Prevalence and costs of treating uncomplicated stage 1 hypertension in primary care: a cross-sectional analysis.

BACKGROUND: Treatment for uncomplicated stage 1 hypertension is recommended in most international guidelines but there is little evidence to indicate that therapy is beneficial. AIM: To estimate the prevalence of this condition in an untreated population and the potential costs of initiating therapy in such patients. DESIGN AND SETTING: Cross-sectional study of anonymised patient records in 19 general practices in the West Midlands, UK. METHOD: Data relating to patient demographics, existing cardiovascular disease (CVD), and risk factors (blood pressure and cholesterol) were extracted from patient records. Patients with a blood pressure of 140/90-159/99 mmHg, no CVD, and <20% 10-year cardiovascular risk were classified as having uncomplicated stage 1 hypertension. Missing data were imputed. The prevalence of untreated, uncomplicated stage 1 hypertension was estimated using descriptive statistics and extrapolated using national data. The cost of achieving blood pressure control in this population was examined in a cost-impact analysis using published costs from previous studies. RESULTS: Of the 34 975 patients (aged 40-74 years) in this study, untreated, uncomplicated stage 1 hypertension was present in 2867 individuals (8.2%, 95% confidence interval [CI] = 7.9 to 8.5). This is equivalent to 1 892 519 patients in England and Wales, for whom the additional cost of controlling blood pressure, according to guidelines, was estimated at £106-229 million per annum, depending on the health professional delivering care. CONCLUSION: Untreated, uncomplicated stage 1 hypertension is relatively common, affecting 1 in 12 patients aged 40-74 years in primary care. Current international guidelines and pay-for-performance targets, if followed, will incur significant costs for a patient benefit that is debatable.This work forms part of a larger programme on stroke prevention in primary care supported by the National Institute for Health Research (NIHR) (RP-PG-0606-1153). James P Sheppard holds a Medical Research Council Strategic Skills PostDoctoral Fellowship. Richard J McManus holds an NIHR Professorship. The views and opinions expressed are those of the authors and do not necessarily reflect those of the NHS, NIHR, or the Department of Health

Predicting out-of-office blood pressure level using repeated measurements in the clinic: an observational cohort study.

OBJECTIVES: Identification of people with lower (white-coat effect) or higher (masked effect) blood pressure at home compared to the clinic usually requires ambulatory or home monitoring. This study assessed whether changes in SBP with repeated measurement at a single clinic predict subsequent differences between clinic and home measurements. METHODS: This study used an observational cohort design and included 220 individuals aged 35-84 years, receiving treatment for hypertension, but whose SBP was not controlled. The characteristics of change in SBP over six clinic readings were defined as the SBP drop, the slope and the quadratic coefficient using polynomial regression modelling. The predictive abilities of these characteristics for lower or higher home SBP readings were investigated with logistic regression and repeated operating characteristic analysis. RESULTS: The single clinic SBP drop was predictive of the white-coat effect with a sensitivity of 90%, specificity of 50%, positive predictive value of 56% and negative predictive value of 88%. Predictive values for the masked effect and those of the slope and quadratic coefficient were slightly lower, but when the slope and quadratic variables were combined, the sensitivity, specificity, positive and negative predictive values for the masked effect were improved to 91, 48, 24 and 97%, respectively. CONCLUSION: Characteristics obtainable from multiple SBP measurements in a single clinic in patients with treated hypertension appear to reasonably predict those unlikely to have a large white-coat or masked effect, potentially allowing better targeting of out-of-office monitoring in routine clinical practice.This study presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG-1209–10051). R.J.Mc.M. holds an NIHR Professorship. J.S. was funded by the NIHR Birmingham and Black Country Collaboration for Leadership in Applied Health Research and Care during part of this work, but now holds a Medical Research Council Strategic Skills Postdoctoral Fellowship. B.W. is a NIHR Senior Investigator and is supported by the NIHR UCL Hospitals Biomedical Research Centre. The TASMINH2 trial was funded by the UK Department of Health Policy Research Programme and the National Coordinating Centre for Research Capacity Development. The views and opinions expressed are those of the authors and do not necessarily reflect those of the NHS, NIHR, or the Department of Health. All equipment used in the study was purchased commercially

Impact of Changes to National Hypertension Guidelines on Hypertension Management and Outcomes in the United Kingdom.

In recent years, national and international guidelines have recommended the use of out-of-office blood pressure monitoring for diagnosing hypertension. Despite evidence of cost-effectiveness, critics expressed concerns this would increase cardiovascular morbidity. We assessed the impact of these changes on the incidence of hypertension, out-of-office monitoring and cardiovascular morbidity using routine clinical data from English general practices, linked to inpatient hospital, mortality, and socio-economic status data. We studied 3 937 191 adults with median follow-up of 4.2 years (49% men, mean age=39.7 years) between April 1, 2006 and March 31, 2017. Interrupted time series analysis was used to examine the impact of changes to English hypertension guidelines in 2011 on incidence of hypertension (primary outcome). Secondary outcomes included rate of out-of-office monitoring and cardiovascular events. Across the study period, incidence of hypertension fell from 2.1 to 1.4 per 100 person-years. The change in guidance in 2011 was not associated with an immediate change in incidence (change in rate=0.01 [95% CI, -0.18-0.20]) but did result in a leveling out of the downward trend (change in yearly trend =0.09 [95% CI, 0.04-0.15]). Ambulatory monitoring increased significantly in 2011/2012 (change in rate =0.52 [95% CI, 0.43-0.60]). The rate of cardiovascular events remained unchanged (change in rate =-0.02 [95% CI, -0.05-0.02]). In summary, changes to hypertension guidelines in 2011 were associated with a stabilisation in incidence and no increase in cardiovascular events. Guidelines should continue to recommend out-of-office monitoring for diagnosis of hypertension

Conservation of tree species richness in a traditional agroforestry landscape in the Vhembe Biosphere Reserve, South Africa

DATA AVAILABILITY STATEMENT : The data are available from the corresponding author upon reasonable request.SUPPLEMENTARY MATERIAL : TABLE S1: Species list from species richness plots and nominated species derived from the FGD sessions.Tree species richness is a critical element concerning trees on farms, on communal land and in protected areas to support biodiversity and socio-economic livelihoods in traditional agroforestry landscapes. Tree species richness is directly linked to the use of provisioning ecosystem services and to management practices in traditional agroforestry landscapes. The study aimed to investigate the link between socio-ecological and conservation strategies regarding tree species richness in traditional agroforestry landscapes. The study was conducted in the Damani, Thenzheni, Tshiombo and Tshipako villages located in Thulamela Municipality of the Vhembe Biosphere Reserve, South Africa. The data were collected using a mixed method approach combining forestry inventory and focus group discussion. The study recorded a total number of 126 tree species: 83 communal-landhosted species, 68 species of trees on farms and 81 species in the protected areas. The indigenous species Englerophytum magalismontanum (Sond.) T.D.Penn. was the most cited (62%) by interviewees, with a primary use for wild fruits, followed by Pteleopsis myrtifolia (M.A. Lawson) Engl. & Diels. (57%) for fuelwood, Combretum molle R.Br. ex G.Don (36%) for traditional medicine and Albizia adianthifolia (Schumach.) W.F.Wight (12%) for fodder. Species richness was found to be commonly driven by provisioning ecosystem services with trees on farms and on communal land. Distance was found to be major driving factor of species richness in protected areas. This study found that the local people have no conservation strategy and practices targeting the enhancement of tree species richness in the traditional agroforestry landscape. This study advocates for the establishment of a conservation strategic framework for restoring tree species richness by targeting traditional agroforestry landscapes.A Short-Term Scientific Mission as part of the ASAP project (Agroforestry in Southern Africa: new pathways for innovative land-use systems under a changing climate) sponsored by the German Federal Ministry for Research and Education (BMBF).https://www.mdpi.com/journal/forestsam2023Plant Production and Soil Scienc

A Study of the Diverse T Dwarf Population Revealed by WISE

We report the discovery of 87 new T dwarfs uncovered with the Wide-field Infrared Survey Explorer (WISE) and three brown dwarfs with extremely red near-infrared colors that exhibit characteristics of both L and T dwarfs. Two of the new T dwarfs are likely binaries with L7+/-1 primaries and mid-type T secondaries. In addition, our follow-up program has confirmed 10 previously identified T dwarfs and four photometrically-selected L and T dwarf candidates in the literature. This sample, along with the previous WISE discoveries, triples the number of known brown dwarfs with spectral types later than T5. Using the WISE All-Sky Source Catalog we present updated color-color and color-type diagrams for all the WISE-discovered T and Y dwarfs. Near-infrared spectra of the new discoveries are presented, along with spectral classifications. To accommodate later T dwarfs we have modified the integrated flux method of determining spectral indices to instead use the median flux. Furthermore, a newly defined J-narrow index differentiates the early-type Y dwarfs from late-type T dwarfs based on the J-band continuum slope. The K/J indices for this expanded sample show that 32% of late-type T dwarfs have suppressed K-band flux and are blue relative to the spectral standards, while only 11% are redder than the standards. Comparison of the Y/J and K/J index to models suggests diverse atmospheric conditions and supports the possible re-emergence of clouds after the L/T transition. We also discuss peculiar brown dwarfs and candidates that were found not to be substellar, including two Young Stellar Objects and two Active Galactic Nuclei. The coolest WISE-discovered brown dwarfs are the closest of their type and will remain the only sample of their kind for many years to come.Comment: Accepted to ApJS on 15 January 2013; 99 pages in preprint format, 30 figures, 12 table

The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study.

BACKGROUND: Hospital prealerting in acute stroke improves the timeliness of subsequent treatment, but little is known about the impact of prehospital assessments on in-hospital care. OBJECTIVE: Examine the association between prehospital assessments and notification by emergency medical service staff on the subsequent acute stroke care pathway. METHODS: This was a cohort study of linked patient medical records. Consenting patients with a diagnosis of stroke were recruited from two urban hospitals. Data from patient medical records were extracted and entered into a Cox regression analysis to investigate the association between time to CT request and recording of onset time, stroke recognition (using the Face Arm Speech Test (FAST)) and sending of a prealert message. RESULTS: 151 patients (aged 71±15 years) travelled to hospital via ambulance and were eligible for this analysis. Time of symptom onset was recorded in 61 (40%) cases, the FAST test was positive in 114 (75%) and a prealert message was sent in 65 (44%). Following adjustment for confounding, patients who had time of onset recorded (HR 0.73, 95% CI 0.52 to 1.03), were FAST-positive (HR 0.54, 95% CI 0.37 to 0.80) or were prealerted (HR 0.26, 95% CI 0.18 to 0.38), were more likely to receive a timely CT request in hospital. CONCLUSIONS: This study highlights the importance of hospital prealerting, accurate stroke recognition, and recording of onset time. Those not recognised with stroke in a prehospital setting appear to be excluded from the possibility of rapid treatment in hospital, even before they have been seen by a specialist

Exploring the branch wood supply potential of an agroforestry system with strategically designed harvesting interventions based on terrestrial LiDAR data

Agroforestry systems hold potential for wood and tree biomass production without the need of felling trees. Branch wood harvesting provides access to considerable amounts of lignocellulosic biomass while leaving the tree standing. Aiming at alternatives for wood provision, we assessed the actual woody structure of a silvopastoral system in the African Savannah ecoregion, utilising terrestrial LiDAR technology and quantitative structure models to simulate branch removals and estimate harvesting yields. In addition, the stand structure and harvested wood were examined for the provision of four types of assortments meeting local needs, and operational metrics for each treatment were derived. The stand had large variability in woody structures. Branch harvesting interventions removed up to 18.2% of total stand volume, yielded 5.9 m3 ha−1 of branch wood, and delivered 2.54 m3 ha−1 of pole wood quality, retaining on average more than 75% of the original tree structures. Among the most intense simulations, a mean of 54.7 litres (L) of branch wood was provided per tree, or approximately 34.2 kg of fresh biomass. The choice of an ideal harvesting treatment is subject to practitioners’ interests, while the discussion on aspects of the operation, and stand and tree conditions after treatment, together with outputs, assist decision making. The partitioning of tree structures and branch removal simulations are tools to support the design of tending operations aiming for wood and tree biomass harvesting in agroforestry systems while retaining different functional roles of trees in situ.Supplementary File S1. Figure S1: Individual tree point clouds identified by colours (up), leaf-on mode evidenced by intensity values (middle), and the leaf-off point clouds (bottom); Figure S2: Stand-level wood assortments available in linear meters for each simulated harvesting treatment; Figure S3: Boxplots of the absolute branch volume removal in each harvesting simulation with the red crosses representing treatment means; Table S1: QSM-derived tree parameters for trees in the stand (n = 66); Table S2: Optimised QSM input parameters for each tree; Table S3: Summary of available assortments and yields per harvesting treatment.Supplementary File S2 contains the assessment of assortments on a tree basis for each harvesting simulation.The German Federal Ministry of Education and Research (BMBF). The article processing charge was funded by the Baden-Württemberg Ministry of Science, Research and Art and the University of Freiburg in the funding programme Open Access Publishing.https://www.mdpi.com/journal/forestsdm2022Plant Production and Soil Scienc

GPs’ mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

Background:  Optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines — tacit, internalised guidelines developed over time from multiple sources — may be of particular importance in such situations. Aim:  To explore GPs’ decision-making on deprescribing antihypertensives in patients with multimorbidity aged ≥80 years, drawing on the concept of mindlines. Design and setting: Qualitative interview study set in English general practice. Method Thematic analysis of face-to-face interviews with a sample of 15 GPs from seven practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older patients with multimorbidity with hypertension. Results:  GPs are typically confident making decisions to deprescribe antihypertensive medication in older patients with multimorbidity when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making. Conclusion:  In the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop ‘mindlines’ over time through practicebased experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice