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

‘Time critical’ rapid amputation using fire service hydraulic cutting equipment

Introduction: Entrapped trauma victims require extrication, which, on rare occasions, may involve amputation of a limb. Standard extrication techniques sometimes fail or may be impossible, leading to the death of the entrapped victim. We propose that the use of fire service hydraulic cutting equipment can be used effectively to urgently amputate a limb, where conventional techniques are unusable. Method: The study aims to determine: (i) the potential use of this equipment to achieve expeditious life-saving amputations and (ii) the effect the fire service hydraulic cutting equipment has on the bony and surrounding soft tissues. Initially a porcine limb was used followed by fresh-frozen cadaveric lower limbs. We recorded the time, number of cuts, proximal fracture propagation and quality of bone cut when performing amputations at five levels. Results: The experiment confirms that faster guillotine amputations in human cadaveric lower limb specimens can be achieved by using fire service hydraulic cutting equipment. Overall, the average time to complete an amputation in these ideal experimental circumstances at all five levels was quicker using the hydraulic cutting equipment. Either one or two cutting actions were required to achieve the amputation using fire service hydraulic cutting equipment. The degree and proximal extent of the comminution were greater using the fire service hydraulic cutting equipment. Conclusion: If circumstances and time constrains allow, a conventional amputation technique carried out by a trained medical practitioner would be preferable to the use of the fire service hydraulic cutting equipment. However, we feel that this technique could be used to perform emergent amputation under trained medical supervision, if it is felt that a standard amputation technique would take too long or the environment is too restrictive to perform a standard amputation safely.</p