Copyright 2016 American Medical Association. All rights reserved.
Intensive vs Standard Blood Pressure Control
and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years
A Randomized Clinical Trial
Jeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William B. Applegate, MD, MPH; Dan R. Berlowitz, MD; Ruth C. Campbell, MD, MSPH;
Glenn M. Chertow, MD; Larry J. Fine, MD; William E. Haley, MD; Amret T. Hawfield, MD; Joachim H. Ix, MD, MAS; Dalane W. Kitzman, MD;
John B. Kostis, MD; Marie A. Krousel-Wood, MD; Lenore J. Launer, PhD; Suzanne Oparil, MD; Carlos J. Rodriguez, MD, MPH;
Christianne L. Roumie, MD, MPH; Ronald I. Shorr, MD, MS; Kaycee M. Sink, MD, MAS; Virginia G. Wadley, PhD; Paul K. Whelton, MD;
Jeffrey Whittle, MD; Nancy F. Woolard; Jackson T. Wright Jr, MD, PhD; Nicholas M. Pajewski, PhD; for the SPRINT Research Group
IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older
patients with hypertension remains uncertain.
OBJECTIVE To evaluate the effects of intensive (<120 mm Hg) compared with standard
(<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension
but without diabetes.
DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged
75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).
Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015.
INTERVENTIONS Participants were randomized to an SBP target of less than 120 mm Hg
(intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard
treatment group, n = 1319).
MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a
composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a
myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death
from cardiovascular causes. All-cause mortality was a secondary outcome.
RESULTS Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%)
provided complete follow-up data. At a median follow-up of 3.14 years, there was a
significantly lower rate of the primary composite outcome (102 events in the intensive
treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66
[95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67
[95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between
treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard
treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in
the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI,
0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs
2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute
kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for inj.
The SPRINT study compared an intensive blood pressure treatment target of less than 120 mm Hg to a standard target of less than 140 mm Hg in 9,361 patients at high risk for cardiovascular events but without diabetes. At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive group and 136.2 mm Hg in the standard group. After a median follow up of 3.26 years, the primary composite outcome of heart attack, acute coronary syndrome, stroke, heart failure or cardiovascular death occurred less frequently in the intensive group compared to the standard group. All-cause mortality was also lower in the intensive group, though rates of some adverse events were higher.
Predicting Trends in Preventive Care Service Utilization Impacting Cardiovasc...gpartha85
This study aimed to characterize patterns of preventive care service utilization for cardiovascular disease and predict trends in a U.S. population using national health survey data. Descriptive analyses found high utilization of blood pressure and cholesterol screening across populations. Logistic regression identified factors associated with screening, such as women and Asians being less likely than men and other races to receive screenings. The results can help guide policies to reinforce screening guidelines for underserved groups.
Predicting Trends in Preventive Care Service Utilization Impacting Cardiovasc...gpartha85
National reports point towards disparities in the utilization of preventive care services but sparse literature exists regarding predicting utilization pattern of preventive care services.
METHODS: The 2007 Medical Expenditure Panel Survey (MEPS), a national probability sample survey of the ambulatory civilian US population, was analyzed to determine demographic patterns of utilization. Recommendations by JNC-VII and NCEP were used to determine guideline adherence to blood pressure and cholesterol checkup respectively. Utilization of blood pressure screening and cholesterol checkup services were used as the dependent variable while age, gender, race, ethnicity, insurance status, perceived health status were used as independent variables. Since guidelines differ for people with elevated blood pressure, respondents with elevated blood pressure were identified in the MEPS database by self-reported diagnosis. Descriptive statistics were used to describe the population, chi-square analysis was used to determine the group differences for the categorical variables. Multivariate logistic regression model was built to predict odds of utilizing appropriate preventive se!
rvices. All analysis was carried out using SAS v9.1.
RESULTS: Total number of adult respondents was 20,434 of which data was available for blood pressure checkup for 20,187 respondents and 15,784 respondents for cholesterol checkup. Overall, respondents were found to adhere to guideline recommendations for getting the blood pressure (n=17,959, 89.0%) and cholesterol (n=14,956, 94.7%) check-up done. A univariate chi-square analysis showed statistically significant differences across all independent variables between people who utilized the preventive care service and those who didn t for blood pressure checkup (p<0><0>65) had much higher odds of using the blood pressure (OR=2.815, CI=2.317-3.420 ) and cholesterol (OR=3.190, CI=2.396-4.!
249 ) preventive services. Males had much lower odds of getting blood pressure (OR=0.350, CI=0.318-0.384) and cholesterol (OR=0.597, CI=0.516-0.692) checks done compared to females. Odds of utilization were nearly similar for all races. Uninsured had lower odds for blood pressure (OR=0.282, CI=0.253-0.315) and cholesterol (OR=0.314, CI=0.262-0.376) use compared to privately insured people.
CONCLUSIONS: Overall MEPS respondents adhered to blood pressure and cholesterol check up guidelines. The study was however successful in identifying existing age, race, income, insurance status related disparities in US population.
The HOPE-3 trial found that combining treatment with rosuvastatin, candesartan, and hydrochlorothiazide reduced the risk of cardiovascular events by 29% compared to placebo in a population at intermediate cardiovascular risk. The combination therapy lowered LDL cholesterol by 33.7 mg/dL and systolic blood pressure by 6.2 mmHg on average over 5.6 years. It reduced the risk of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to placebo, with numbers needed to treat of 72 and 63 to prevent an event in the primary outcomes. Subgroup analyses suggested greater benefit for those with higher baseline blood pressure.
This document summarizes a study examining medical and neurological complications in 279 patients with acute ischemic stroke. The study found that 95% of patients experienced at least one complication. The most common serious medical complication was pneumonia (5%) and the most common serious neurological complication was new or extended cerebral infarction (5%). Medical complications contributed to 51% of deaths within 3 months. Patients with serious medical complications had significantly worse outcomes on functional scales even after accounting for baseline differences.
Why should we measure endothelial functionEndothelix
This document discusses the importance of measuring endothelial function for cardiovascular risk assessment. It begins with background on cardiovascular disease being the leading cause of death globally and the problems with traditional risk assessment based only on risk factors. It then discusses how endothelial dysfunction underlies many disease states and can serve as an integrated measure of risk. The document reviews different techniques for measuring endothelial function, including flow-mediated dilation of the brachial artery. It argues that a comprehensive cardiovascular risk assessment should include measures of both subclinical disease and endothelial function.
This document summarizes the recommendations from an expert panel on the management of high blood pressure in adults. Key recommendations include:
1) Treating all adults aged 60 or older to a blood pressure under 150/90 mm Hg and those aged 30-59 to under 140/90 mm Hg.
2) Initial drug treatment for most nonblack adults should include a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black adults, initial treatment is a calcium channel blocker or thiazide diuretic.
3) Treatment goals are the same for adults with diabetes or nondiabetic kidney disease as the
The SPRINT study compared an intensive blood pressure treatment target of less than 120 mm Hg to a standard target of less than 140 mm Hg in 9,361 patients at high risk for cardiovascular events but without diabetes. At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive group and 136.2 mm Hg in the standard group. After a median follow up of 3.26 years, the primary composite outcome of heart attack, acute coronary syndrome, stroke, heart failure or cardiovascular death occurred less frequently in the intensive group compared to the standard group. All-cause mortality was also lower in the intensive group, though rates of some adverse events were higher.
Predicting Trends in Preventive Care Service Utilization Impacting Cardiovasc...gpartha85
This study aimed to characterize patterns of preventive care service utilization for cardiovascular disease and predict trends in a U.S. population using national health survey data. Descriptive analyses found high utilization of blood pressure and cholesterol screening across populations. Logistic regression identified factors associated with screening, such as women and Asians being less likely than men and other races to receive screenings. The results can help guide policies to reinforce screening guidelines for underserved groups.
Predicting Trends in Preventive Care Service Utilization Impacting Cardiovasc...gpartha85
National reports point towards disparities in the utilization of preventive care services but sparse literature exists regarding predicting utilization pattern of preventive care services.
METHODS: The 2007 Medical Expenditure Panel Survey (MEPS), a national probability sample survey of the ambulatory civilian US population, was analyzed to determine demographic patterns of utilization. Recommendations by JNC-VII and NCEP were used to determine guideline adherence to blood pressure and cholesterol checkup respectively. Utilization of blood pressure screening and cholesterol checkup services were used as the dependent variable while age, gender, race, ethnicity, insurance status, perceived health status were used as independent variables. Since guidelines differ for people with elevated blood pressure, respondents with elevated blood pressure were identified in the MEPS database by self-reported diagnosis. Descriptive statistics were used to describe the population, chi-square analysis was used to determine the group differences for the categorical variables. Multivariate logistic regression model was built to predict odds of utilizing appropriate preventive se!
rvices. All analysis was carried out using SAS v9.1.
RESULTS: Total number of adult respondents was 20,434 of which data was available for blood pressure checkup for 20,187 respondents and 15,784 respondents for cholesterol checkup. Overall, respondents were found to adhere to guideline recommendations for getting the blood pressure (n=17,959, 89.0%) and cholesterol (n=14,956, 94.7%) check-up done. A univariate chi-square analysis showed statistically significant differences across all independent variables between people who utilized the preventive care service and those who didn t for blood pressure checkup (p<0><0>65) had much higher odds of using the blood pressure (OR=2.815, CI=2.317-3.420 ) and cholesterol (OR=3.190, CI=2.396-4.!
249 ) preventive services. Males had much lower odds of getting blood pressure (OR=0.350, CI=0.318-0.384) and cholesterol (OR=0.597, CI=0.516-0.692) checks done compared to females. Odds of utilization were nearly similar for all races. Uninsured had lower odds for blood pressure (OR=0.282, CI=0.253-0.315) and cholesterol (OR=0.314, CI=0.262-0.376) use compared to privately insured people.
CONCLUSIONS: Overall MEPS respondents adhered to blood pressure and cholesterol check up guidelines. The study was however successful in identifying existing age, race, income, insurance status related disparities in US population.
The HOPE-3 trial found that combining treatment with rosuvastatin, candesartan, and hydrochlorothiazide reduced the risk of cardiovascular events by 29% compared to placebo in a population at intermediate cardiovascular risk. The combination therapy lowered LDL cholesterol by 33.7 mg/dL and systolic blood pressure by 6.2 mmHg on average over 5.6 years. It reduced the risk of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to placebo, with numbers needed to treat of 72 and 63 to prevent an event in the primary outcomes. Subgroup analyses suggested greater benefit for those with higher baseline blood pressure.
This document summarizes a study examining medical and neurological complications in 279 patients with acute ischemic stroke. The study found that 95% of patients experienced at least one complication. The most common serious medical complication was pneumonia (5%) and the most common serious neurological complication was new or extended cerebral infarction (5%). Medical complications contributed to 51% of deaths within 3 months. Patients with serious medical complications had significantly worse outcomes on functional scales even after accounting for baseline differences.
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This document discusses the importance of measuring endothelial function for cardiovascular risk assessment. It begins with background on cardiovascular disease being the leading cause of death globally and the problems with traditional risk assessment based only on risk factors. It then discusses how endothelial dysfunction underlies many disease states and can serve as an integrated measure of risk. The document reviews different techniques for measuring endothelial function, including flow-mediated dilation of the brachial artery. It argues that a comprehensive cardiovascular risk assessment should include measures of both subclinical disease and endothelial function.
This document summarizes the recommendations from an expert panel on the management of high blood pressure in adults. Key recommendations include:
1) Treating all adults aged 60 or older to a blood pressure under 150/90 mm Hg and those aged 30-59 to under 140/90 mm Hg.
2) Initial drug treatment for most nonblack adults should include a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black adults, initial treatment is a calcium channel blocker or thiazide diuretic.
3) Treatment goals are the same for adults with diabetes or nondiabetic kidney disease as the
Physical activity and risk of cardiovascular disease—aArhamSheikh1
High levels of both leisure time physical activity and moderate levels of occupational physical activity are associated with a 20-30% lower risk of cardiovascular disease among men and women. The meta-analysis included 21 prospective cohort studies with over 650,000 participants followed for an average of 10 years. Both high leisure time physical activity and moderate occupational physical activity were associated with roughly a 20-30% lower risk of coronary heart disease and stroke for men and women. No evidence of publication bias was found across the studies.
The document is a summary of evidence-based guidelines for managing high blood pressure in adults. It recommends:
1) Treating hypertensive persons aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to less than 140/90 mm Hg.
2) Initiating drug treatment for nonblack populations with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, or thiazide-type diuretics. For black populations, recommend calcium channel blockers or thiazide-type diuretics.
3) Treating hypertensive adults with diabetes or chronic kidney disease to
This study evaluated shock index (SI), defined as heart rate divided by systolic blood pressure, as a predictor of morbidity and mortality in pediatric trauma patients. The study used data from the 2010 National Trauma Data Bank and found that an elevated age-adjusted SI was strongly associated with mortality, need for blood transfusion, ventilation, procedures, and ICU stay. Compared to hypotension alone, elevated SI had improved sensitivity for predicting negative outcomes while maintaining high specificity. The findings support using SI as a simple tool to identify pediatric trauma patients at risk of shock-related complications.
The document summarizes the key findings and recommendations from a systematic review of evidence on the management of high blood pressure conducted by the Eighth Joint National Committee panel members. The panel recommends treating hypertensive patients aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to a goal of less than 140/90 mm Hg. For nonblack patients, including those with diabetes, initial drug treatment should include a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black patients, including those with diabetes, a calcium channel blocker or thiazide-type di
The new guidelines for treatment of primary hypertension. JNC 8. Samir Rafla-JNC 8-2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults.
This document summarizes guidelines from the Eighth Joint National Committee for the management of high blood pressure in adults. It recommends treating hypertensive patients aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to a diastolic goal of less than 90 mm Hg. For those under 60, the recommended goal is less than 140/90 mm Hg based on expert opinion due to insufficient evidence. The same thresholds and goals are recommended for hypertensive adults with diabetes or chronic kidney disease under age 60. The guidelines recommend initial drug treatment for nonblack patients with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers,
The study evaluated the efficacy and safety of combining LDL cholesterol lowering (rosuvastatin 10 mg) and blood pressure lowering (candesartan 16-12.5 mg and hydrochlorothiazide 12.5 mg) therapies versus placebo in 12,705 participants without cardiovascular disease but with risk factors. The combined therapy group experienced significantly fewer cardiovascular events (29% risk reduction) and fewer secondary outcomes (28% risk reduction) compared to the dual placebo group. The number needed to treat over 5.6 years was 72 to prevent one primary outcome and 63 to prevent one secondary outcome. While statistically significant differences were observed, the overall clinical benefit was modest given the event rates in both groups.
This study compared the long-term (18-month) outcomes of supervised exercise (SE), stent revascularization (ST), and optimal medical therapy (OMT) for patients with claudication due to aortoiliac peripheral artery disease. 79 patients completed the 18-month follow-up assessment. The study found that both SE and ST resulted in significantly greater improvements in peak walking time and claudication onset time compared to OMT. SE and ST also provided durable improvements in quality of life measures up to 18 months. Both SE and ST had better long-term outcomes than OMT alone for treating claudication, demonstrating the durability of exercise interventions for peripheral artery disease.
Comparative study to assess the Effect of Standing Position & Sitting Positio...Kailash Nagar
This study assessed the effects of standing and sitting position on blood pressure readings in 80 normotensive subjects. The majority of subjects were female, aged 21-30 years, weighing 31-50kg. Blood pressure was measured in both sitting and standing positions. The results found that blood pressure was higher when measured in the standing position compared to sitting position. Specifically, 55% of subjects had normal blood pressure while standing compared to 66.25% while sitting. More subjects also had pre-hypertension while standing (36.25%) than sitting (28.75%). The study concluded that body position affects blood pressure measurements, with higher readings observed in the standing position among normotensive individuals.
Interheart risk modifiable factors in micardio infraction 2004Medicina
This document summarizes the objectives and methods of the INTERHEART study, a large international case-control study designed to assess the importance of cardiovascular risk factors worldwide. The study aimed to enroll approximately 15,000 cases of acute myocardial infarction and a similar number of controls from 52 countries representing all inhabited continents. The study investigated the association between nine modifiable risk factors (smoking, lipids, hypertension, diabetes, obesity, diet, physical activity, alcohol consumption, psychosocial factors) and the risk of myocardial infarction. Standardized questionnaires and physical examinations were used to collect information from all participants. Blood samples were also collected to analyze lipid levels. The results of this large, global study could help determine if cardiovascular risk factors have similar or
This document discusses strategies for preventing stroke through lifestyle modifications. It recommends maintaining a healthy diet low in salt and sugar and high in fruits and vegetables. It also stresses the importance of regular physical activity, maintaining a healthy weight, not smoking, and managing risk factors like blood pressure, cholesterol and blood sugar. Following these lifestyle guidelines can significantly reduce one's risk of having a stroke.
This document summarizes guidelines from the Eighth Joint National Committee for the management of high blood pressure in adults. It recommends treating hypertensive persons aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to a diastolic goal of less than 90 mm Hg. For those under 60, the recommended goal is less than 140/90 mm Hg based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or chronic kidney disease. The guidelines recommend initial drug treatment for nonblack populations with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics. For black populations, calcium channel blockers or th
This research article examines whether African Americans with chronic systolic heart failure respond differently to cardiac resynchronization therapy-defibrillator (CRT-D) compared to non-African Americans. The study analyzed data from 212 patients who received CRT-D implants between 2009-2013. Baseline characteristics were similar between the 130 African American patients and 82 non-African American patients. The primary outcome of left ventricular ejection fraction improvement of at least 5% was seen in 62.3% of African Americans and 59.8% of non-African Americans, showing similar response rates. Secondary clinical outcomes like hospitalizations and mortality were also comparable between the groups. Among responders, factors like age, comorbidities, and ech
This document provides guidelines for the management of high blood pressure in adults based on a rigorous review of evidence from randomized controlled trials. Some of the key recommendations include:
1) For adults aged 60 years or older, the panel recommends initiating antihypertensive drug treatment when systolic blood pressure is 150 mmHg or higher or diastolic blood pressure is 90 mmHg or higher.
2) For adults aged 30-59 years, the panel recommends initiating antihypertensive drug treatment when systolic blood pressure is 140 mmHg or higher or diastolic blood pressure is 90 mmHg or higher.
3) For all adults, including those with diabetes, the panel recommends a blood pressure treatment goal of
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This document provides guidelines for the management of high blood pressure in adults based on a rigorous review of evidence from randomized controlled trials. Some of the key recommendations include:
1) For adults aged 60 years or older, the guideline recommends initiating antihypertensive drug treatment when systolic blood pressure is 150 mmHg or higher or diastolic blood pressure is 90 mmHg or higher.
2) For adults aged 30-59 years, the guideline recommends initiating antihypertensive drug treatment when systolic blood pressure is 140 mmHg or higher or diastolic blood pressure is 90 mmHg or higher.
3) The guideline recommends treating hypertension in adults aged 18-29 based on an overall systolic blood
The SPRINT trial studied over 9,000 patients at high risk for cardiovascular events to compare intensive blood pressure control (target <120 mm Hg systolic) to standard control (target <140 mm Hg). It found that intensive control significantly reduced rates of fatal and nonfatal heart attacks, heart failure, and death from any cause. However, intensive control also increased some adverse effects like acute kidney injury and hypotension. Overall, the trial demonstrated benefits of very tight blood pressure control for high-risk patients without diabetes.
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Constructivism and Self-Directed Learning in Adult learners An.docxmelvinjrobinson2199
Constructivism and Self-Directed Learning in Adult learners
Analyzes assessment methodologies for adult learners, and identifies roadblocks for implementing assessment methodologies.
please use information attached below to help with the assignment:
3-4 pages
APA format
.
Construction Management Jump StartChapter 5Project Sta.docxmelvinjrobinson2199
Construction Management Jump Start
Chapter 5
Project Stages
Chapter 5
Project StagesThis chapter introduces you to the people, activities, and requirements that must be coordinated to execute the construction project. This chapter focuses on the stages of the design and construction process.
The Design and Construction Process
The design and construction of buildings, bridges, and roadways follow a consistent linear path from initial concept to occupancy.
The Design StageProgramming and feasibilityDone prior to design and engages the owner to clarify needs.Schematic designFirst step of the creative process consisting of sketches that identify preliminary design characteristics. Design development (DD)Detail work of the design occurs here. Selection of material, equipment and systems to go into the building.Contract documents (CDs)Final detailed drawings known working drawings and the project specifications are known as the CD’s
Codes and Compliance IssuesThe major goal of the design team is to make the building compliant with various statutory regulationsThe duration of this process varies. It can take weeks, months, or even years.The success of the project depends on the successful execution of this stages
The Bidding StagePlans and Specifications produced for biddersThis stage is traditionally coordinated by the architect to assist the owner in contractor selectionNotice to Proceed with construction is issued to the winning contractor.
Pre-construction StageProject manager plays the lead role in assembling and orchestrating the team that will complete the job.Detailed planning is invaluable at the this stageOne of the hardest stages of the job to manageAssigning the team is dependent on the size and complexity of the job. Usually there is…
Assigning the Project Team
Team Roles Project manager (PM)Captain of the team, usually with extensive experience in construction and management. Contract administratorAssists the PM and Super with the details of the contract.SuperintendentCoordinates all of the on-site construction activities. He/she is the daily point contact for the owner other representatives.Field EngineerEntry level position that is the first step in progressing through the ranks of project management. Primarily handle paperwork such as requests for information (RFI), submittals, and shop drawings
Due DiligenceSite InvestigationLooking for hidden geological problems, hazardous material, or historical remnants that may delay or alter the job.Soil testing and engineeringShould be provided by owner, reviewed by architect for design, and used by the contractor to price and conduct work
The process of identifying any problems or areas of concern that exist and addressing them during the preconstruction phase
Value EngineeringThe point when this occurs depends on the selected delivery method.Field personnel are underutilized and can provide valuable information during this process.
T.
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This study compared the long-term (18-month) outcomes of supervised exercise (SE), stent revascularization (ST), and optimal medical therapy (OMT) for patients with claudication due to aortoiliac peripheral artery disease. 79 patients completed the 18-month follow-up assessment. The study found that both SE and ST resulted in significantly greater improvements in peak walking time and claudication onset time compared to OMT. SE and ST also provided durable improvements in quality of life measures up to 18 months. Both SE and ST had better long-term outcomes than OMT alone for treating claudication, demonstrating the durability of exercise interventions for peripheral artery disease.
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This document provides guidelines for the management of high blood pressure in adults based on a rigorous review of evidence from randomized controlled trials. Some of the key recommendations include:
1) For adults aged 60 years or older, the panel recommends initiating antihypertensive drug treatment when systolic blood pressure is 150 mmHg or higher or diastolic blood pressure is 90 mmHg or higher.
2) For adults aged 30-59 years, the panel recommends initiating antihypertensive drug treatment when systolic blood pressure is 140 mmHg or higher or diastolic blood pressure is 90 mmHg or higher.
3) For all adults, including those with diabetes, the panel recommends a blood pressure treatment goal of
The document summarizes key information about acute heart failure, including epidemiology, pathophysiology, treatment approaches, and trial data. It describes the ASCEND-HF trial which investigated the effects of nesiritide vs placebo on outcomes in over 7,000 patients hospitalized for acute decompensated heart failure. The trial found no significant differences between nesiritide and placebo for its co-primary endpoints of 30-day mortality or heart failure rehospitalization and dyspnea relief at 6 and 24 hours.
This document provides guidelines for the management of high blood pressure in adults based on a rigorous review of evidence from randomized controlled trials. Some of the key recommendations include:
1) For adults aged 60 years or older, the guideline recommends initiating antihypertensive drug treatment when systolic blood pressure is 150 mmHg or higher or diastolic blood pressure is 90 mmHg or higher.
2) For adults aged 30-59 years, the guideline recommends initiating antihypertensive drug treatment when systolic blood pressure is 140 mmHg or higher or diastolic blood pressure is 90 mmHg or higher.
3) The guideline recommends treating hypertension in adults aged 18-29 based on an overall systolic blood
The SPRINT trial studied over 9,000 patients at high risk for cardiovascular events to compare intensive blood pressure control (target <120 mm Hg systolic) to standard control (target <140 mm Hg). It found that intensive control significantly reduced rates of fatal and nonfatal heart attacks, heart failure, and death from any cause. However, intensive control also increased some adverse effects like acute kidney injury and hypotension. Overall, the trial demonstrated benefits of very tight blood pressure control for high-risk patients without diabetes.
Cardiac risk evaluation: searching for the vulnerable patient FELIX NUNURA
The document discusses screening patients for cardiovascular risk factors and disease. It outlines various risk assessment tools like the Framingham Risk Score and SCORE that estimate risk based on factors like age, cholesterol levels, blood pressure, smoking status. It discusses limitations of risk factor-based screening and emphasizes the importance of directly measuring subclinical disease using tests like coronary artery calcium scoring and carotid intima-media thickness to identify vulnerable patients. The document advocates screening for and treating the underlying atherosclerotic disease rather than just risk factors to improve prevention outcomes.
Similar to Copyright 2016 American Medical Association. All rights reserv.docx (20)
Constructivism and Self-Directed Learning in Adult learners An.docxmelvinjrobinson2199
Constructivism and Self-Directed Learning in Adult learners
Analyzes assessment methodologies for adult learners, and identifies roadblocks for implementing assessment methodologies.
please use information attached below to help with the assignment:
3-4 pages
APA format
.
Construction Management Jump StartChapter 5Project Sta.docxmelvinjrobinson2199
Construction Management Jump Start
Chapter 5
Project Stages
Chapter 5
Project StagesThis chapter introduces you to the people, activities, and requirements that must be coordinated to execute the construction project. This chapter focuses on the stages of the design and construction process.
The Design and Construction Process
The design and construction of buildings, bridges, and roadways follow a consistent linear path from initial concept to occupancy.
The Design StageProgramming and feasibilityDone prior to design and engages the owner to clarify needs.Schematic designFirst step of the creative process consisting of sketches that identify preliminary design characteristics. Design development (DD)Detail work of the design occurs here. Selection of material, equipment and systems to go into the building.Contract documents (CDs)Final detailed drawings known working drawings and the project specifications are known as the CD’s
Codes and Compliance IssuesThe major goal of the design team is to make the building compliant with various statutory regulationsThe duration of this process varies. It can take weeks, months, or even years.The success of the project depends on the successful execution of this stages
The Bidding StagePlans and Specifications produced for biddersThis stage is traditionally coordinated by the architect to assist the owner in contractor selectionNotice to Proceed with construction is issued to the winning contractor.
Pre-construction StageProject manager plays the lead role in assembling and orchestrating the team that will complete the job.Detailed planning is invaluable at the this stageOne of the hardest stages of the job to manageAssigning the team is dependent on the size and complexity of the job. Usually there is…
Assigning the Project Team
Team Roles Project manager (PM)Captain of the team, usually with extensive experience in construction and management. Contract administratorAssists the PM and Super with the details of the contract.SuperintendentCoordinates all of the on-site construction activities. He/she is the daily point contact for the owner other representatives.Field EngineerEntry level position that is the first step in progressing through the ranks of project management. Primarily handle paperwork such as requests for information (RFI), submittals, and shop drawings
Due DiligenceSite InvestigationLooking for hidden geological problems, hazardous material, or historical remnants that may delay or alter the job.Soil testing and engineeringShould be provided by owner, reviewed by architect for design, and used by the contractor to price and conduct work
The process of identifying any problems or areas of concern that exist and addressing them during the preconstruction phase
Value EngineeringThe point when this occurs depends on the selected delivery method.Field personnel are underutilized and can provide valuable information during this process.
T.
Create a 10- to 12-slide presentation in which you Compare .docxmelvinjrobinson2199
Create
a 10- to 12-slide presentation in which you:
Compare health systems of various countries.
Describe approaches to connecting public health and the health care system.
Describe lessons learned from past issues.
Identify future trends in public health.
Include
at least 3 references.
USE THESE COUNTRIES: France, Italy, Iran, US, & Indonesia.
no speaker notes required. Use pictures
.
Create a 10-12-slide presentation about the role of scientist-pr.docxmelvinjrobinson2199
Create a 10-12-slide presentation about the role of scientist-practitioners. Include the following in your presentation:
A title page
A description of the key knowledge, skills, and abilities of an effective scientist-practitioner
A description of how research reports are an essential component for the scientist-practitioner
A description of why data management and presentation are key components of research reports
A reference page
At least three scholarly sources
Detailed speaker notes that represent what would be said if giving the presentation in person
.
Create a 1-page (front and back) information fact sheet on postpartu.docxmelvinjrobinson2199
Create a 1-page (front and back) information fact sheet on postpartum depression that will help to educate the vulnerable population on the disease or condition. The fact sheet should address prevention, detection, and treatment.
**Will provide more detailed instructions for the accepted bid**
.
Create a 1-2-page resource that will describe databases that are.docxmelvinjrobinson2199
Create a 1-2-page resource that will describe databases that are relevant to EBP around a diagnosis you chose and could be used to help a new hire nurse better engage in EBP.
Evidence-based practice (EBP) integrates the best evidence available to guide optimal nursing care, with a goal to enhance safety and quality. EBP is crucial to nursing practice because it incorporates the best evidence from current literature, along with the expertise of the practicing nurse. The concern for quality care that flows from EBP generates a desired outcome. Without these factors, a nurse cannot be an effective leader. It is important to lead not only from this position but from knowledge and expertise. To gain the knowledge, you require a good understanding of how to search for scholarly resources, as well as identify which databases and websites are credible for the purposes of implementing evidence-based changes in practice.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
Competency 1: Interpret findings from scholarly quantitative, qualitative, and outcomes research articles and studies.
Explain why the sources selected should provide the best evidence for the chosen diagnosis.
Competency 2: Analyze the relevance and potential effectiveness of evidence when making a decision.
Describe the best places to complete research and what types of resources one would want to access to find pertinent information for the diagnosis within the context of a specific health care setting.
Competency 4: Plan care based on the best available evidence.
Identify five sources of online information (medical journal databases, websites, hospital policy databases, et cetera) that could be used to locate evidence for a clinical diagnosis.
Competency 5: Apply professional, scholarly communication strategies to lead practice changes based on evidence.
Describe communication strategies to encourage nurses to research the diagnosis, as well as strategies to collaborate with the nurses to access resources.
Communicate using writing that is clear, logical, and professional with correct grammar and spelling using current APA style.
Professional Context
As a baccalaureate-prepared nurse, you will be responsible for providing patient-centered, competent care based on current evidence-based best practices. You will be required to do research, analysis, and dissemination of best evidence to stay abreast of these best practices. Understanding where to go to find credible sources and locate evidence, as well as which search terms to use, is the foundation of incorporation of best practices.
Scenario
You are supervising three nurses working on the medical-surgical floor of a local teaching hospital. This hospital is nationally recognized as a leader in education and has a computer lab with an online libr.
Create a 1-2 page single-spaced Analysis of Research abstract pu.docxmelvinjrobinson2199
Create a 1-2 page single-spaced Analysis of Research abstract published scholarly articles related to a topic you selected in 2.2. (topic cybersecurity)
Brevity and being concise are important as this analysis is intended to be a brief summation of the research.
Each abstract must therefore consist of the following in this order:
1. Bibliographic Citation – use the correctly formatted APA style citation for the work as the title of your abstract, displaying the full citation in bold font.
2. Author Qualifications – name and qualification of each author conducting the research
3. Research Concern – one paragraph summary of the reason for the overall research topic
4. Research Purpose Statement AND Research Questions or Hypotheses – specific focus of the research
5. Precedent Literature – key literature used in proposing the needed research (not the full bibliography or reference list)
6. Research Methodology – description of the population, sample, and data gathering techniques used in the research
7. Instrumentation – description of the tools used to gather data (surveys, tests,interviews, etc.)
8. Findings – summation of what the research discovered and the types of analysis that were used to describe the findings (tables, figures, and statistical measures)
Additional information on writing scholarly abstracts can be found via this
link
See completed example
.
Cover/Title Page
Abstract
Body of Paper
10-12 pages words long
Introduction
Explanation of the research topic
How the topic fits into Emergency Management
How the Emergency Management cycle applies to your chosen topic
Conclusion
References Page
Format of Paper
Times New Roman font ONLY
12 point font
1 inch margins (you will have to change your margins if using Word 2003 or earlier)
Double Spaced
.
Cover LetterA significant part of a registered nurse’s job i.docxmelvinjrobinson2199
Cover Letter
A significant part of a registered nurse’s job involves communicating with patients and providing emotional support. A successful cover letter should emphasize examples of your bedside manner and empathy as well as your emotional stability and composure in difficult situations.
Follow these steps to create your customized entry-level, registered nurse cover letter:
You are applying for a job at Kindred Hospital in South Florida. Research the unique needs, characteristics, and culture of the hospital.
1. Specify how you're a good fit for the position. (10 points)
2. Highlight your specialties and skills which set you apart from other nurses, paying particular attention to those that required additional training. (10 points)
3. Don't neglect soft skills that are highly relevant to a position as a registered nurse, such as problem solving, teamwork, communication, and leadership. (5 points)
4. Carefully proofread your cover letter before submitting to make sure all contact information is correct and that there are no misspellings.(5 points)
.
Coventry University 385ACC (Part-time) Advanced Study fo.docxmelvinjrobinson2199
Coventry University
385ACC (Part-time)
Advanced Study for Accounting and Finance
ASSIGNMENT 2019
Coursework Submission
Coursework should be submitted on given dateline in electronic format, via Turnitin and a hard
copy submitted to the Lecturer for second-marking.
Coursework Assignment
This is an Individual written assignment. Prepare a report for about 7,000 words (+/- 10%)
Learning Outcomes Assessed
The intended learning outcomes are that on completion of this project the student should be able
to:
1) Work independently, but with tutor guidance, on a project of their choice.
2) Synthesise a wide range of academic literature in order to evaluate critically current
research and contemporary issues in accounting or finance.
3) Utilise and apply relevant accounting and finance models, theories and concepts in order
to produce a properly researched written report.
4) Gather and organise evidence and draw appropriate conclusions based on a sound
understanding of the models, concepts and theories utilised.
5) Produce clear and coherent written work, supported by appropriate references to the
sources used (using the Coventry Harvard method of referencing).
Other Information:
• Assignments should not exceed 7,000 words. Please include a word count at very end of the
assignment.
• Title page, TOC, bibliography and further appropriate and relevant appendices do not count
towards the word limit. A 10% deduction (pro-rata) will be made from your mark for every
1,000 words over this limit (i.e. 1% if 100 words over limit etc).
• Coursework assignments should not be copied in part or in whole from any other source,
except for any clearly marked up quotations. Students found copying from internet or other
sources will get zero marks and may be excluded from the university.
• You can refer to the attached marking scheme to understand the criteria for the marking of
your courework.
385ACC - Assessment Criteria
Guidelines for what would be expected from a project at each particular level.
Note that not every criterion phrase need apply. Your mark will be a matter of balance.
1ST
70 - 100
The project is well structured and communicated. It is coherent and shows an
excellent level of synthesis and/or evaluation with clear signs of originality and
insight. Has read beyond the immediately relevant reading.
2:1
60 – 69
The project has worthwhile aims and objectives clearly expressed and an
appropriate methodology. Clear evidence of independent inquiry and critical
judgement in selecting, ordering, analysing and synthesising. Has read the
immediately relevant literature and, to a limited extent, beyond.
2:2
50 – 59
Aims and objectives clearly expressed. Some appropriate theory plus an attempt at
analysis but with only basic linkages made between theory and analysis. Has read
enough of the immediately relevant literature to be credible.
3RD
40 – 49
Makes on.
COV-19 -Corona Virus -- What a past week in our country and globally.docxmelvinjrobinson2199
COV-19 -Corona Virus -- What a past week in our country and globally ! Tremendous changes with compulsory disorganization and vigilance everywhere in our great country and throughout our world ! The news seems to captivate with an approach of sensitivity to the economical impacts each American as well as every nation on our planet is facing dealing with this emergency management (EM) disaster/pandemic event. Our governments national grip and charge for social distancing with the mandatory closing of non-essential businesses has reach a crucial point in every persons desire to see this horrible virus erracticated. We are all eager to resume our life's, go back to work and make sure we remain and stay healthy and safe as we move forward and into the future. However, will life as Americans ever be the same again for this country and every person in it ? Are face masks the new norm? What about social distancing ? (SD) ? Is SD also a new norm?
Today April 15th is the 6th of 7th classes in this EMA 205 class/course. I was looking forward to enjoying a class room environment with each and all the students enrolled in this EMA 205 course. I enjoy and believe social interaction and amalgamation where we would be able to interact, share, discuss and learn about the many accountable responsibilities in the profession of emergency management could have provided a more balanced understanding of EM. Unfortunately, we were unable to congregate as a group and this is where I find a topic of interest for your next assignment:
The corona virus and COVID-19, the illness it causes, are spreading among communities in the United States and other countries, phrases such as “social distancing,” “self-quarantine” and “flattening the curve” are showing up in the media. What do these terms mean? how do these terms apply to you, your family, your work place, your friends and your community? Have you seen --"Please limit the spread of infection and this diseases and be sure to follow public health guidance programs as the situation develops". What are the public health guidance programs?
Emergency vs. Disaster : An emergency is defined as an unforeseen combination of circumstances, resulting in a state that calls for immediate action or an urgent need for assistance or relief. Large-scale emergencies are usually considered disasters. An emergency can be a temporary disruption of services due to a short power outage, a longer-term situation causing an organization to relocate due to substantial building damage or even a larger scale, city-wide or regional emergency. Depending on the magnitude of the event, services may be provided as usual, services may need to be altered temporarily or, in extreme situations, services may be re-located or even discontinued. In any type of event, the goal is to have plans in place that will: • minimize damage • ensure the safety of staff and clients • protect vital records/assets • allow for self-sufficiency for at least 72 hours .
Course ScenarioReynolds Tool & Die
Reynolds Mission Statement
“We are committed to providing our customers quality products with the highest engineering standards.”
Reynolds Vision Statement
“We are committed to achieving our goal of being a market leader for engineering solutions and will investment in technical innovation. Our desire is to continue to expand our markets, our technical competence, and our intellectual curiosity to serve our customers.”
Additional Information
Reynolds Tool & Die is an automotive component manufacturer supplying suspension pieces and technology to both other suppliers and major U.S. and foreign manufacturers. Annual revenue is around $50 million, and the company is profitable.
Reynolds has production facilities at their headquarters in Akron, OH; in Bloomington, IN; and in Memphis, TN. Approximately 300 people work for Reynolds, including 7 in IT. The IT staff is broken down as follows:
· IT Director
· 2 Help Desk personnel
· 3 Network Engineers
· 1 Software Engineer, primarily supporting the company’s ERP system
One network engineer works in Bloomington, one in Memphis, and the rest of the IT staff is located in Akron.
The three sites are networked via an MPLS circuit. In addition to SAP® software, the company uses Microsoft® Office 2010 for administrative work along with several specialized CAD programs for design. The SAP software is two versions behind, but not at end of its life. A data center is in Akron, while the other two sites have smaller hardware footprints consisting of Microsoft Exchange servers for email, a small file and print server, and redundant Active Directory servers. EMC Storage Area Network (SAN) devices are at each site. Redundant backup appliances are in Akron and Bloomington, and data can be cycled among the SANS for further redundancy. While some server virtualization has been achieved, only about 20 percent of all servers have been virtualized with the help of VMWare. All sites use Cisco® switches, routers, and firewalls. Servers, desktops, laptops and printers are all HP®, and are between 3 and 5 years old and the desktops and Laptops use Windows® 7 as the operating system. All servers are on Microsoft Server 2012.
There are no cloud applications. There has been a demand by administrative personnel and engineers for integrating mobile devices with Microsoft Exchange and other apps but to date the company has not implemented a BYOD (Bring Your Own Device) or a MDM (Mobile Device Management) solution.
The IT budget typically is between $1.2 and $1.5 million annually, depending on capital expense. Note that this budget ONLY covers hardware, software, services, and licensing. Personnel costs are not included, nor do you need to include them for the Week 4 budget assignment.
This year the company is embarking on significant expansion. A joint venture has been signed with a firm from Mexico Peraltada LLC in order to gain access to a new supplier market. Both companies will remain in.
COURSE REFLECTIONJune 11, 2020How has this course helped you.docxmelvinjrobinson2199
COURSE REFLECTION
June 11, 2020
How has this course helped you be more prepared for successful leadership?
This course has helped prepare me for successful leadership. It has enlightened me about various rights regarding the treatment of students. The learning standards in the course have been helpful. Through the learning standards, knowledge of the freedom of religion and expression was gained. As a successful educational leader understanding that the students have the freedom of religion. Also understanding that students who come from minority groups are likely to be discriminated against or denied their rights. Therefore, advocates for equity in the course of educational leadership and honors diverse views. However, being a successful educational leader understands that children have different learning needs, and this makes them strive to create a strong educational opportunity and provide adequate learning resources.
How do you see yourself using the information in this course to support your leadership goals?
The course enabled me to learn about how to handle student records. As an educational leader, I am in a better position to safeguard the records of students. Upon completion of the course, one understands how to communicate with parents about the progress of children and their rights. I learned that I should ensure that student records are accessed only for educational legitimate reasons. Researchers are likely to ask for students' records, and this means an educational leader must have a proper understanding of privacy laws. The knowledge acquired about the safety of students was important. It was useful to know that teachers are responsible for the safety of students as they must care for them when they are at school or during school-related events. Regarding school attire, it was good to know that one must create opportunities for open discussion with parents and teachers and even community members to decide on the appropriate attire for students.
The information gained in this course will be used to create safe learning environments for children in the future. Students will be protected from harassment, discrimination, and other potential dangers they could face at school. The information will also be used to create adequate policies about various issues such as school uniforms and the level of expression. It will also help to find learning resources for students, especially from the community members. While creating policies regarding various school issues such as student privacy and search, I will use the information acquired from this course. For students with disabilities, adequate learning aids will be provided and they will be treated fairly. Positive relationships will be developed with families and caregivers of the children. There will also be a high level of collaboration and supervision of instruction.
How might the information in this course change or add to your own personal definition of leadership (Especially .
Course Reflection GuidelinesPurposeThe purpose of this assignmen.docxmelvinjrobinson2199
Course Reflection GuidelinesPurpose
The purpose of this assignment is to provide the student an opportunity to reflect on selected RN-BSN competencies acquired through the NUR3165 course. Course Outcomes
This assignment provides documentation of student ability to meet the following course outcomes:
· The student will be able to produce a complete research paper.
· The student will identify the research methods, sources and application in nursing practice.
Points
This assignment is worth a total of 100 points (10%).
Due Date
Submit your completed assignment under the Assignment tab by Sunday 11:59 p.m. EST of Week 15 as directed.Requirements
1. The Course Reflection is worth 100 points (10%) and will be graded on quality of self-assessment, use of citations, use of Standard English grammar, sentence structure, and overall organization based on the required components as summarized in the directions and grading criteria/rubric.
2. Follow the directions and grading criteria closely. Any questions about your essay may be posted under the Q & A forum under the Discussions tab.
3. The length of the reflection is to be within three to six pages excluding title page and reference pages.
4. APA format is required with both a title page and reference page. Use the required components of the review as Level 1 headers (upper and lower case, centered):
Note: Introduction – Write an introduction but do not use “Introduction” as a heading in accordance with the rules put forth in the Publication manual of the American Psychological Association (2010, p. 63).
a. Course Reflection
b. ConclusionPreparing Your Reflection
The BSN Essentials (AACN, 2008) outline a number of healthcare policy and advocacy competencies for the BSN-prepared nurse. Reflect on the NUR3165 course readings, discussion threads, and applications you have completed across this course and write a reflective essay regarding the extent to which you feel you are now prepared to:
1. “Explain the interrelationships among theory, practice, and research.
2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice.
3. Advocate for the protection of human subjects in the conduct of research.
4. Evaluate the credibility of sources of information, including but not limited to databases and Internet resources.
5. Participate in the process of retrieval, appraisal, and synthesis of evidence in collaboration with other members of the healthcare team to improve patient outcomes.
6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care.
7. Collaborate in the collection, documentation, and dissemination of evidence.
8. Acquire an understanding of the process for how nursing and related healthcare quality and safety measures are developed, validated, and endorsed.
9. Describe mechanisms to resolve identified practice discrepancies .
Course ProjectExamine the statement of cash flows for the compan.docxmelvinjrobinson2199
Course Project
Examine the statement of cash flows for the companies you selected in
Week 1
for the most recent year.
Tasks:
Summarize your course project to this point. What have you learned about your companies?
What are the two largest investing activities and financing activities for each firm?
Compare and contrast the investing and financing activities of the two companies.
Evaluate the investing and financing strategies of the two firms? Provide a rationale for your opinion as to the effectiveness of each of the strategies.
Submission Details:
Submit a 3-4 page Microsoft Word document, using APA style.
Name your file: SU_FIN4060_W3_CP_LastName_FirstInitial.doc
Submit your assignment to the
Submissions Area
by
the due date assigned.
.
Course PHYSICAL SECURITYDiscussion Question – Primary post du.docxmelvinjrobinson2199
Course: PHYSICAL SECURITY
Discussion Question – Primary post due Wednesday by 11:55 pm EST
"There are many different types of physical barriers, internal and external to an organization or facility.How can physical aid in the protection of high dollar assets that an organization wants to protect?"
"APA Format"
"NO PLAGIARISM"
Plagiarism includes copying and pasting material from the internet into assignments without properly citing the source of the material.
.
Course Project Layers of Me” My Humanitarian Professional Pro.docxmelvinjrobinson2199
Course Project: “Layers of Me”: My Humanitarian Professional Profile
It is a best practice to create a professional development plan as part of a professional journey. Plans can be quite extensive, detailing everything you need to do in order to complete a degree and engage in the profession. For this Assignment, you are expected to consider one element of a professional development plan which is reflective of your self-assessment. What skills and abilities, characteristics do you possess that will make you an effective leader? In addition, how do your cultural identity and personal values fit in your aspirations to engage in this type of work?
To prepare for this Assignment:
Complete the interactive media, “Layers of Me: Skills and Abilities.”
Using a scale of 1–10 (1 being the lowest rating and 10 being the highest), assign yourself a score for each of the following questions:
How would you rate your leadership skills?
How would you rate your interpersonal skills (e.g., empathy, listening, sharing, caring)?
How would you rate your oral and written communication skills?
How would you rate your collaboration skills? (Do you work well with others? Are you a team player?)
How would you rate your stress-management skills?
How would you rate your level of perseverance?
How well do you respond to disappointment and frustration?
How would you rate your optimism?
How would you rate your negotiation skills?
After you have completed your self-assessment, review your blog posts throughout the course. Combine your assessment information to create your own professional profile. This is only the start in developing this profile; however, it will give you a better understanding of who you are as a humanitarian professional, what you hope to do within this field of work, and how you will affect social change.
To complete the Assignment:
Create a 4- to 5-page paper assembling all the assessment data you gathered throughout the course. Summarize the data and describe yourself as a humanitarian professional. Include the following:
The skills and characteristics you possess that will allow you to be effective in your role
An explanation of the role your cultural identity will play in your success as a humanitarian professional and your ability to demonstrate cultural competence
How your ethics and values will guide you in your future work
How your profile fits in with your professional goals
.
Course ObjectivesCLO #1 Assess elements of contemporary le.docxmelvinjrobinson2199
Course Objectives:
CLO #1: Assess elements of contemporary leadership theories and models.
CLO #2: Analyze qualities and skills of a highly effective, ethical leader.
Assignment Prompt:
Take both the American College of Healthcare Executives (ACHE)
Ethics Self Assessment
and the Project Management Institute (PMI)
Ethics Self-Assessment
.
Watch the MindTools video on
Values
.
Instructions:
Conduct an analysis of your personal ethical beliefs and values. Use the ethics self-assessments to help determine your strengths, weaknesses, and opportunities. Develop a
3-4 page
essay that discusses the results of those assessments, your personal ethical beliefs and values, and your own personal philosophy of ethical leadership. Your essay must be supported by at least
2-3 scholarly sources
.
.
Course Name Intro to big data.Assignment Big data and CO.docxmelvinjrobinson2199
Course Name: Intro to big data.
Assignment: Big data and COVID -19
1-How is Big Data used in the fight against COVID-19?
2. How can we extend these applications to the marketing field after the crisis is under control?
3. What are the ethical concerns from the use of Big Data? Use COVID-19 as an example
.
COURSE MGT211Using the Internet, and credible electronic se.docxmelvinjrobinson2199
COURSE: MGT211
Using the Internet, and credible electronic search tools, research various options for delivering worker performance training programs in this 21st century. Select a minimum of three training methods (e.g., classroom, directed study, video conferencing, self-paced, computer-mediated, manual, etc.). Using the aforementioned “Guidelines for Writing Papers”,
write a 4-5 academic paper
that describes a minimum of three methods of today’s training options. Include a minimum of two credible references that were used in your research.
Guidelines for Writing Papers
Your papers should be:
word-processed using Microsoft’s Word (extension .doc or .docx)
double-spaced
Your papers should have:
one-inch margins
a font size of 12
a cover page that includes your paper’s title, your name, the date, and the course identification
an introduction that states the purpose of the paper, and provides a roadmap of the paper’s contents
paragraphs that develop and support your ideas
section titles or headings, that help to organize your presentation
a conclusion that summarizes the paper
a logical flow
smooth transitions between ideas
in-text citations and a reference (bibliography) page using APA style (no footnotes)
No grammatical, punctuation, or spelling errors
.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
How to Setup Warehouse & Location in Odoo 17 InventoryCeline George
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
South African Journal of Science: Writing with integrity workshop (2024)
Copyright 2016 American Medical Association. All rights reserv.docx
1. Copyright 2016 American Medical Association. All rights
reserved.
Intensive vs Standard Blood Pressure Control
and Cardiovascular Disease Outcomes in Adults Aged ≥75
Years
A Randomized Clinical Trial
Jeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William
B. Applegate, MD, MPH; Dan R. Berlowitz, MD; Ruth C.
Campbell, MD, MSPH;
Glenn M. Chertow, MD; Larry J. Fine, MD; William E. Haley,
MD; Amret T. Hawfield, MD; Joachim H. Ix, MD, MAS; Dalane
W. Kitzman, MD;
John B. Kostis, MD; Marie A. Krousel-Wood, MD; Lenore J.
Launer, PhD; Suzanne Oparil, MD; Carlos J. Rodriguez, MD,
MPH;
Christianne L. Roumie, MD, MPH; Ronald I. Shorr, MD, MS;
Kaycee M. Sink, MD, MAS; Virginia G. Wadley, PhD; Paul K.
Whelton, MD;
Jeffrey Whittle, MD; Nancy F. Woolard; Jackson T. Wright Jr,
MD, PhD; Nicholas M. Pajewski, PhD; for the SPRINT
Research Group
IMPORTANCE The appropriate treatment target for systolic
blood pressure (SBP) in older
patients with hypertension remains uncertain.
OBJECTIVE To evaluate the effects of intensive (<120 mm Hg)
compared with standard
(<140 mm Hg) SBP targets in persons aged 75 years or older
with hypertension
but without diabetes.
2. DESIGN, SETTING, AND PARTICIPANTS A multicenter,
randomized clinical trial of patients aged
75 years or older who participated in the Systolic Blood
Pressure Intervention Trial (SPRINT).
Recruitment began on October 20, 2010, and follow-up ended
on August 20, 2015.
INTERVENTIONS Participants were randomized to an SBP
target of less than 120 mm Hg
(intensive treatment group, n = 1317) or an SBP target of less
than 140 mm Hg (standard
treatment group, n = 1319).
MAIN OUTCOMES AND MEASURES The primary
cardiovascular disease outcome was a
composite of nonfatal myocardial infarction, acute coronary
syndrome not resulting in a
myocardial infarction, nonfatal stroke, nonfatal acute
decompensated heart failure, and death
from cardiovascular causes. All-cause mortality was a
secondary outcome.
RESULTS Among 2636 participants (mean age, 79.9 years;
37.9% women), 2510 (95.2%)
provided complete follow-up data. At a median follow-up of
3.14 years, there was a
significantly lower rate of the primary composite outcome (102
events in the intensive
treatment group vs 148 events in the standard treatment group;
hazard ratio [HR], 0.66
[95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107
deaths, respectively; HR, 0.67
[95% CI, 0.49-0.91]). The overall rate of serious adverse events
was not different between
treatment groups (48.4% in the intensive treatment group vs
3. 48.3% in the standard
treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates
of hypotension were 2.4% in
the intensive treatment group vs 1.4% in the standard treatment
group (HR, 1.71 [95% CI,
0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23
[95% CI, 0.76-2.00]), 4.0% vs
2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-
2.33]), 5.5% vs 4.0% for acute
kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs
5.5% for injurious falls (HR, 0.91
[95% CI, 0.65-1.29]).
CONCLUSIONS AND RELEVANCE Among ambulatory adults
aged 75 years or older, treating to
an SBP target of less than 120 mm Hg compared with an SBP
target of less than 140 mm Hg
resulted in significantly lower rates of fatal and nonfatal major
cardiovascular events
and death from any cause.
TRIAL REGISTRATION clinicaltrials.gov Identifier:
NCT01206062
JAMA. 2016;315(24):2673-2682. doi:10.1001/jama.2016.7050
Published online May 19, 2016.
Editorial page 2669
Author Video Interview at
jama.com
Supplemental content at
jama.com
CME Quiz at
4. jamanetworkcme.com and
CME Questions page 2728
Author Affiliations: Author
affiliations are listed at the end of this
article.
Group Information: The members of
the SPRINT Research Group have
been published elsewhere.
Corresponding Author: Jeff D.
Williamson, MD, MHS, Section on
Gerontology and Geriatric Medicine,
Sticht Center on Aging, Department
of Internal Medicine, Wake Forest
School of Medicine, Medical Center
Boulevard, Winston-Salem, NC 27157
([email protected]).
Research
Original Investigation
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6. above 160 mm Hg for persons aged 80 years or older.5 A re-
cent US guideline, a report from the panel appointed to the
Eighth Joint National Committee, recommended a SBP treat-
ment target of 150 mm Hg for adults aged 60 years or older.6
However, a report from a minority of the members argued to
retain the previously recommended SBP treatment goal of
140 mm Hg, highlighting the lack of consensus.7
Whether treatment targets should consider factors such
as frailty or functional status is also unknown. Observational
studies have noted differential associations among elevated
blood pressure (BP) and cardiovascular disease, stroke, and
mortality risk when analyses are stratified according to mea-
sures of functional status.8-10 A recent secondary analysis of
the Systolic Hypertension in the Elderly Program showed that
the benefit of antihypertensive therapy was limited to partici-
pants without a self-reported physical ability limitation.11 In
contrast, analyses from the Hypertension in the Very Elderly
Trial (HYVET) showed a consistent benefit with antihyperten-
sive therapy on outcomes irrespective of frailty status.12
The Systolic Blood Pressure Intervention Trial (SPRINT)
recently reported that participants assigned to an intensive
SBP treatment target of less than 120 mm Hg vs the standard
SBP treatment goal of less than 140 mm Hg had a 25% lower
rela-
tive risk of major cardiovascular events and death, and a 27%
lower relative risk of death from any cause.13 This trial was
spe-
cifically funded to enhance recruitment of a prespecified sub-
group of adults aged 75 years or older, and the study protocol
(appears in Supplement 1) also included measures of functional
status and frailty. This article details results for the prespecified
subgroup of adults aged 75 years or older with hypertension.
7. Methods
Population
The design, eligibility, and baseline characteristics of SPRINT
have been described.14 The trial protocol was approved by
the institutional review board at each participating site.
Study participants signed written informed consent and were
required to be at increased risk for cardiovascular disease
(based on a history of clinical or subclinical cardiovascular
disease, chronic kidney disease [CKD], a 10-year Framingham
General cardiovascular disease risk ≥15%, or age ≥75 years). A
person was excluded if he or she had type 2 diabetes, a his-
tory of stroke, symptomatic heart failure within the past 6
months or reduced left ventricular ejection fraction (<35%), a
clinical diagnosis of or treatment for dementia, an expected
survival of less than 3 years, unintentional weight loss (>10%
of body weight) during the preceding 6 months, an SBP of
less than 110 mm Hg following 1 minute of standing, or
resided in a nursing home.
Study Measurements
Sociodemographic data were collected at baseline, whereas
both clinical and laboratory data were obtained at baseline and
every 3 months. Race and ethnicity information was ob-
tained via self-report. Blood pressure was determined using
the mean of 3 properly sized automated cuff readings, taken 1
minute apart after 5 minutes of quiet rest without staff in the
room. Gait speed was measured via a timed 4-m walk per-
formed twice at the participant’s usual pace from a standing
start. The use of an assistive device was permitted if typically
used by the participant to walk short distances. The faster of
the 2 gait speeds (measured in meters/second) was used in the
analysis. Frailty status at randomization was quantified using
a previously reported 37-item frailty index.15
Clinical Outcomes
A committee unaware of treatment assignment adjudicated
8. the protocol-specified clinical outcomes. The primary
cardiovas-
cular disease outcome was a composite of nonfatal myocardial
infarction, acute coronary syndrome not resulting in a myocar-
dial infarction, nonfatal stroke, nonfatal acute decompensated
heart failure, and death from cardiovascular causes. Secondary
outcomes included all-cause mortality and the composite of the
SPRINT primary outcome and all-cause mortality.
The primary renal disease outcome was assessed in par-
ticipants with CKD at baseline (estimated glomerular filtra-
tion rate [eGFR] <60 ml/min/1.73 m2 based on the 4-variable
Modification of Diet in Renal Disease equation). It was based
on the composite incidence of either a decrease in eGFR of 50%
or greater (confirmed by subsequent laboratory test ≥90 days
later) or the development of end-stage renal disease requir-
ing long-term dialysis or transplantation. A secondary renal dis-
ease outcome (assessed in participants without CKD at base-
line) was based on incidence of a decrease in eGFR from 30%
or greater at baseline to a value less than 60 mL/min/1.73 m2
(also confirmed by a subsequent test ≥90 days later).
Definition of Serious Adverse Events
Serious adverse events (SAEs) were defined as events that
were fatal or life threatening, resulted in signific ant or
persistent disability, required hospitalization or resulted in
prolonged hospitalization, or medical events that the investi-
gator judged to be a significant hazard or harm to the partici-
pant and required medical or surgical intervention to prevent
any of these. The following conditions of interest were
reported as adverse events if they were evaluated in an emer-
gency department: hypotension, syncope, injurious falls,
electrolyte abnormalities, and bradycardia. Episodes of acute
kidney injury (or acute renal failure) were monitored if they
led to hospitalization and were reported in the hospital dis-
9. charge summary.
Statistical Analysis
Power to detect a 25% treatment effect for the primary out-
come within the subgroup of participants aged 75 years or older
was estimated assuming an enrollment of 3250. With a 2-year
recruitment period, maximum follow-up of 6 years, and an-
nual loss to follow-up of 2%, power was estimated to be 81.9%,
Research Original Investigation Intensive Blood Pressure
Control in Adults Aged 75 Years or Older
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assuming an event rate of 3.25% per year in the standard treat-
ment group (Appendix B in Supplement 1).
10. Linear-mixed models with an unstructured covariance ma-
trix, assuming independence across participants, were used
to model longitudinal differences in SBP between treatment
groups. Fixed effects in the model were BP at randomization
and a treatment group indicator. The time to first occurrence
of the primary composite outcome, all-cause mortality, pri-
mary composite outcome plus all-cause mortality, SAEs, and
loss to follow-up or withdrawing consent were compared be-
tween the 2 randomized groups using Cox proportional haz-
ards regression models with the baseline hazard function strati-
fied by clinic site (participants were recruited at 100 clinics).
Follow-up time was censored on the date of last event ascer-
tainment on or before August 20, 2015, the date on which the
National Heart, Lung, and Blood Institute director decided to
stop the intervention.
Exploratory secondary analyses were conducted to exam-
ine modification of the treatment effect by frailty status and gait
speed. Neither frailty status nor gait speed was a prespecified
subgroup in the trial protocol. We fit separate Cox regression
models for frailty status classified as fit (frailty index ≤0.10),
less
fit (frailty index >0.10 to ≤0.21), or frail (frailty index
>0.21),16,17
and for gait speed classified as 0.8 m/s or greater (normal
walker),
less than 0.8 m/s (slow walker), or missing.18 Interactions be-
tween treatment group, frailty status, and gait speed were for-
mally tested by including interaction terms within a Cox regres-
sion model (ie, using likelihood ratio tests to compare with a
model that did not allow the treatment effect to vary by frailty
status or gait speed). For the primary cardiovascular disease
11. Figure 1. Eligibility, Randomization, and Follow-up for Systolic
Blood Pressure (SBP) Intervention Trial (SPRINT)
Participants Aged 75 Years or Older
14 692 Assessed for eligibility
3756 Aged ≥75 y
9361 Randomized
2636 Aged ≥75 y
1317 Participants aged ≥75 y included
in primary analysis
66 Did not complete gait speed
assessment at baseline
7 Frailty index could not be
computed at baseline
1319 Participants aged ≥75 y included
in primary analysis
57 Did not complete gait speed
assessment at baseline
9 Frailty index could not be
computed at baseline
4678 Randomized to an SBP treatment
target <120 mm Hg (intensive
treatment)
1317 Aged ≥75 y
4683 Randomized to an SBP treatment
target <140 mm Hg (standard
treatment)
12. 1319 Aged ≥75 y
All participants
224 Discontinued intervention
111 Were lost to follow-up
154 Withdrew consent
Participants aged ≥75 y
80 Discontinued intervention
26 Were lost to follow-up
36 Withdrew consent
All participants
242 Discontinued intervention
134 Were lost to follow-up
121 Withdrew consent
Participants aged ≥75 y
82 Discontinued intervention
31 Were lost to follow-up
33 Withdrew consent
5331 Ineligible or declined to participate
2284 Were taking too many medications
or had SBP that was out of range a
718 Were not at increased cardiovascular risk b
703 Had miscellaneous reasons
587 Did not give consent
187 Had miscellaneous reasons
191 Did not give consent
155 Did not complete screening
653 Did not complete screening
13. Participants aged ≥75 y
1120 Ineligible or declined to participate
78 Had low SBP at 1 min after standing
(<110 mm Hg)
509 Were taking too many medications
or had SBP that was out of range a
34 Were <50 y of age
352 Had low SBP at 1 min
after standing (<110 mm Hg)
All participants
a Systolic blood pressure was
required to be between 130 mm Hg
and 180 mm Hg for participants
taking 0 or 1 medication,
130 mm Hg to 170 mm Hg for
participants taking 2 medications
or fewer, 130 mm Hg to 160 mm Hg
for participants taking
3 medications or fewer, and
130 mm Hg to 150 mm Hg for
participants taking 4 medications
or fewer.
b Increased cardiovascular risk was
defined as presence of 1 or more of
the following: (1) clinical or
subclinical cardiovascular disease
other than stroke, (2) chronic kidney
disease (defined as an estimated
14. glomerular filtration rate of
20 mL/min/1.73 m2 to
59 mL/min/1.73 m2 based on the
4-variable Modification of Diet in
Renal Disease equation and the
latest laboratory value within the
past 6 months), (3) Framingham risk
score for 10-year cardiovascular risk
of 15% or greater based on
laboratory work done within the
past 12 months for lipids, or (4) age
of 75 years or older.
Intensive Blood Pressure Control in Adults Aged 75 Years or
Older Original Investigation Research
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15. reserved.
composite outcome, sensitivity analyses accounting for the com-
peting risk of death were conducted using the subdistribution
hazard model of Fine and Gray.19 All hypothesis tests were
2-sided at the 5% level of significance.
Additional analyses compared the total burden of SAEs be-
tween the randomized groups (allowing for recurrent events)
using the mean cumulative count estimator (standard errors
computed using bootstrap resampling).20 Hazard ratios (HRs)
were computed to compare the randomized groups using the
gap-time formation of the Prentice, Williams, and Peterson re-
current events regression model.21 All analyses were per-
formed using SAS version 9.4 (SAS Institute Inc) and the R Sta-
tistical Computing Environment (http://www.r-project.org).
Results
Baseline Characteristics and Study Retention
Participants aged 75 years or older were randomized to an SBP
target of less than 120 mm Hg (intensive treatment group,
n = 1317) or an SBP target of less than 140 mm Hg (standard
treatment group, n = 1319) (Figure 1). The treatment groups
were similar for most characteristics with the exception of
frailty status and aspirin use (Table 1). Overall, 815 partici-
pants (30.9%) were classified as frail and 1456 (55.2%) as less
fit (Table 1). A total of 2510 (95.2%) participants provided
com-
plete follow-up data.
Table 1. Baseline Characteristics of Participants Aged 75 Years
or Older
Intensive Treatment
(n = 1317)
16. Standard Treatment
(n = 1319)
Female sex 499 (37.9) 501 (38.0)
Age, mean (SD), y 79.8 (3.9) 79.9 (4.1)
Race/ethnicity, No. (%)
White 977 (74.2) 987 (74.8)
Black 225 (17.1) 226 (17.1)
Hispanic 89 (6.8) 85 (6.4)
Other 26 (2.0) 21 (1.6)
Seated blood pressure, mean (SD), mm Hg
Systolic 141.6 (15.7) 141.6 (15.8)
Diastolic 71.5 (11.0) 70.9 (11.0)
Orthostatic hypotension, No. (%) 127 (9.6) 124 (9.4)
Serum creatinine, median (IQR), mg/dL 1.1 (0.9-1.3) 1.1 (0.9-
1.3)
Estimated GFRa
Mean (SD), mL/min/1.73 m2 63.4 (18.2) 63.3 (18.3)
Level <60 mL/min/1.73 m2, No. (%) 584 (44.3) 577 (43.7)
Level <45 mL/min/1.73 m2, No. (%) 207 (15.7) 212 (16.1)
17. Urinary albumin to creatinine ratio, median (IQR), mg/g 13.0
(7.2-31.6) 13.4 (7.2-33.4)
History of cardiovascular disease, No. (%) 338 (25.7) 309
(23.4)
Total cholesterol, mean (SD), mg/dL 181.4 (39.0) 181.8 (38.7)
Fasting HDL cholesterol, mean (SD), mg/dL 55.9 (15.1) 55.7
(14.9)
Fasting total triglycerides, median (IQR), mg/dL 96.0 (71.0-
130.0) 99.0 (72.0-134.5)
Fasting plasma glucose, mean (SD), mg/dL 97.9 (12.1) 98.2
(11.6)
Statin use, No. (%) 682 (51.8) 697 (52.8)
Aspirin use, No. (%) 820 (62.3) 765 (58.0)
10-y Framingham cardiovascular disease risk,
median (IQR), %
24.2 (16.8-32.8) 25.0 (17.0-33.4)
Body mass index, mean (SD)b 27.8 (4.9) 27.7 (4.6)
No. of antihypertensive agents taking at baseline visit,
mean (SD)
1.9 (1.0) 1.9 (1.0)
Gait speed
18. Median (IQR), m/s 0.90 (0.77-1.05) 0.92 (0.77-1.06)
Speed <0.8 m/s, No. (%) 371 (28.2) 369 (28.0)
Frailty index, median (IQR)c 0.18 (0.13-0.23) 0.17 (0.12-0.22)
Frailty status, No. (%)
Fit (frailty index ≤0.10) 159 (12.1) 190 (14.4)
Less fit (frailty index >0.10 to ≤0.21) 711 (54.0) 745 (56.5)
Frail (frailty index >0.21) 440 (33.4) 375 (28.4)
Montreal Cognitive Assessment score, median (IQR)d 22.0
(19.0-25.0) 22.0 (19.0-25.0)
Abbreviations: GFR, glomerular
filtration rate; HDL, high-density
lipoprotein; IQR, interquartile range.
SI conversion factors: To convert HDL
and total cholesterol to mmol/L,
multiply by 0.0259; triglycerides to
mmol/L, multiply by 0.0113; and
glucose to mmol/L, multiply by
0.0555.
a Based on the 4-variable
Modification of Diet in Renal
Disease equation.
b Calculated as weight in kilograms
divided by height in meters
squared.
19. c Scores range from 0 to 1,
with higher values indicating
greater frailty.
d Scores range from 0 to 30,
with higher scores denoting better
cognitive function.
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In the intensive treatment group, 440 participants (33.4%)
were classified as frail compared with 375 participants (28.4%)
in the standard treatment group. A total of 740 participants
(28.1%) were classified as slow walkers (<0.8 m/s). There was
no baseline treatment group difference in the proportion of par-
ticipants classified as slow walkers or in performance on the
20. Montreal Cognitive Assessment screening test.22
Even though participants who were less fit, frail, or with
reduced gait speed exhibited higher rates of loss to follow-up
or withdrawal of consent, there were no significant differ-
ences between the treatment groups for frailty or low gait speed
(eTable 1 in Supplement 2). The frequency at which partici-
pants discontinued the intervention but continued follow-up
was 6.2% in the intensive treatment group vs 6.4% in the stan-
dard treatment group (P = .87).
Blood Pressure Levels
Throughout follow-up, the mean SBP in the intensive treat-
ment group was 123.4 mm Hg, and it was 134.8 mm Hg in the
standard treatment group. The between-group difference in
mean SBP was 11.4 mm Hg (95% CI, 10.8-11.9 mm Hg), which
is a smaller relative difference than the mean SBP of
14.8 mm Hg observed in the trial overall (Table 2). Mean dia-
stolic BPs during follow-up were 62.0 mm Hg in the inten-
sive treatment group and 67.2 mm Hg in the standard treat-
ment group.
On average, participants in the intensive treatment
group required 1 more medication to reach the achieved
lower BP (eTable 2 and eFigure 1 in Supplement 2). Within
the intensive treatment group, mean SBP during follow-up
was higher for participants classified as less fit or frail com-
pared with those considered fit. Differences in mean SBP by
treatment group differed by frailty status (P = .01), with frail
participants exhibiting smaller intertreatment group differ-
ences (10.8 mm Hg) compared with less fit participants
(11.3 mm Hg) and fit participants (13.5 mm Hg). Treatment
group differences in SBP were similar across subgroups
defined by gait speed.
21. Clinical Outcomes
A primary composite outcome event was observed for 102
participants (2.59% per year) in the intensive treatment
group and for 148 participants (3.85% per year) in the stan-
d a rd t re at m e nt g ro u p ( H R , 0.6 6 [ 9 5% C I , 0. 5 1-
0.85 ] ;
Table 3). Results were similar for all-cause mortality (there
were 73 deaths in the intensive treatment group and 107
deaths in the standard treatment group; HR, 0.67 [95% CI,
0. 49 - 0.9 1 ] ) . I n f e r e n c e f o r t h e p r i m a r y o u t c o
m e w a s
unchanged when non–cardiovascular disease death was
treated as a competing risk (HR, 0.66 [95% CI, 0.52-0.85]).
At 3.14 years, the number needed to treat (NNT) estimate for
the primary outcome was 27 (95% CI, 19-61) and for all-
cause mortality it was 41 (95% CI, 27-145).
Bec ause the treatment effect estimate was not sta-
tistically significant for cardiovascular disease death, the
NNT estimate (using the abbreviations of Altman23) was an
Table 2. Least-Square Means for Postrandomization Blood
Pressure Achieved by Treatment Group
Intensive Treatment Standard Treatment Difference Between
Groups, Mean
(95% CI)a
P Value for
InteractionbNo. Mean (95% CI) No. Mean (95% CI)
Systolic blood pressure
Overall, mm Hg 1317 123.4 (123.0-123.9)c 1319 134.8 (134.3-
135.2)c 11.4 (10.8-11.9)
23. Gait speed
Speed ≥0.8 m/s 880 62.0 (61.6-62.3) 893 67.2 (66.9-67.6) 5.3
(4.8-5.8)
.08Speed <0.8 m/s 371 62.3 (61.7-62.8) 369 66.8 (66.2-67.4)
4.6 (3.8-5.4)
Missing 66 61.4 (60.1-62.7) 57 68.2 (66.7-69.6) 6.8 (4.8-8.8)
a P < .001 for all mean differences.
b From a mixed model.
c Least-square means for blood pressure estimated from mixed
model
conditioned on baseline blood pressure.
d Frailty status classified using 37-item frailty index (FI): fit
(FI �0.10), less fit
(FI >0.10 to �0.21), or frail (FI >0.21).
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NNTBenefit of 116 (NNTHarm of 544 to � to NNTBenefit of
68).
In participants without CKD at the time of randomization,
more participants in the intensive treatment group com-
pared with the standard treatment group experienced the
secondary CKD outcome (a 30% decrease in eGFR from
baseline to an eGFR <60 mL/min/1.73 m2 [1.70% vs 0.58%
per year, respectively]; HR, 3.14 [95% CI, 1.66-6.37]). There
were no significant treatment group differences in the pri-
mary renal outcome in those with baseline CKD; however,
power to detect differences was limited due to low numbers
of events.
Exploratory Subgroup Analyses
Results stratified by baseline frailty status showed higher event
rates with increasing frailty in both treatment groups (Table 4
and Figure 2). However, within each frailty stratum, absolute
event rates were lower for the intensive treatment group
(P = .84 for interaction). Results were similar when partici-
pants were stratified by gait speed (P = .85 for interaction),
with
the HRs in favor of the intensive treatment group in each gait
speed stratum (eFigure 2 in Supplement 2).
25. Serious Adverse Events
Detailed information regarding SAEs appears in eTable 3 and
eTable 4 in Supplement 2. Data on SAEs in participants older
than 75 years have been previously reported (Table S613). In
the intensive treatment group, SAEs occurred in 637 partici-
pants (48.4%) compared with 637 participants (48.3%) in the
standard treatment group (HR, 0.99 [95% CI, 0.89-1.11];
P = .90). The absolute rate of SAEs was higher but was not sta-
tistically significantly different in the intensive treatment group
for hypotension (2.4% vs 1.4% in the standard treatment group;
HR, 1.71 [95% CI, 0.97-3.09]), syncope (3.0% vs 2.4%, respec-
tively; HR, 1.23 [95% CI, 0.76-2.00]), electrolyte abnormali-
ties (4.0% vs 2.7%; HR, 1.51 [95% CI, 0.99-2.33]), and …