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Shirtcliff EA, Finseth TT, Winer EH, Glahn DC, Conrady RA, Drury SS. Virtual stressors with real impact: what virtual reality-based biobehavioral research can teach us about typical and atypical stress responsivity. Transl Psychiatry 2024; 14:441. [PMID: 39420000 DOI: 10.1038/s41398-024-03129-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 09/18/2024] [Accepted: 09/24/2024] [Indexed: 10/19/2024] Open
Abstract
Stress contributes to transdiagnostic morbidity and mortality across a wide range of physical and mental health problems. VR tasks have been validated as stressors with robust effect sizes for VR-based stressors to evoke stress across the most common autonomic and adrenocortical stress biomarkers. However, meta-analytic validation of VR stressors have resulted in inconsistent logic: why should something that isn't real evoke a very real suite of stress responses? This review posits that conceptually addressing this question requires differentiating a cause, "stressor", from effects, "stress". Stress comprises a series of well-delineated perturbations in biological systems, such as autonomic and adrenocortical biomarkers in response to stressors. Despite their ubiquity, decades of literature have back-calculated stressor intensity based on the magnitude of a stress response. This causal directionality is not logical, yet remains pervasive because seemingly objective stress indices have generated a wealth of findings showing how stress gets under the skin and skull. This has created challenges for providing clear guidance and strategies to measure acute stressor intensity. Binary thinking about whether something is (not) real has stifled advances in understanding how to measure the dosage of a stressful environment. As a function of being programmed, individualizable, and titrated, virtual reality (VR) based stressors offer the field a platform for quantifying the dose of a stressor and generating reliable dose-response curves. This also raises the possibility to safely and ethically integrate psychosocial stressor administration into clinical and therapeutic settings. For example, Social Evaluative Threat experiments effectively trigger a stress response both in a laboratory setting and in built environments, while also upholding hard-fought trust and rapport with care providers. By focusing attention on the measurement of the stressor, VR paradigms can advance tangible understanding of stressors themselves and the pathways to the stress response.
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Affiliation(s)
| | | | - Eliot H Winer
- Department of Mechanical Engineering (Main), Aerospace Engineering and Electrical and Computer Engineering, VRAC, Iowa State University, Ames, IA, USA
| | - David C Glahn
- Department of Psychiatry and Behavioral Sciences, Tommy Fuss Center for Neuropsychiatric Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Roselynn A Conrady
- Visualize • Reason • Analyze • Collaborate, Iowa State University, Ames, IA, USA
| | - Stacy S Drury
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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2
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Ma S, Hu L, Chen H, Liu Y, Hocher JG, Xu X, Gong F, Krämer BK, Lin G, Hocher B. Inverse association of prepregnancy systolic blood pressure and live birth rate in normotensive women undergoing in vitro fertilization/intracytoplasmic sperm injection. Fertil Steril 2024; 122:667-677. [PMID: 38782112 DOI: 10.1016/j.fertnstert.2024.05.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To explore whether maternal baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) affect pregnancy outcomes particularly in normotensive women (SBP, 90-139 mm Hg; DBP, 60-89 mm Hg) and hypertensive women undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). DESIGN Retrospective cohort study. SETTING Maximum care hospital for reproductive medicine. PATIENT(S) This study included 73,462 patients who underwent IVF/ICSI at the Reproductive and Genetic Hospital of CITIC-Xiangya between January 1, 2016, and November 30, 2020, selected on the basis of pre-established criteria. Analysis was limited to the first transfer cycle of the first stimulation cycle. INTERVENTION Baseline SBP and DBP. MAIN OUTCOME MEASURE(S) The primary outcome focused on the live birth rate (LBR), with the secondary outcomes including clinical pregnancy rate, ectopic pregnancy rate, first-trimester miscarriage rate, second- or third-trimester fetal loss, and delivery/neonatal/maternal outcomes. Analytic methods included Poisson regression, linear regression, linear mixed-effect model, and restricted cubic spline analysis as appropriate. RESULT(S) For normotensive women, a 10-mm Hg increase in SBP was associated with an adjusted relative risk of 0.988 (95% confidence interval, 0.981-0.995) for live birth likelihood. However, DBP was not significantly associated with LBR after adjustments. The secondary outcomes indicated that increases in SBP and DBP were associated with higher risks of first-trimester miscarriage, gestational diabetes mellitus, and gestational hypertension in the normotensive subset. Sensitivity analyses confirmed these associations between SBP/DBP and LBR, consistent with the main findings even under stricter guidelines and after adjusting for multiple confounders. Subgroup analyses showed variation in the impact of blood pressure on LBR across different demographics and conditions. Consistent with earlier studies on blood pressure and birth outcomes, we found a 10-mm Hg increase in SBP was associated with a 5.4% (adjusted relative risk per 10 mm Hg, 0.946; 95% confidence interval, 0.907-0.986) reduction in LBR in the hypertensive subgroup. CONCLUSION(S) Systolic blood pressure impacted LBR outcomes in normotensive women who underwent IVF/ICSI, which suggests the need for reconsidering blood pressure management guidelines for reproductive-age women, focusing on reproductive health in addition to cardiovascular risk.
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Affiliation(s)
- Shujuan Ma
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, Hunan, People's Republic of China; Key Laboratory of Reproductive and Stem Cell Engineering, Central South University, Changsha, Hunan, People's Republic of China
| | - Liang Hu
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, Hunan, People's Republic of China; Key Laboratory of Reproductive and Stem Cell Engineering, Central South University, Changsha, Hunan, People's Republic of China; Key Laboratory of National Health and Family Planning Commission, Central South University, Changsha, Hunan, People's Republic of China
| | - Huijun Chen
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, Hunan, People's Republic of China; Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany; Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Yvonne Liu
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany; Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann-Georg Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany; Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - XiangWang Xu
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, Hunan, People's Republic of China; Key Laboratory of National Health and Family Planning Commission, Central South University, Changsha, Hunan, People's Republic of China
| | - Fei Gong
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, Hunan, People's Republic of China; Key Laboratory of Reproductive and Stem Cell Engineering, Central South University, Changsha, Hunan, People's Republic of China; Key Laboratory of National Health and Family Planning Commission, Central South University, Changsha, Hunan, People's Republic of China
| | - Bernhard K Krämer
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany; European Center for Angioscience ECAS, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Center for Preventive Medicine and Digital Health Baden-Württemberg, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ge Lin
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, Hunan, People's Republic of China; Key Laboratory of Reproductive and Stem Cell Engineering, Central South University, Changsha, Hunan, People's Republic of China; Key Laboratory of National Health and Family Planning Commission, Central South University, Changsha, Hunan, People's Republic of China
| | - Berthold Hocher
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, Hunan, People's Republic of China; Key Laboratory of Reproductive and Stem Cell Engineering, Central South University, Changsha, Hunan, People's Republic of China; Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany; Institute of Medical Diagnostics, Berlin-Potsdam, Germany.
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3
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Dahl M, Andersen JW, Lindholt J, Krarup NT, Borregaard B, Uberg N, Høgh A. Prevalence of interarm blood pressure difference is notably higher in women; the Viborg population-based screening program (VISP). BMC Public Health 2024; 24:1868. [PMID: 38997668 PMCID: PMC11245839 DOI: 10.1186/s12889-024-19388-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Bilateral blood pressure (BP) measurement is important in cardiovascular prevention for identifying systolic interarm BP difference (IAD) and hypertension. We investigated sex-stratified IAD prevalence and its associations and coexistence with screen-detected peripheral atherosclerosis and hypertension. Furthermore, we determined the proportion misclassified as non-hypertensive when using the lower versus the higher reading arm. METHODS This sub-study formed part of the Viborg Screening Program (VISP), a cross-sectorial population-based cardiovascular screening programme targeting 67-year-old Danes. VISP includes screening for peripheral atherosclerosis (lower extremity arterial disease and carotid plaque), abdominal aortic aneurysm, hypertension, diabetes mellitus, and cardiac disease. Self-reported comorbidities, risk factors, and medication use were also collected. Among 4,602 attendees, 4,517 (82.1%) had eligible bilateral and repeated BP measurements. IAD was defined as a systolic BP difference ≥ 10 mmHg. IAD-associated factors (screening results and risk factors) were estimated by logistic regression; proportional coexistence was displayed by Venn diagrams (screening results). RESULTS We included 2,220 women (49.2%) and 2,297 men (50.8%). IAD was more predominant in women (26.8%) than men (21.0%) (p < 0.001). This disparity persisted after adjustment [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.32-1.77]. No other association was recorded with the conditions screened for, barring potential hypertension: BP 140-159/90-99 mmHg (OR 1.68, 95% CI 1.44-1.97) and BP ≥ 160/100 mmHg (OR 1.82, 95% CI 1.49-2.23). Overall, IAD and BP ≥ 160/100 mmHg coexistence was 4% in women and 5% in men; for BP ≥ 140/90 mmHg, 13% and 14%, respectively. Among those recording a mean BP ≥ 140/90 mmHg in the higher reading arm, 14.5% of women and 15.3% of men would be misclassified as non-hypertensive compared with the lowest reading arm. CONCLUSION Female sex was an independent factor of IAD prevalence but not associated with other arterial lesions. Approximately 15% needed reclassification according to BP ≥ 140/90 mmHg when the lower rather than the higher reading arm was used; verifying bilateral BP measurements improved detection of potential hypertension. In future, the predictive value of sex-stratified IAD should be assessed for cardiovascular events and death to verify its potential as a screening tool in population-based cardiovascular screening. TRIAL REGISTRATION FOR VISP NCT03395509:10/12/2018.
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Affiliation(s)
- Marie Dahl
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark.
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, Aarhus, 8200, Denmark.
- Department of Cardiac, Thoracic and Vascular Surgery, Odense University Hospital, JB Winsløwsvej 4, Odense, 5000, Denmark.
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark.
| | - Jesper Winkler Andersen
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark
| | - Jes Lindholt
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, Aarhus, 8200, Denmark
- Department of Cardiac, Thoracic and Vascular Surgery, Odense University Hospital, JB Winsløwsvej 4, Odense, 5000, Denmark
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark
- Department of Cardiothoracic and Vascular Surgery, Elite Centre of Individualized Treatment of Arterial Diseases (CIMA), Clinical Institute, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Nikolaj Thure Krarup
- Department of Cardiology, Viborg Regional Hospital, Heibergs Alle 5A, Viborg, 8800, Denmark
| | - Britt Borregaard
- Department of Cardiac, Thoracic and Vascular Surgery, Odense University Hospital, JB Winsløwsvej 4, Odense, 5000, Denmark
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark
- Department of Cardiology, Odense University Hospital, JB Winsløwsvej 4, Odense, 5000, Denmark
| | - Nikolai Uberg
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark
| | - Annette Høgh
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, Aarhus, 8200, Denmark
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Lacy PS, Jedrzejewski D, McFarlane E, Williams B. Blood pressure measurement modalities and indexed left ventricular mass in men with low-risk hypertension confirmed by ambulatory monitoring. J Hypertens 2023; 41:941-950. [PMID: 36927831 DOI: 10.1097/hjh.0000000000003415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Blood pressure (BP) measurement modalities such as ambulatory monitoring (ABPM) and noninvasive central aortic systolic pressure (CASP), have been reported to improve prediction of hypertension-mediated organ damage (HMOD) compared with conventional clinic BP. However, clinic BP is often confounded by poor measurement technique and 'white-coat hypertension' (WCH). We compared prediction of cardiac MRI (cMRI)-derived left ventricular mass index (LVMI) by differing BP measurement modalities in young men with elevated BP, confirmed by ABPM. METHODS One hundred and forty-three treatment-naive men (<55 years) with hypertension confirmed by ABPM and no clinical evidence of HMOD or cardiovascular disease (37% with masked hypertension) were enrolled. Relationships between BP modalities and cMRI-LVMI were evaluated. RESULTS Men with higher LVMI (upper quintile) had higher clinic, central and ambulatory SBP compared with men with lower LVMI. Regression coefficients for SBP with LVMI did not differ across BP modalities ( r = 0.32; 0.3; 0.31, for clinic SBP, CASP and 24-h ABPM, respectively, P < 0.01 all). Prediction for high LVMI using receiver-operated curve analyses was similar between measurement modalities. No relationship between DBP and LVMI was seen across measurement modalities. CONCLUSION In younger men with hypertension confirmed by ABPM and low cardiovascular risk, clinic SBP and CASP, measured under research conditions, that is, with strict adherence to guideline recommendations, performs as well as ABPM in predicting LVMI. Prior reports of inferiority for clinic BP in predicting HMOD and potentially, clinical outcomes, may be due to poor measurement technique and/or failure to exclude WCH.
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Affiliation(s)
- Peter S Lacy
- Institute of Cardiovascular Sciences, University College London
- National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, London, UK
| | | | - Ewan McFarlane
- Institute of Cardiovascular Sciences, University College London
| | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London
- National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, London, UK
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Kinberg EC, Taree A, Gray M, Filip P, Courey M. Patient reported outcome measures: The impact of environment on VHI-10 responses. Laryngoscope Investig Otolaryngol 2023; 8:150-155. [PMID: 36846431 PMCID: PMC9948561 DOI: 10.1002/lio2.1016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/30/2022] [Accepted: 01/08/2023] [Indexed: 01/31/2023] Open
Abstract
Objective A key outcome measure in the clinical evaluation of dysphonia is the Voice Handicap Index (VHI-10). The clinical validity of the VHI-10 was established from surveys administered in the physician's office. We aim to understand whether VHI-10 responses remain reliable when the questionnaire is completed in settings other than the physician's office. Methods This is a prospective observational study conducted over a 3-month period in the outpatient laryngology setting. Thirty-five adult patients presenting with a complaint of dysphonia, which was symptomatically stable for the preceding 3 months, were identified. Each patient completed a VHI-10 survey during the initial office visit, followed by three weekly out-of-office (termed "ambulatory") VHI-10 surveys, over the course of 12 weeks. The specific setting in which the patient completed the survey was recorded (social, home, or work). The Minimal Clinically Important Difference (MCID) is defined as 6 points based on existing literature. T-tests and a test of one proportion were used for analysis. Results A total of 553 responses were collected. Of these, 347 ambulatory scores (63%) differed from the Office score by at least the MCID. Specifically, 94 (27%) were higher than the in-office score by 6 or more points while 253 (73%) were lower. Conclusion The setting in which the VHI-10 is completed affects how the patient answers the questions. The score is dynamic, reflecting effects of the patients' environment during completion. Utilization of VHI-10 scores to measure clinical treatment response is only valid if each response is obtained in the same setting. Level of Evidence 4.
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Affiliation(s)
- Eliezer C. Kinberg
- Department of Otolaryngology‐Head and Neck SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Amir Taree
- Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Mingyang Gray
- Department of Otolaryngology‐Head and Neck SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Peter Filip
- Department of Otolaryngology‐Head and Neck SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Mark Courey
- Department of Otolaryngology‐Head and Neck SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Fanelli E, Di Monaco S, Pappaccogli M, Eula E, Fasano C, Bertello C, Veglio F, Rabbia F. Comparison of nurse attended and unattended automated office blood pressure with conventional measurement techniques in clinical practice. J Hum Hypertens 2022; 36:833-838. [PMID: 34285354 DOI: 10.1038/s41371-021-00575-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 06/20/2021] [Accepted: 06/28/2021] [Indexed: 11/09/2022]
Abstract
Accuracy in blood pressure measurement is critical for proper hypertension diagnosis and treatment in clinical practice. Automated office blood pressure (AOBP) can simplify the measurement process, reducing human error and minimizing the white-coat effect in the unattended mode. The aim of this study was to compare AOBP, both unattended and nurse attended, with conventional office and out-of-office blood pressure measurement techniques. Four different methods of blood pressure measurement were performed in a cohort of hypertensive patients: conventional office blood pressure (OBP), unattended automated office blood pressure (uAOBP), nurse attended automated office blood pressure (nAOBP), and home blood pressure monitoring (HBPM). uAOBP and nAOBP were conducted with the same rigorous standardized procedure. We enrolled 118 consecutive patients. nAOBP values were slightly higher than uAOBP ones (respectively 132.8/73.3 ± 19.4/12.9 and 129.2/71.1 ± 19.0/12.3 mmHg), even if the difference was influenced by order of execution of AOBP measurement. nAOBP was significantly lower than HBPM and OBP (mean values 135.2/80.9 ± 16.6/8.1 and 140.9/84.6 ± 18.7/10.8 mmHg, respectively). AOBP, either attended or unattended, provides lower values than conventional OBP. uAOBP and nAOBP values showed small differences, even if they are not completely interchangeable. This evidence reflects a lower white-coat effect, even in nurse attended technique, but is also due to a lower measurement error through the application of a rigorous standardized protocol.
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Affiliation(s)
- Elvira Fanelli
- Department of Medical Sciences, University of Turin, Internal Medicine and Hypertension Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy.
| | - Silvia Di Monaco
- Department of Medical Sciences, University of Turin, Internal Medicine and Hypertension Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marco Pappaccogli
- Department of Medical Sciences, University of Turin, Internal Medicine and Hypertension Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Elisabetta Eula
- Department of Medical Sciences, University of Turin, Internal Medicine and Hypertension Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Fasano
- Department of Medical Sciences, University of Turin, Internal Medicine and Hypertension Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Bertello
- Department of Medical Sciences, University of Turin, Internal Medicine and Hypertension Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Franco Veglio
- Department of Medical Sciences, University of Turin, Internal Medicine and Hypertension Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Franco Rabbia
- Department of Medical Sciences, University of Turin, Internal Medicine and Hypertension Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
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Choi WS, Kim NS, Kim AY, Woo HS. Nurse-Coordinated Blood Pressure Telemonitoring for Urban Hypertensive Patients: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:6892. [PMID: 34199019 PMCID: PMC8297065 DOI: 10.3390/ijerph18136892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/23/2022]
Abstract
Coronavirus disease 2019 (COVID-19) has put hypertensive patients in densely populated cities at increased risk. Nurse-coordinated home blood pressure telemonitoring (NC-HBPT) may help address this. We screened studies published in English on three databases, from their inception to 30 November 2020. The effects of NC-HBPT were compared with in-person treatment. Outcomes included changes in blood pressure (BP) following the intervention and rate of BP target achievements before and during COVID-19. Of the 1916 articles identified, 27 comparisons were included in this review. In the intervention group, reductions of 5.731 mmHg (95% confidence interval: 4.120-7.341; p < 0.001) in systolic blood pressure (SBP) and 2.342 mmHg (1.482-3.202; p < 0.001) in diastolic blood pressure (DBP) were identified. The rate of target BP achievement was significant in the intervention group (risk ratio, RR = 1.261, 1.154-1.378; p < 0.001). The effects of intervention over time showed an SBP reduction of 3.000 mmHg (-5.999-11.999) before 2000 and 8.755 mmHg (5.177-12.334) in 2020. DBP reduced by 2.000 mmHg (-2.724-6.724) before 2000 and by 3.529 mmHg (1.221-5.838) in 2020. Analysis of the target BP ratio before 2010 (RR = 1.101, 1.013-1.198) and in 2020 (RR = 1.906, 1.462-2.487) suggested improved BP control during the pandemic. NC-HBPT more significantly improves office blood pressure than UC among urban hypertensive patients.
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Affiliation(s)
- Woo-Seok Choi
- Moon Soul Graduate School of Future Strategy, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Korea; (A.-Y.K.); (H.-S.W.)
- Keyu Internal Medicine Clinic, Daejeon 35250, Korea
| | - Nam-Suk Kim
- Public Health and Welfare Bureau, Daejeon City Hall, Daejeon 35242, Korea;
| | - Ah-Young Kim
- Moon Soul Graduate School of Future Strategy, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Korea; (A.-Y.K.); (H.-S.W.)
| | - Hyung-Soo Woo
- Moon Soul Graduate School of Future Strategy, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Korea; (A.-Y.K.); (H.-S.W.)
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Siddique S, Hameed Khan A, Shahab H, Zhang YQ, Chin Tay J, Buranakitjaroen P, Turana Y, Verma N, Chen CH, Cheng HM, Wang TD, Van Minh H, Chia YC, Kario K. Office blood pressure measurement: A comprehensive review. J Clin Hypertens (Greenwich) 2021; 23:440-449. [PMID: 33420745 PMCID: PMC8029522 DOI: 10.1111/jch.14169] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 01/05/2023]
Abstract
The conventional auscultatory methods for measuring blood pressure have been used to screen, diagnose, and manage hypertension since long. However, these have been found to be prone to errors especially the white coat phenomena which cause falsely high blood pressure readings. The Mercury sphygmomanometer and the Aneroid variety are no longer recommended by WHO for varying reasons. The Oscillometric devices are now recommended with preference for the Automated Office Blood Pressure measurement device which was found to have readings nearest to the Awake Ambulatory Blood Pressure readings. The downside for this device is the cost barrier. The alternative is to use the simple oscillometric device, which is much cheaper, with the rest and isolation criteria of the SPRINT study. This too may be difficult due to space constraints and the post‐clinic blood measurement is a new concept worth further exploration.
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Affiliation(s)
| | - Aamir Hameed Khan
- Section of Cardiology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Hunaina Shahab
- Advanced Cardiac Imaging, Icahn School of Medicine at Mount Sinai, MSSM-MSSLW, New York, NY, USA
| | - Yu-Qing Zhang
- Divisions of Hypertension and Heart Failure, Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jam Chin Tay
- Department of General Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Peera Buranakitjaroen
- Division of Hypertension, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yuda Turana
- School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Narsingh Verma
- Department of Physiology, King George's Medical University, Lucknow, India
| | - Chen-Huan Chen
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hao-Min Cheng
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Medical Education, Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzung-Dau Wang
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Huynh Van Minh
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Vietnam
| | - Yook-Chin Chia
- Department of Medical Sciences, School of Healthcare and Medical Sciences, Sunway University, Selangor Darul Ehsan, Bandar Sunway, Malaysia.,Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
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Hypertension Prevalence Based on Blood Pressure Measurements on Two vs. One Visits: A Community-Based Screening Programme and a Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249395. [PMID: 33333948 PMCID: PMC7765379 DOI: 10.3390/ijerph17249395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/27/2020] [Accepted: 12/12/2020] [Indexed: 12/12/2022]
Abstract
We assessed the difference in the prevalence of hypertension in community surveys when blood pressure (BP) was measured on two vs. one visits and its impact on hypertension awareness, treatment and control proportions. A community-based BP screening programme was conducted in public places in the Seychelles (619 adults) and BP was rechecked a few days later among untreated participants with high BP (≥140/90 mmHg). A narrative review of the literature on this question was also conducted. Only 64% of untreated participants with high BP still had high BP at the second visit. The prevalence of hypertension in the whole sample decreased by 13% (from 33.8% to 29.5%) when BP was measured on two vs. one visits. These results concurred with our findings in our narrative review based on 10 surveys. In conclusion, the prevalence of hypertension can be markedly overestimated in community surveys when BP is measured on two vs. one visits. The overestimation could be addressed by measuring BP on a second visit among untreated individuals with high BP or, possibly, by taking more readings at the first visit. These findings have relevance for clinical practice, policy and surveillance.
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Elias MF, Goodell AL. Human Errors in Automated Office Blood Pressure Measurement: Still Room for Improvement. Hypertension 2020; 77:6-15. [PMID: 33296246 DOI: 10.1161/hypertensionaha.120.16164] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this review of the literature and commentary, we examine the literature on automated blood pressure (BP) measurements in the office and clinic. Our purpose is to revisit issues as to the pros and cons of automated BP measurement published in Hypertension in June 2020 and to identify areas needing additional research. Despite initial reservations about automated BP, it is here to stay. A number of experts suggest that human error will be reduced when we move from the more complex skills required by aneroid sphygmomanometer measurement to the fewer skills and steps required by automated BP measurement. Our review indicates there is still need for reduction in errors in automated BP assessment, for example, retraining programs and monitoring of assessment procedures. We need more research on the following questions: (1) which classes of health care providers are least likely to measure BP accurately, usually by ignoring necessary steps; (2) how accurate is BP assessment by affiliated health care providers for example the dental office, the optometrist; and (3) why do some dedicated and well-informed health care professionals fail to follow simple directions for automated BP measurement? We offer additional solutions for improving automated BP assessment in the office and clinic.
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Affiliation(s)
- Merrill F Elias
- Department of Psychology (M.F.E., A.L.G.), The University of Maine, Orono.,Graduate School of Biomedical Science and Engineering (M.F.E.), The University of Maine, Orono
| | - Amanda L Goodell
- Department of Psychology (M.F.E., A.L.G.), The University of Maine, Orono
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11
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Padwal R, Campbell NRC, Schutte AE, Olsen MH, Delles C, Etyang A, Cruickshank JK, Stergiou G, Rakotz MK, Wozniak G, Jaffe MG, Benjamin I, Parati G, Sharman JE. Optimización del desempeño del observador al medir la presión arterial en el consultorio: declaración de posición de la Comisión Lancet de Hipertensión. Rev Panam Salud Publica 2020; 44:e88. [PMID: 32684918 PMCID: PMC7363287 DOI: 10.26633/rpsp.2020.88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 03/11/2019] [Indexed: 01/17/2023] Open
Abstract
La hipertensión arterial es una causa modificable muy prevalente de enfermedades cardiovasculares, accidentes cerebrovasculares y muerte. Medir con exactitud la presión arterial es fundamental, dado que un error de medición de 5 mmHg puede ser motivo para clasificar incorrectamente como hipertensas a 84 millones de personas en todo el mundo. En la presente declaración de posición se resumen los procedimientos para optimizar el desempeño del observador al medir la presión arterial en el consultorio, con atención especial a los entornos de ingresos bajos o medianos, donde esta medición se ve complicada por limitaciones de recursos y tiempo, sobrecarga de trabajo y falta de suministro eléctrico. Es posible reducir al mínimo muchos errores de medición con una preparación adecuada de los pacientes y el uso de técnicas estandarizadas. Para simplificar la medición y prevenir errores del observador, deben usarse tensiómetros semiautomáticos o automáticos de manguito validados, en lugar del método por auscultación. Pueden ayudar también la distribución de tareas, la creación de un área específica de medición y el uso de aparatos semiautomáticos o de carga solar. Es fundamental garantizar la capacitación inicial y periódica de los integrantes del equipo de salud. Debe considerarse la implementación de programas de certificación de bajo costo y fácilmente accesibles con el objetivo de mejorar la medición de la presión arterial.
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Affiliation(s)
- Raj Padwal
- Departamento de Medicina, Universidad de Alberta, Edmonton (Canadá)
| | - Norm R. C. Campbell
- Departamento de Medicina, Fisiología y Farmacología y Salud Comunitaria, Instituto O’Brien de Salud Pública e Instituto Cardiovascular Libin de Alberta, Universidad de Calgary, Calgary, Alberta (Canadá)
| | - Aletta E. Schutte
- Equipo de Investigación de la Hipertensión en África (HART), Unidad de Investigación MRC: Hipertensión y Enfermedades Cardiovasculares, Universidad del Noroeste, Potchefstroom (Sudáfrica)
| | - Michael Hecht Olsen
- Departamento de Medicina Interna, Hospital de Holbæk, Dinamarca; y Centro de Medicina Individualizada en Enfermedades Arteriales
(CIMA), Hospital Universitario de Odense, Universidad del Sur de Dinamarca, Odense (Dinamarca)
| | - Christian Delles
- Instituto de Ciencias Cardiovasculares y Médicas, Universidad de Glasgow (Reino Unido)
| | - Anthony Etyang
- Programa de Investigación KEMRI-Fundación Wellcome, Kilifi (Kenya)
| | - J. Kennedy Cruickshank
- Escuela de Ciencias de la Nutrición y del Curso de la Vida, King’s College, Hospitales St. Thomas & Guy, Londres (Reino Unido)
| | - George Stergiou
- Centro de Hipertensión STRIDE-7, Universidad Nacional y Capodistríaca de Atenas, Facultad de Medicina, Departamento de Medicina III, Hospital Sotiria, Atenas (Grecia)
| | - Michael K. Rakotz
- Asociación Médica Estadounidense (AMA), Chicago (Estados Unidos de América)
| | - Gregory Wozniak
- Asociación Médica Estadounidense (AMA), Chicago (Estados Unidos de América)
| | - Marc G. Jaffe
- Iniciativa de Estrategias Vitales “Resolve to Save Lives”, Nueva York (Estados Unidos de América); y Centro Médico Kaiser Permanente de South San Francisco (Estados Unidos de América)
| | - Ivor Benjamin
- Asociación Estadounidense del Corazón (AHA), Centro Cardiovascular, Facultad de Medicina de Wisconsin, Wauwatosa (Estados Unidos de América)
| | - Gianfranco Parati
- Departamento de Medicina y Cirugía, Universidad de Milán-Bicocca, Milán (Italia); e Instituto Auxológico Italiano, IRCCS, Departamento de Ciencias Cardiovasculares, Neurales y Metabólicas, Hospital S. Luca, Milán (Italia)
| | - James E. Sharman
- Instituto Menzies de Investigación Médica, Universidad de Tasmania, Hobart (Australia)
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McBride TJ, Wilke A, Chisholm J, Martin KD. Visual Analog Pain Scores Reported to a Nurse and a Physician in a Postoperative Setting. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420948500. [PMID: 35097404 PMCID: PMC8697173 DOI: 10.1177/2473011420948500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The purpose of this study was to compare postoperative foot and ankle patient-reported visual analog pain scores (VAS) to nursing staff and the treating surgeon during a single encounter. Prior literature established preoperative patients reported higher pain scores to a surgeon as compared to nursing staff. We hypothesized that there will be no differences in postoperative patients’ pain scores when reporting to nursing staff vs a surgeon. Methods: This study was a retrospective cohort of 201 consecutive postoperative foot and ankle patients with 3 follow-up encounters treated by a single surgeon. The patients were asked to rate their pain intensity using the VAS with 0 “no pain” and 10 “worst pain” at 2, 6, and 12 weeks postoperatively by a nurse and surgeon. Results: At all time intervals, the mean pain score was significantly higher when reported to the surgeon, although these were not clinically relevant. The mean scores at 2 weeks were 2.8 reported to the surgeon and 2.5 reported to the nurse (P < .001). The mean scores at 6 weeks were 2.0 reported to the surgeon and 1.8 reported to the nurse (P = .002). The mean scores at 12 weeks were 2.3 reported to the surgeon and 2.0 reported to the nurse (P = .005). Conclusion: This study found that postoperative foot and ankle patients did not overemphasize their VAS pain scores to the physician vs nursing staff. These findings contrast with our 2 previous studies that found preoperative and nonoperative patients reported clinically significant higher scores to the surgeon. Level of Evidence: Level III, comparative study.
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Optimizing observer performance of clinic blood pressure measurement: a position statement from the Lancet Commission on Hypertension Group. J Hypertens 2020; 37:1737-1745. [PMID: 31034450 PMCID: PMC6686964 DOI: 10.1097/hjh.0000000000002112] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
High blood pressure (BP) is a highly prevalent modifiable cause of cardiovascular disease, stroke, and death. Accurate BP measurement is critical, given that a 5-mmHg measurement error may lead to incorrect hypertension status classification in 84 million individuals worldwide. This position statement summarizes procedures for optimizing observer performance in clinic BP measurement, with special attention given to low-to-middle-income settings, where resource limitations, heavy workloads, time constraints, and lack of electrical power make measurement more challenging. Many measurement errors can be minimized by appropriate patient preparation and standardized techniques. Validated semi-automated/automated upper arm cuff devices should be used instead of auscultation to simplify measurement and prevent observer error. Task sharing, creating a dedicated measurement workstation, and using semi-automated or solar-charged devices may help. Ensuring observer training, and periodic re-training, is critical. Low-cost, easily accessible certification programs should be considered to facilitate best BP measurement practice.
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14
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Ojo OS, Egunjobi AO, Fatusin AJ, Fatusin BB, Ojo OO, Taiwo BA, Ghazali IB, Gbadamosi NA. Variation between pragmatic and standardised blood pressure measurements in a Nigerian primary care clinic. S Afr Fam Pract (2004) 2020; 62:e1-e11. [PMID: 32242434 PMCID: PMC8378171 DOI: 10.4102/safp.v62i1.5035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 11/25/2022] Open
Abstract
Background A significant difference in the blood pressure (BP) value of a patient taken by different health workers has been a subject of discussion among health workers. This study investigated the variations between usual-care and guideline-concordant BP measurement protocols and evaluated the implications of the disparities on diagnosis and treatment decision. Methods A cross-sectional study was conducted among 206 participants. The usual-care and guideline-concordant BP readings taken from each participant by the regular clinic nurses and research-trained nurses, respectively, were obtained. Results Majority of the regular clinic nurses following the usual-care protocol used the left arm for BP measurement (59.7%). The systolic BP (SBP) and diastolic BP (DBP) readings were higher on the right arm in 55.3% and 39.2% of the participants, respectively. The mean guideline-concordant BP was 7.67 mmHg higher than the mean usual-care for SBP (p ≤ 0.05) and 7.14 mmHg higher for DBP (p ≤ 0.05). The proportion of participants classified as having hypertension and uncontrolled BP was 11.8% and 15.0% lower when using usual-care BP compared to guideline-concordant BP, respectively. Fifty-one (24.8%) respondents were advised incorrect treatment based on usual-care BP measurement. The Bland-Altman plot showed that limits of agreement were wider than within the 10 mmHg clinical reference range and unacceptable for clinical purposes. Conclusion The usual-care and guideline-concordant BP measurement protocols were significantly different, and the disparity had significant consequences on the diagnosis and treatment of hypertension. Health workers should strictly adhere to the guidelines on BP measurement to avoid mismanagement of patients.
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Affiliation(s)
- Oluwaseun S Ojo
- Department of Family Medicine, Federal Medical Center, Abeokuta, Ogun State.
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15
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Band R, Hinton L, Tucker KL, Chappell LC, Crawford C, Franssen M, Greenfield S, Hodgkinson J, McCourt C, McManus RJ, Sandall J, Santos MD, Velardo C, Yardley L. Intervention planning and modification of the BUMP intervention: a digital intervention for the early detection of raised blood pressure in pregnancy. Pilot Feasibility Stud 2019; 5:153. [PMID: 31890265 PMCID: PMC6925434 DOI: 10.1186/s40814-019-0537-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 11/28/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hypertensive disorders in pregnancy, particularly pre-eclampsia, pose a substantial health risk for both maternal and foetal outcomes. The BUMP (Blood Pressure Self-Monitoring in Pregnancy) interventions are being tested in a trial. They aim to facilitate the early detection of raised blood pressure through self-monitoring. This article outlines how the self-monitoring interventions in the BUMP trial were developed and modified using the person-based approach to promote engagement and adherence. METHODS Key behavioural challenges associated with blood pressure self-monitoring in pregnancy were identified through synthesising qualitative pilot data and existing evidence, which informed guiding principles for the development process. Social cognitive theory was identified as an appropriate theoretical framework. A testable logic model was developed to illustrate the hypothesised processes of change associated with the intervention. Iterative qualitative feedback from women and staff informed modifications to the participant materials. RESULTS The evidence synthesis suggested women face challenges integrating self-monitoring into their lives and that adherence is challenging at certain time points in pregnancy (for example, starting maternity leave). Intervention modification included strategies to address adherence but also focussed on modifying outcome expectancies, by providing messages explaining pre-eclampsia and outlining the potential benefits of self-monitoring. CONCLUSIONS With an in-depth understanding of the target population, several methods and approaches to plan and develop interventions specifically relevant to pregnant women were successfully integrated, to address barriers to behaviour change while ensuring they are easy to engage with, persuasive and acceptable.
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Affiliation(s)
- Rebecca Band
- Academic unit of psychology, University of Southampton, Southampton, SO17 1BJ UK
| | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Katherine L. Tucker
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Lucy C. Chappell
- Division of Women and Children’s Health, King’s College London, London, SE1 7EH UK
| | - Carole Crawford
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Marloes Franssen
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Sheila Greenfield
- Institute of Applied Health, University of Birmingham, Birmingham, B15 2TT UK
| | - James Hodgkinson
- Institute of Applied Health, University of Birmingham, Birmingham, B15 2TT UK
| | - Christine McCourt
- Centre for Maternal and Child Health, School of Health Sciences, City University, London, EC1R IUW UK
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Jane Sandall
- Division of Women and Children’s Health, King’s College London, London, SE1 7EH UK
| | - Mauro Dala Santos
- Institute of Biomedical Engineering, Department of Engineering Science, Building, University of Oxford, Oxford, OX3 7DQ UK
| | - Carmelo Velardo
- Institute of Biomedical Engineering, Department of Engineering Science, Building, University of Oxford, Oxford, OX3 7DQ UK
| | - Lucy Yardley
- Academic unit of psychology, University of Southampton, Southampton, SO17 1BJ UK
- School of Psychological Science, University of Bristol, Bristol, UK
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16
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Barrett R, Hodgkinson J. Quality evaluation of community pharmacy blood pressure (BP) screening services: an English cross-sectional survey with geospatial analysis. BMJ Open 2019; 9:e032342. [PMID: 31831543 PMCID: PMC6924779 DOI: 10.1136/bmjopen-2019-032342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The primary objective was to assess the accuracy (calibration and validation status) of digital blood pressure (BP) monitors used within community pharmacy in England and the secondary objectives were to assess the overall quality of the BP service by assessing service prevalence, service utilisation and other in-service considerations. DESIGN A cross-sectional survey. SETTING Primary-care retail-pharmacies. PARTICIPANTS 500 pharmacies that contribute to government dispensing-data were invited by post to complete the survey. Private contractors were excluded. INTERVENTIONS We conducted a questionnaire survey with a follow-up (September 2018 to December 2018). RESULTS 109 responses were received. 61% (n=66) of responding pharmacies provided a free BP check to their patients. 40 (61%) pharmacies used recommended validated clinical metres, 6 (9%) had failed validation and 20 (30%) provided too little information to enable us to determine their monitor's status. CONCLUSIONS Responding pharmacies were able to provide useful BP monitoring services to their patients, though quality enhancements need to be implemented. Majority of pharmacies use validated BP monitors, however, there was a lack of range of cuff sizes, variation in replacement and calibration of monitors and apparent absence of such practice in a minority of pharmacies alongside variation in training standards. We noted higher frequency of BP screening in the most deprived postcodes.We recommend in-service redesign and delivery improvements, and suggest professional bodies and researchers work together to create clearer frameworks for front-line practitioners, creating appropriate incentives to facilitate this service redesign.Funders and policy setters should consider the value added to the National Health Service and other healthcare agencies of such screening by pharmacy providers both nationally and internationally. It has the potential to reduce complications of undiagnosed hypertension and the medicines burden that it creates. Future work should examine the impact of pharmacist-led BP screening on patients.
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Affiliation(s)
- Ravina Barrett
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK
- Pharmacy Practice, School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - James Hodgkinson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Rhodehouse BC, Fan J, Chen W, McNeal MJ, Durham CG, Erwin JP. Effect of repeat manual blood pressure measurement on blood pressure and stage of hypertension. Proc (Bayl Univ Med Cent) 2019; 32:498-501. [DOI: 10.1080/08998280.2019.1626657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Bryce C. Rhodehouse
- Department of Medicine, Baylor Scott & White Health, Temple, Texas
- Department of Medicine, Texas A&M Health Science Center College of Medicine, Temple, Texas
| | - Jerry Fan
- Department of Medicine, Baylor Scott & White Health, Temple, Texas
- Department of Medicine, Texas A&M Health Science Center College of Medicine, Temple, Texas
| | - Wencong Chen
- Department of Biostatistics, Baylor Scott & White Health, Temple, Texas
| | - Michael J. McNeal
- Department of Medicine, Baylor Scott & White Health, Temple, Texas
- Department of Medicine, Texas A&M Health Science Center College of Medicine, Temple, Texas
| | - Charis G. Durham
- Department of Medicine, Baylor Scott & White Health, Temple, Texas
- Department of Medicine, Texas A&M Health Science Center College of Medicine, Temple, Texas
| | - John P. Erwin
- Department of Medicine, Baylor Scott & White Health, Temple, Texas
- Department of Medicine, Texas A&M Health Science Center College of Medicine, Temple, Texas
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Choy B, Ganesan K, Fong NS. Task sharing with non-physician health-care workers for management of blood pressure. LANCET GLOBAL HEALTH 2019; 7:e1326. [PMID: 31537363 DOI: 10.1016/s2214-109x(19)30325-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 06/28/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Bennett Choy
- The Medical School, University of Sheffield, Sheffield S10 2RX, UK.
| | | | - Nien Sze Fong
- The Medical School, University of Sheffield, Sheffield S10 2RX, UK
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Booth JN, Hubbard D, Sakhuja S, Yano Y, Whelton PK, Wright JT, Shimbo D, Muntner P. Proportion of US Adults Recommended Out-of-Clinic Blood Pressure Monitoring According to the 2017 Hypertension Clinical Practice Guidelines. Hypertension 2019; 74:399-406. [PMID: 31230550 DOI: 10.1161/hypertensionaha.119.12775] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 2017 Hypertension Clinical Practice Guidelines recommend out-of-clinic BP monitoring to screen for white coat and masked hypertension among adults not taking antihypertensive medication and white coat effect and masked uncontrolled hypertension among adults taking antihypertensive medication. We estimated the percentage of US adults meeting criteria for out-of-clinic BP monitoring by the American College of Cardiology/American Heart Association guideline using the 2011 to 2014 National Health and Nutrition Examination Survey (n=9623). Among US adults not taking antihypertensive medication, 92.6% (95% CI, 90.7%-94.1%) with systolic/diastolic BP ≥130/80 mm Hg met criteria for out-of-clinic BP monitoring to screen for white coat hypertension and 32.8% (95% CI, 30.4%-35.3%) with systolic/diastolic BP<130/80 mm Hg met criteria to screen for masked hypertension. Criteria for out-of-clinic BP monitoring to screen for white coat hypertension were less often met at an older age and did not differ by race/ethnicity or sex. The proportion meeting criteria for out-of-clinic BP monitoring to screen for masked hypertension was higher at an older age, among men versus women and non-Hispanic blacks and whites versus non-Hispanic Asians or Hispanics. Among US adults taking antihypertensive medication, 12.5% (95% CI, 10.5%-14.9%) with systolic/diastolic BP ≥130/80 mm Hg met criteria to screen for white coat effect and 57.4% (95% CI, 52.7%-62.1%) with systolic/diastolic BP<130/80 mm Hg met criteria to screen for masked uncontrolled hypertension. Criteria for out-of-clinic BP monitoring to screen for white coat effect was more commonly met at an older age and among non-Hispanic blacks than non-Hispanic whites and to screen for masked uncontrolled hypertension in older adults and men. In conclusion, ≈103.8 million US adults (45.8%) met the 2017 Hypertension Clinical Practice Guidelines criteria for out-of-clinic BP monitoring.
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Affiliation(s)
- John N Booth
- From the University of Alabama at Birmingham (J.N.B., D.H., S.S., P.M.)
| | - Demetria Hubbard
- From the University of Alabama at Birmingham (J.N.B., D.H., S.S., P.M.)
| | - Swati Sakhuja
- From the University of Alabama at Birmingham (J.N.B., D.H., S.S., P.M.)
| | | | | | - Jackson T Wright
- Case Western Reserve University and University Hospitals Cleveland Medical Center, OH (J.T.W.)
| | | | - Paul Muntner
- From the University of Alabama at Birmingham (J.N.B., D.H., S.S., P.M.)
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20
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Abstract
The role of psychological mechanisms in the treatment process cannot be underestimated, the well-known placebo effect unquestionably being a factor in treatment. However, there is also a dark side to the impact of mental processes on health/illness as exemplified by the nocebo effect. This phenomenon includes the emergence or exacerbation of negative symptoms associated with the therapy, but arising as a result of the patient's expectations, rather than being an actual complication of treatment. The exact biological mechanisms of this process are not known, but cholecystokinergic and dopaminergic systems, changes in the HPA axis, and the endogenous secretion of opioids are thought to be involved. The nocebo effect can affect a significant proportion of people undergoing treatment, including cancer patients, leading in some cases to the cessation of potentially effective therapy, because of adverse effects that are not actually part of the biological effect of treatment. In extreme cases, as a result of suggestions and expectations, a paradoxical effect, biologically opposite to the mechanism of the action of the drug, may occur. In addition, the nocebo effect may significantly interfere with the results of clinical trials, being the cause of a significant proportion of complications reported. Knowledge of the phenomenon is thus necessary in order to facilitate its minimalization and thus improve the quality of life of patients and the effectiveness of treatment.
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21
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Del Giorno R, Heiniger PS, Balestra L, Gabutti L. Blood Pressure Measurements with Different Currently Available Methods in Elderly Hypertensive Hospitalized Patients: A Real World Cross-Sectional Study. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6274545. [PMID: 31058190 PMCID: PMC6463632 DOI: 10.1155/2019/6274545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/25/2019] [Accepted: 03/10/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The reliability of blood pressure (BP) measurement in hospitalized patients is a topic of debate and the therapeutic implication of the routinely collected BP profiles is probably overestimated. When measurements are performed in elderly patients, further potential sources of misinterpretation occur. METHODS We conducted a subanalysis of a previous study including 79 over 80-year-old hypertensive patients, hospitalized in an internal medicine ward. Five modalities of BP evaluations (measurement by physicians and nurses, self-measurement by patients, Finometer® beat-to-beat finger monitoring, and 24h monitoring) were analyzed, considering agreement and accuracy. RESULTS The mean (SD) age of the patients was 86.9±4.9 years (50% women). Patients' self-measurements of both systolic and diastolic BP (SBP and DBP) did not differ significantly from daytime 24-hour monitoring (D24hBPM) (mean difference -1.52, SE 1.71; p: ns and -0.58, SE 1.19 mmHg; p: ns). Conversely, SBP and DBP registered by nurses did significantly differ (mean difference -7.34, SE 1.42; p=0.007 and -4.7, SE 1.05 mmHg; p=0.003). SBP and DBP measured by patients also showed the better concordance, with lowest biases, and narrowest limits of agreements (LoA) and for SBP higher Kappa statistic values (bias 1.5, LoA -28.9 to 31.9; κ 0.563 and bias 0.6, LoA -20.4 to 21.5 mmHg; κ 0.412). The patients' sensitivity and specificity in predicting hypertensive systolic D24hBPM were 84.8% and 69.7%, respectively. CONCLUSIONS In elderly hospitalized patients an alternative to 24hBPM, self-measurements by patients offer the better agreement and reliability in detecting hypertensive values.
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Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland
| | | | - Lorenzo Balestra
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland
| | - Luca Gabutti
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland
- Institute of Biomedicine, University of Southern Switzerland, Lugano, Switzerland
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Pappaccogli M, Di Monaco S, Perlo E, Burrello J, D’Ascenzo F, Veglio F, Monticone S, Rabbia F. Comparison of Automated Office Blood Pressure With Office and Out-Off-Office Measurement Techniques. Hypertension 2019; 73:481-490. [DOI: 10.1161/hypertensionaha.118.12079] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Marco Pappaccogli
- From the Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences (M.P., S.D.M., E.P., J.B., S.M., F.R., F.V.), University of Turin, Italy
| | - Silvia Di Monaco
- From the Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences (M.P., S.D.M., E.P., J.B., S.M., F.R., F.V.), University of Turin, Italy
| | - Elisa Perlo
- From the Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences (M.P., S.D.M., E.P., J.B., S.M., F.R., F.V.), University of Turin, Italy
| | - Jacopo Burrello
- From the Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences (M.P., S.D.M., E.P., J.B., S.M., F.R., F.V.), University of Turin, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Department of Medical Sciences (F.D.), University of Turin, Italy
| | - Franco Veglio
- From the Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences (M.P., S.D.M., E.P., J.B., S.M., F.R., F.V.), University of Turin, Italy
| | - Silvia Monticone
- From the Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences (M.P., S.D.M., E.P., J.B., S.M., F.R., F.V.), University of Turin, Italy
| | - Franco Rabbia
- From the Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences (M.P., S.D.M., E.P., J.B., S.M., F.R., F.V.), University of Turin, Italy
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23
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Boonyasai RT, Carson KA, Marsteller JA, Dietz KB, Noronha GJ, Hsu YJ, Flynn SJ, Charleston JM, Prokopowicz GP, Miller ER, Cooper LA. A bundled quality improvement program to standardize clinical blood pressure measurement in primary care. J Clin Hypertens (Greenwich) 2017; 20:324-333. [PMID: 29267994 DOI: 10.1111/jch.13166] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/28/2017] [Accepted: 09/30/2017] [Indexed: 12/17/2022]
Abstract
We evaluated use of a program to improve blood pressure measurement at 6 primary care clinics over a 6-month period. The program consisted of automated devices, clinical training, and support for systems change. Unannounced audits and electronic medical records provided evaluation data. Clinics used devices in 81.0% of encounters and used them as intended in 71.6% of encounters, but implementation fidelity varied. Intervention site systolic and diastolic blood pressure with terminal digit "0" decreased from 32.1% and 33.7% to 11.1% and 11.3%, respectively. Improvement occurred uniformly, regardless of sites' adherence to the measurement protocol. Providers rechecked blood pressure measurements less often post-intervention (from 23.5% to 8.1% of visits overall). Providers at sites with high protocol adherence were less likely to recheck measurements than those at low adherence sites. Comparison sites exhibited no change in terminal digit preference or repeat measurements. This study demonstrates that clinics can apply a pragmatic intervention to improve blood pressure measurement. Additional refinement may improve implementation fidelity.
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Affiliation(s)
- Romsai T Boonyasai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn A Carson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jill A Marsteller
- Johns Hopkins Center for Health Equity, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Katherine B Dietz
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Baltimore, MD, USA
| | - Gary J Noronha
- Center for Primary Care and Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sarah J Flynn
- Johns Hopkins Center for Health Equity, Baltimore, MD, USA
| | - Jeanne M Charleston
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Greg P Prokopowicz
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edgar R Miller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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24
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Albasri A, O'Sullivan JW, Roberts NW, Prinjha S, McManus RJ, Sheppard JP. A comparison of blood pressure in community pharmacies with ambulatory, home and general practitioner office readings: systematic review and meta-analysis. J Hypertens 2017; 35:1919-1928. [PMID: 28594707 PMCID: PMC5585128 DOI: 10.1097/hjh.0000000000001443] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 04/27/2017] [Accepted: 05/25/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blood pressure (BP) readings are traditionally taken in a clinic setting, with treatment recommendations based on these measurements. The clinical interpretation of BP readings taken in community pharmacies is currently unclear. This study aimed to systematically review all literature comparing community pharmacy BP (CPBP) readings with ambulatory BP monitoring (ABPM), home BP monitoring and general practitioner clinic readings. METHOD Studies were included if they compared CPBP with at least one other measurement modality used for the diagnosis or management of hypertension. Mean CPBP readings were compared with other measurement modalities and summarized using random-effects meta-analyses. The primary outcome was to compare CPBP with gold standard ABPM readings. RESULTS Searches generated 3815 studies of which eight were included in the meta-analyses. The mean systolic CPBP-daytime ABPM difference was small [+1.6 mmHg (95% confidence interval -1.2 to 4.3) three studies, n = 319]. CPBP was significantly higher than 24-h ABPM [+7.8 mmHg (95% confidence interval 1.5-14.1) three studies n = 429]. Comparisons with general practitioner clinic readings (six studies, n = 2100) were inconclusive with significant heterogeneity between studies. CPBP and home BP monitoring readings (five studies, n = 1848) were nonsignificantly different. Diastolic comparisons mirrored systolic comparisons in all but the CPBP-daytime ABPM comparison, where CPBP was significantly higher. CONCLUSION Current evidence around the clinical interpretation of CPBP is inconclusive. Although this review suggests that adopting the 135/85 mmHg threshold for hypertension might be reasonable and potentially result in a higher sensitivity for detecting patients with truly raised BP in pharmacies, the impact of this lower threshold on increased referrals to general practice clinics must be considered.
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Affiliation(s)
- Ali Albasri
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter
| | - Jack W. O'Sullivan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter
| | - Nia W. Roberts
- Bodleian Health Care Libraries – Knowledge Centre Site, Knowledge Centre, Oxford, UK
| | - Suman Prinjha
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter
| | - James P. Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter
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25
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26
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Rinfret F, Cloutier L, L'Archevêque H, Gauthier M, Laskine M, Larochelle P, Ilinca M, Birnbaum L, Ng Cheong N, Wistaff R, Van Nguyen P, Roederer G, Bertrand M, Lamarre-Cliche M. The Gap Between Manual and Automated Office Blood Pressure Measurements Results at a Hypertension Clinic. Can J Cardiol 2017; 33:653-657. [DOI: 10.1016/j.cjca.2017.01.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/13/2017] [Accepted: 01/21/2017] [Indexed: 11/25/2022] Open
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27
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Mejzner N, Clark CE, Smith LF, Campbell JL. Trends in the diagnosis and management of hypertension: repeated primary care survey in South West England. Br J Gen Pract 2017; 67:e306-e313. [PMID: 28347984 PMCID: PMC5409425 DOI: 10.3399/bjgp17x690461] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/23/2016] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Previous surveys identified a shift to nurse-led care in hypertension in 2010. In 2011 the National Institute for Health and Care Excellence (NICE) recommended ambulatory (ABPM) or home (HBPM) blood pressure (BP) monitoring for diagnosis of hypertension. AIM To survey the organisation of hypertension care in 2016 to identify changes, and to assess uptake of NICE diagnostic guidelines. DESIGN AND SETTING Questionnaires were distributed to all 305 general practices in South West England. METHOD Responses were compared with previous rounds (2007 and 2010). Data from the 2015 Quality and Outcomes Framework (QOF) were used to compare responders with non-responders, and to explore associations of care organisation with QOF achievement. RESULTS One-hundred-and-seventeen practices (38%) responded. Responders had larger list sizes and greater achievement of the QOF target BP ≤150/90 mmHg. Healthcare assistants (HCAs) now monitor BP in 70% of practices, compared with 37% in 2010 and 19% in 2007 (P<0.001). Nurse prescribers alter BP medication in 26% of practices (11% in 2010, none in 2007; P<0.001). Of the practices, 89% have access to ABPM, but only 71% report confidence in interpreting results. Also, 87% offer HBPM, with 93% of these confident in interpreting results. CONCLUSION In primary care BP monitoring has devolved from GPs and nurses to HCAs. One in 10 practices are not implementing NICE guidelines on ABPM and HBPM for diagnosis of hypertension. Most practices express confidence interpreting HBPM results but less so with ABPM. The need for education and quality assurance for allied health professionals is highlighted, and for training in ABPM interpretation for GPs.
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Affiliation(s)
- Natasha Mejzner
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon
| | - Christopher E Clark
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon
| | - Lindsay Fp Smith
- East Somerset Research Consortium, Westlake Surgery, Yeovil, Somerset
| | - John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon
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28
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Salisu AD, Bakari A, Abdullahi H. Impact of operator hearing threshold on manual blood pressure measurement. Ann Afr Med 2017; 16:1-5. [PMID: 28300044 PMCID: PMC5452700 DOI: 10.4103/aam.aam_31_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Undetected hearing impairment among health personnel could affect their ability to obtain accurate blood pressure (BP) measurements with consequent negative impact on patient care. The aim of this paper was to determine the impact of operator hearing threshold on manual BP measurement. Methodology: A cross-sectional study involving 25 patients and 60 health personnel consisting of 25 doctors (Group 1), 25 nurses (Group 2), and 10 specially selected, normal hearing and trained control group (Group 3). Group 3 personnel measured BP of each patient and this was considered accurate. After preliminary training on BP measurement technique, one person each from Groups 1 and 2 measured BP of a patient using manual auscultation technique and then proceeded to have a screening pure tone audiogram (PTA) with threshold of the best hearing ear recorded. Results: Majority of personnel had normal hearing (PTA ≤25 dB), 22% had hearing threshold >25 dB on screening, with debilitating hearing loss noted in one person (2%). There was a complete agreement in BP measurements between participants with hearing threshold ≤25 dB and the control group, but in participants with threshold >25 dB, 100% recorded inaccurate diastolic BP and 64% recorded inaccurate systolic BP with tendency to underestimate systolic and overestimate diastolic BP. Conclusion: Hearing impairment is not uncommon among health personnel, resulting in inaccurate BP recordings. Audiograms should be obtained whenever health personnel notice frequent differences in measured BP compared to colleagues. Training on BP measurement technique resulted in accurate BP measurement by all normal hearing participants.
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Affiliation(s)
| | | | - Hamisu Abdullahi
- Department of Otolaryngology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
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Gemmiti M, Hamed S, Lauber-Biason A, Wildhaber J, Pharisa C, Klumb PL. Pediatricians' affective communication behavior attenuates parents' stress response during the medical interview. PATIENT EDUCATION AND COUNSELING 2017; 100:480-486. [PMID: 27816315 DOI: 10.1016/j.pec.2016.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 09/12/2016] [Accepted: 09/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate whether the medical interview in the pediatric context generates a stressful response in parents in form of heightened cortisol activity, and whether pediatricians' empathetic communication is able to attenuate this stress response. METHODS 68 parents were recruited at pediatric out-patient and in-patient consultations. Salivary samples were collected between 60 and 30min prior to the consultation, shortly before the consultation, 20min as well as 45min after the consultation. 19 pediatricians participated in the study and effectuated the medical visit as usual. We videotaped the consultations and coded pediatricians' affective communication using the RIAS and the Four Habits Coding Scheme. RESULTS Parents' cortisol increased during the medical visit with a peak at 20min after the medical encounter. Furthermore, multilevel analysis revealed a lesser increase in parents' cortisol response associated with pediatricians' levels in supportive communication behaviors. CONCLUSION As indicated by their humoral stress responses, the medical encounter was stressful for the parents. Pediatricians' affective communication modulated this stress response in that more supportive communication was related to smaller cortisol increases. PRACTICE IMPLICATION Pediatricians' affective communication behavior during the medical visit can alleviate parents' distress and anxiety, representing a source of social and emotional support.
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Affiliation(s)
- Marco Gemmiti
- Department of Psychology, University of Fribourg, Fribourg, Switzerland.
| | - Selei Hamed
- Department of Pediatrics, Canton Hospital Fribourg, Fribourg, Switzerland
| | | | - Johannes Wildhaber
- Department of Pediatrics, Canton Hospital Fribourg, Fribourg, Switzerland
| | - Cosette Pharisa
- Department of Pediatrics, Canton Hospital Fribourg, Fribourg, Switzerland
| | - Petra L Klumb
- Department of Psychology, University of Fribourg, Fribourg, Switzerland
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30
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Band R, Morton K, Stuart B, Raftery J, Bradbury K, Yao GL, Zhu S, Little P, Yardley L, McManus RJ. Home and Online Management and Evaluation of Blood Pressure (HOME BP) digital intervention for self-management of uncontrolled, essential hypertension: a protocol for the randomised controlled HOME BP trial. BMJ Open 2016; 6:e012684. [PMID: 27821598 PMCID: PMC5129001 DOI: 10.1136/bmjopen-2016-012684] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Self-management of hypertension, including self-monitoring and antihypertensive medication titration, lowers blood pressure (BP) at 1 year compared to usual care. The aim of the current trial is to assess the effectiveness of the Home and Online Management and Evaluation of Blood Pressure (HOME BP) intervention for the self-management of hypertension in primary care. METHODS AND ANALYSIS The HOME BP trial will be a randomised controlled trial comparing BP self-management-consisting of the HOME BP online digital intervention with self-monitoring, lifestyle advice and antihypertensive drug titration-with usual care for people with uncontrolled essential hypertension. Eligible patients will be recruited from primary care and randomised to usual care or to self-management using HOME BP. The primary outcome will be the difference in mean systolic BP (mm Hg) at 12-month follow-up between the intervention and control groups adjusting for baseline BP and covariates. Secondary outcomes (also adjusted for baseline and covariates where appropriate) will be differences in mean BP at 6 months and diastolic BP at 12 months; patient enablement; quality of life, and economic analyses including all key resources associated with the intervention and related services, adopting a broad societal perspective to include NHS, social care and patient costs, considered within trial and modelled with a lifetime horizon. Medication beliefs, adherence and changes; self-efficacy; perceived side effects and lifestyle changes will be measured for process analyses. Qualitative analyses will explore patient and healthcare professional experiences of HOME BP to gain insights into the factors affecting acceptability, feasibility and adherence. ETHICS AND DISSEMINATION This study has received NHS ethical approval (REC reference 15/SC/0082). The findings from HOME BP will be disseminated widely through peer-reviewed publications, scientific conferences and workshops. If successful, HOME BP will be directly applicable to UK primary care management of hypertension. TRIAL REGISTRATION NUMBER ISRCTN13790648; pre-results.
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Affiliation(s)
- Rebecca Band
- Academic Unit of Psychology, University of Southampton, Southampton, UK
| | - Katherine Morton
- Academic Unit of Psychology, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James Raftery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | | | | | - Shihua Zhu
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Academic Unit of Psychology, University of Southampton, Southampton, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Serrat-Costa M, Baltasar Bagué A, Machado Velasco R, Juvinyà Canal D, Bertran Noguer C, Ricart W. Are nurses sufficiently well prepared to take on the detection of hypertension? HIPERTENSION Y RIESGO VASCULAR 2016; 33:126-132. [PMID: 27443260 DOI: 10.1016/j.hipert.2016.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/11/2016] [Accepted: 06/15/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The detection of arterial hypertension requires training and knowledge by the responsible health professional. The current guidelines recommend doctors and nurses to work together for the screening of hypertension. OBJECTIVES To assess the level of knowledge among primary healthcare nurses' in the screening of arterial hypertension. METHODS Descriptive, observational and transversal study. A random representative sample of 165 nurses working with adult patients in community-based primary healthcare centres were asked to complete an evaluation test of theoretical knowledge about hypertension. Higher scores indicated a greater knowledge about the detection of hypertension. RESULTS 32.1% of the participants obtained a score equal to or more than 72.7 which corresponded to the 75th percentile of correct answers. Nurses with lower scores were older, permanent employees with technical training studies. A higher age and technical training studies contributed independently to a lower score. In the multiple linear regression model, age and type of studies contributed independently to questionnaire's score variance. CONCLUSION Currently, primary care nurses in the studied region do not have sufficient theoretical knowledge to detect hypertension. The results show the need to establish strategies to achieve the necessary knowledge for the implementation of a correct hypertension screening. For professional nurses, continuing education is essential to safe and effective nursing care.
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Affiliation(s)
- M Serrat-Costa
- Institut Català de la Salut, Generalitat de Catalunya, Spain.
| | | | - R Machado Velasco
- Residéncia geriátrica Gent Gran Palafrugell, Ayuntamiento de Palafrugell, Girona, Spain
| | | | | | - W Ricart
- Institut Català de la Salut, Generalitat de Catalunya, Spain
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Sheppard JP, Fletcher B, Gill P, Martin U, Roberts N, McManus RJ. Predictors of the Home-Clinic Blood Pressure Difference: A Systematic Review and Meta-Analysis. Am J Hypertens 2016; 29:614-25. [PMID: 26399981 PMCID: PMC4829055 DOI: 10.1093/ajh/hpv157] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 08/14/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients may have lower (white coat hypertension) or higher (masked hypertension) blood pressure (BP) at home compared to the clinic, resulting in misdiagnosis and suboptimal management of hypertension. This study aimed to systematically review the literature and establish the most important predictors of the home-clinic BP difference. METHODS A systematic review was conducted using a MEDLINE search strategy, adapted for use in 6 literature databases. Studies examining factors that predict the home-clinic BP difference were included in the review. Odds ratios (ORs) describing the association between patient characteristics and white coat or masked hypertension were extracted and entered into a random-effects meta-analysis. RESULTS The search strategy identified 3,743 articles of which 70 were eligible for this review. Studies examined a total of 86,167 patients (47% female) and reported a total of 60 significant predictors of the home-clinic BP difference. Masked hypertension was associated with male sex (OR 1.47, 95% confidence interval (CI) 1.18–1.75), body mass index (BMI, per kg/m2 increase, OR 1.07, 95% CI 1.01–1.14), current smoking status (OR 1.32, 95% CI 1.13–1.50), and systolic clinic BP (per mm Hg increase, OR 1.10, 95% CI 1.01–1.19). Female sex was the only significant predictor of white coat hypertension (OR 3.38, 95% CI 1.64–6.96). CONCLUSIONS There are a number of common patient characteristics that predict the home-clinic BP difference, in particular for people with masked hypertension. There is scope to incorporate such predictors into a clinical prediction tool which could be used to identify those patients displaying a significant masked or white coat effect in routine clinical practice.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK;
| | - Ben Fletcher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paramjit Gill
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Una Martin
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Nia Roberts
- Bodleian Healthcare Libraries, Knowledge Centre, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Planès S, Villier C, Mallaret M. The nocebo effect of drugs. Pharmacol Res Perspect 2016; 4:e00208. [PMID: 27069627 PMCID: PMC4804316 DOI: 10.1002/prp2.208] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 11/09/2015] [Accepted: 11/20/2015] [Indexed: 12/17/2022] Open
Abstract
While the placebo effect has been studied for a long time, much less is known about its negative counterpart, named the nocebo effect. However, it may be of particular importance because of its impact on the treatment outcomes and public health. We conducted a review on the nocebo effect using PubMed and other databases up to July 2014. The nocebo effect refers by definition to the induction or the worsening of symptoms induced by sham or active therapies. Examples are numerous and concerns both clinical trials and daily practice. The underlying mechanisms are, on one hand, psychological (conditioning and negative expectations) and, on the other hand, neurobiological (role of cholecystokinin, endogenous opioids and dopamine). Nocebo effects can modulate the outcome of a given therapy in a negative way, as do placebo effects in a positive way. The verbal and nonverbal communications of physicians contain numerous unintentional negative suggestions that may trigger a nocebo response. This raises the important issue of how physicians can at the same time obtain informed consent and minimize nocebo-related risks. Every physician has to deal with this apparent contradiction between primum non nocere and to deliver truthful information about risks. Meticulous identification of patients at risk, information techniques such as positive framing, contextualized informed consent, and even noninformation, is valuable.
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Affiliation(s)
- Sara Planès
- Centre Régional de Pharmacovigilance Grenoble University Hospital Grenoble France
| | - Céline Villier
- Centre Régional de Pharmacovigilance Grenoble University Hospital Grenoble France
| | - Michel Mallaret
- Centre Régional de Pharmacovigilance Grenoble University Hospital Grenoble France
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Dillon KM, Seacat JD, Saucier CD, Doyle-Campbell CJ. Could Blood Pressure Phobia Go Beyond the White Coat Effect? Am J Hypertens 2015; 28:1306-9. [PMID: 25851644 DOI: 10.1093/ajh/hpv040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND While it is known that excessive anxiety surrounding the measuring of blood pressure may preclude an accurate measurement, it is not known whether it could also lead to phobic avoidance behavior. METHODS Self-reported information was collected on 125 individuals who made postings on 5 internet-based medical forums. RESULTS Qualitative thematic analysis revealed that these individuals reported experiencing intense fear associated with the measuring of blood pressure, that was excessive or irrational and which contributed to avoidance of medical treatment and interference with life decisions. CONCLUSIONS Based on these preliminary observations, we are speculating that these symptoms could be considered consistent with a diagnosis of a Specific Phobia. Investigations using quantitative methods, representative samples, and standardized clinical instruments need to be conducted before definitive conclusions can be reached.
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Affiliation(s)
- Kathleen M Dillon
- Department of Psychology, Western New England University, Springfield, Massachusetts, USA;
| | - Jason D Seacat
- Department of Psychology, Western New England University, Springfield, Massachusetts, USA
| | - Cory D Saucier
- Department of Psychology, Western New England University, Springfield, Massachusetts, USA
| | - Courtney J Doyle-Campbell
- Department of Pharmacy Practice, Western New England University, Springfield, Massachusetts, USA; Riverbend Medical Group, Hypertension Clinic, Springfield, Massachusetts, USA
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36
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Lacruz ME, Kluttig A, Hartwig S, Löer M, Tiller D, Greiser KH, Werdan K, Haerting J. Prevalence and Incidence of Hypertension in the General Adult Population: Results of the CARLA-Cohort Study. Medicine (Baltimore) 2015; 94:e952. [PMID: 26039136 PMCID: PMC4616348 DOI: 10.1097/md.0000000000000952] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hypertension is a leading cause of cardiovascular disease. There are very few studies dealing with the incidence of hypertension and changes in blood pressure (BP) over time. We aimed to evaluate the prevalence and incidence of hypertension within an adult population-based cohort.The sample included 967 men and 812 women aged 45 to 83 years at baseline, 1436 subjects completed follow-up1 after 4 years and 1079 completed follow-up2 after 9 years. BP was measured according to a standardized protocol with oscillometric devices and hypertension was defined as mean systolic BP (SBP) ≥140 mmHg and/or diastolic BP (DBP) ≥90 mmHg and/or use of antihypertensive medication if hypertension was known. We examined prevalence and incidence of hypertension, by age and sex.The age-standardized prevalence of hypertension at baseline was 74.3% for men and 70.2% for women. The age-standardized annual incidence rate of hypertension for men was 8.6 (95% confidence interval [95% CI] 4.3-12.9) for follow-up period1 and 5.4 (95% CI 2.8-10.6) for follow-up period2 and for women 8.2 (95% CI 3.6-12.8) for follow-up1 and 5.6 (95%CI 2.7-11.4) for follow-up2. A clear decrease in SBP and DBP between baseline and follow-up1 and follow-up2 was seen, accompanied by an increase in anti-hypertensive medication consumption and a higher awareness of the condition.Hypertension prevalence and incidence in the CARLA Study appear to be elevated compared with other studies. The decrease of BP over time seems to be caused by improved hypertension control due to interventional effects of our observational study and improved health care.
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Affiliation(s)
- Maria E Lacruz
- From the Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg (MEL, AK, SH, DT, JH), Evangelisches Diakonie-Krankenhaus, Halle (ML), Division of Cancer Epidemiology, German Cancer Research Centre, Heidelberg (KHG), and Department of Medicine III, Martin-Luther-University Halle-Wittenberg, Halle, Germany (KW)
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Martin U, Haque MS, Wood S, Greenfield SM, Gill PS, Mant J, Mohammed MA, Heer G, Johal A, Kaur R, Schwartz C, McManus RJ. Ethnicity and differences between clinic and ambulatory blood pressure measurements. Am J Hypertens 2015; 28:729-38. [PMID: 25398890 DOI: 10.1093/ajh/hpu211] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 10/04/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND This study investigated the relationship of ethnicity to the differences between blood pressure (BP) measured in a clinic setting and by ambulatory blood pressure monitoring (ABPM) in individuals with a previous diagnosis of hypertension (HT) and without a previous diagnosis of hypertension (NHT). METHODS A cross-sectional comparison of BP measurement was performed in 770 participants (white British (WB, 39%), South Asian (SA, 31%), and African Caribbean (AC, 30%)) in 28 primary care clinics in West Midlands, United Kingdom. Mean differences between daytime ABPM, standardized clinic (mean of 3 occasions), casual clinic (first reading on first occasion), and last routine BP taken at the general practitioner practice were compared in HT and NHT individuals. RESULTS Daytime systolic and diastolic ABPM readings were similar to standardized clinic BP (systolic: 128 (SE 0.9) vs. 125 (SE 0.9) mm Hg (NHT) and 132 (SE 0.7) vs. 131 (SE 0.7) mm Hg (HT)) and were not associated with ethnicity to a clinically important extent. When BP was taken less carefully, differences emerged: casual clinic readings were higher than ABPM, particularly in the HT group where the systolic differences approached clinical relevance (131 (SE 1.2) vs. 129 (SE 1.0) mm Hg (NHT) and 139 (SE 0.9) vs. 133 (SE 0.7) mm Hg (HT)) and were larger in SA and AC hypertensive individuals (136 (SE 1.5) vs. 133 (SE 1.2) mm Hg (WB), 141 (SE 1.7) vs. 133 (SE 1.4) mm Hg (SA), and 142 (SE 1.6) vs. 134 (SE 1.3) mm Hg (AC); mean differences: 3 (0-7), P = 0.03 and 4 (1-7), P = 0.01, respectively). Differences were also observed for the last practice reading in SA and ACs. CONCLUSIONS BP differences between ethnic groups where BP is carefully measured on multiple occasions are small and unlikely to alter clinical management. When BP is measured casually on a single occasion or in routine care, differences appear that could approach clinical relevance.
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Affiliation(s)
- Una Martin
- Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK;
| | - M Sayeed Haque
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Sally Wood
- Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Sheila M Greenfield
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Paramjit S Gill
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jonathan Mant
- Primary Care Unit, University of Cambridge, Cambridge, UK
| | | | - Gurdip Heer
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Amanpreet Johal
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Ramendeep Kaur
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Claire Schwartz
- Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
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In general practice, doctors record higher blood pressures in the presence of students. Br J Gen Pract 2014; 64:277. [DOI: 10.3399/bjgp14x680029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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White coat hypertension: is it all just in the look? Br J Gen Pract 2014; 64:277-8. [DOI: 10.3399/bjgp14x680041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Affiliation(s)
- Richard J McManus
- Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Oxford OX1 2GG, UK.
| | - Jonathan Mant
- Primary Care Unit, University of Cambridge, Cambridge, UK
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