Three simple steps for improving diagnostic accuracy in hypertension

Neðst á síðunni er hægt að nálgast greinina í heild sinni með því að smella á hlekkinn View/OpenObjective: Most patients have only had three measurements of blood pressure before being labelled as hypertensive. This abbreviated assessment may lead to inaccurate classification, unnecessary treatment and dilution in treatment benefit for the population. We aimed to explore how accurate current methods are in diagnosing mild hypertension, and to explore practical methods of improving targeting of antihypertensive treatment using clinic visits but without lengthy observation. Material and methods: We applied current diagnostic methods to 3965 individuals with mild hypertension who were followed for a year in the placebo arm of the MRC Mild Hypertension Trial (Medical Research Council). We thus calculated the proportion selected for treatment by current methods and the diagnostic accuracy, using average blood pressure beyond six months as representing "true" long-term blood pressure. We looked at the benefit of averaging blood pressures, prolonging observation modestly and estimating within-person blood pressure variability. Results: Prolonging observation to three months selects a smaller (by about 12%) proportion of the sample for treatment. At three months the proportion of the sample selected is similar to the proportion defined as "truly" hypertensive. The diagnostic accuracy of current methods is poor with up to 69% discrepancy in classification. This discrepancy was improved in absolute terms by up to 18% by prolonging observation to three months and using average blood pressures. Identifying those individuals with low within-person variability allows marked improvement in the prediction of "true" hypertension. Conclusion: Although some inaccuracy in the diagnosis of hypertension is inevitable, observation for three months, averaging blood pressures and estimating within-person blood pressure variability can markedly improve upon current methods used for targeting antihypertensive treatment.Tilgangur: Flestir sem greindir hafa verið með háþrýsting hafa fengið greininguna eftir þrjár eða færri mælingar á blóðþrýstingi hjá lækni. Þetta skyndimat gæti leitt til ónákvæmni í greiningu, ónauðsynlegrar meðhöndlunar og minni meðferðarávinnings en efni standa til. Við höfum reynt að meta hversu nákvæm greining fæst með hefðbundnum aðferðum og skoðað hagnýt ráð sem beita mætti til þess að bæta öryggi greiningarinnar án þess að seinka greiningu um of. Efniviður og aðferðir: 3965 manns var fylgt eftir í lyfleysuhluta "MRC Mild Hypertension Trial" (Medical Research Council). Hlutfall hópsins sem myndi hafa valist til meðferðar samkvæmt algengum klínískum vinnubrögðum var metið og einnig var reynt að áætla nákvæmni þeirrar greiningar með samanburði við meðalþrýsting eftir meira en sex mánaða eftirfylgni sem var talið ígildi raunverulegs langtímablóðþrýstings. Við litum á kosti þess að nota meðalþrýsting nokkurra heimsókna, eftirlit og bið í tiltölulega skamman tíma (þrjá mánuði) og áhrif þess að taka tillit til breytileika blóðþrýstings hvers einstaklings. Niðurstöður: Greining háþrýstings eftir þriggja mánaða eftirlit fremur en eftir þrjár mælingar minnkar hópinn sem talinn er hafa háþrýsting um næstum 12%. Ekki virtist ávinningur af því að lengja eftirlitið frekar. Greining háþrýstings samkvæmt þeim hefðbundnu vinnubrögðum sem oftast er beitt núna er ónákvæm og leiðir hugsanlega til rangrar greiningar hjá allt að 69% einstaklinga. Ónákvæmnina má minnka um allt að 18% með því að bíða með greiningu í þrjá mánuði og með því að nota meðalblóðþrýsting nokkurra heimsókna. Auðveldara reynist að spá fyrir um raunverulegan langtímablóðþrýsting með því að leggja mat á breytileika blóðþrýstings. Ályktun: Nokkur ónákvæmni í greiningu háþrýstings er óhjákvæmileg en auka má verulega öryggi greiningarinnar með því að fylgja fólki eftir í þrjá mánuði, nota meðalblóðþrýsting og leggja mat á breytileika blóðþrýstings hvers og eins

The case for home monitoring in hypertension

Although the assessment of cardiovascular risk in individual patients takes into account a range of risk factors, the diagnosis and management of hypertension (high blood pressure) is largely determined by a single numerical value, albeit that often several readings are taken over time. Given the critical impact of a decision to embark on lifelong drug therapy, the importance of ensuring that a blood pressure (BP) record is both accurate and representative is clear. However, there is good evidence that the variability of BP is such that even if measurement is of the highest quality, it can be difficult to say with confidence whether a patient is above or below a treatment threshold. This commentary argues that current BP measurement is inadequate to make the clinical decisions that are necessary and that multiple readings are required to deliver an acceptable degree of accuracy for safe decision-making. This is impractical in a doctor's surgery, and the only realistic long-term strategy is to involve the patient in measuring his or her own BP in their own environment. Evidence is presented that such a strategy is better able to predict risk, is cost-effective for diagnosing hypertension, can improve BP control and is thus better able to protect individuals in the future

Sketch-based interaction and modeling: where do we stand?

Sketching is a natural and intuitive communication tool used for expressing concepts or ideas which are difficult to communicate through text or speech alone. Sketching is therefore used for a variety of purposes, from the expression of ideas on two-dimensional (2D) physical media, to object creation, manipulation, or deformation in three-dimensional (3D) immersive environments. This variety in sketching activities brings about a range of technologies which, while having similar scope, namely that of recording and interpreting the sketch gesture to effect some interaction, adopt different interpretation approaches according to the environment in which the sketch is drawn. In fields such as product design, sketches are drawn at various stages of the design process, and therefore, designers would benefit from sketch interpretation technologies which support these differing interactions. However, research typically focuses on one aspect of sketch interpretation and modeling such that literature on available technologies is fragmented and dispersed. In this paper, we bring together the relevant literature describing technologies which can support the product design industry, namely technologies which support the interpretation of sketches drawn on 2D media, sketch-based search interactions, as well as sketch gestures drawn in 3D media. This paper, therefore, gives a holistic view of the algorithmic support that can be provided in the design process. In so doing, we highlight the research gaps and future research directions required to provide full sketch-based interaction support

Peat swamp forest conservation withstands pervasive land conversion to oil palm plantation in North Selangor, Malaysia

Tropical deforestation remains one of the major global challenges of the twenty-first century driven to a large extent by the conversion of land for agricultural purposes, such as palm oil production. Malaysia is one of the world’s largest palm oil producers and has seen widespread conversion to oil palm from primary forest, including peat swamp forest (PSF). This study investigates the rate and extent of pervasive oil palm expansion in and around North Selangor Peat Swamp Forest (NSPSF) over the last three decades, exploring how land conversion has affected the region’s tropical forests, and assessing the relative success of PSF conservation measures. Time-series Landsat imagery was used to assess thematic land cover change and improvement in vegetation condition since NSPSF was given protected status in 1990. The results show a near tripling in oil palm cover throughout North Selangor, from 24,930 ha in 1989 to 70,070 ha in 2016; while at the same time tropical forest cover shrank from 145,570 ha to 88,400 ha. Despite concerns over the sustainability and environmental impact of such rapid oil palm conversion at a regional level, at the local scale, NSPSF represents a relative conservation success story. Effective land stewardship by government and non-governmental organization (NGO) management actors has limited illegal encroachment of oil palm around the reserve boundary. PSF rehabilitation measures have also markedly improved vegetation condition in NSPFS’s interior. These findings have broad significance for how oil palm agriculture is managed and especially for PSF stewardship and conservation, and the approaches described here may be usefully adopted elsewhere in Southeast Asia and around the world

An online parenting intervention to prevent affective disorders in high-risk adolescents : the PIPA trial protocol

Background: Adolescent depression can place a young person at high risk of recurrence and a range of psychosocial and vocational impairments in adult life, highlighting the importance of early recognition and prevention. Parents/carers are well placed to notice changes in their child’s emotional wellbeing which may indicate risk, and there is increasing evidence that modifiable factors exist within the family system that may help reduce the risk of depression and anxiety in an adolescent. A randomised controlled trial (RCT) of the online personalised ‘Partners in Parenting’ programme developed in Australia, focused on improving parenting skills, knowledge and awareness, showed that it helped reduce depressive symptoms in adolescents who had elevated symptom levels at baseline. We have adapted this programme and will conduct an RCT in a UK setting. Methods: In total, 433 family dyads (parents/carers and children aged 11–15) will be recruited through schools, social media and parenting/family groups in the UK. Following completion of screening measures of their adolescent’s depressive symptoms, parents/carers of those with elevated scores will be randomised to receive either the online personalised parenting programme or a series of online factsheets about adolescent development and wellbeing. The primary objective will be to test whether the personalised parenting intervention reduces depressive symptoms in adolescents deemed at high risk, using the parent-reported Short Mood & Feelings Questionnaire. Follow-up assessments will be undertaken at 6 and 15 months and a process evaluation will examine context, implementation and impact of the intervention. An economic evaluation will also be incorporated with cost-effectiveness of the parenting intervention expressed in terms of incremental cost per quality-adjusted life year gained. Discussion: Half of mental health problems emerge before mid-adolescence and approximately three-quarters by mid-20s, highlighting the need for effective preventative strategies. However, few early interventions are family focused and delivered online. We aim to conduct a National Institute for Health and Care Research (NIHR) funded RCT of the online personalised ‘Partners in Parenting’ programme, proven effective in Australia, targeting adolescents at risk of depression to evaluate its effectiveness, cost-effectiveness and usability in a UK setting. Trial registration {2a}: ISRCTN63358736. Registered 18 September 2019