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

All that wheezes: A young infant with a mediastinal mass

Wheezing infants are frequently encountered in the emergency department. Bronchiolitis is the most commonly seen cause. Radiographs are not recommended in the routine management of bronchiolitis. We present the case of a young wheezing infant with a mildly abnormal chest x-ray whose cystic hygroma caused life-threatening respiratory distress soon after he was admitted to the hospital

Outcome of infants requiring cardiopulmonary resuscitation before extracorporeal membrane oxygenation.

BACKGROUND/PURPOSE: Cardiopulmonary resuscitation (CPR) is reported to be used in a significant number of neonates before initiation of extracorporeal membrane oxygenation (ECMO). This report establishes the incidence of infants who require CPR before initiation of ECMO and elucidates survival rates and long-term neurological outcomes. In addition, the authors sought prognostic factors that could reliably predict survival or long-term neurological outcome before initiating ECMO support. METHODS: The Extracorporeal Life Support Organization (ELSO) registry provided data on 839 neonates who received CPR before ECMO from January 1989 to April 1995. Supplemental questionnaires on 414 infants were returned from 64 ECMO centers regarding details of the CPR event and subsequent neurological development. One-year neurological evaluations were provided on 112 infants. Data were analyzed for statistical significance using chi2, multiple logistic regression, and Kruskal Wallis one-way analysis of variance as applicable, with significance set at P \u3c .05. RESULTS: The incidence of infants requiring pre-ECMO CPR was 13.1%. Infants who received pre-ECMO CPR had a survival rate of 60.8% versus 81.6% survival for infants who did not require CPR (P \u3c .00001). Analysis of ELSO registry data showed survival was significantly associated with primary diagnosis, location of CPR, last pH level before ECMO, and the presence of intraventricular hemorrhage. Questionnaire data on 12-month neurological assessment showed 63% had no impairment and 4% were graded as severely impaired. Twelve-month neurological outcome was significantly associated only with primary diagnosis. CONCLUSION: A survival rate of 60.8% with good neurological outcome at 12 months in 63.4% of infants suggests that CPR alone should not be a contraindication to placing a neonate on ECMO

Management of parapneumonic collections in infants and children

Background/Purpose: Video-assisted thoracoscopic surgery (VATS) has a recognized role in treatment of empyema thoracis. The purpose of this report is to show the value of initial VATS as the primary treatment of parapneumonic collections. Methods: A retrospective review was done of 139 children who required surgical consultation for parapneumonic collections between January 1992 and July 1998. Management options were (M1) thoracentesis, chest tube drainage, or fibrinolytic therapy and delayed thoracotomy for unresolved collections; (M2) thoracentesis, chest tube drainage, fibrinolytic therapy with delayed VATS if the child remained ill; or (M3) primary VATS. Comparative data included age, duration of prehospital illness, oxygen requirements, white blood cell count, bacterial culture results, number of procedures performed per patient, duration of chest tube drainage, complications, and length of stay. Kruskal-Wallis 1-way analysis was used, with significance at P less than .05. Results: A total of 60 children were treated by M1, 38 by M2, and 41 by M3. Age, duration of prehospital illness, oxygen requirements, white blood cell count, bacterial culture results, and complication rates were comparable. The median length of stay was 12 days for M1, 11 days for M2, and 7 days for M3, with M3 significantly shorter at P\u3c .001. The number of procedures was a median of 2 in M1, 2 in M2, and 1 in M3, with M3 significantly fewer at P \u3c .001. Duration of chest tube drainage was a median 5 days for M1 and 3 days for M2 and M3, with M1 significantly longer at P \u3c .001. There were 9 thoracotomies in the M1 group, 3 in the M2 group, and none in the M3 group. One child in M3 required a second VATS. Conclusions: Primary VATS has significantly decreased the number of procedures, duration of chest tube drainage and length of stay for children with parapneumonic effusions. Primary VATS appears to be of value in management of bacterial pneumonia with effusion. Copyright (C) 2000 by W.B. Saunders Company

Breast Malignancies in Children: Presentation, Management, and Survival.

PURPOSE: Pediatric breast malignancies are rare, and descriptions in the literature are limited. The purpose of our study was to compare pediatric and adult breast malignancy. METHODS: We performed a retrospective cohort study using the National Cancer Data Base comparing patients ≤21 years to those \u3e21 years at diagnosis (1998-2012). Generalized linear models estimated differences in demographic, tumor, and treatment characteristics. Cox regression was used to compare overall survival. RESULTS: Of 1,999,181 cases of invasive breast malignancies, 477 (0.02%) occurred in patients ≤21 years. Ninety-nine percent of adult patients had invasive carcinoma compared with 64.8% of pediatric patients with the remaining patients having sarcoma, malignant phyllodes, or malignancy not otherwise specified (p \u3c 0.001). Pediatric patients were twice as likely to have an undifferentiated malignancy [relative risk (RR) 2.19; 95% confidence interval (CI) 1.72-3.79]. Half of adults presented with Stage I disease compared with only 22.7% of pediatric patients (p \u3c 0.001). Pediatric patients were 40% more likely to have positive axillary nodes (RR 1.42; 95% CI 1.10-1.84). Among patients with invasive carcinoma, pediatric patients were more than four times as likely to receive a bilateral than a unilateral mastectomy compared with adults (RR 4.56; 95% CI 3.19-6.53). There was no difference in overall survival between children and adults. CONCLUSIONS: Pediatric breast malignancies are more advanced at presentation, and there is variability in treatment practices. Adult and pediatric patients with invasive carcinoma have similar overall survival