-practice processes that do not fit specific company needs.
overtrust in technology solutions.
performing BPR as a one-off project with limited strategy alignment and long-term perspective.
poor project management.
Development after 1995
With the publication of critiques in 1995 and 1996 by some of the early BPR proponents, coupled with abuses and misuses of the concept by others, the reengineering fervor in the U.S. began to wane. Since then, considering business processes as a starting point for business analysis and redesign has become a widely accepted approach and is a standard part of the change methodology portfolio, but is typically performed in a less radical way as originally proposed.
More recently, the concept of Business Process Management (BPM) has gained major attention in the corporate world and can be considered as a successor to the BPR wave of the 1990s, as it is evenly driven by a striving for process efficiency supported by information technology. Equivalently to the critique brought forward against BPR, BPM is now accused of focusing on technology and disregarding the people aspects of change.
See also
Kaizen
Business Process Management
process improvement
workflow
Service-Oriented Modeling Framework (SOMF)
Business Process Modeling Notation (BPMN)
External links
BPR Articles
Hammering Hammer (A Critical Analysis of Michael Hammer's Process Enterprise approach.)
BPR : Decision engineering in a strained industrial and business environment
Notes
Davenport, Thomas & Short, J. (1990), The New Industrial Engineering: Information Technology and Business Process Redesign, in: Sloan Management Review, Summer 1990, pp 11-27
Davenport, Thomas (1993), Process Innovation: Reengineering work through information technology, Harvard Business School Press, Boston
Davenport, Thomas (1995), Reengineering - The Fad That Forgot People, Fast Company, November 1995.
Drucker, Peter (1972), Work and Tools, in: W. Kranzberg and W.H. Davenport (eds), Technology and Culture, New York
Greenbaum, Joan (1995), Windows on the workplace, Cornerstone
Guha, S.; Kettinger, W.J. & Teng, T.C., Business Process Reengineering: Building a Comprehensive Methodology, Information Systems Management, Summer 1993
Hammer, Michael (1990), Reengineering Work: Don’t automate, obliterate, Harvard Business Review, Jul/Aug 1990, pp 104-112
Hammer, Michael and Champy, James (1993), Reengineering the Corporation: A Manifesto for Business Revolution, Harper Business Chapter 1 excerpt
Industry Week (1994), De-engineering the corporation, Industry Week article, 4/18/94
Johansson, Henry J. et.al. (1993), Business Process Reengineering: BreakPoint Strategies for Market Dominance, John Wiley & Sons
Leavitt, H.J. (1965), Applied Organizational Change in Industry: Structural, Technological and Humanistic Approaches, in: James March (ed.), Handbook of Organizations, Rand McNally, Chicago
Loyd, Tom (1994), Giants with Feet of Clay, Financial Times, Dec 5 1994, p 8
Malhotra, Yogesh (1998), Business Process Redesign: An Overview, IEEE Engineering Management Review, vol. 26, no. 3, Fall 1998.
Roberts, Lon (1994), Process Reengineering: The Key To Achieving Breakthrough Success, Quality Press, Milwaukee.
Taylor (1911), Frederick, The principles of scientific management, Harper & Row, New York
Thompson, James D. (1969), Organizations in Action, MacGraw-Hill, New York
White, JB (1996), Wall Street Journal. New York, N.Y.: Nov 26, 1996. pg. A.1
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Reengineering Success Factors
More than half of early reengineering projects failed to be completed or did not achieve bottom-line business results, and for this reason business process reengineering "success factors" have become an important area of study. The success factors below are derived from benchmarking studies with more than 150 companies over a 24 month period.
Success factors are a collection of lessons learned from reengineering projects. Reengineering team members and consultants that have struggled to make their projects successful often say,
"If I had it to do over again, I would…" ,
and from these lessons common themes have emerged. In this module we examine these themes or success factors that lead to successful outcomes for reengineering projects. These include:
Top Management Sponsorship (strong and consistent involvement)
Strategic Alignment (with company strategic direction)
Compelling Business Case for Change (with measurable objectives)
Proven Methodology (that includes a vision process)
Effective Change Management (address cultural transformation)
Line Ownership (pair ownership with accountability)
Reengineering Team Composition (in both breadth and knowledge)
Top Management Sponsorship
Major business process change typically affects processes, technology, job roles and culture in the workplace. Significant changes to even one of these areas requires resources, money, and leadership. Changing them simultaneously is an extraordinary task. If top management does not provide strong and consistent support, most likely one of these three elements (money, resources, or leadership) will not be present over the life of the project, severely crippling your chances for success.
It may be true that consultants and reengineering managers give this topic a lot of attention. Mostly because current models of re-designing business processes use staff functions and consultants as change agents, and often the targeted organizations are not inviting the change. Without top management sponsorship, implementation efforts can be strongly resisted and ineffective.
Top management support for large companies with corporate staff organizations has another dimension. If the top management in the "line" organization and "staff" organization do not partner and become equal stakeholders in the change, AND you only have staff management support, you most likely are ill-prepared for a successful reengineering project (line management in this context are the top managers of the operation ultimately accountable for business performance -- P&L, customer service, etc.). Projects that result in major change in an organization rarely succeed without top management support in the line organization.
Strategic Alignment
You should be able to tie your reengineering project goals back to key business objectives and the overall strategic direction for the organization. This linkage should show the thread from the top down, so each person can easily connect the overall business direction with your reengineering effort. You should be able to demonstrate this alignment from the perspective of financial performance, customer service, associate (employee) value, and the vision for the organization.
Reengineering projects not in alignment with the company's strategic direction can be counterproductive. It is not unthinkable that an organization may make significant investments in an area that is not a core competency for the company, and later this capability be outsourced. Such reengineering initiatives are wasteful and steal resources from other strategic projects.
Moreover, without strategic alignment your key stakeholders and sponsors may find themselves unable to provide the level of support you need in terms of money and resources, especially if there are other projects more critical to the future of the business, and more aligned with the strategic direction.
Business Case for Change
In one page or less you must be able to communicate the business case for change. Less is preferred. If it requires more than this, you either don't understand the problem or you don't understand your customers.
You may find your first attempt at the business case is 100 pages of text, with an associated presentation of another 50 view graphs (overhead slides). After giving the business case 20 times you find out that you can articulate the need for change in 2 minutes and 3 or 4 paragraphs. Stick with the shorter version.
Why is this important? First, your project is not the center of the universe. People have other important things to do, too. Second, you must make this case over and over again throughout the project and during implementation - the simpler and shorter it is, the more understandable and compelling your case will be.
Cover the few critical points. Talk to the current state, and what impact this condition has on customers, associates and business results. State the drivers that are causing this condition to occur. State what your going to do about it (vision and plan), and make specific commitments. Keep focusing on the customer. Connect this plan to specific, measurable objectives related to customers, associates, business results, and strategic direction. Show how much time and money you need and when you expect to get it back. Don't sell past the close. No matter how long you talk, you will get resistance from some, and support from others, so you might as well keep it short.
The business case for change will remain the center piece that defines your project, and should be a living document that the reengineering team uses to demonstrate success. Financial pay back and real customer impact from major change initiatives are difficult to measure and more difficult to obtain; without a rigorous business case both are unlikely.
Proven Methodology
The previous module presented several BPR methodologies, and it is important to note that your methodology does matter. Seat-of-the-pants reengineering is just too risky given the size of the investment and impact these projects have on processes and people.
Not only should your team members understand reengineering, they should know how to go about it. In short, you need an approach that will meet the needs of your project and one that the team understands and supports.
Change Management
One of the most overlooked obstacles to successful project implementation is resistance from those whom implementers believe will benefit the most. Most projects underestimate the cultural impact of major process and structural change, and as a result do not achieve the full potential of their change effort.
Change is not an event, despite our many attempts to call folks together and have a meeting to make change happen. Change management is the discipline of managing change as a process, with due consideration that we are people, not programmable machines. It is about leadership with open, honest and frequent communication.
It must be OK to show resistance, to surface issues, and to be afraid of change. Organizations do not change. People change, one at a time. The better you manage the change, the less pain you will have during the transition, and your impact on work productivity will be minimized.
Line Ownership
Many re-design teams are the SWAT type -- senior management responding to crisis in line operations with external consultants or their own staff. It's a rescue operation. Unfortunately the ability of external consultants to implement significant change in an organization is small. The chances are only slightly better for staff groups. Ultimately the solution and results come back to those accountable for day-to-day execution.
That does not mean that consultants or staff are not valuable. What it does mean, though, is that the terms of engagement and accountability must be clear. The ownership must ultimately rest with the line operation, whether it be manufacturing, customer service, logistics, sales, etc.
This is where it gets messy. Often those closest to the problem can't even see it. They seem hardly in a position to implement radical change. They are, in a matter of speaking, the reason you're in this fix to begin with. They lack objectivity, external focus, technical re-design knowledge, and money.
On the other hand, they know today's processes, they know the gaps and issues, they have front-line, in-your-face experience. They are real. The customers work with them, not your consultants and staff personnel.
Hence your dilemma. The line operation probably cannot heal itself when it comes to major business re-design. Staff and consultants have no lasting accountability for the solution, and never succeed at forcing solutions on line organizations.
You need both. You need the line organization to have the awareness that they need help, to contribute their knowledge, and to own the solution and implementation. At the same time you need the expertise and objectivity from outside of the organization.
Building this partnership is the responsibility of the line organization, stakeholders and re-design team. No group is off the hook.
Reengineering Team Composition
The reengineering team composition should be a mixed bag. For example,
some members who don't know the process at all,
some members that know the process inside-out,
include customers if you can,
some members representing impacted organizations,
one or two technology gurus,
each person your best and brightest, passionate and committed, and
some members from outside of your company.
Moreover, keep the team under 10 players. If you are finding this difficult, give back some of the "representative" members. Not every organization should or needs to be represented on the initial core team. If you fail to keep the team a manageable size, you will find the entire process much more difficult to execute effectively.
Seven reengineering success factors have been introduced in this module. Subsequent modules in this series written by industry experts will take several of these success factors into greater depth.
Source: Prosci's 1998-1999 Reengineering Best Practices study (248 companies)
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The BPR Online Learning Center offers several sources to help with reengineering and business process design projects:
free tutorials (provided in this series)
bookstore where you can purchase reengineering toolkits, templates, checklists and reference material
research results from studies with more than 400 companies involved in major change projects
article indexes of online material from other sources
yellow pages of vendors, consultants, and other resources for project teams
Welcome to the BPR Tutorial Series
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Purpose of this module:
Gain an understanding of what is meant by "business process".
Understand and contrast continuous process improvement and business process reengineering (BPR).
If you have ever waited in line at the grocery store, you can appreciate the need for process improvement. In this case, the "process" is called the check-out process, and the purpose of the process is to pay for and bag your groceries. The process begins with you stepping into line, and ends with you receiving your receipt and leaving the store. You are the customer (you have the money and you have come to buy food), and the store is the supplier.
The process steps are the activities that you and the store personnel do to complete the transaction. In this simple example, we have described a business process. Imagine other business processes: ordering clothes from mail order companies, requesting new telephone service from your telephone company, developing new products, administering the social security process, building a new home, etc.
Business processes are simply a set of activities that transform a set of inputs into a set of outputs (goods or services) for another person or process using people and tools. We all do them, and at one time or another play the role of customer or supplier.
You may see business processes pictured as a set of triangles as shown below. The purpose of this model is to define the supplier and process inputs, your process, and the customer and associated outputs. Also shown is the feedback loop from customers.
So why business process improvement?
Improving business processes is paramount for businesses to stay competitive in today's marketplace. Over the last 10 to 15 years companies have been forced to improve their business processes because we, as customers, are demanding better and better products and services. And if we do not receive what we want from one supplier, we have many others to choose from (hence the competitive issue for businesses). Many companies began business process improvement with a continuous improvement model. This model attempts to understand and measure the current process, and make performance improvements accordingly.
The figure below illustrates the basic steps. You begin by documenting what you do today, establish some way to measure the process based on what your customers want, do the process, measure the results, and then identify improvement opportunities based on the data you collected. You then implement process improvements, and measure the performance of the new process. This loop repeats over and over again, and is called continuous process improvement. You might also hear it called business process improvement, functional process improvement, etc.
This method for improving business processes is effective to obtain gradual, incremental improvement. However, over the last 10 years several factors have accelerated the need to improve business processes. The most obvious is technology. New technologies (like the Internet) are rapidly bringing new capabilities to businesses, thereby raising the competitive bar and the need to improve business processes dramatically.
Another apparent trend is the opening of world markets and increased free trade. Such changes bring more companies into the marketplace, and competing becomes harder and harder. In today's marketplace, major changes are required to just stay even. It has become a matter of survival for most companies.
As a result, companies have sought out methods for faster business process improvement. Moreover, companies want breakthrough performance changes, not just incremental changes, and they want it now. Because the rate of change has increased for everyone, few businesses can afford a slow change process. One approach for rapid change and dramatic improvement that has emerged is Business Process Reengineering (BPR).
Business Process Reengineering (BPR)
BPR relies on a different school of thought than continuous process improvement. In the extreme, reengineering assumes the current process is irrelevant - it doesn't work, it's broke, forget it. Start over. Such a clean slate perspective enables the designers of business processes to disassociate themselves from today's process, and focus on a new process. In a manner of speaking, it is like projecting yourself into the future and asking yourself: what should the process look like? What do my customers want it to look like? What do other employees want it to look like? How do best-in-class companies do it? What might we be able to do with new technology?
Such an approach is pictured below. It begins with defining the scope and objectives of your reengineering project, then going through a learning process (with your customers, your employees, your competitors and non-competitors, and with new technology). Given this knowledge base, you can create a vision for the future and design new business processes. Given the definition of the "to be" state, you can then create a plan of action based on the gap between your current processes, technologies and structures, and where you want to go. It is then a matter of implementing your solution.
In summary, the extreme contrast between continuous process improvement and business process reengineering lies in where you start (with today's process, or with a clean slate), and with the magnitude and rate of resulting changes.
Over time many derivatives of radical, breakthrough improvement and continuous improvement have emerged that attempt to address the difficulties of implementing major change in corporations. It is difficult to find a single approach exactly matched to a particular company's needs, and the challenge is to know what method to use when, and how to pull it off successfully such that bottom-line business results are achieved. Such are the topics for this module series.
The BPR Online Learning Center offers several sources to help with reengineering and business process design projects:
free tutorials (provided in this series)
bookstore where you can purchase reengineering toolkits, templates, checklists and reference material
research results from studies with more than 400 companies involved in major change projects
article indexes of online material from other sources
yellow pages of vendors, consultants, and other resources for project teams
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