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Vuylsteke et al. Critical Care 2011, 15:R271 http://ccforum.com/content/15/6/R271
Open Access
Characteristics, practice patterns, and outcomes in patients with acute hypertension: European registry for Studying the Treatment of Acute hyperTension (Euro-STAT) Alain Vuylsteke1*, Jean-Louis Vincent2, Didier Payen de La Garanderie3, Frederick A Anderson4, Leigh Emery5, Allison Wyman4, Sophie Rushton-Smith4 and Joel M Gore4, for the Euro-STAT Investigators
Abstract Introduction: Although effective strategies are available for the management of chronic hypertension, less is known about treating patients with acute, severe elevations in blood pressure. Using data from the European registry for Studying the Treatment of Acute hyperTension (Euro-STAT), we sought to evaluate 'real-life' management practices and outcomes in patients who received intravenous antihypertensive therapy to treat an episode of acute hypertension. Methods: Euro-STAT is a European, hospital-based, observational study of consecutive adult patients treated with intravenous antihypertensive therapy while in the emergency department, perioperative unit or ICU. Enrolment took place between 1 July and 15 October 2009 in 11 hospitals in 7 European countries (Austria, Belgium, Germany, Italy, Spain, Sweden and the United Kingdom). Results: The study population was composed of 791 consecutive patients (median age 69 years, 37% women). Median arterial blood pressure before treatment was 166 mmHg systolic blood pressure (IQR 141 to 190 mmHg) and 80 mmHg diastolic blood pressure (IQR 68 to 95). Nitroglycerine was the most commonly used antihypertensive treatment overall (40% of patients), followed by urapidil (21%), clonidine (16%) and furosemide (8%). Treatment was associated with hypotension in almost 10% of patients. Overall 30-day mortality was 4%, and new or worsening end-organ damage occurred in 19% of patients. Conclusions: High blood pressure requiring intravenous therapy is currently managed with a variety of agents in Europe, with those most commonly used being nitroglycerine, urapidil and clonidine. Patients with acute hypertension have substantial concomitant morbidity and mortality, and intravenous antihypertensive treatment is associated with hypotension in almost 10% of cases.
Introduction Over 1 billion people worldwide are estimated to have hypertension [1,2], which increases their risk of cardiovascular morbidity and mortality [3,4] and organ injury [5,6]. One percent of all hypertensive patients experience at least one episode of acute, severe hypertension, necessitating intravenous (IV) antihypertensive therapy * Correspondence:
[email protected]
1 Department of Anaesthesia & Intensive Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE, UK Full list of author information is available at the end of the article
and placing these patients at risk of overt, acute endorgan damage over their lifetime. The actual prevalence may in fact be much higher [7,8]. One-fourth of patients who present to busy emergency departments (EDs) have acute, severe hypertension [7,8]. In the present study, we defined this population by using a pragmatic approach according to whether the treating physicians decided to use IV antihypertensive therapy. Multiple effective strategies are used for the management of chronic hypertension [1], but less is known about treating patients who present with acute, severe
© 2011 Vuylsteke et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Vuylsteke et al. Critical Care 2011, 15:R271 http://ccforum.com/content/15/6/R271
elevations in arterial blood pressure (BP). The optimal target for BP lowering has yet to be defined; the definitions of hypertensive urgencies, emergencies and outcome measures lack uniformity; evidence supporting the use of one drug over another is lacking; and whether certain treatments are better than others is unknown [7]. As a consequence, treatment practices vary [9]. The European registry for Studying the Treatment of Acute hyperTension (Euro-STAT) was conducted to evaluate 'real-life' management practices and outcomes in patients treated with IV antihypertensive therapy for an episode of acute hypertension.
Methods Study design
Euro-STAT is a European, hospital-based, observational study of consecutive patients treated with IV antihypertensive therapy while in the critical care setting. Enrolment took place between 1 July and 15 October 2009 in 11 hospitals in 7 European countries (Austria, Belgium, Germany, Italy, Spain, Sweden and the United Kingdom). The study sites were selected to include a mix of public and private hospitals across a broad geographic area to ensure a rich and diverse population of patients (Table 1). Participating sites had institutional research board approval for the study and adhered to local regulatory and ethical rules. Patient consent was waived in Austria, Belgium, Germany, Italy, Sweden and the United Kingdom, and oral patient consent was required in Spain. The registry was conducted in accordance with European Union directives on the protection of human subjects in research, local ethical guidelines and the Guidelines for Good Epidemiological Practice http:// www.ieaweb.org/index.php?view=article&catid=20:goodepidemiological-practice-gep&id=15:good-epidemiological-practice-gep&format=pdf&option=com_content&Itemid=43. The patients provided their written informed
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consent to participate if required to do so by local ethical committees. As Euro-STAT is an observational registry, no specific treatments, tests or procedures were mandated or withheld from the patients. Study objectives
The objectives of the registry were (1) to improve the understanding of the characteristics of patients with acute BP elevation cared for in EDs, perioperative units and ICUs; (2) to describe contemporary IV management practices, including the timing of treatment initiation, medications used to control BP within selected ranges and the time required to achieve BP control; and (3) to determine in-hospital and postdischarge outcomes as they relate to the management of an episode of acute hypertension. A preliminary goal was to establish the rates of key variables, which could then be used to develop formal sample size estimates for a planned larger study in the same setting. Patient selection and enrolment criteria
Consecutive adult male and female patients at least 18 years of age with a qualifying episode of acute hypertension on or after 1 July 2009 were identified by trained data abstractors through prospective identification of patients admitted to EDs, perioperative units and ICUs. To qualify for enrolment, a patient had to meet the following two criteria: (1) The clinician had to have attempted BP control with either an IV infusion or at least two IV boluses of an antihypertensive drug, and (2) the initial treatment had to have been started within 24 hours of the patient's arrival in the ED, at any time during the perioperative period (defined as the time from the initiation of anaesthesia to discharge from the postanaesthesia recovery area) or within 14 days of ICU admission. Patients were excluded from participating in the study if they had received IV antihypertensive treatment
Table 1 Sites and investigators participating in Euro-STAT Country
National coordinator/investigator
Austria Belgium
AKH General Hospital Erasme University Hospital
Michael J Hiesmayr Jean-Louis Vincent
Universitätsklinik Bonn
Andreas Hoeft
Claudia Spies
Università degli Studi di Firenze
A Raffaele De Gaudio
Sant'Andrea Hospital
Salvatore Di Somma
Hospital de Sabadell
Antonio Artigas
Karolinska Universitetssjukhuset, Solna
Jan Ostergren
United Kingdom United Kingdom
New Cross Hospital Wolverhampton Papworth Hospital NHS Trust
Giampaolo Martinelli Alain Vuylsteke
United Kingdom
Southampton General Hospital
David Smith
Euro-STAT, European registry for Studying the Treatment of Acute hyperTension; NHS, National Health Service.
Vuylsteke et al. Critical Care 2011, 15:R271 http://ccforum.com/content/15/6/R271
initiated in a transferring hospital, if they were admitted for burn treatment, if they had drug-induced (iatrogenic) hypertension, if the qualifying event had occurred while being treated with comfort measures only, and if medical records were not available. ED patients were excluded if they were transferred directly from the ED to another healthcare facility after initiation of IV antihypertensive treatment. Perioperative patients were excluded if they had planned perioperative controlled hypotension and if the qualifying event occurred before the induction of anaesthesia. Data acquisition
All eligible patients were assigned a unique study identification number, and abstractors completed a standardised case report form that had been piloted and subsequently validated. Data were abstracted from hospital medical records. Outcome measures
The main clinical outcome measures were all-cause inhospital mortality, end-organ injury (including ischaemic stroke, encephalopathy (defined as acute mental status changes without other identifiable causes), acute coronary syndrome, congestive heart failure, renal insufficiency ('chronic kidney failure' was defined as previously diagnosed renal insufficiency or documentation of creatinine clearance less than 60 ml/minute before admission) and aortic dissection), and survival at 30 days following hospital discharge. Data quality and management
Training material and guidelines for data abstractors were developed by the data-coordinating centre at the Center for Outcomes Research (COR) at the University of Massachusetts Medical School (Worcester, MA, USA). A one-day course was held at each enrolling hospital to maintain common definitions, improve data abstraction and address training needs. Data were collected, handled and analysed independently of the sponsor by the data-coordinating centre. Study coordinators at COR reviewed the data collection forms to identify variances from norms and missing data and followed up with the principal investigators by mail or by telephone to resolve any queries. Statistical analyses
Descriptive statistics were calculated for all patients. Data are summarised as means (± SD) or as medians (25% and 75% percentiles) for continuous data and as counts and percentages for categorical data. All results shown are univariate and unadjusted. No variable had a level of missing data greater than 10%. Any missing data were simply excluded from the analyses. All eligible
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patients underwent chart review, and there was no loss to follow-up. Patients' charts were reviewed until the patient's death or discharge from the hospital up to 30 days after initiation of IV antihypertensive therapy (whichever came first). Statistical analyses were performed using the SAS version 9.2 software package (SAS Institute, Cary, NC, USA).
Results Overview of study population
The study population comprised 791 consecutive patients with a median age of 69 years, and 37% were women (Table 2). In the overall cohort, 62% had a history of hypertension, 24% had diabetes mellitus, 14% had undergone previous cardiac surgery (including coronary artery bypass graft or valve surgery) and 12% had had a prior myocardial infarction. Patients who were treated during the perioperative period were the youngest and had the highest numerical rates of peripheral vascular disease, tobacco smoking and alcohol misuse compared with the other patients. Patients admitted to the ED were older than the postoperative and ICU populations. The prevalence of history of hypertension (including prior hospitalisation for hypertension), diabetes, neurological disease or dysfunction, chronic kidney disease and end-stage kidney disease was numerically highest among the ED population. The ICU population had the highest prevalence of cardiac surgery and previous myocardial infarction. The overall median (IQR) initial and peak creatinine values were 89 μmol/L (72 to 113 μmol/L) and 103 μmol/L (82 to 146 μmol/L), and these values were highest among patients admitted to the ED and lowest among perioperative patients. The median (IQR) arterial pressure at the initiation of treatment was 166 mmHg for systolic blood pressure (SBP) (141 to 190 mmHg) and 80 mmHg for diastolic blood pressure (DBP) (68 to 95 mmHg) (Table 3). The initial BP values were highest among the ED patients. Intravenous antihypertensive drugs
The median number (IQR) of IV antihypertensive drugs used during the first three hours was 1 (1 to 2) overall and was similar across the clinical settings: 1 (1 to 2) in ED and perioperative patients and 1 (1 and 1) in ICU patients. The four most frequently used IV antihypertensive drugs in each clinical setting are shown in Figure 1. Nitroglycerine was the most commonly used drug overall (40% of patients), driven largely by its high rate of use among ICU patients (60%). Urapidil and clonidine were the next most frequently used drugs overall, which was due to the high rates of use among perioperative patients. Furosemide was the fourth most often used drug and the most commonly used treatment in the ED
Vuylsteke et al. Critical Care 2011, 15:R271 http://ccforum.com/content/15/6/R271
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Table 2 Baseline characteristics of the study population Variables
Median age, years (IQR)
All patients (N = 791)
Enrolment setting ED (n = 180)
ICU (n = 382)
Perioperative (n = 229)
69 (58 to 77)
70 (60 to 79)
69 (59 to 76)
66 (53 to 76)
Females, n (%) Medical history, n (%)
295 (37)
94 (52)
107 (28)
94 (41)
491 (62)
126 (70)
230 (60)
135 (59)
7 (0.9)
6 (3.3)
0 (0.0)
1 (0.4)
108 (14)
6 (3.3)
71 (19)
31 (14) 21 (9.2)
Hospitalisation for hypertension Cardiac surgery Myocardial infarction
96 (12)
19 (11)
56 (15)
Diabetes mellitus
189 (24)
49 (27)
88 (23)
52 (23)
Chronic kidney disease
80 (10)
25 (14)
43 (11)
12 (5.2)
End-stage renal disease Neurological dysfunction or disease
18 (2.3) 91 (12)
5 (2.8) 29 (16)
10 (2.6) 45 (12)
3 (1.3) 17 (7.4)
Peripheral vascular disease
91 (12)
13 (7.2)
47 (12)
31 (14)
Tobacco smoker
176 (22)
30 (17)
83 (22)
63 (28)
Alcohol misuse (≥2 drinks/day)
45 (5.7)
2 (1.1)
23 (6.0)
20 (8.7)
Drug abuse (amphetamines, cocaine, other)
2 (0.3)
1 (0.6)
1 (0.3)
0 (0.0)
Medication nonadherence (ED)
11 (6.1)
Medications withheld > 12 hours (ICU and perioperative)
39 (10)
21 (9.2)
Predisposing factors, n (%)
ED, emergency department; -, no data.
population. Among the ED patients whose first IV treatment was nitroglycerine, hypertension was the most common admitting diagnosis (n = 16, 33%), followed by acute coronary syndrome (n = 8, 16%), chest pain, and heart failure or pulmonary oedema (both n = 6, 12%). In each group, more than 90% of patients achieved a 10% decrease in SBP within the first 72 hours following initiation of IV antihypertensive therapy. The median time to 10% decrease was 28 minutes after starting the antihypertensive drug. The following is the breakdown of patients who did not achieve a 10% decrease within 72 hours: 6 of 180 ED patients (3.3%), 22 of 382 ICU patients (5.8%) and 8 of 229 perioperative patients (3.5%).
started in the ED; 9 patients (5.5%) had it started in the ambulance; 4.4% experienced an episode of hypotension requiring discontinuation of the antihypertensive drug, and/or the administration of vasopressors or fluids, or reverse Trendelenburg positioning within 72 hours of starting treatment; and 3.3% relapsed (requiring resumption of IV antihypertensive treatment) within 72 hours of discontinuation of the initial IV treatment. The majority of the ED patients were admitted to a non-ICU inpatient unit (n = 104, 58%). Fifty-three patients (29%) were discharged to home, 16 (8.9%) were admitted to the ICU, 5 (2.8%) left against medical advice and 2 (1.1%) died in the ED. Perioperative patients
Emergency department patients
Among the 180 patients who presented to the ED, the most common symptoms were shortness of breath (n = 60, 33%) and chest pain (n = 50, 28%) and, less frequently, headache (n = 20, 11%), focal neurological deficit (n = 18, 10%) and altered mental status (n = 13, 7.2%). The most common presumptive primary diagnoses were hypertension, heart failure or pulmonary oedema, stroke, acute coronary syndrome or myocardial infarction, and chest pain (Figure 2A). The median (IQR) number of hours in the ED was 8.0 (4.0 to 20), the minimum ED stay was one-half hour and the maximum stay was 144 hours. Most ED patients (n = 155, 95%) had their IV antihypertensive treatment
The preoperative diagnoses of the 229 perioperative patients are shown in Figure 2B. Most operating or recovery room patients had undergone cardiac (40%), gastrointestinal (17%), orthopaedic (11%) or vascular (9.2%) surgery. The median duration of surgery was 190 minutes. Nearly one-half of the patients (n = 112, 49%) had undergone cardiac surgery and were evaluated on the basis of their EuroSCORE (European System for Cardiac Operative Risk Evaluation; available at http:// www.euroscore.org/). The median score (IQR) was 2.5 (1.2 to 6.4; minimum 0, maximum 68.6), which is equivalent to a median predicted mortality rate of 2.5% (1.2% to 6.4%). For most patients (n = 143, 67%) IV antihypertensive treatment started in the operating
Vuylsteke et al. Critical Care 2011, 15:R271 http://ccforum.com/content/15/6/R271
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Table 3 Blood pressure, laboratory values, end-organ damage and outcomes (in-hospital) Variables
All patients (n = 791)
Enrolment setting ED (n = 180)
ICU (n = 382)
Perioperative (n = 229)
200 (174 to 220)
160 (138 to 180)
160 (140 to 180)
100 (90 to 110) 20 (5.0 to 30)
73 (64 to 85) 5.0 (1.0 to 15)
80 (68 to 90) 5.0 (1.0 to 5.0)
31 (18 to 87)
30 (12 to 70)
18 (8.0 to 43)
Median blood pressure, mmHg (IQR) Qualifying SBP
166 (141 to 190)
Qualifying DBP 80 (68 to 95) Median time from qualifying BP to initiation of IV antihypertensive therapy, 5.0 (2.0 to 17) minutes (IQR) Median time from IV initiation to 10% decrease in SBP, minutes (IQR) 28 (11 to 60) Median laboratory values (IQR) Peak troponin
0.03 (0.01 to 0.23)
Peak creatine kinase-MB
33 (9.4 to 88)
5.1 (3.8 to 78)
50 (31 to 152)
38 (24 to 79)
Peak NT-proBNP
910 (295 to 2, 240)
1, 672 (429 to 2, 637)
1, 451 (428 to 2, 709)
359 (242 to 970)
Peak BNP
99 (82 to 132)
116 (91 to 146)
20 (20 to 20)
Initial creatinine, μmol/L
89 (72 to 113)
94 (78 to 125)
91 (74 to 116)
83 (69 to 102)
103 (82 to 146)
119 (99 to 222)
107 (84 to 151)
92 (73 to 122)
25 (3.2)
22 (12)
2 (0.5)
1 (0.4)
10 (1.3) 28 (3.5)
8 (4.4) 19 (11)
2 (0.5) 7 (1.8)
0 (0.0) 2 (0.9)
Peak creatinine, μmol/L End-organ injurya, n (%) Acute coronary syndrome (new) Previous worsened Acute LV dysfunction/pulmonary oedema (new) Previous worsened
0.03 (0.01 to 0.12) 0.04 (0.01 to 0.33) 0.03 (0.01 to 0.23)
20 (2.5)
16 (8.9)
4 (1.1)
0 (0.0)
Aortic dissection (new)
5 (0.6)
2 (1.1)
3 (0.8)
0 (0.0)
Previous worsened
2 (0.3)
1 (0.6)
1 (0.3)
0 (0.0)
22 (2.8)
8 (4.4)
11 (2.9)
3 (1.3)
2 (0.3)
1 (0.6)
0 (0.0)
1 (0.4)
Acute kidney failure (new)
36 (4.6)
8 (4.4)
23 (6.0)
5 (2.2)
Previous worsened Stroke (new)
19 (2.4) 13 (1.6)
5 (2.8) 8 (4.4)
12 (3.1) 5 (1.3)
2 (0.9) 0 (0.0)
7 (0.9)
3 (1.7)
2 (0.6)
2 (0.9)
114 (14) 104 (13)
17 (9.4) 14 (7.8)
19 (5.0)b 55 (14)
78 (34)
Encephalopathy (new) Previous worsened
Previous worsened Outcomes n (%) ICU admission Hypertension relapse
35 (15)
BP = blood pressure; DBP = diastolic blood pressure; ED = emergency department; IV = intravenous; LV = left ventricular; n/a = not applicable; NT-proBNP = Nterminal prohormone of brain natriuretic peptide; SBP = systolic blood pressure. aCategories are not mutually exclusive. bReadmission to ICU.
room or theatre, and in 33% (n = 71) it was begun after surgery. Postoperatively, 57% (n = 130) of the patients were transferred to a postanaesthesia recovery area, 31% (n = 72) were transferred directly to the ICU and 12% (n = 27) were transferred directly to an inpatient ward or unit. Ten percent of patients experienced an episode of hypotension within 72 hours of starting treatment, and 4.8% of patients relapsed within 72 hours of the discontinuation of the initial IV treatment. Thirty-nine percent (n = 89) of patients received two or more different IV antihypertensive drugs. ICU patients
Most ICU patients (304 of 382, 80%) were direct postoperative admissions (that is, patients whose initial
acute, severe hypertension developed after ICU admission). Their primary diagnoses are shown in Figure 2C. The majority of patients in the ICU population were cardiac or cardiac surgery patients (62%), 25% were mixed surgical and medical patients, 7% were surgical patients, 4% were medical patients and 3% were classified as 'other'. Patients spent a median (IQR) of 3 days (2 to 6) in the ICU. Among ICU patients, the minimum stay was 1 day and the maximum stay was 54 days. Thirteen patients (3.4%) died in the ICU. The median time (IQR) in the ICU before IV treatment began was 3.4 hours (0.6 to 18). Overall, 8.4% of ICU patients experienced an episode of hypotension within 72 hours of the start of IV antihypertensive treatment, 6.0% relapsed within 72 hours of discontinuation of the initial
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Figure 1 Most frequent first intravenous antihypertensive drugs used across patient groups.
IV treatment, and 17% required treatment with more than one agent. Upon discharge, 90% (n = 343) of the patients were transferred to an inpatient unit, 3.7% (n = 14) were transferred to another healthcare facility, 2.9% (n = 11) were discharged to home and 0.3% (n = 1) left against medical advice. Thirty-day outcomes
The overall rate of 30-day death rate was 4%, and the overall rate of new or worsening end-organ damage was 19%. The rates of both outcomes were highest among patients in the ED (6% and 43%, respectively), intermediate in the ICU patients (5% and 15%, respectively) and lowest among patients in the perioperative setting (2% and 7%, respectively).
Discussion These contemporary data derived from the Euro-STAT study demonstrate heterogeneous patterns of care for patients presenting with acute elevation of BP across a range of acute care settings, with high rates of morbidity and mortality. Of the 791 patients included in EuroSTAT, 48% were treated for acute hypertension in the
ICU. Many of them had undergone surgery and developed severe hypertension postoperatively, 29% developed it perioperatively and 23% developed it in the ED. Median BP was higher among patients treated in the ED (200/100 mmHg) than in those treated in the ICU (160/ 73 mmHg) or perioperatively (160/80 mmHg). The Studying the Treatment of Acute Hypertension (STAT) registry in the United States [9,10] involved patients with a qualifying episode of acute, severe hypertension (that is, (1) SBP greater than 180 and/or DBP greater than 110 mmHg or (2) SBP above 140 mmHg and/or DBP greater than 90 mmHg when presenting with subarachnoid haemorrhage) who received IV antihypertensive therapy in a critical care setting. Compared with the STAT study, the patients' median age in the Euro-STAT study was higher (69 vs 58 years) and fewer patients had a history of hypertension (62% vs 89%). Overall, the median BP was lower in the Euro-STAT study than in the STAT study (166/80 vs 200/110 mmHg). This finding could indicate that patients in the Euro-STAT study had less severe hypertension, or it could be related to the different qualifying criteria and hence the distribution of patients in the STAT studies.
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Figure 2 Presumptive primary admitting diagnoses. (A) Emergency department patients. (B) Perioperative patients. (C) ICU patients. ACS = acute coronary syndrome; HF = heart failure; MI = myocardial infarction.
In Euro-STAT, perioperative patients were also included, and there were many more ICU patients (mainly in a postoperative context) than there were in the STAT study. The decision to amalgamate ED, perioperative and ICU patients was made because the purpose of this descriptive study was to evaluate the efficacy of IV therapy for the control of elevated BP level in different locations within a hospital, thereby assessing similarities and differences in treatments and outcomes in different contexts.
The first antihypertensive drug used varied by treatment location. In the ICU, nitroglycerine was by far the most widely used (60%); in the ED, furosemide was used in 34% of patients and nitroglycerine was used in 27%; and perioperatively, urapidil was used in 34% of patients and clonidine was used in 28%. The high use of furosemide in the ED (34%) indicates that pulmonary oedema associated with high BP was the likely primary diagnosis, which is backed up by the higher rates of new or worsened acute coronary syndrome (17% vs 1.1% and 0.5%) and acute left ventricular dysfunction (19.4% vs 2.9%
Vuylsteke et al. Critical Care 2011, 15:R271 http://ccforum.com/content/15/6/R271
Page 8 of 9
and 0.9%) in ED vs ICU and perioperative patients, respectively. In Euro-STAT overall, the most frequently used antihypertensive drugs were nitroglycerine (40%), urapidil (21%), clonidine (16%) and furosemide (8.3%). This pattern is very different from the results of the STAT study, where the most common initial antihypertensive drugs were labetalol (32%), metoprolol (17%), nitroglycerine (15%) and hydralazine (15%) [9]. The variations in drug use between the Euro-STAT and STAT studies may reflect differences in the drugs available in these regions. The percentage of patients who required a second IV antihypertensive was 34% in both the EuroSTAT and STAT studies. This variability in treatment between continents, studies and hospital departments is not surprising, given the paucity of evidence regarding the superiority of one drug over another and the absence of guidelines for the treatment of acute hypertension. There are, however, various papers that have provided recommendations that are not evidence-based. Acute hypertension can be split into hypertensive emergencies (severe BP elevation with evidence of impending or progressive end-organ damage) and hypertensive urgencies (severe BP elevation without progressive target organ dysfunction) [1]. In general, hypertensive urgencies can be treated with oral antihypertensive drugs [11], and researchers who published a recent meta-analysis found angiotensin-converting enzyme inhibitors to be superior to calcium channel blockers [12]. Hypertensive emergencies generally require IV treatment to achieve a rapid decrease in BP, and patients admitted to these care settings may be sicker than patients treated with oral agents. Recommendations (based on expert consensus due to a lack of clinical trials) for which antihypertensive to use based on different disease states are shown in Table 4[13]. While nitroglycerine should be used as an adjunctive therapy, the high rates of use in the Euro-STAT population likely reflect familiarity with its use, together with its ease of administration, titration and rapid reversibility. In the ED, the ICU and perioperatively, 4.4%, 8.4% and 10% of patients, respectively, had hypotension
within 72 hours of the start of treatment, resulting in (1) discontinuation of the antihypertensive drug or (2) treatment with vasopressors, fluids or reverse Trendelenburg positioning. The overall incidence of hypotension in the Euro-STAT study was higher than that in the STAT study (8.1% vs 4.0%) [9]. As expected, mortality rates at discharge from the ICU, ED or surgical department in the Euro-STAT study were highest among ICU patients (3.4% vs 1.1% of ED patients and 0% of perioperative patients). Total inhospital mortality in the Euro-STAT study was highest among ED patients (5.7% vs 5.1% of ICU patients and 2.3% of perioperative patients), which is lower than the comparable rate in the STAT study (6.9%) [9]. New or worsened end-organ damage was observed in 43% of ED patients, 15% of ICU patients and 6.6% of perioperative patients. Limitations
The observational Euro-STAT registry is a relatively small data set, and the sites may not be representative of all hospitals in Europe. Treatment choices may therefore be biased by institution choices. Also, populations of acute hypertension are heterogeneous and are likely to differ by country. Amalgamation of all countries into one data set therefore gives an overview, but no country-specific data. As our entry criteria required the physician to initiate IV antihypertensive therapy, there was no comparison with other patients in relation to morbidity. Also, we do not have complete information on post-hospital discharge follow-up. Furthermore, we do not know what happened to patients for whom a reduction in BP was not achieved despite treatment.
Conclusions Acute hypertension is currently managed with a wide range of IV agents in the various clinical settings in which it arises. These patients have substantial concomitant morbidity and mortality, and IV antihypertensive treatment is associated with hypotension in almost 10% of patients. Further data are required to identify optimal
Table 4 Recommended treatments for hypertensive emergenciesa Emergency type
Pulmonary oedema + systolic dysfunction
Nicardipine Yes
Nitroglycerine b
Sodium nitroprusside
Pulmonary oedema + diastolic dysfunction
Myocardial infarction
Aortic dissection
Postoperative hypertension
Hypertensive encephalopathy Kidney failure
Yes Yes
Yes Yes
Adapted from Smithburger et al. [13]. bAs adjunctive therapy. cIn combination with intravenous nitroglycerine.
Vuylsteke et al. Critical Care 2011, 15:R271 http://ccforum.com/content/15/6/R271
management strategies for these patients, thereby ensuring the best possible outcomes.
Key messages • High blood pressure requiring intravenously administered drug therapy is currently managed with a variety of agents in Europe, with the most commonly used being nitroglycerine, urapidil and clonidine. • Intravenous antihypertensive treatment is associated with hypotension in almost 10% of patients. • Patients with acute, severe hypertension have substantial concomitant morbidity and mortality. Abbreviations BP: blood pressure; COR: Center for Outcomes Research; ED: emergency department; Euro-STAT: European registry for Studying the Treatment of Acute hyperTension. Acknowledgements We thank the physicians and study coordinators participating in Euro-STAT and the staff at COR. Euro-STAT Steering Committee members Co-Chairs: Didier Payen de la Garanderie, Paris, France; Alain Vuylsteke, Cambridge, UK. Members: Frederick A Anderson, Worcester, MA, USA; Antonio Artigas, Sabadell, Spain; Jean-Daniel Chiche, Paris, France; A Raffaele De Gaudio, Florence, Italy; Salvatore Di Somma, Rome, Italy; Joel M Gore, Worcester, MA, USA; Christopher B Granger, Durham, NC, USA; Michael J Hiesmayr, Vienna, Austria; Andreas Hoeft, Bonn, Germany; Bengt Jönsson, Stockholm, Sweden; Andreas Koster, Berlin, Germany; Thomas Lüscher, Zurich, Switzerland; Jan Ostergren, Stockholm, Sweden; W Frank Peacock, Cleveland, OH, USA; Kees Polderman, Utrecht, The Netherlands; David Smith, Southampton, UK; Jean-Louis Vincent, Brussels, Belgium. Author details 1 Department of Anaesthesia & Intensive Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE, UK. 2Department of Intensive Care, Erasme University Hospital, Route de Lennik 808 1070, University of Brussels, Brussels, Belgium. 3l'hôpital Lariboisière, 2 Rue Ambroise Paré, 75475 Paris Cedex 10 Assistance publique-Hôpitaux de Paris (AP-HP), Université Paris Diderot-Paris 7, Paris, France. 4Center for Outcomes Research, University of Massachusetts Medical School, One Innovation Drive, Suite 110 Worcester, MA 01605 USA. 5Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655 USA. Authors' contributions The Euro-STAT Steering Committee was responsible for the design and scientific and ethical conduct of the study, including assurance that appropriate measures for the protection of the participants, including hospitals, physicians and patients, were instituted and followed consistently. AV, JLV, DPG, FAA and JMG were fully involved in the design and conduct of the study, had access to all study analyses, drafted and edited the paper and agreed upon its final contents. Competing interests The Euro-STAT study was supported by a grant from The Medicines Company to the COR at the University of Massachusetts Medical School. All authors have connections to The Medicines Company (Parsippany, NJ, USA). All authors were either employees of, or consultants to, the Center for Outcomes Research, University of Massachusetts Medical School (UMMS), which received a contract from TMC to perform this work. Received: 29 July 2011 Revised: 15 November 2011 Accepted: 16 November 2011 Published: 16 November 2011
Page 9 of 9
References 1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ, Joint National Committee on Prevention, and Treatment of High Blood Pressure. National Heart, and Blood Institute, National High Blood Pressure Education Program Coordinating Committee: JNC 7: Complete report. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003, 42:1206-1252. 2. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, Hailpern SM, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O'Donnell C, Roger V, Sorlie P, Steinberger J, Thom T, Wilson M, Hong Y, American Heart Association Statistics Committee and Stroke Statistics Subcommittee: Heart disease and stroke statistics-2008 update: a Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008, 117: e25-e146. 3. Lawes CM, Rodgers A, Bennett DA, Parag V, Suh I, Ueshima H, MacMahon S, Asia Pacific Cohort Studies Collaboration: Blood pressure and cardiovascular disease in the Asia Pacific region. J Hypertens 2003, 21:707-716. 4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration: Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002, 360:1903-1913, A published erratum appears in Lancet 2003, 361:1060. 5. MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J: Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 1990, 335:765-774. 6. Wiederkehr M, Toto R, Fenves AZ, Ram CV: Hypertension and the kidney. Semin Nephrol 2005, 25:236-245. 7. Cherney D, Straus S: Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. J Gen Intern Med 2002, 17:937-945. 8. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P: Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension 1996, 27:144-147. 9. Katz JN, Gore JM, Amin A, Anderson FA, Dasta JF, Ferguson JJ, Kleinschmidt K, Mayer SA, Multz AS, Peacock WF, Peterson E, Pollack C, Sung GY, Shorr A, Varon J, Wyman A, Emery LA, Granger CB, on behalf of the STAT Investigators: Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe hypertension: The Studying the Treatment of Acute hyperTension (STAT) Registry. Am Heart J 2009, 158:599-606, e1. 10. Gore JM, Peterson E, Amin A, Anderson FA Jr, Dasta JF, Levy PD, O'Neil BJ, Sung GY, Varon J, Wyman A, Granger CB, for the STAT Investigators: Predictors of 90-day readmission among patients with acute severe hypertension: The cross-sectional observational Studying the Treatment of Acute hyperTension (STAT) study. Am Heart J 2010, 160:521-527, e1. 11. Rodriguez MA, Kumar SK, De Caro M: Hypertensive crisis. Cardiol Rev 2010, 18:102-107. 12. Souza LM, Riera R, Saconato H, Demathé A, Atallah AN: Oral drugs for hypertensive urgencies: systematic review and meta-analysis. Sao Paulo Med J 2009, 127:366-372. 13. Smithburger PL, Kane-Gill SL, Nestor BL, Seybert AL: Recent advances in the treatment of hypertensive emergencies. Crit Care Nurse 2010, 30:24-31. doi:10.1186/cc10551 Cite this article as: Vuylsteke et al.: Characteristics, practice patterns, and outcomes in patients with acute hypertension: European registry for Studying the Treatment of Acute hyperTension (Euro-STAT). Critical Care 2011 15:R271.
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Software development is the collective processes involved in creating software programs, comprising and encompassing all the stages throughout the systems development life cycle (SDLC).
SDLC methodologies support the design of software to meet business needs and the development of software to meet the specified design and the deployment of software to production. Such a methodology should also support maintenance.
The original SDLC method (called the Waterfall Model), is linear and sequential, generally following these stages and in this order:
- Identification of required software;
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- Software design;
- Programming;
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- Maintenance
At the most basic level, software is designed, developed, tested and then released. Upon release, the software is maintained until it is discontinued.
Various SDLC models however exist (not just the waterfall model) and choosing the right one depends on your business needs and your project in this regard. Several models can for example be combined into a hybrid methodology.
Apart from the mentioned models, you also get the Agile model where the SDLC follow a more modular and flexible approach. Agile approaches software development in incremental cycles, called sprints. Each sprint is computational, and the code is designed to be modular.
NBS Digital Technologies is trained and skilled to assist you in choosing the right model which will correspond with your particular business needs. We will also be able to assist with the development, implementation and maintenance of the software solutions you choose.
Our software applications offer an array of tools and products to help define and map your processes
IT Consulting Services
IT consulting services are where an IT service provider has the necessary IT skills and experience to provide expert advice
Product Engineering
Principles used in the field of engineering is applied when software products are engineered and developed.
Mainframe and Applications
Introduction to the copy that will be contained on the page referenced in the heading

subset: commoncrawl


text:
Our care
Information about our services for patients and families.Find out more
Information about our services for patients and families.Find out more
Find out about the service we provide, who, and how we can help.Find out more
There's so many ways you can get involved and support St Barnabas House.
Whatever your event there's a way for you to help raise valuable funds - cycling, walking, skydiving, have a browse, get inspired and get in touch
St Barnabas House depends on over 1,000 volunteers who help in the hospice, in our charity shops and at our fundraising events
Whether you are taking part in an organised event or putting on your own we can help you make it a success
Find out how your business or company can help raise money and support our charity
Keep up-to-date with all the news from St Barnabas House. Here you'll find updates on everything from our new fundraising events, news on our amazing volunteers and news about the hospice.
For all media enquiries, please contact the Communications and Marketing Team by emailing firstname.lastname@example.com or calling 01903 706319 / 706320.
As the festive season approaches, our thoughts turn to family gatherings and celebrations. For many of us, it's also important to make time to remember and celebrate the life of a loved one who sadly won't be with you this year.
You are warmly invited to join your local community at one of the two services at either 4.30pm or 7pm on Monday 9 December at Worthing Assembly Hall. Everyone who comes along will receive a special Light Up a Life candle to be lit at home in memory of your loved one. Many people also like to bring along a photo of their friend or relative, which you can display on a memory wall after each service. If you can't make the services, but would still like a candle, you can collect one from the hospice on Titnore Lane, Worthing, or from any St Barnabas charity shop.
It's thanks to your generosity that local people receive expert care when they need it most. So any contribution you are able to make with your dedication will be greatly appreciated. All dedications made in honour of a family member or friend will be included in a commemorative programme.
I look forward to joining some of you at the services. You can find out more about Light Up a Life, download a donation form or light a virtual candle in memory of a loved one here.


text:
Gómez De La Torre & Guerrero arquitectos | The lawyer house
The large spaces of this home, clearly express architectonical emotions. The lawyer House is an organism that transmits life by its pores to those that inhabits it. And not only at the informational level, but it also expresses the dynamics of daily life, because its transparent appearance is revealed.
The house is composed by interconnected volumes, some acute ones smoothed with other curved ones that lower the volumetric tension. Perforations communicate the functional structure, spatial hierarchies and finally the pretensions of each volume within the total organization. And as such, the pretensions are established in a friendly communion with all levels of the house.
The outer formal construction of each ambiance has a different language to balance the monumental quality of the house with elements that results in a warm product to the service of those that inhabits it.
The first level is destined to social and service spaces visually integrated with the garden and outer terrace; standing out is the space of the entrance due to its high altitude. The second level hosts the private areas: the lawyer's office and the guest and service quarters. The third level hosts the family intimate areas. The den and bar, located in a slightly lower level, enjoys privacy and simultaneously it communicates horizontally with the garden.Architect: Gómez De La Torre & Guerrero arquitectos
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text:
Mismanage Baloch social media activists on divided table – Sarban Baloch
Quetta (Republican News) Those military generals wins the wars who honour and respect their ground warriors and focus on their physical and mental readiness.
Social media is just a buzzword until you come up with a plan."UnknownSocial media use has grown rapidly over the last decade. Today world use a wide range of social media.
It is a modern way of political engagement to highlight issues to convey their message . Modern era considers the effectiveness and vulnerability of social media. It is impressive platform and toil to get social and political goals by gaining attention of people. It creates sustained movement for social change.
Social media give a chance to speak underdressed groups and classes. It has played a prominent role in raising awareness regarding important social, economical and political issues which being unnoticeable in mainstream media. Social media platform give a chance for everyone to express his views regarding any issue.
Social media day by day getting strong roots on human culture. From latest survey conducted by PEW research centre half of American citizen engage is political and social minded activity in the past year.
Sharing ، encouraging ، commenting ، forwarding ، like unlike ، using hashtags and twitting are main actions media activist use to show their response.
Researcher on social media believe that social media as a free and powerful platform make it effective for accountable powerful people accountable for their actions which was not easy in electronic media, which is in under control by big media houses which are funded by big corporate those have their own political and economical agenda. With the growth of technology in every aspect of human society developed which boosted human resources and helped the human race in every field.
Social media in modern era which bring his own laws and above the norms which generally follows. Regarding social media, we need to train social media activist and give guidelines for the awareness campaigns. By training people properly we can get much better results.Baloch political circles have a very well educated section of youth people which need to properly guidelines and a working framework.
If Baloch social media activist focus on their work, we can get good results.There are many basic issues that need to be addressed. Our leaders, especially our educated cadre class is not paying due attention to these problems which we are facing on social media activism.
If all Baloch pro independent parties together create a joint media group and people connected to the media are placed in a suitable platform, we can get much fruitful results. It has been seen that our people are not properly trained and mostly criticise each other this trend produce confusion hatred within our ranks.
All of us know that the electronic media in Pakistan is under the state control. They do not have any of their free status Punjabi state imposing their own will on them. All those media groups living in the state's jurisdiction will expect the voices of our people to move forward, nothing but foolishness.
To move our message forward, we have to expand our scope and we need to draft a comprehensive plan, we need a strong team who need to work hard on that issue that will give us good results and thereby bring our voices and Baloch cases before the civilised world community.
If the process of division is not stopped, its results will be very damaging this will increase the distance and cause us to face losses in our movement.To get success in this movement, we have to look at all our mistakes, It is very important to review the history in these situations and we need to learn the lesson from our past experience and to correct our weaknesses, if it has not been done, we have to be defeated.
keeping us all ground realities its a demand to form a new strategy which should be fruitful for our movement.
Disclaimer: The views expressed are those of the author and do not reflect the official policy of the Republican News"
Written by: Sarban Baloch


text:
Michigan is poised to become the next state to adopt a data security law similar to the Insurance Data Security Model Law advocated by the National Association of Insurance Commissioners (NAIC). Michigan House Bill 6491, passed by the Michigan House during Michigan's 99th Legislative Session on December 6, 2018, and passed by the Michigan Senate on December 19, 2018, was presented to its then-Governor Rick Snyder on December 27, 2018.Read more »
Tag: michigan
Michigan Next State to Adopt Insurance Data Security Model Law Posted on: January 03, 2019 In: Data Privacy & Cybersecurity
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Collection: Current Monitors - Wide Band Current Monitors
Pearson Electronics is the original and leading manufacturer of precision current-monitoring transformers used for accurate AC current measurements. The company was founded in 1955 by Dr. Paul Pearson, inventor and patent holder, of the precision wide-band current transformer. The Pearson design plus careful workmanship and quality control produce current monitors with excellent frequency response and amplitude accuracy. Originally developed for measuring pulse-currents, Pearson Current Monitors™ are now also widely used to measure more complicated transients and periodic signals from a few Hertz to well into the megaHertz region.
1 product
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system installation – how to optimize Ubuntu for older hardware – Unix & Linux Stack Exchange
Open the gnome volume control panel right-click on the sound icon by the clock, click 'Open Volume Control' 3. You need to ixh8 in to change this bug's status.
Analog Devices ID The LEDs and volume applet main volume control both control the main speakers correctly as above. Use the 'Surround' channel to change the volume for your headphones or the volume control in the program you're using.
Do you have something like this: However, when I reboot it's telling me it's still loading 1. Scared me though, when I rebooted and the start up sound came blasting linyx the speakers. Disable snd-hda-intel, in favor of lum updated version.
[ubuntu] Intel Corporation H(ICH8 Family) HD Audio Controler
Intel [HDA Intel], device 1: For my T61p, what do I need to download to fix my sound problem? The fully-opened volume applet liunx four devices: BotLobsta kjenks-deactivatedaccount wrote on I forgot to mention that I have windoze Drivers, on my windoze partition, if that's any help.
Removing linux-ubuntu- modules- 2. So for now I'm just booting generic and all is good.
Sound is working again: I think that my alsaconf works correctly, because my sound card is detected fine, but when the configuration puts the example, no sound apears.
For adjustment of volumes, use your favorite mixer.
Your spanish is good, sorry about my english. Christoph Lechleitner lech wrote on Intel AD Audio Chipset.
Any ideas on how to get more? Just follow this guide here http: You will need to have kernel headers and development packages installed.
ACPI: apply quirk_ich6_lpc_acpi to more ICH8 and ICH9 [Linux 2.6.24]
Share This Page Tweet. All times are GMT I note that my audio amplifier have 4 ohm impedance, and earplug generally have 32 ohms I think.
There's a workaround running a python script in the background in bug that works on Thinkpads my T61P, anyway. I'm on an Acer Aspire Could someone point me to the place that explains the difference between the e and the ee driver?
16 commands to check hardware information on Linux
I have not figured out yet, although it may not be related to your issue. Like for every thing, there are plenty of commands to check information about the hardware of your linux system. Ubuntu Audio Team Edit.


text:
Tonight's Jimmy Fallon clip is brought to you by synergy. Blake Shelton and Gwen Stefani are coaches on the upcoming season of The Voice on NBC, so they stopped by The Tonight Show to help promote with a new installment of Fallon's lip sync battles.
The highlight is definitely Gwen Stefani. She takes time to make fun of her own Emmy flub and then goes all out with Carly Rae Jepsen's "Call Me Maybe" and the theme from Endless Love. It isn't as fun as the other attempts, but this lip sync battle gets the job done.
(Via The Tonight Show)


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Wonderful Updated and Beautifully Maintained Ranch Home with 3 Bedrooms, 1.5 Bath and a Large 4 Season Sunroom Addition. So much to Offer....Gleaming Hardwood Flooring throughout most of the Home, Updated Kitchen with Oak Cabinetry with Crown Moldings, Granite Counters, Undermount 1 1/2 Bowl Sink, Tile Backsplash, 2 Glass Cabinets and Breakfast Bar, Replaced Doors, Living Room and Dining Room with Crown Molding and Recessed Lighting, Several Ceiling Fans, Newer Roof, Furnace, Air Conditioner and Hot Water Heater, All Replaced Windows, Renovated Hall Bath and Powder Room, Custom Window Treatments and Storage Shed. The Wonderful Light and Bright Vaulted Sun Room Addition features Vermont Weather Board, a Gas Stove for Heating plus individual Air Conditioning, French Doors and Ceiling Fan. Exit into the Inviting Landscaped Yard via the Deck with Trellis and Benches, Paver Walkway and Storage Shed. The Attached 1 Car Garage has been converted into a storage room but can be converted back into a functioning Garage. (NOTE: Sqft.is 1,344 for original house + 249 for addition = 1,593). Don't miss this Great Value in a Desirable Neighborhood close to Shopping, Restaurants, Library and Major Roadways.
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- Heating
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Exterior / Lot Features
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- Irregular
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Financial Considerations
Fee Simple
Standard Sale
School Rating Out of 10
|Public Schools
|Private Schools
Data Provided by GreatSchools.org
Walk Score measures the walkability of any address, Transit Score measures access to public transit on a scale of 1-100.
Walk Score
Transit Score
Active Market Trends
Source: MLS DATA
Median list price
Days On Market
Properties For Sale
Sold Market Trends
Source: MLS DATA
Median sold price
Sales-List Price
Properties sold
Median Sq. Ft. Price
Arrows indicate 90 day trend
Source: Bright MLS


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Octave Lounge and Bar
The Octave Rooftop Lounge and Bar is 3 tier starting on 45th floor, open daily from 18.00 – 02.00 am
Octave brings to life the sounds, the city, the sky…
started from the 45th floor, this multi-zone outlet features a restaurant, a private dining room, a bar and a rooftop lounge, the last being the signature space.
With resident DJs on weekdays and special acts on weekends, music is an essential factor of the lounge experience here. Showcasing new-age fusion food like Asian-style tapas platters and a seafood bar along with the finest in wines and cocktails, Octave is effortlessly the hippest destination in town!
Atmosphere: Sophisticated and casual
Menu: Western and Thai
Height: 148 mtrs (3 tier) 45th to 48th flr
why go: unique views of this zone of Bangkok, multiple aspects, easy access
360 Spherical photo: front entrance
image below hosted in Theta, more controls via external link
Zoom all the way out to make a crystal ball effect and then spin it..
for Virtual Reality mode view Dermander
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to see control options go to link . tba
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show some love ......
all SM channels and best hashtags
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"Bangkok Marriott Hotel", on Sukhumvit Soi 57, Klong Toei, Bangkok
Longdo map link Longdo map is Thai & English for taxi driver, Google link below in Social media menu for GPS navigation
Getting there:
100 mtrs from BTS (skytrain) Station Thong Lo, short walk to corner of Sukhumvit Soi 57
Facebook album at B.Pac - open album
In Production
360 Spherical photos
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why: VR: Virtual Reality effect, turn device at any angle or better turn around while holding the device for 360 / Spherical view,
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100m South West rooftop look right
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Starting point: Entrance
external link
note: if not accurate use Octave Rooftop - Google Map / Pics / Reviews
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Tour Zone Icons
Recommended: Bangkok Marriott Hotel Sukhumvit with Agoda
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Social Media
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Bangkok Directory > Bars > Rooftop Bars & Restaurants >
Octave Lounge and Bar
Subpages (1): 360 Spherical


text:
The government's plan to impose a best interest duty on mortgage brokers has been criticised for being selective in its application, with inconsistent exclusions. A draft bill issued for consultation also bans conflicted remuneration.
In a commentary on the bill, National Consumer Credit Protection Amendment (Mortgage Brokers) Bill, law firm Dentons says the legislation does not apply to all finance brokers.
"Rather, it applies to mortgage brokers, being finance brokers who provide credit assistance in respect of regulated loans secured by mortgages over residential property," the firm says.
"However, once a finance broker is categorised as a finance broker, the law applies in respect of all Code regulated loans, not just mortgage loans."
Similarly, the conflicted remuneration rules apply to mortgage brokers and mortgage intermediaries (such as referrers and aggregators) but only in respect of regulated credit predominantly secured by residential property.
"Conflicted remuneration will not apply to unlicensed intermediaries and referrers," Dentons says.
Lenders also appear to be exempt. "It's not just brokers who provide credit assistance. Lenders provide credit assistance in respect of their own loans, and sometimes act as intermediaries, and would be subject to the rules if it was not for the exclusion in section 15B(2)(b) and section 15C(1)(b), which excludes licensees and credit representatives who perform the obligations, or exercise the rights , of a credit provider in relation to the majority of those contracts."
Dentons says this exclusion will also exclude mortgage managers and servicers, but only so long as their business is such that the majority of the loans they handle are where they are the lender, manager or servicer.
This will likely mean that white label loans, some mortgage manager loans and some servicers will be subject to the duties because the majority of the loans written are brokered.
"This is inappropriate and an unintended result in respect of servicers and mortgage managers, and those loans need to be excluded in full from the rules."
Treasury released an exposure draft of the bill last week, which amends the Credit Act to require brokers to act in the best interests of consumers and to address conflicted remuneration for brokers and other mortgage intermediaries.
The explanatory memorandum accompanying the bill says: "Requiring mortgage brokers to act in the best interests of consumers and addressing conflicted remuneration are intended to strengthen existing protections for consumers who deal with mortgage brokers.
"They bring the law into line with what consumers expect – that any advice provided by a mortgage broker serves the consumer's interests first and foremost."
The best interest obligation applies to credit assistance provided by mortgage brokers in relation to any credit contract, such as a personal loan or credit card, and not just in relation to mortgages.
Where there is a conflict of interest, brokers must give priority to consumers in providing credit assistance in relation to credit contracts.
For the purposes of the new law, a mortgage intermediary is either a licensee or a credit representative that acts as an intermediary in relation to mortgages.
The best interest duty is a principles-based standard. Conduct that satisfies the obligation will depend on the individual circumstances in which credit assistance is provided to a consumer. The duty does not prescribe conduct that will be taken to satisfy the duty in specific circumstances.
Guidelines in the explanatory memorandum say any recommendation would be expected to be based on consumer benefits, rather than benefits that may be realised by the broker.
Prior to recommending a product, it could be expected that the broker consider a range of such products and inform the consumer of that range and the options it contains.
A broker would not suggest a white label mortgage that has the same features as a branded product from the same lender, but with a higher interest rate.
During an annual review a broker would not suggest that the consumer remain in a credit contract without considering whether this would be in the consumer's best interests.
Conflicted remuneration is defined as any benefit, whether monetary or non-monetary, that could reasonably be expected to influence the credit assistance provided, because of the nature of the benefit or the circumstances in which it is given.
The bill says mortgage brokers and other mortgage intermediaries must not accept conflicted remuneration. It also says employers, credit providers and mortgage intermediaries must not give conflicted remuneration to mortgage brokers or mortgage intermediaries.
Regulations may prescribe circumstances in which a benefit is conflicted.


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16th Birthday Gift
Novelty Survival Kit for a 'Sweet Sixteen' Birthday
- 16th Birthday Small Novelty Survival Kit
- Presented in a gorgeous purple organza bag (appox 13x18cm)
- Laminated label highlights the significance of each item
- Great keepsake and guaranteed to make the recipient smile.
- Bag contains ONE of each item listed on label. See production description below or image for more details.
To survive your 16th birthday you will need... Confetti - It is time to celebrate your birthday Balloon - To start the celebrations with a BANG! Cola bottle - Have a drink on me. Candle - To add to the birthday cake! Coloured Pencil - To make your day bright and colourful Sherbet Sticks - To add some fizz to your special day Toothpick - To 'pick' out your best memories of your day Playing card - Make sure you have lots of fun Love Hearts - To remind you how much you are loved Coffee - To give lots of energy to celebrate Mint - You are worth a 'mint' to your friends and family Tea bag - So you can put your feet up and relax Sweet- You are now 'Sweet Sixteen'
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Price: £6.95
Status: New and Instock.
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New Additions Debut at The Landing at Disney Springs
From Darcy Clark, Disney Springs Marketing Manager and posted on the Disney Parks Blog.
With its opening just days away, all eyes are on Town Center, the newest Disney Springs neighborhood set to debut this Sunday, May 15, 2016. While there's much to buzz about – new locations include ZARA, Under Armour Brand House and Sprinkles Cupcakes – it's not the only neighborhood with "new" on the horizon.
The Landing, home to Morimoto Asia, The BOATHOUSE and unique boutiques like Chapel Hats, is also getting some exciting additions. Lest they be left out, check out a few of my favorite enhancements being added to the area near Portobello Country Italian Trattoria and the opening-this-fall Paddlefish restaurant:
What a view: With the removal of several construction walls, the spring of Disney Springs is now in clear view – and it's gorgeous! I predict that this stunning waterway will be the site of many family photos, and maybe even an engagement or two.
Waterworks: A new water feature with intricately carved horses and fanciful birds is a stately fountain. The sound of cascading water creates a peaceful oasis, making this a perfect resting spot for guests en route to the nearby Marketplace.
New retailers: Two new kiosk locations will offer unique delights for Disney Springs guests:
- Savannah Bee Company will feature a variety of specialty and everyday honey as well as all-natural body care products ranging from body wash and lotion to lip balm and body butter. The company's mission is to provide pure, delicious honey and luxurious honeybee products to consumers while educating them about the wonders of the hive. How sweet is that? When it opens on May 15th, it will be the only Savannah Bee retail location in the state of Florida.
- Filthy Rich, also opening May 15, will showcase celebrity-inspired jewelry at far-less-than-Beverly-Hills prices. The location specializes in authentic replicas of iconic jewelry and accessories worn by past legends of the silver screen and current celebrity style icons.
s Pam Brandon recently shared, Morimoto Asia will also open their new Asian Street Food window at The Landing on May 15th – I've seen the menu and it's definitely worth a visit!
With so much opening so soon, I hope to see you out at Disney Springs throughout the spring and summer months! Over the next several weeks, we'll be sharing more updates about what's new and what's next, so stay tuned to the Disney Parks Blog and be sure to follow us on Twitter andInstagram via @DisneySprings.
Author: TMSM Avenger
Co-Owner / Webmaster / Business Relations / PT Writer
As co-owner and co-creator of The Main Street Mouse. Working in a technical support position for 18 years, it was time for a change. As the Webmaster and Project Planner, I spend most of my time researching everything from the latest Disney News, technology advances and of course keeping up on all the Marvel news that comes out. I never considered myself a writer but I've come to like blogging and sharing news with all. I feel blessed everyday that I get to spend my days working with my best friend and love of my life while we continue to grow and expand what started as a hobby all those years ago.
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1000 Goals
World Cup 2018
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Leicester City FC vs Manchester United highlights (5-3)
Manchester United still haven't managed to get themselves out from their early slump this season as Louis Van Gaal's men suffered a shock defeat from Leicester City. Coming away of a convincing league win over QPR, Manchester United put on a confident display early on as they found themselves leading 2-0 after 16 minutes through Robin Van Persie and Angel Di Maria.
Leicester City FC vs Arsenal highlights (1-1)
Arsenal found themselves in another difficulties to get all three points after being held into a draw by Leicester City this past weekend. Playing straight after their hard fought Champions League battle, Gunners were looking rather tired but still determined in getting all three points despite playing away from home.
Leicester City FC vs Everton highlights (2-2)
Newly promoted side, Leicester City picked up a pretty positive result on their Premier League opener after holding Everton into a 2-2 draw this Saturday. Playing in front of their home crowd, Leicester didn't have the best of start as it was Everton that got themselves in front through Aiden McGeady's effort on 20 minutes.
Nottingham Forest vs Brighton & Hove Albion highlights (1-2)
Brighton & Hove Albion secured their play offs spot in England Championship standings as they grabbed an important away win over Nottingham Forest on the weekend. Playing in the final day of regular season, both teams were gunning for all three points, especially Brighton as they must win to secure that final play offs seat.
Leicester City FC vs Brighton & Hove Albion highlights (1-4)
Already confirming their promotion to English Premier League for next season, Leicester City lost a bit of their way as they suffered a disappointing home defeat against Brighton & Hove Albion.
Latest Football Highlights
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