Access to antenatal blood pressure measurement in Malawi

Aim To identify service side factors associated with access to antenatal blood pressure measurement at health facilities in Malawi. Methods Secondary data analysis of 1499 observations of antenatal consultations undertaken in the Service Provision Assessment survey 2013-14, a census of all formal health facilities in the country. Results Differentials in access to antenatal blood pressure measurements by client age or educational status and provider gender or in-service training did not reach statistical significance although clinically important effects cannot be excluded. There was substantial variation among districts, ranging from 14% to 100% of observed consultations. Facilities in the Central and Southern regions had lower odds of providing blood pressure measurement relative to the Northern region (OR 0.17, 95% CI 0.03 to 0.30 and 0.11, 95% 0.04 to 0.31 respectively). Facilities affiliated to the Christian Health Association of Malawi and facilities under private management had higher odds of provision relative to government facilities (OR 3.24, 95% CI 1.71 to 6.11 and 5.77, 95% CI 1.87 to 17.79 respectively). Where observed consultations included taking the client’s weight and measuring the symphysis-fundus height, the odds of blood pressure measurement were significantly increased (OR 6.4, 95% CI 3.32 to 12.34 and 1.71, 95% CI 1.01 to 2.88 respectively). Conclusion An indicator for effective coverage, the proportion of antenatal visits that included blood pressure measurement, recorded in health passports examined at the time of admission for delivery, should be tested for incorporation into the District Health Information System to enable tracking of quality improvement in antenatal care. Further research is needed to elucidate the reasons for the variations identified here

Temporal and bidirectional association between blood pressure variability and arterial stiffness: Cross-lagged cohort study

BACKGROUND: The causal relationship between blood pressure variability (BPV) and arterial stiffness remains debated. OBJECTIVE: This study aimed to explore the temporal and bidirectional associations between long-term BPV and arterial stiffness using a cohort design with multiple surveys. METHODS: Participants from the Beijing Health Management Cohort who underwent health examinations from visit 1 (2010-2011) to visit 5 (2018-2019) were enrolled in this study. Long-term BPV was defined as intraindividual variation using the coefficient of variation (CV) and SD. Arterial stiffness was measured by brachial-ankle pulse wave velocity (baPWV). The bidirectional relationship between BPV and arterial stiffness was explored using cross-lagged analysis and linear regression models, with records before and after visit 3 categorized as phase 1 and phase 2, respectively. RESULTS: Of the 1506 participants, who were a mean of 56.11 (SD 8.57) years old, 1148 (76.2%) were male. The cross-lagged analysis indicated that the standardized coefficients of BPV at phase 1 directing to the baPWV level at phase 2 were statistically significant but not vice-versa. The adjusted regression coefficients of the CV were 4.708 (95% CI 0.946-8.470) for systolic blood pressure, 3.119 (95% 0.166-6.073) for diastolic pressure, and 2.205 (95% CI 0.300-4.110) for pulse pressure. The coefficients of the SD were 4.208 (95% CI 0.177-8.239) for diastolic pressure and 4.247 (95% CI 0.448-8.046) for pulse pressure. The associations were predominant in the subgroup with hypertension, but we did not observe any significant association of baPWV level with subsequent BPV indices. CONCLUSIONS: The findings supported a temporal relationship between long-term BPV and arterial stiffness level, especially among people with hypertension

Goal-directed therapy in intraoperative fluid and hemodynamic management.

Intraoperative fluid management is pivotal to the outcome and success of surgery, especially in high-risk procedures. Empirical formula and invasive static monitoring have been traditionally used to guide intraoperative fluid management and assess volume status. With the awareness of the potential complications of invasive procedures and the poor reliability of these methods as indicators of volume status, we present a case scenario of a patient who underwent major abdominal surgery as an example to discuss how the use of minimally invasive dynamic monitoring may guide intraoperative fluid therapy

An evaluation of type 2 diabetes care in the primary care setting

Objectives: To assess the clinical outcome of type 2 diabetes care currently provided at the primary healthcare centres. Method: A clinical audit was performed among 110 type 2 diabetes patients in the two major primary healthcare centres. The measurements of fasting blood glucose, HbA1c, serum lipid profile, blood pressure, serum creatinine, body mass index and waist circumference were carried out during a clinical examination. Knowledge, behaviour and attitude among the participants were assessed via a questionnaire composed of four sections concerning diabetes and its complications, physical activity, nutrition and smoking. Results: The ideal standards recommended by the International Diabetes Federation were employed for data analysis. HbA1c level was controlled in 37. 3%, systolic blood pressure was controlled in 44. 5%, cholesterol was controlled in 30% while LDL was controlled in 10.9 % of patients. Body Mass Index was above the normal threshold in 72.7% of participants while waist circumference was abnormally high in 96.3% of females and 64.7% of males. Serum creatinine level was controlled in 60% of patients. Significant correlations with HbA1c were registered for BMI (p-value 0.038) and serum creatinine (p-value 0.04). Patients showed limited knowledge on diabetes, its complications and exercise but were better informed on nutrition and smoking. Inappropriate eating habits were evident among participants while better behaviour was demonstrated in relation to the adherence to medication, physical activity and smoking. Conclusion: The framework for structured care is in place at the primary healthcare centres and compliance with process measures was confirmed. The present local care is based on good practice and is compatible with that provided in developed countries. However the health status of these patients is under imminent threat by a cluster of risk factors. This necessitates improvement in all components of present care while additional efforts must address the inadequacies in cardiovascular risk and lifestyle management.peer-reviewe

Does self-monitoring reduce blood pressure? Meta-analysis with meta-regression of randomized controlled trials

Introduction. Self-monitoring of blood pressure (BP) is an increasingly common part of hypertension management. The objectives of this systematic review were to evaluate the systolic and diastolic BP reduction, and achievement of target BP, associated with self-monitoring. Methods. MEDLINE, Embase, Cochrane database of systematic reviews, database of abstracts of clinical effectiveness, the health technology assessment database, the NHS economic evaluation database, and the TRIP database were searched for studies where the intervention included self-monitoring of BP and the outcome was change in office/ambulatory BP or proportion with controlled BP. Two reviewers independently extracted data. Meta-analysis using a random effects model was combined with meta-regression to investigate heterogeneity in effect sizes. Results. A total of 25 eligible randomized controlled trials (RCTs) (27 comparisons) were identified. Office systolic BP (20 RCTs, 21 comparisons, 5,898 patients) and diastolic BP (23 RCTs, 25 comparisons, 6,038 patients) were significantly reduced in those who self-monitored compared to usual care (weighted mean difference (WMD) systolic −3.82 mmHg (95% confidence interval −5.61 to −2.03), diastolic −1.45 mmHg (−1.95 to −0.94)). Self-monitoring increased the chance of meeting office BP targets (12 RCTs, 13 comparisons, 2,260 patients, relative risk = 1.09 (1.02 to 1.16)). There was significant heterogeneity between studies for all three comparisons, which could be partially accounted for by the use of additional co-interventions. Conclusion. Self-monitoring reduces blood pressure by a small but significant amount. Meta-regression could only account for part of the observed heterogeneity

Personalized medicine—a modern approach for the diagnosis and management of hypertension

The main goal of treating hypertension is to reduce blood pressure to physiological levels and thereby prevent risk of cardiovascular disease and hypertension-associated target organ damage. Despite reductions in major risk factors and the availability of a plethora of effective antihypertensive drugs, the control of blood pressure to target values is still poor due to multiple factors including apparent drug resistance and lack of adherence. An explanation for this problem is related to the current reductionist and ‘trial-and-error’ approach in the management of hypertension, as we may oversimplify the complex nature of the disease and not pay enough attention to the heterogeneity of the pathophysiology and clinical presentation of the disorder. Taking into account specific risk factors, genetic phenotype, pharmacokinetic characteristics, and other particular features unique to each patient, would allow a personalized approach to managing the disease. Personalized medicine therefore represents the tailoring of medical approach and treatment to the individual characteristics of each patient and is expected to become the paradigm of future healthcare. The advancement of systems biology research and the rapid development of high-throughput technologies, as well as the characterization of different –omics, have contributed to a shift in modern biological and medical research from traditional hypothesis-driven designs toward data-driven studies and have facilitated the evolution of personalized or precision medicine for chronic diseases such as hypertension

Instrumental variable methods to assess quality of care the marginal effects of process-of-care on blood pressure change and treatment costs

Background: Hypertension is poorly controlled. Team-based care and changes in the process of care have been proposed to address these quality problems. However, assessing care processes is difficult because they are often confounded even in randomized behavioral studies by unmeasured confounders based on discretion of health care providers. Objective: To evaluate the effects of process measures including number of counseling sessions about lifestyle modification and number of antihypertensive medications on blood pressure change and payer-perspective treatment costs. Methods: Data were obtained from two prospective, cluster randomized controlled clinical trials (Trial A and B) implementing physician-pharmacist collaborative interventions compared with usual care over six months in community-based medical offices in the Midwest. Multivariate linear regression models with both instrumental variable methods and as-treated methods were utilized. Instruments were indicators for trial and study arms. Models of blood pressure change and costs included both process measures, demographic variables, and clinical variables. Results: The analysis included 496 subjects. As-treated methods showed no significant associations between process and outcomes. The instruments used in the study were insufficient to simultaneously identify distinct process effects. However, the post-hoc instrumental variable models including one process measure at a time while controlling for the other process demonstrated significant associations between the processes and outcomes with estimates considerably larger than as-treated estimates. Conclusions: Instrumental variable methods with combined randomized behavioral studies may be useful to evaluate the effects of different care processes. However, substantial distinct process variation across studies is needed to fully capitalize on this approach. Instrumental variable methods focusing on individual processes provided larger and stronger outcome relationships than those found using as-treated methods which are subject to confounding

An international comparative study of blood pressure in populations of European vs. African descent

Background: The consistent finding of higher prevalence of hypertension in US blacks compared to whites has led to speculation that African-origin populations are particularly susceptible to this condition. Large surveys now provide new information on this issue. Methods: Using a standardized analysis strategy we examined prevalence estimates for 8 white and 3 black populations (N = 85,000 participants). Results: The range in hypertension prevalence was from 27 to 55% for whites and 14 to 44% for blacks. Conclusions: These data demonstrate that not only is there a wide variation in hypertension prevalence among both racial groups, the rates among blacks are not unusually high when viewed internationally. These data suggest that the impact of environmental factors among both populations may have been under-appreciated