Nurse led interventions in Hypertension

This is the author accepted manuscript. The final version is available from Springer via the DOI in this record.Hypertension is predominantly detected and managed in primary or community care settings. Nurses are key members of the multidisciplinary primary care team, and are commonly involved in measuring or managing blood pressure. Nurses undertake a range of tasks in hypertension care and many randomised controlled trials of different nurse led interventions have been conducted, providing evidence from different populations. There is good evidence to support better blood pressure outcomes when nurses deliver care face to face, but not remotely. Other important components of these complex interventions appear to be the inclusion of a structured care algorithm, ability to prescribe or altering medications, and maintaining contact at least monthly until blood pressure is controlled to target. There is limited reporting of the costs of interventions and evidence for cost effectiveness of nurse led care compared to usual care is lacking, and there is no clear evidence from longer term follow up of the effect of nurse led interventions on cardiovascular outcomes. The design of programmes for nurse led care in hypertension should take account of the existing evidence and areas of uncertainly. Nurses generally work within teams and future studies of team approaches to hypertension, either including or led by nurses, are needed. Any future studies of nurse led care should include a robust cost effectiveness analysis

Interarm blood pressure difference: more than an epiphenomenon

This is a pre-copyedited, author-produced PDF of an article accepted for publication in Nephrology Dialysis transplantation following peer review. The version of record is available online via the DOI in this record.None availabl

Accuracy of automated blood pressure measurements in the presence of atrial fibrillation: systematic review and meta-analysis

This is the author accepted manuscript. The final version is available from Springer Nature via the DOI in this recordAtrial fibrillation (AF) affects ~3% of the general population and is twice as common with hypertension. Validation protocols for automated sphygmomanometers exclude people with AF, raising concerns over accuracy of hypertension diagnosis or management, using out-of-office blood pressure (BP) monitoring, in the presence of AF. Some devices include algorithms to detect AF; a feature open to misinterpretation as offering accurate BP measurement with AF. We undertook this review to explore accuracy of automated devices, with or without AF detection, for measuring BP. We searched Medline and Embase to October 2018 for studies comparing automated BP measurement devices to a standard mercury sphygmomanometer contemporaneously. Data were extracted by two reviewers. Mean BP differences between devices and mercury were calculated, where not reported and compared; meta-analyses were undertaken where possible. We included 13 studies reporting 14 devices. Mean systolic and diastolic BP differences from mercury ranged from −3.1 to + 6.1/−4.6 to +9.0 mmHg. Considerable heterogeneity existed between devices (I 2 : 80 to 90%). Devices with AF detection algorithms appeared no more accurate for BP measurement with AF than other devices. A previous review concluded that oscillometric devices are accurate for systolic but not diastolic BP measurement in AF. The present findings do not support that conclusion. Due to heterogeneity between devices, they should be evaluated on individual performance. We found no evidence that devices with AF detection measure BP more accurately in AF than other devices. More home or ambulatory automated BP monitors require validation in populations with AF.National Institute for Health Research (NIHR

Inter-arm blood pressure difference, when is it a useful risk marker for cardiovascular events?

This is the final version. Available on open access from Springer Nature via the DOI in this recordNational Institute for Health Research (NIHR

Severe loss-of-function mutations in the adrenocorticotropin receptor (ACTHR, MC2R) can be found in patients diagnosed with salt-losing adrenal hypoplasia

Objective: Familial glucocorticoid deficiency type I (FGD1) is a rare form of primary adrenal insufficiency resulting from recessive mutations in the ACTH receptor (MC2R, MC2R). Individuals with this condition typically present in infancy or childhood with signs and symptoms of cortisol insufficiency, but disturbances in the renin-angiotensin system, aldosterone synthesis or sodium homeostasis are not a well-documented association of FGD1. As ACTH stimulation has been shown to stimulate aldosterone release in normal controls, and other causes of hyponatraemia can occur in children with cortisol deficiency, we investigated whether MC2R changes might be identified in children with primary adrenal failure who were being treated for mineralocorticoid insufficiency. Design: Mutational analysis of MC2R by direct sequencing. Patients: Children (n = 22) who had been diagnosed with salt-losing forms of adrenal hypoplasia (19 isolated cases, 3 familial), and who were negative for mutations in DAX1 (NR0B1) and SF1 (NR5A1). Results: MC2R mutations were found in three individuals or kindred (I: homozygous S74I; II: novel compound heterozygous R146H/560delT; III: novel homozygous 579-581delTGT). These changes represent severely disruptive loss-of-function mutations in this G-protein coupled receptor, including the first reported homozygous frameshift mutation. The apparent disturbances in sodium homeostasis were mild, manifest at times of stress (e.g. infection, salt-restriction, heat), and likely resolved with time. Conclusions: MC2R mutations should be considered in children who have primary adrenal failure with apparent mild disturbances in renin-sodium homeostasis. These children may have been misdiagnosed as having salt-losing adrenal hypoplasia. Making this diagnosis has important implications for treatment, counselling and long-term prognosi

Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis

This is a freely-available open access publication. Please cite the published version which is available via the DOI link in this record.OBJECTIVE: To review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. STUDY SELECTION: Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults. DATA EXTRACTION: Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken. DATA SYNTHESIS: Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference -8.2 mm Hg, 95% confidence interval -11.5 to -4.9), nurse prescribing showed greater reductions in blood pressure (systolic -8.9 mm Hg, -12.5 to -5.3 and diastolic -4.0 mm Hg, -5.3 to -2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic -4.8 mm Hg, 95% confidence interval -7.0 to -2.7 and diastolic -3.5 mm Hg, -4.5 to -2.5). CONCLUSIONS: Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.Scientific Foundation Board of the Royal College of General PractitionersSouth West GP Trus

The difference in blood pressure readings between arms and survival: primary care cohort study

addresses: Primary Care Research Group, Institute of Health Services Research, Peninsula College of Medicine and Dentistry, University of Exeter, Devon EX1 2LU, UK. [email protected]: PMCID: PMC3309155To determine whether a difference in systolic blood pressure readings between arms can predict a reduced event free survival after 10 years

Collaborative Deep Learning Models to Handle Class Imbalance in FlowCam Plankton Imagery

Usingautomatedimagingtechnologies,itisnowpossibletogeneratepreviouslyunprecedented volumes of plankton image data which can be used to study the composition of plankton assemblages. However, the current need to manually classify individual images introduces a bottleneck into processing chains.AlthoughMachineLearningtechniqueshavebeenusedtotryandaddressthisissue,pasteffortshave suffered from accuracy limitations, especially in minority classes. Here we use state-of-the-art methods in Deep Learning to investigate suitable architectures for training an automated plankton classification system which achieves high efficacy for both abundant and rare taxa. We collected live plankton from Station L4 in the Western English Channel and imaged 11,371 particles covering 104 taxonomic groups using the automatedplanktonimagingsystemFlowCam.Theimagesetcontainedasevereclassimbalance,withsome taxa represented by > 600 images while other, rarer taxa were represented by just 14. We demonstrate that by allowing multiple Deep Learning models to collaborate in a single classification system, classification accuracyimprovesforminorityclasseswhencomparedwiththebestindividualmodel.Thetopcollaborative model achieved a 6 % improvement in F1 accuracy over the best individual model, while overall accuracy improved by 3.2 %. This resulted in a 97.4 % overall accuracy score and a 96.2 % F1 macro score on a separate holdout test set containing 104 taxonomic groups. Based on a survey of similar studies in the literature, we believe collaborative deep learning models can significantly improve the accuracy of existing automated plankton classification systems

Cardiovascular disease risk assessment and reduction: summary of updated NICE guidance

NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the guideline committee's (GC's) experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. Definitions of evidence certainty are given in box 1