Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial.

BACKGROUND: Studies evaluating titration of antihypertensive medication using self-monitoring give contradictory findings and the precise place of telemonitoring over self-monitoring alone is unclear. The TASMINH4 trial aimed to assess the efficacy of self-monitored blood pressure, with or without telemonitoring, for antihypertensive titration in primary care, compared with usual care. METHODS: This study was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mm Hg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group). Randomisation was by a secure web-based system. Neither participants nor investigators were masked to group assignment. The primary outcome was clinic measured systolic blood pressure at 12 months from randomisation. Primary analysis was of available cases. The trial is registered with ISRCTN, number ISRCTN 83571366. FINDINGS: 1182 participants were randomly assigned to the self-monitoring group (n=395), the telemonitoring group (n=393), or the usual care group (n=394), of whom 1003 (85%) were included in the primary analysis. After 12 months, systolic blood pressure was lower in both intervention groups compared with usual care (self-monitoring, 137·0 [SD 16·7] mm Hg and telemonitoring, 136·0 [16·1] mm Hg vs usual care, 140·4 [16·5]; adjusted mean differences vs usual care: self-monitoring alone, -3·5 mm Hg [95% CI -5·8 to -1·2]; telemonitoring, -4·7 mm Hg [-7·0 to -2·4]). No difference between the self-monitoring and telemonitoring groups was recorded (adjusted mean difference -1·2 mm Hg [95% CI -3·5 to 1·2]). Results were similar in sensitivity analyses including multiple imputation. Adverse events were similar between all three groups. INTERPRETATION: Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care. FUNDING: National Institute for Health Research via Programme Grant for Applied Health Research (RP-PG-1209-10051), Professorship to RJM (NIHR-RP-R2-12-015), Oxford Collaboration for Leadership in Applied Health Research and Care, and Omron Healthcare UK

What causes differences of C-S-H gel grey levels in backscattered electron images?

Backscattered electron (BSE) images of heat-cured concretes show alite grains surrounded by inner C-S-H gel of two distinct grey levels (referred to as two-tone inner C-S-H gel). The lighter rim forms at elevated temperature whereas the darker rim develops during subsequent exposure to moisture at 20 °C. This microstructural feature can potentially be used as an indicator to assess the curing history of a concrete. However, microstructural examinations of room-temperature concretes containing silica fume or which have been exposed to severe conditions (external sulfate, carbonation) also show distinct rims of two-tone inner C-S-H gel. The chemical compositions of the rims were determined by EDX microanalysis in the scanning electron microscope (SEM). Our results show that for heat-cured samples, the different grey levels of the two-tone inner C-S-H are caused by relative differences in microporosity and water content and not by ones in chemical composition. However, in silica-fume blended concrete, sulfate attacked or carbonated specimens the different grey levels of the two-tone inner C-S-H gel were associated with significant differences in chemical composition. This difference allows two-tone inner C-S-H gel arising from heat curing to be distinguished from that arising from these other causes. © 2002 Elsevier Science Ltd. All rights reserved

Nurse practitioner education: a research-based curriculum structure

Background. The process and content of nurse practitioner educational preparation has received scant research attention, despite increasing interest in and investigations into nurse practitioner services in Australia and internationally. Aims. The aim of this paper is to report a study investigating the educational process and content required for nurse practitioner preparation. Methods. A trial of practice was conducted with four nurse practitioner candidates over a 12-month period. The candidates practised in different specialities, giving rise to four models of the nurse practitioner role. The trial had multiple aims related to the role and scope of practice of the nurse practitioner. An action learning model was used, in which participating nurse practitioner candidates 'worked-into-the-role' of extended practice and learned from experience through clinical mentoring, reflection and action. Data collection methods centred on transcripts from group work activities related to a collaborative engagement with and reflections on clinical practice. This resulted in the collaborative production of data to inform a research-based nurse practitioner curriculum structure. Findings. The findings relate to the content and learning process required for nurse practitioner education and are described in terms of three broad areas of study: clinical practice, clinical sciences and nursing studies. Conclusions. A curriculum structure that describes content and process for nurse practitioner education was developed from the findings. A further outcome of this trial was confirmation of importance of the clinical environment for nurse practitioner education. Inherent in this aspect of clinical learning is the role of a committed clinical mentor who can facilitate purposeful learning