David McCartney

Self-Screening and Non-Physician Screening for Hypertension in Communities: A Systematic Review

BACKGROUND Community-based self-screening may provide opportunities to increase detection of hypertension, and identify raised blood pressure (BP) in populations who do not access healthcare. This systematic review aimed to evaluate the effectiveness of non-physician screening and self-screening of BP in community settings. METHODS We searched the Cochrane Central Trials Register, Medline, Embase, CINAHL, and Science Citation Index & Conference Proceedings Citation Index—Science to November 2013 to identify studies reporting community-based self-screening or non-physician screening for hypertension in adults. Results were stratified by study site, screener, and the cut-off used to define high screening BP. RESULTS We included 73 studies, which described screening in 9 settings, with pharmacies (22%) and public areas/retail (15%) most commonly described. We found high levels of heterogeneity in all analyses, despite stratification. The highest proportions of eligible participants screened were achieved by mobile units (range 21%–88%) and pharmacies (range 40%–90%). Self-screeners had similar median rates of high BP detection (25%–35%) to participants in studies using other screeners. Few (16%) studies reported referral to primary care after screening. However, where participants were referred, a median of 44% (range 17%–100%) received a new hypertension diagnosis or antihypertensive medication. CONCLUSIONS Community-based non-physician or self-screening for raised BP can detect raised BP, which may lead to the identification of new cases of hypertension. However, current evidence is insufficient to recommend specific approaches or settings. Studies with good follow-up of patients to definitive diagnosis are needed.

Will Exercise Advice Be Sufficient for Treatment of Young Adults With Prehypertension and Hypertension? A Systematic Review and Meta-Analysis.

Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18–40 years); the intervention had a defined physical activity strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2±6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of −4.40 mm Hg (95% confidence interval, −5.78 to −3.01) and in diastolic blood pressure of −4.17 mm Hg (95% confidence interval, −5.42 to −2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure −1.02 mm Hg (95% confidence interval, −2.34 to 0.29), and in diastolic blood pressure −0.91 mm Hg (95% confidence interval, −1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults.

Evidence based medicine—older, but no better educated?

1484 www.thelancet.com Vol 382 November 2, 2013 (table). This is strikingly (and perhaps disappointingly) consistent with the 82% reported by Sackett and colleagues. It is also consistent with other studies in North America, Sweden, and the UK, which report that 73–84% of patients received evidence-based care. 22% of our patients’ treatments were based on evidence from randomised controlled trials, and 61% were treated according to convincing non-experimental evidence. Sackett and colleagues reported 53% of treatments were supported by randomised controlled trial evidence and 29% were based on convincing non-experimental evidence. This possibly represents the ongoing importance of logic and common sense in medical decision making, and not a failure of evidence. There seems to have been very little change in the percentage of decisions based on good evidence during the past 15 years, despite more trials and a much wider appreciation of evidencebased medicine. Medicine appears to have grown older, but no better educated.

Cervical radiculopathy and cervical myelopathy: diagnosis and management in primary care

It is important in primary care to be able to differentiate between cervical spine disease that can be managed conservatively and that associated with neurological symptoms suggestive of more serious disease, which may require urgent surgery. This article will cover key points in the history, examination, and management of patients with neck and neurological symptoms, with particular reference to cervical myelopathy and radiculopathy. The prevalence of neck pain in the general population is high: it has been estimated that 30–50% of adults will experience neck pain in any given year,1 with the average GP estimated to consult with seven people per week for neck or upper extremity symptoms.2 Neck pain with abnormal neurology (usually cervical radiculopathy) is much less common: it has been estimated to affect around 100 per 100 000 males and 60 per 100 000 females.3 Cervical myelopathy is even rarer but is worthy of discussion given that it requires urgent management and needs to be identified from among the many cases of neck and neurological symptoms that a GP sees on a regular basis — the incidence of cervical myelopathy is poorly quantified but studies have estimated it to be around 4 per 100 000.4 Cervical radiculopathy is due to compression or irritation of either or both of the dorsal (sensory) and ventral (motor) roots of a cervical nerve at one or more vertebral levels. Compression can result from intervertebral disc herniation, osteophyte formation, or other mass effects near the exit foramen of the cervical spine. This results in lower motor neurone symptoms and often presents with arm pain, weakness, and/or sensory loss, with or without associated neck pain. Cervical myelopathy is spinal cord dysfunction due to compression caused by narrowing of the spinal canal. Common causes include disc herniation, spondylosis, and congenital …

Point-of-care lactate testing for sepsis at presentation to health care: a systematic review of patient outcomes

BACKGROUND Lactate is measured in hospital settings to identify patients with sepsis and severe infections, and to guide initiation of early treatment. Point-of-care technology could facilitate measurement of lactate by clinicians in the community. However, there has been little research into its utility in these environments. AIM To investigate the effect of using point-of-care lactate at presentation to health care on mortality and other clinical outcomes, in patients presenting with acute infections. DESIGN AND SETTING Studies comparing the use of point-of-care lactate to usual care in initial patient assessment at presentation to health care were identified using a maximally sensitive search strategy of six electronic databases. METHOD Two independent authors screened 3063 records for eligibility, and extracted data from eligible studies. Quality assessment for observational studies was performed using the ROBINS-I tool. RESULTS Eight studies were eligible for inclusion (3063 patients). Seven studies were recruited from emergency departments, and one from a pre-hospital aeromedical setting. Five studies demonstrated a trend towards reduced mortality with point-of-care lactate; three studies achieved statistical significance. One study demonstrated a significant reduction in length of hospital stay, although another did not find any significant difference. Two studies demonstrated a significant reduction in time to treatment for antibiotics and intravenous fluids. CONCLUSION This review identifies an evidence gap - there is no high-quality evidence to support the use of point-of-care lactate in community settings. There are no randomised controlled trials (RCTs) and no studies in primary care. RCT evidence from community settings is needed to evaluate this potentially beneficial diagnostic technology.

The evaluation of anaemia in an older primary care population: retrospective population-based study

Background Anaemia is common in older people and the identification of potentially reversible haematinic deficiencies relies on appropriate investigation, often undertaken in primary care. Aim To determine the laboratory prevalence of anaemia, the types of anaemia observed, and the biochemical and haematological investigations undertaken to characterise any associated haematinic abnormality in older primary care patients. Design & setting A retrospective primary care based study of patients aged >65 years undergoing a full blood count in Oxfordshire, UK between 1 January 2012 and 31 December 2013. Method Consecutive patients aged >65 years with a full blood count were identified retrospectively from a laboratory database. Patient demographics, number of blood tests and additional laboratory investigations requested were recorded. World Health Organisation (WHO) criteria were used to define anaemia. Results In total 151 473 full blood counts from 53 890 participants were included: 29.6% of patients were anaemic. The majority had a normocytic anaemia (82.4%) and 46.0% of participants with anaemia had no additional investigations performed. The mean haemoglobin was lower in the anaemic group that underwent further investigation than those who did not (Hb 10.68 g/dl versus 11.24 g/dl, P<0.05): 33.2 % of patients with a microcytic anaemia (mean cell volume <80) did not have any markers of iron status measured. Conclusion A large proportion of older adults in primary care with a recent blood test are anaemic, the majority with a normocytic anaemia, with evidence of inadequate investigation. Those with lower haemoglobin are more likely to be further investigated. Further work is needed to understand the approach to anaemia in older adults in primary care.

Will Exercise Advice Be Sufficient for Treatment of Young Adults With Prehypertension and Hypertension

Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18–40 years); the intervention had a defined physical activity strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2±6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of −4.40 mm Hg (95% confidence interval, −5.78 to −3.01) and in diastolic blood pressure of −4.17 mm Hg (95% confidence interval, −5.42 to −2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure −1.02 mm Hg (95% confidence interval, −2.34 to 0.29), and in diastolic blood pressure −0.91 mm Hg (95% confidence interval, −1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults.

Will Exercise Advice Be Sufficient for Treatment of Young Adults With Prehypertension and Hypertension? A Systematic Review and Meta-AnalysisNovelty and Significance

Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18–40 years); the intervention had a defined physical activity strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2±6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of −4.40 mm Hg (95% confidence interval, −5.78 to −3.01) and in diastolic blood pressure of −4.17 mm Hg (95% confidence interval, −5.42 to −2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure −1.02 mm Hg (95% confidence interval, −2.34 to 0.29), and in diastolic blood pressure −0.91 mm Hg (95% confidence interval, −1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults.

Self-monitoring and self-management: new interventions to improve blood pressure control.

Purpose of reviewThis article reviews recent developments in self-monitoring and self-management of hypertension aimed at the improvement of blood pressure (BP) control. Recent findingsThere is an increasing body of evidence examining the effects of self-monitoring on BP control. Several landmark studies in recent years have demonstrated clinically relevant benefit from self-monitoring based interventions. Self-management of BP with self-titration has shown particular promise, as has self-monitoring combined with intensive health-care led support. There is a lack of evidence on the benefits of self-monitoring for those with important comorbidity such as coronary heart disease, chronic kidney disease, diabetes and previous stroke, and future research should be directed towards this. SummaryThere is a growing body of evidence supporting the use of self-monitoring along with additional intervention including telemonitoring and self-titration in improving BP control. Further research is needed to understand which patients are likely to benefit most and how this is best integrated with routine care.

Backgrounds and aspirations of primary care academic clinical fellows.

Dear Editor,Twenty-first century primary care has led the way in evidence-based medicine and emerged at the forefront of a new era of medical research in the United Kingdom. Despite this, only a sm...