The Valsartan Intensified Primary Care Reduction of Blood Pressure (VIPER-Bp) Study compares an intensive blood pressure (BP) management strategy using valsartan-based therapy to achieve individualized BP control targets, to usual primary care management of hypertension. A survey of 500 Australian general practitioners (GPs) showed heterogeneous approaches to hypertension management compared to the intensive VIPER-Bp intervention. Over 2,000 hypertensive patients from 272 GPs were enrolled in the VIPER-Bp Study, with 1,285 randomized to usual care or the intensive intervention. The intensive intervention combines more aggressive BP therapy and structured management to more rapidly reach and sustain individualized BP targets.
Naturopathic Treatmentfor the Prevention ofCardiovascular Disease: A Randomized Pragmatic TrialCCNM – Journal Club Sept 30th, 2010Dugald Seely, ND, MScDirector; Research & Clinical EpidemiologyThe Canadian College of Naturopathic Medicine
This study investigated cardiovascular and gastrointestinal outcomes in clopidogrel users who were also taking proton pump inhibitors (PPIs) using a large cohort of patients in the Netherlands. The study found that clopidogrel users who were also taking PPIs had a 75% higher risk of cardiovascular events compared to clopidogrel-only users. However, the study had limitations such as channeling bias since PPI users had more risk factors, and residual confounding since important risk factors could not be adjusted for. While providing useful insights, the study's findings on the risks of PPI co-administration should be interpreted cautiously due to its limitations.
Introduction true vertigo is a type of vertigo identifieniraj57
This study compared the effectiveness of hyoscine and diazepam in treating true vertigo in 69 patients in an emergency department. Patients were randomly assigned to receive either 5 mg of hyoscine or 10 mg of diazepam. Vertigo severity was assessed before and 1 and 2 hours after drug administration in different positions. Diazepam was significantly more effective at relieving vertigo in all positions compared to hyoscine based on treatment success rates. Complete relief of vertigo occurred in 40-63% of patients given diazepam but only 2.6-12.5% of those given hyoscine. The study suggests that diazepam is a better option than hyoscine for
Garlic may help reduce blood pressure in hypertensive patients. A study of 40 hypertensive patients found that those who took garlic capsules daily for 3 weeks saw significant reductions in both their systolic and diastolic blood pressure compared to baseline. The control group who did not take garlic saw no significant changes. Garlic appears to stimulate the production of nitric oxide and hydrogen sulfide in the body, causing blood vessels to dilate and lower blood pressure. Larger clinical studies are still needed to confirm these effects.
Interdisciplinary care plan7 class nur3400ssuser47f0be
This document summarizes a systematic review that analyzed 48 studies on patient engagement strategies to improve quality of care. The review identified techniques to enhance patient engagement in design, recruitment, involvement and leadership. Engagement strategies ranged from low-level consultation to high-level co-design partnerships. Outcomes included educational tools, policies, and care process improvements. Higher engagement levels led to more impactful outcomes. Some patients felt tokenistic involvement despite positive experiences. Overall, engagement informed various outcomes, but more evidence is needed on its impact on quality and patients' experiences.
This document summarizes a clinical trial that evaluated the safety and efficacy of patiromer for treating hyperkalemia in patients with chronic kidney disease receiving RAAS inhibitors. The trial had two phases - an initial 4-week treatment phase followed by an 8-week randomized withdrawal phase. Results showed that patiromer significantly reduced serum potassium levels and maintained normokalemia compared to placebo. The most common side effects were constipation and diarrhea. The authors concluded that patiromer was effective for treating hyperkalemia and allowing continued use of RAAS inhibitors in patients with chronic kidney disease.
This study investigated whether treatment with the proton pump inhibitor lansoprazole could reduce the frequency of common colds and exacerbations in patients with chronic obstructive pulmonary disease (COPD). The study found that patients taking lansoprazole had significantly fewer COPD exacerbations and a lower risk of frequent common colds compared to the control group. The results suggest that lansoprazole may help reduce airway inflammation and inhibit rhinovirus infection in COPD patients. However, the study was limited by a small sample size, lack of placebo control, and population that was almost entirely male and of Japanese ethnicity.
The DANISH trial investigated whether implanting an ICD in patients with non-ischemic heart failure reduced mortality. Over 67 months of follow-up:
1) ICD implantation did not provide an overall survival benefit compared to usual care.
2) The risk of sudden cardiac death was halved with an ICD.
3) Younger patients and those receiving CRT may benefit more from an ICD.
4) ICDs were associated with device-related complications but reduced inappropriate shocks compared to earlier studies. The trial adds to understanding ICD benefits in non-ischemic heart failure.
Naturopathic Treatmentfor the Prevention ofCardiovascular Disease: A Randomized Pragmatic TrialCCNM – Journal Club Sept 30th, 2010Dugald Seely, ND, MScDirector; Research & Clinical EpidemiologyThe Canadian College of Naturopathic Medicine
This study investigated cardiovascular and gastrointestinal outcomes in clopidogrel users who were also taking proton pump inhibitors (PPIs) using a large cohort of patients in the Netherlands. The study found that clopidogrel users who were also taking PPIs had a 75% higher risk of cardiovascular events compared to clopidogrel-only users. However, the study had limitations such as channeling bias since PPI users had more risk factors, and residual confounding since important risk factors could not be adjusted for. While providing useful insights, the study's findings on the risks of PPI co-administration should be interpreted cautiously due to its limitations.
Introduction true vertigo is a type of vertigo identifieniraj57
This study compared the effectiveness of hyoscine and diazepam in treating true vertigo in 69 patients in an emergency department. Patients were randomly assigned to receive either 5 mg of hyoscine or 10 mg of diazepam. Vertigo severity was assessed before and 1 and 2 hours after drug administration in different positions. Diazepam was significantly more effective at relieving vertigo in all positions compared to hyoscine based on treatment success rates. Complete relief of vertigo occurred in 40-63% of patients given diazepam but only 2.6-12.5% of those given hyoscine. The study suggests that diazepam is a better option than hyoscine for
Garlic may help reduce blood pressure in hypertensive patients. A study of 40 hypertensive patients found that those who took garlic capsules daily for 3 weeks saw significant reductions in both their systolic and diastolic blood pressure compared to baseline. The control group who did not take garlic saw no significant changes. Garlic appears to stimulate the production of nitric oxide and hydrogen sulfide in the body, causing blood vessels to dilate and lower blood pressure. Larger clinical studies are still needed to confirm these effects.
Interdisciplinary care plan7 class nur3400ssuser47f0be
This document summarizes a systematic review that analyzed 48 studies on patient engagement strategies to improve quality of care. The review identified techniques to enhance patient engagement in design, recruitment, involvement and leadership. Engagement strategies ranged from low-level consultation to high-level co-design partnerships. Outcomes included educational tools, policies, and care process improvements. Higher engagement levels led to more impactful outcomes. Some patients felt tokenistic involvement despite positive experiences. Overall, engagement informed various outcomes, but more evidence is needed on its impact on quality and patients' experiences.
This document summarizes a clinical trial that evaluated the safety and efficacy of patiromer for treating hyperkalemia in patients with chronic kidney disease receiving RAAS inhibitors. The trial had two phases - an initial 4-week treatment phase followed by an 8-week randomized withdrawal phase. Results showed that patiromer significantly reduced serum potassium levels and maintained normokalemia compared to placebo. The most common side effects were constipation and diarrhea. The authors concluded that patiromer was effective for treating hyperkalemia and allowing continued use of RAAS inhibitors in patients with chronic kidney disease.
This study investigated whether treatment with the proton pump inhibitor lansoprazole could reduce the frequency of common colds and exacerbations in patients with chronic obstructive pulmonary disease (COPD). The study found that patients taking lansoprazole had significantly fewer COPD exacerbations and a lower risk of frequent common colds compared to the control group. The results suggest that lansoprazole may help reduce airway inflammation and inhibit rhinovirus infection in COPD patients. However, the study was limited by a small sample size, lack of placebo control, and population that was almost entirely male and of Japanese ethnicity.
The DANISH trial investigated whether implanting an ICD in patients with non-ischemic heart failure reduced mortality. Over 67 months of follow-up:
1) ICD implantation did not provide an overall survival benefit compared to usual care.
2) The risk of sudden cardiac death was halved with an ICD.
3) Younger patients and those receiving CRT may benefit more from an ICD.
4) ICDs were associated with device-related complications but reduced inappropriate shocks compared to earlier studies. The trial adds to understanding ICD benefits in non-ischemic heart failure.
This study assessed the relationship between non-compliance to antihypertensive treatment and the development of stroke using a case-control design. The study found that non-compliance to medication, diet, exercise, alcohol restrictions and smoking increased the odds of developing stroke among hypertensive patients. Overall, the study concluded that non-compliance to an antihypertensive management regimen significantly increased the risk of stroke.
Update on the evidence to support deprescribing, a presentation by David Erskine, Director – London & South East Medicine Information Service (July 2017).
1) Hospitalization for coronary heart disease presents an opportunity to initiate lipid-lowering therapy to treat the underlying disease process and improve long-term outcomes. However, studies show many high-risk patients are discharged without receiving lipid-lowering medications.
2) Initiating lipid-lowering therapy during hospitalization through programs that incorporate order sets and reminders can significantly increase treatment rates compared to conventional outpatient initiation after discharge.
3) In-hospital initiation is associated with improved long-term compliance, lower LDL cholesterol levels, and reduced mortality and heart attack rates compared to delayed outpatient initiation after discharge.
This document discusses the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively known as venous thromboembolism (VTE). It covers:
1) Anticoagulants like unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) play a central role in treating VTE. UFH is administered via intravenous infusion using weight-based dosing and monitoring with aPTT levels, while LMWH allows for outpatient treatment with subcutaneous injections without monitoring.
2) Treatment of VTE in the elderly is complicated by an increased risk of bleeding from anticoagulants. While
the 1-year cumulative incidence of a composite end point consisting of cardiovascular death, myocardial infarction, ischemic or hemorrhagic stroke, definite stent thrombosis, and major bleeding was 2.4% in the 1-month DAPT group and 3.7% in the 12-month DAPT group, a difference that met the noninferiority margin of a hazard ratio of 0.5, as well as superiority.
Erectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis Patientsasclepiuspdfs
Introduction: Erectile dysfunction (ED) is a common condition in patients with renal disease, but little is known about the prevalence of ED in some specific groups of patients such as Peruvian hemodialysis (HD) patients. Materials and Methods: A cross‑sectional study was conducted to determine the frequency of ED in HD patients (n = 390) in Lima, Peru. The prevalence and severity of ED were assessed using the International Index of Erectile Function with the validated Peruvian version. The dependence of ED on independent variables was evaluated by logistic regression. P ≤ 0.05 was regarded as statistically significant.
Acute Telogen Efluvium is associated with the presence of female androgenetic alopecia. Potential Therapeutic Implications - A retrospective study of 503 female patients
This document summarizes findings from a survey of 50 primary care physicians on their knowledge and perceptions related to treating type 2 diabetes. The survey found that many physicians were unfamiliar with current guidelines regarding appropriate A1c targets and misunderstood results from the ACCORD trial. Physicians were also more likely to recall claims made in marketing materials compared to evidence from clinical studies. Overall, the survey suggests that disseminating evidence-based practices to physicians remains challenging and that new strategies are needed to accelerate adoption of optimal treatment guidelines.
The AFFIRM trial compared rate control and rhythm control strategies for treating atrial fibrillation. Over 7,000 patients with recurrent atrial fibrillation aged 65 or older were randomized to either rate or rhythm control. The primary outcome was overall mortality, with secondary outcomes including death from cardiovascular causes, stroke, bleeding, and hospitalization. The trial found no significant difference in mortality between the two groups. However, rhythm control was associated with greater need for hospitalization and higher rates of crossover to rate control. The study concluded that rate control should be the primary treatment approach for atrial fibrillation.
Intensive Insulin Therapy In The Medical IcuNadSamm
Intensive insulin therapy (IIT) aimed at maintaining tight glycemic control between 4.4-6.1 mmol/L significantly reduced morbidity but not overall in-hospital mortality compared to conventional insulin treatment targeting levels below 10-12 mmol/L in critically ill adult medical ICU patients. Among patients who received at least 3 days of IIT, in-hospital mortality was reduced from 21% to 14% and complications such as newly acquired kidney injury and length of stay were also lower. However, IIT did not reduce mortality in the overall intention-to-treat analysis and may have caused harm in patients treated for less than 3 days. Further research is needed to confirm these preliminary findings.
This study investigated the effects of intensive glucose control versus conventional glucose control in critically ill patients admitted to the ICU. Over 6000 patients were randomly assigned to either a tight glucose control target of 81-108 mg/dL or a more conventional target of 180 mg/dL or less. The primary outcome was all-cause mortality within 90 days. Results showed that intensive glucose control was associated with a higher mortality rate compared to conventional control, with 27.5% of patients in the intensive group dying compared to 24.9% in the conventional group. Intensive control also significantly increased the risk of severe hypoglycemia.
The document discusses the role of peroxisome proliferator activated receptor gamma (PPARγ) agonists in treating type 2 diabetes and reducing cardiovascular risk. PPARγ agonists like thiazolidinediones improve insulin sensitivity and have beneficial effects on lipids, inflammation, and vascular cell proliferation. They may reduce cardiovascular events in type 2 diabetes through these metabolic and anti-inflammatory mechanisms. However, PPARγ agonists can also cause side effects like fluid retention, weight gain, and congestive heart failure, so their risks and benefits must be carefully weighed.
Copeptin as a Novel Biomarker in the Diagnosis of Acute Myocardial Infarction...Premier Publishers
To evaluate the diagnostic value of Copeptin as a novel biomarker in early diagnosis of Acute Myocardial Infarction. 56 patients with acute Myocardial Infarction (STEMI) and 25 healthy controls who were admitted to the Cardiology and Clinical Pathology Departments, national heart institute (NHI) from October 2015 to April 2016. The kit used a double-antibody sandwich enzyme-linked immune-sorbent assay (ELISA) to assay the level of Human Copeptin in samples. As regard copeptin, the median range of copeptin level was 242.5pg/ml in patient group and 75pg/ml in control group. The comparative study between the two groups shows a significant difference (p < 0.05) Conclusion: Copeptin is a reliable diagnostic tool in patients with AMI (STEMI) with sensitivity 85.7%, specificity 86.7%, PPV 96% and NPV 61.9%.
The document summarizes guidelines for treating hypertension and their evidence basis. It discusses several major studies that informed guidelines recommending a target blood pressure of 130/80 mmHg or lower to slow kidney disease progression, including the MDRD trial which found a 32% reduction in kidney failure risk with intensive control to 125/75 mmHg compared to 140/90 mmHg. However, later trials like ACCORD and REIN-2 found no additional benefit from intensive control below 130/80 mmHg or additional medications to reach lower targets.
The HOPE-3 trial evaluated the effects of rosuvastatin 10 mg daily alone or combined with candesartan/hydrochlorothiazide on cardiovascular outcomes in 12,705 participants without cardiovascular disease at intermediate risk, and found that the combination therapy reduced the primary composite outcome of cardiovascular death, myocardial infarction, or stroke by 29% compared to dual placebo. Significant reductions in LDL cholesterol and blood pressure were seen with combination therapy compared to dual placebo. Adverse events including muscle pain were increased but serious adverse events did not differ significantly between groups.
Nivolumab, a programmed death 1 (PD-1) checkpoint inhibitor, was associated with encouraging overall survival in uncontrolled studies involving previously treated patients with advanced renal-cell carcinoma. This randomized, open-label, phase 3 study compared nivolumab with everolimus in patients with renal-cell carcinoma who had received previous treatment.
This document summarizes a study that examined the risk of new diabetes with higher potency statins compared to lower potency statins. It discusses two previous meta-analyses that found a small increased risk of diabetes with statin use. The study analyzed administrative databases covering millions of patients and found a 15% higher rate of new diabetes over 2 years in those prescribed higher potency statins for secondary prevention of cardiovascular events compared to lower potency statins. Higher potency statins were associated with one additional case of diabetes for every 342 patients treated over 2 years. The increased risk was highest in the first 4 months of statin use.
This document discusses hypoperfusion in acute heart failure. It begins with case examples from Duke Hospital and considerations for diagnosis. It then covers inotropic options and mechanical support devices. Various studies on inotropes, percutaneous support devices, and extracorporeal membrane oxygenation are summarized. The conclusion is that hypoperfusion in acute heart failure presents major challenges for diagnosis and treatment.
Este documento describe brevemente las Tecnologías de la Información y Comunicación (TIC), incluyendo ejemplos como televisores, teléfonos, computadoras y tabletas. Explica que las TIC sirven para administrar y transmitir información, divertirse, aprender y mantenerse en contacto. Finalmente, señala que las TIC han multiplicado los canales para llegar a los clientes en el turismo, han informado más a los clientes y les han permitido generar y recomendar productos turísticos.
2016 march 28th dicwg holistic treatment cultural genocidesue barstow
The document discusses the failure to properly implement the recommendations of the Royal Commission into Aboriginal Deaths in Custody. It notes that grassroots participation is needed for successful social integration but that mainstream departments have not taken responsibility to effectively implement changes. Barriers of distrust and alienation continue between Aboriginal and non-Aboriginal communities because the difficulties of transition after colonization have not been adequately addressed.
This study assessed the relationship between non-compliance to antihypertensive treatment and the development of stroke using a case-control design. The study found that non-compliance to medication, diet, exercise, alcohol restrictions and smoking increased the odds of developing stroke among hypertensive patients. Overall, the study concluded that non-compliance to an antihypertensive management regimen significantly increased the risk of stroke.
Update on the evidence to support deprescribing, a presentation by David Erskine, Director – London & South East Medicine Information Service (July 2017).
1) Hospitalization for coronary heart disease presents an opportunity to initiate lipid-lowering therapy to treat the underlying disease process and improve long-term outcomes. However, studies show many high-risk patients are discharged without receiving lipid-lowering medications.
2) Initiating lipid-lowering therapy during hospitalization through programs that incorporate order sets and reminders can significantly increase treatment rates compared to conventional outpatient initiation after discharge.
3) In-hospital initiation is associated with improved long-term compliance, lower LDL cholesterol levels, and reduced mortality and heart attack rates compared to delayed outpatient initiation after discharge.
This document discusses the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively known as venous thromboembolism (VTE). It covers:
1) Anticoagulants like unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) play a central role in treating VTE. UFH is administered via intravenous infusion using weight-based dosing and monitoring with aPTT levels, while LMWH allows for outpatient treatment with subcutaneous injections without monitoring.
2) Treatment of VTE in the elderly is complicated by an increased risk of bleeding from anticoagulants. While
the 1-year cumulative incidence of a composite end point consisting of cardiovascular death, myocardial infarction, ischemic or hemorrhagic stroke, definite stent thrombosis, and major bleeding was 2.4% in the 1-month DAPT group and 3.7% in the 12-month DAPT group, a difference that met the noninferiority margin of a hazard ratio of 0.5, as well as superiority.
Erectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis Patientsasclepiuspdfs
Introduction: Erectile dysfunction (ED) is a common condition in patients with renal disease, but little is known about the prevalence of ED in some specific groups of patients such as Peruvian hemodialysis (HD) patients. Materials and Methods: A cross‑sectional study was conducted to determine the frequency of ED in HD patients (n = 390) in Lima, Peru. The prevalence and severity of ED were assessed using the International Index of Erectile Function with the validated Peruvian version. The dependence of ED on independent variables was evaluated by logistic regression. P ≤ 0.05 was regarded as statistically significant.
Acute Telogen Efluvium is associated with the presence of female androgenetic alopecia. Potential Therapeutic Implications - A retrospective study of 503 female patients
This document summarizes findings from a survey of 50 primary care physicians on their knowledge and perceptions related to treating type 2 diabetes. The survey found that many physicians were unfamiliar with current guidelines regarding appropriate A1c targets and misunderstood results from the ACCORD trial. Physicians were also more likely to recall claims made in marketing materials compared to evidence from clinical studies. Overall, the survey suggests that disseminating evidence-based practices to physicians remains challenging and that new strategies are needed to accelerate adoption of optimal treatment guidelines.
The AFFIRM trial compared rate control and rhythm control strategies for treating atrial fibrillation. Over 7,000 patients with recurrent atrial fibrillation aged 65 or older were randomized to either rate or rhythm control. The primary outcome was overall mortality, with secondary outcomes including death from cardiovascular causes, stroke, bleeding, and hospitalization. The trial found no significant difference in mortality between the two groups. However, rhythm control was associated with greater need for hospitalization and higher rates of crossover to rate control. The study concluded that rate control should be the primary treatment approach for atrial fibrillation.
Intensive Insulin Therapy In The Medical IcuNadSamm
Intensive insulin therapy (IIT) aimed at maintaining tight glycemic control between 4.4-6.1 mmol/L significantly reduced morbidity but not overall in-hospital mortality compared to conventional insulin treatment targeting levels below 10-12 mmol/L in critically ill adult medical ICU patients. Among patients who received at least 3 days of IIT, in-hospital mortality was reduced from 21% to 14% and complications such as newly acquired kidney injury and length of stay were also lower. However, IIT did not reduce mortality in the overall intention-to-treat analysis and may have caused harm in patients treated for less than 3 days. Further research is needed to confirm these preliminary findings.
This study investigated the effects of intensive glucose control versus conventional glucose control in critically ill patients admitted to the ICU. Over 6000 patients were randomly assigned to either a tight glucose control target of 81-108 mg/dL or a more conventional target of 180 mg/dL or less. The primary outcome was all-cause mortality within 90 days. Results showed that intensive glucose control was associated with a higher mortality rate compared to conventional control, with 27.5% of patients in the intensive group dying compared to 24.9% in the conventional group. Intensive control also significantly increased the risk of severe hypoglycemia.
The document discusses the role of peroxisome proliferator activated receptor gamma (PPARγ) agonists in treating type 2 diabetes and reducing cardiovascular risk. PPARγ agonists like thiazolidinediones improve insulin sensitivity and have beneficial effects on lipids, inflammation, and vascular cell proliferation. They may reduce cardiovascular events in type 2 diabetes through these metabolic and anti-inflammatory mechanisms. However, PPARγ agonists can also cause side effects like fluid retention, weight gain, and congestive heart failure, so their risks and benefits must be carefully weighed.
Copeptin as a Novel Biomarker in the Diagnosis of Acute Myocardial Infarction...Premier Publishers
To evaluate the diagnostic value of Copeptin as a novel biomarker in early diagnosis of Acute Myocardial Infarction. 56 patients with acute Myocardial Infarction (STEMI) and 25 healthy controls who were admitted to the Cardiology and Clinical Pathology Departments, national heart institute (NHI) from October 2015 to April 2016. The kit used a double-antibody sandwich enzyme-linked immune-sorbent assay (ELISA) to assay the level of Human Copeptin in samples. As regard copeptin, the median range of copeptin level was 242.5pg/ml in patient group and 75pg/ml in control group. The comparative study between the two groups shows a significant difference (p < 0.05) Conclusion: Copeptin is a reliable diagnostic tool in patients with AMI (STEMI) with sensitivity 85.7%, specificity 86.7%, PPV 96% and NPV 61.9%.
The document summarizes guidelines for treating hypertension and their evidence basis. It discusses several major studies that informed guidelines recommending a target blood pressure of 130/80 mmHg or lower to slow kidney disease progression, including the MDRD trial which found a 32% reduction in kidney failure risk with intensive control to 125/75 mmHg compared to 140/90 mmHg. However, later trials like ACCORD and REIN-2 found no additional benefit from intensive control below 130/80 mmHg or additional medications to reach lower targets.
The HOPE-3 trial evaluated the effects of rosuvastatin 10 mg daily alone or combined with candesartan/hydrochlorothiazide on cardiovascular outcomes in 12,705 participants without cardiovascular disease at intermediate risk, and found that the combination therapy reduced the primary composite outcome of cardiovascular death, myocardial infarction, or stroke by 29% compared to dual placebo. Significant reductions in LDL cholesterol and blood pressure were seen with combination therapy compared to dual placebo. Adverse events including muscle pain were increased but serious adverse events did not differ significantly between groups.
Nivolumab, a programmed death 1 (PD-1) checkpoint inhibitor, was associated with encouraging overall survival in uncontrolled studies involving previously treated patients with advanced renal-cell carcinoma. This randomized, open-label, phase 3 study compared nivolumab with everolimus in patients with renal-cell carcinoma who had received previous treatment.
This document summarizes a study that examined the risk of new diabetes with higher potency statins compared to lower potency statins. It discusses two previous meta-analyses that found a small increased risk of diabetes with statin use. The study analyzed administrative databases covering millions of patients and found a 15% higher rate of new diabetes over 2 years in those prescribed higher potency statins for secondary prevention of cardiovascular events compared to lower potency statins. Higher potency statins were associated with one additional case of diabetes for every 342 patients treated over 2 years. The increased risk was highest in the first 4 months of statin use.
This document discusses hypoperfusion in acute heart failure. It begins with case examples from Duke Hospital and considerations for diagnosis. It then covers inotropic options and mechanical support devices. Various studies on inotropes, percutaneous support devices, and extracorporeal membrane oxygenation are summarized. The conclusion is that hypoperfusion in acute heart failure presents major challenges for diagnosis and treatment.
Este documento describe brevemente las Tecnologías de la Información y Comunicación (TIC), incluyendo ejemplos como televisores, teléfonos, computadoras y tabletas. Explica que las TIC sirven para administrar y transmitir información, divertirse, aprender y mantenerse en contacto. Finalmente, señala que las TIC han multiplicado los canales para llegar a los clientes en el turismo, han informado más a los clientes y les han permitido generar y recomendar productos turísticos.
2016 march 28th dicwg holistic treatment cultural genocidesue barstow
The document discusses the failure to properly implement the recommendations of the Royal Commission into Aboriginal Deaths in Custody. It notes that grassroots participation is needed for successful social integration but that mainstream departments have not taken responsibility to effectively implement changes. Barriers of distrust and alienation continue between Aboriginal and non-Aboriginal communities because the difficulties of transition after colonization have not been adequately addressed.
International education helps the students to grow personally and professionally by learning to appreciate and embrace differences while exploring key professional components of their field.
Hướng dẫn cách làm bánh trung thu dẻo nước cốt dừa đơn giản nhất tại nhà cho chị em trổ tài trong mùa Trung thu năm nay. Còn bây giờ thì hãy cũng lambanhtrungthu.org khám phá công thức này thôi nào !
El Sony Xperia Z5 tiene una pantalla de 5.2 pulgadas con resolución 1080p, es impulsado por un procesador Snapdragon 810 de 8 núcleos con 3GB de RAM y 32GB de almacenamiento, y funciona con Android 5.1 Lollipop, además de tener una batería de 2900mAh y ser resistente al agua, polvo y golpes.
El documento resume la historia de la tecnología desde la Edad de Piedra hasta la actualidad. En la Edad de Piedra, los primeros humanos eran cazadores recolectores que construían herramientas tallando piedras. Más adelante, se desarrollaron medios de transporte como la rueda y la agricultura. Luego, surgieron civilizaciones antiguas en regiones fluviales como Egipto y Mesopotamia, así como la cultura clásica y la Edad Media. Finalmente, la Revolución Industrial en la Edad
El documento define un proyecto como un conjunto de actividades coordinadas para alcanzar un objetivo determinado dentro de un periodo de tiempo y presupuesto establecidos. Explica que un proyecto tiene componentes técnicos, científicos, presupuestales y de talento humano. Además, identifica varios tipos de proyectos como de inversión, infraestructura, investigación, educativo, social, científico, ambiental y de grado.
This document provides guidance on appropriate behavior for interns in Germany from other countries. It discusses the importance of:
- Being punctual and respecting a company's dress code at work. Interns represent their home country and influence whether a company hosts more interns.
- Seeking help from AIESEC contacts for any issues, while recognizing they are volunteers. Be solution-oriented when providing feedback.
- Attending Local Committee Meetings to network and introduce oneself. Clear communication of feedback is valued to improve, though it should be constructive and not generalize negatives.
This document outlines a pitch for a short film exploring youth culture and the intersection with drugs. The genres will be thriller, drama, and social realism. The film focuses on a 17-year-old boy, George, whose daily routine revolves around sleep, drugs, and alcohol, taking a mental toll on him. Camera work and editing will convey a sense of paranoia. The target audience is 15-25 year olds from middle-class backgrounds to show a raw portrayal of modern youth culture and stereotypes. The narrative purposefully does not follow Todorov's theory of returning to equilibrium.
PDF GM China CSR Newsletter_Autumn 2016_ENJasmine Liao
The document summarizes GM China's corporate social responsibility activities in the third quarter of 2016, focusing on safety, sustainability, and education. Some of the key initiatives discussed include the Safe Kids Safe Ride program that educated over 200 children on passenger safety, GM China's green supply chain project that helped suppliers reduce CO2 emissions by over 5.5 million kg, and GM employees volunteering to teach underprivileged children in rural kindergartens to support their development.
Para producir un video exitoso, se deben seguir varios pasos clave como determinar la audiencia y el mensaje, crear un concepto atractivo, elegir las herramientas adecuadas, grabar el contenido teniendo en cuenta las leyes, y distribuir y promocionar el video final para analizar los resultados. La preproducción incluye la planificación, la producción es la grabación siguiendo el guion y considerando tendencias estéticas, y la postproducción manipula el material para editarlo y añadir efectos.
- Cardiovascular disease is the leading cause of death in Canada, and high blood pressure is the number one modifiable risk factor. However, many Canadians are unaware they have high blood pressure or it is not adequately controlled.
- The document outlines a strategy to improve hypertension management in Canada through initiatives targeted at primary healthcare providers and patients. It involves developing and testing education and management tools.
- An evaluation of the initial pilot phase found improvements in screening, diagnosis and control of high blood pressure among participating providers and patients compared to non-participants. Most providers also reported the strategy was effective and positively impacted their management of hypertensive patients.
The actual prevalence of RH may be lower than what is
perceived in the literature when triple-A (accuracy of BP
measurement, adherence of medications, and adequacy
of anti-HTN medications) are ensured. It is important to
emphasize that the sea of RH starts when the shore of secondary
HTN is over and the island of RfH is still uncharted. RfH is
emerging as a novel phenotype, and growing evidence suggest
that these patients have sympathetic hyperactivity. However,
the role of beta-blockers and interventions such as RDN and
baroreceptor activation techniques is yet to be studied.
Clinical Outcomes of Intensive Inpatient Blood Pressure.pdfSHINTU5
OBJECTIVE To examine the association of intensive treatment of elevated inpatient BPs
with in-hospital clinical outcomes of older adults hospitalized for noncardiac conditions.
DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined Veterans
Health Administration data between October 1, 2015, and December 31, 2017, for patients
aged 65 years or older hospitalized for noncardiovascular diagnoses and who experienced
elevated BPs in the first 48 hours of hospitalization.
INTERVENTIONS Intensive BP treatment following the first 48 hours of hospitalization,
defined as receipt of intravenous antihypertensives or oral classes not used prior to
admission.
MAIN OUTCOME AND MEASURES The primary outcomewas a composite of inpatient mortality,
intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation,
and troponin elevation. Data were analyzed between October 1, 2021, and January 10, 2023,
with propensity score overlap weighting used to adjust for confounding between those who
did and did not receive early intensive treatment.
RESULTS Among 66 140 included patients (mean [SD] age, 74.4 [8.1] years; 97.5%male
and 2.6%female; 17.4%Black, 1.7%Hispanic, and 75.9%White), 14 084 (21.3%) received
intensive BP treatment in the first 48 hours of hospitalization. Patients who received early
intensive treatment vs those who did not continued to receive a greater number of additional
antihypertensives during the remainder of their hospitalization (mean additional doses, 6.1
[95%CI, 5.8-6.4] vs 1.6 [95%CI, 1.5-1.8], respectively). Intensive treatment was associated
with a greater risk of the primary composite outcome (1220 [8.7%] vs 3570 [6.9%]; weighted
odds ratio [OR], 1.28; 95%CI, 1.18-1.39), with the highest risk among patients receiving
intravenous antihypertensives (weighted OR, 1.90; 95%CI, 1.65-2.19). Intensively treated
patients were more likely to experience each component of the composite outcome except
for stroke and mortality. Findings were consistent across subgroups stratified by age, frailty,
preadmission BP, early hospitalization BP, and cardiovascular disease history.
CONCLUSIONS AND RELEVANCE The study’s findings indicate that among hospitalized
older adults with elevated BPs, intensive pharmacologic antihypertensive treatment
was associated with a greater risk of adverse events. These findings do not support
the treatment of elevated inpatient BPs without evidence of end organ damage,
and they highlight the need for randomized clinical trials of inpatient BP treatment targets
The document discusses updated guidelines for diagnosing and treating hypertension that were released in 2017. Some key points:
- The new guidelines lower the threshold for stage 1 hypertension to 130/80 mm Hg from 140/90 mm Hg. This means nearly half of US adults now have hypertension based on these guidelines.
- Lifetime risk of developing hypertension is approximately 90% for adults aged 55-65 based on data from the Framingham Heart Study.
- Self-monitoring and ambulatory blood pressure monitoring provide benefits over office-based measurements alone for managing hypertension.
- Lifestyle modifications such as weight loss, reduced sodium intake, increased potassium and physical activity are recommended as first-line treatment for many with elevated blood pressure
Management of Hypertension and Diabetes in Aging People 2014Nemencio Jr
This module discusses the issues in the management and treatment goals for hypertension and diabetes in the older population based on the most recent guidelines
Intensive glycemic control aimed at maintaining blood glucose between 80-110 mg/dl in adult ICU patients does not reduce mortality and significantly increases the risk of hypoglycemia compared to conventional control between 140-180 mg/dl. Multiple large randomized controlled trials found no benefit to intensive control and post-hoc analyses determined hypoglycemia independently increases mortality. Current guidelines recommend insulin therapy only for blood glucose over 180 mg/dl and targeting 140-180 mg/dl range to minimize hypoglycemia risk while avoiding hyperglycemia's harmful effects.
This study investigated the prevalence of thyroid abnormalities in 100 type 2 diabetic patients in eastern Nepal. The results found:
1) 40% of patients had subclinical hypothyroidism, defined as elevated TSH levels despite normal FT3 and FT4 levels.
2) 12% of patients had overt hypothyroidism, defined as low FT3 and FT4 levels along with elevated TSH.
3) Smaller percentages of 8% and 6% had subclinical and overt hyperthyroidism respectively, defined as abnormal FT3 and FT4 levels with low or suppressed TSH.
The study concludes subclinical hypothyroidism is the most common thyroid abnormality associated with type 2 diabetes
This document summarizes the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It outlines recommendations for classifying and treating hypertension based on blood pressure levels. Key points include classifying blood pressure into normal, prehypertension, and stages 1 and 2 of hypertension, and recommending lifestyle modifications and drug treatments to lower blood pressure to reduce cardiovascular risks. Compelling indications for certain drug classes are noted for conditions like heart disease, diabetes, and chronic kidney disease.
This document summarizes a study that aims to use a mobile app and behavioral intervention to help lower blood pressure by following the DASH diet plan. Participants will use the app to track their diet, weight, blood pressure and activity levels over 12 weeks. They will also receive weekly counseling from health coaches. The main goal is to see if this mHealth approach can successfully reduce blood pressure and improve healthy behaviors. Materials for the study include a custom mobile app, web portal, Bluetooth devices to track metrics, and health coaches trained in the DASH plan and motivational interviewing.
The SPRINT study found that treating systolic blood pressure to 120 mm Hg rather than 140 mm Hg significantly reduced mortality and cardiovascular events such as heart attack and stroke. This challenges the current JNC 8 guideline target of 140 mm Hg and below. The PATHWAY2 study found that adding spironolactone was more effective at reducing blood pressure than other drugs for patients resistant to three-drug treatment. Research also showed that ACE inhibitors resulted in poorer cardiovascular outcomes for black hypertensive patients compared to other antihypertensive drugs.
Interdisciplinary care plan7 class nur3400ssuserd93c47
This document provides background information on an interdisciplinary care plan for a patient named McKay Johnson who has been diagnosed with diabetes and heart disease. It includes details about Johnson's medical history and current condition based on examinations and lab results. It then outlines the nursing interventions and treatment goals that are part of Johnson's interdisciplinary care plan to manage his diabetes and heart condition. The care plan involves monitoring Johnson's symptoms, administering and adjusting his medications, educating him on his conditions and treatment, and ensuring he follows a healthy diet and lifestyle to control his health issues. The overarching goal is to lower Johnson's blood glucose, BMI, and other marker levels through this collaborative treatment approach.
Carvedilol was studied for its efficacy and safety in treating hypertension, especially in high-risk elderly patients and those with diabetes or renal disease. Over 12 weeks, carvedilol alone or combined with other drugs significantly reduced blood pressure from 168/95 mmHg to 144/83 mmHg. Nearly half of patients achieved their blood pressure goals. Carvedilol was well-tolerated with few side effects and did not negatively impact glucose or renal function in high-risk patients. The study concluded that carvedilol is an effective and safe option for treating hypertension, including in elderly patients and those with complications.
J2016 - Tecson et al AJC Impact of EECP on Heart Failure RehospitalizationEmily Hu
1) The study assessed the impact of enhanced external counterpulsation (EECP) combined with heart failure education on reducing 90-day readmission rates in 99 patients with heart failure due to ischemic cardiomyopathy who began EECP within 90 days of hospital discharge.
2) Only 6 patients (6.1%) had unplanned readmissions within 90 days, which was significantly lower than the predicted rate of 34%. Functional status, walk distance, and symptoms also improved after EECP based on various clinical measures.
3) In conclusion, patients who received EECP and education within 90 days of discharge had significantly lower readmission rates than predicted, and also showed improvements in functional status, walk distance, and symptoms.
A Study to Assess the Effectiveness of Hibiscus Sabdariffa on Hypertensive Pa...ijtsrd
The present study aim was the assess the effectiveness of hibiscus sabdariffa on hypertensive patients in rural area. A Quantitaive research approach and Quasi experimental pre test and post test control group design have adopted for the present study. 60 participants were selected who are satisfied with inclusion criteria whereas 30 samples in experimental group other 30 sample were in control group, they were selected by convenient sampling technique. A structured questionnaire method to collect the demographic variables and clinical variables, blood pressure is assessed by the sphygmomanometer. Among 60 patient, 30 hypertensive patient participated in the reveals the pretest mean score was 1.83±0.36 and the post test mean score was 1.23±0.66 in systolic blood pressure and the pretest mean score was 1.4±0.48 and post test mean score was 0.5±0.40 in diastolic blood pressure. Paired t test to compare the pre and posttest level of blood pressure among experimental group. The present study regard to the pre and post test level of systolic blood pressure among experimental group it was found that the t value was5.86, With regard to the pre and post test level of diastolic blood pressure among experimental group it was found that the t value was 12.3, indicating that the rewash a highly significant reduction in post test level of blood pressure among the experimental group at p 0.05level. The present study reveals the pretest mean score was 1.83±0.53 and the post test mean score was 1.96 ±1.6 in systolic blood pressure and the pretest mean score was 1.26 ±0.49 and post test mean score was 0.22 ±0.71 in diastolic blood pressure. paired t test to compare the pre and post test level of blood pressure among control group. With regard to the pre and post test level of systolic blood pressure among control group it was found that the t value was 2.35, With regard to the pre and post test level of diastolic blood pressure among control group it was found that the t value was 2.48, indicating that there was no significant reduction in post test level of blood pressure among the control group at p 0.05 level. Sathiyabama. G | Narmadha K | Nivetha. S "A Study to Assess the Effectiveness of Hibiscus Sabdariffa on Hypertensive Patients in Rural Area" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-6 | Issue-6 , October 2022, URL: https://www.ijtsrd.com/papers/ijtsrd52202.pdf Paper URL: https://www.ijtsrd.com/medicine/nursing/52202/a-study-to-assess-the-effectiveness-of-hibiscus-sabdariffa-on-hypertensive-patients-in-rural-area/sathiyabama-g
Patient support programmes within medicines optimisation – the pros and consPM Society
Patient support programs have the potential to improve medication adherence and patient outcomes while also providing a return on investment. A personalized text message program for asthma patients improved adherence from 43% in the control group to 58% in the intervention group. The program continued to show benefits in adherence even after the intervention ended. A support program for age-related macular degeneration patients led to an 8-fold decrease in treatment discontinuation and a 941% return on investment. Personalized interventions that address patients' beliefs and perceptions have the most potential to positively impact adherence long-term.
The document discusses the importance of glycemic control for hospitalized patients with diabetes or hyperglycemia. It notes that hyperglycemia is common in hospitalized patients and associated with worse outcomes. The document reviews evidence that intensive insulin therapy to maintain tight glycemic control can reduce mortality, infection rates, and length of stay in intensive care units and improve outcomes for patients with acute myocardial infarction. It discusses guidelines developed for recommended glycemic targets in hospitals.
The document summarizes guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It outlines classifications for blood pressure levels, risk factors, treatment goals, lifestyle modifications, and drug therapy recommendations. The guidelines emphasize individualizing treatment based on a patient's specific cardiovascular risks and medical conditions.
The document summarizes the key recommendations from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It introduces new classifications for blood pressure levels, emphasizes the importance of lifestyle modifications and use of thiazide-type diuretics as initial treatment, and recommends treating to lower blood pressure targets to reduce cardiovascular disease risk. It also provides guidance on proper blood pressure measurement techniques, evaluating patient risk factors, and conducting follow-up assessments.
2. dose anti-hypertensive combination therapy compared to usual care
(64.7% versus 52.7%; absolute difference: 12.0%; 95% CI: 1.5% to 22.4%;
p=0.026) [13].
The accumulated evidence from studies focussing on more structured
management of hypertension and pharmacological studies investigating
the benefits of greater BP control with combination anti-hypertensive
therapy is clear [14–16]. The key ingredients for achieving optimal BP
control, which can be overlooked in (busy) real-life clinical care, are to not
only set an appropriate BP target, but also establish a schedule of
treatment and contacts between individuals and their GP to achieve the
target goal. This is in parallel with achieving an overall reduction in cardiac
risk given that BP targets are now being stratified according to the risk of a
subsequent cardiovascular event [1]. In light of some evidence to suggest
that early BP control in hypertensive individuals confers longer-term
benefits in respect to reduced risk of fatal and non-fatal CV events [14], it is
worthconsideringtheadditionalbenefitsofapplyingintensive,structured
management with pharmacological therapy that achieves optimal BP
control as early as possible. To attain long-term BP control in a real-world
setting, therefore, a currently unproven but promising strategy involves
combining two independently effective components of BP control in the
primary care setting: 1) intensive initiation of BP management for early
control to provide potential prognostic benefits as well as early
identification of patients who require more aggressive anti-hypertensive
treatment, and 2) more pro-active application of modern “combination”
anti-hypertensiveformulationsthatmayprovideincreasedBPcontrol and
greater treatment adherence. We hypothesised that this type of strategy is
not a common feature of contemporary hypertension management in
Australia.
2. Pilot survey of BP management in primary care
In order to identify the features of contemporary primary care
management of hypertension we surveyed (unpaid) 500 national GPs
using a case scenario (see Box 1), similar to the application of a recent
lipid management survey in primary care [17]. The following
characteristics of hypertension management in primary care became
apparent:
• Variable BP surveillance and follow-up patterns to determine
treatment efficacy.
• Low uptake of individualised BP targets advocated by the National
Heart Foundation of Australia (NHFA) [1] based on their clinical
profile.
• Application of a wide variety of anti-hypertensive therapies
(reflecting the lack of precise guidelines for BP lowering in this
setting).
• Lack of ancillary profiling to calculate absolute cardiovascular risk in
eligible individuals (i.e. adults aged N45 years with a history of CVD)
to determine the need for more integrated primary (and secondary)
prevention in hypertensive individuals.
The study cohort appeared to be broadly representative of
Australian primary care in that 69% (n=347) of GPs were male
with a mean age of 48 years (range 28–80 years). A total of 475 GPs
(95%) used a computerised record/prescription system. Overall, 70%
(n=365) of GPs employed at least one practice nurse, with 22% of
these having 3 or more practice nurses. The estimated case load was
on average 5400 patients per year (104 per week) with an annual
range between 100 and 48,000 patients per year.
Overall, 140 GPs (28%) nominated a higher than recommended [1]
(N130/80 mm Hg) BP target for this hypothetical patient. In order to
reduce their BP, a majority of GPs indicated that a combination of
lifestyle modification and prescribed pharmacotherapy (72%) would
best achieve their nominated BP target; 19% nominated lifestyle
modifications alone and 9% pharmacotherapy alone. The most popular
“first-line” agent was the angiotensin converting enzyme inhibitor
perindopril (204 GPs, 49%) followed by the beta blocker carvedilol (80
GPs, 20%) and the angiotensin receptor blocker candesartan (54 GPs,
13%). Overall, therefore, a range of pharmacological agents were
nominated to control this individual's BP.
When asked to nominate the likely impact of their chosen therapy,
80% of GPs (387 of 445 with a valid response) expected a reduction in
systolic BP of up to 20 mm Hg with around one in two (46%) expecting
a reduction between 11 and 20 mm Hg. Approximately 70% of GPs
expected a reduction in diastolic BP of up to 10 mm Hg yet many GPs
(n=328, 70%) nominated a reduction in systolic BP as their most
important therapeutic target. In order to determine the impact of their
management, just over half (53%) would review this patient within
2 weeks and one third (33%) between 2 and 4 weeks; the remainder
nominating a longer period.
When informed that Mr Smith returns with a BP of 138/85 mm Hg
and an improved CVD risk profile but has developed proteinuria (N1 g
per day confirmed by urine dipstick), 90% of GPs nominated an original
or revised (336, 67%) BP target that is consistent with NHFA guidelines
[1]. If further management resulted in “ideal” BP control, more than half
of the GPs (53%) would schedule a follow-up visit N2 months later while
42% nominated a follow-up review between 1 and 2 months.
Overall, these data confirm a large degree of variability in respect
to a number of important features relating to the contemporary
management of BP in Australian primary care. These include:
1) Identification of ideal BP targets — despite being (reassuringly)
largely consistent with relevant guidelines.
2) Strategies used to control the BP of a high risk individual — a majority
of GPs indicated they would apply anti-hypertensive treatment but
in relatively low doses and rarely as combination therapy.
3) Follow-up monitoring and ongoing surveillance.
Within the many caveats inherent to the methodology applied, the
findings broadly support the need to apply a more structured
approach to hypertension management in primary care.
3. The Viper-BP Study
In view of the literature supporting the application of more intensive
and aggressive anti-hypertensive therapy as part of structured BP
management and our own data suggesting that this is rarely applied in
Australian primary care, we planned the Valsartan Intensified Primary
carE Reduction of Blood Pressure Study (VIPER-BP) Study. This study
was specifically designed to address that outside of the clinical trial
setting (i.e. in a real world environment), it is unknown whether it is safe
and efficacious to apply a pro-active and aggressive form of BP
management.
3.1. Objective and hypothesis
The VIPER-BP Study seeks to examine the safety and efficacy of a
more intensive approach to BP management from both pharmacologic
and non-pharmacologic perspectives. It was hypothesised that in a
primary care setting, a greater proportion of patients with a sub-optimal
BP according to their clinical profile (contemporary NHFA criteria [1])
who are exposed to the VIPER-BP intervention (an intensive BP
Box 1
Case scenario: Mr Smith has a history of coronary artery
disease. He has multiple risk factors including:
• Fasting total cholesterol level=5.81 mmol/L
• Excess body weight (body mass index=27.8 kg/m2
)
• Two sitting BP readings providing an average value of 166/
92 mm Hg
318 S. Stewart et al. / International Journal of Cardiology 153 (2011) 317–322
3. management strategy using three forms of valsartan-based therapy) will
demonstrate greater BP control against their individualised BP target at
26 weeks follow-up post initiation of the VIPER-BP intervention, relative
toa controlgroup of patients exposed tousualcareforthemanagementof
their hypertension (as determined by baseline profiling using the same
type of scenario-based questionnaire described above).
4. Methods
4.1. GP Investigators
Based on the pilot survey of 500 Australian GPs, we estimated that a minimum of 250 GP
Investigators would be required to recruit an average target of 10 eligible patients during a
12–18 month recruitment period commencing in July 2009. During the active recruitment
phase of the study, information about the VIPER-BP Study was presented to more than 6000
GPs(including 4900mail-outs)throughout Australia.A total of620GPslocated in every State
and Territory of Australia (except the Northern Territory) initially registered their interest in
being a GP Investigator. After reviewing the full protocol and study requirements, 455 of
these GPs (72%) received a formal site initiation visit. Of these, just over half (272, 60%) of GPs
from 122 primary care clinics had formally entered at least one patient into the study at
November 2010. The greatest contribution of study patients came from GPs located in New
South Wales (around 40%) and Western Australia (around 20%). A total of 104 GPs (38%)
practice in a non-metropolitan area (N30 km from the CBD). A separate manuscript
describing the location, characteristics and indicative hypertension management of the
VIPER-BP GP Investigators is planned for the near future.
4.2. Participants
Primary care patients being managed by the VIPER-BP Study GP Investigators are eligible
to participate if they are: 1) aged 18 years or more; 2) determined to have hypertension
requiring active pharmacological treatment (based on current guidelines [1]) and; 3) consent
to participate. Key exclusion criteria include: 1) a mean sitting systolic BP≥180 mm Hg at
study visits1 or2; 2)currently prescribed three or moreanti-hypertensive agentstomaintain
an optimal BP; 3) history of severe renal disease and/or; 4) contra-indications to an
angiotensin receptor blocker, calcium channel blocker or a thiazide diuretic.
Ethics approval for the VIPER-BP Study was received from the Alfred Human
Research Ethics Committee, the Royal Australian College of General Practitioners and
the Australian Institute of Health and Welfare. Approval for GP Investigators to access
Medicare reimbursement for the gold-standard management of hypertension
(additional funding to support study activities was provided) and for Baker IDI to
access participant Medicare claims information was sought from Medicare Australia.
The ClinicalTrials.gov registry number for VIPER-BP is NCT00902304.
4.3. Design
Fig. 1 shows the overall design of the VIPER-BP Study. This is an open-label,
randomised trial comparing usual primary care with an intensive BP management
strategy, using three standardised forms of angiotensin receptor blocker-based therapy
(valsartan alone and in combination with a thiazide diuretic or calcium channel
blocker) to determine its impact on achieving a pre-designated individualised BP
target. At the point of study design, valsartan and its combinations (in a single pill) had
been newly approved under the Pharmaceutical Benefits Scheme for subsidised
prescriptions and offered the unique flexibility built into the combination arm of the
study. The study is being undertaken according to the CONSORT guidelines [18].
Blinded randomisation at a ratio of 1:2 (usual care versus intervention arm) is stratified
according to each patient's individualised BP target with block randomisation for each
GP Investigator. The increased ratio of intervention patients reflects randomisation to two
different strategies using valsartan-based therapies; initial mono therapy versus combination
therapy at a ratio of 1:2, further reflecting the availability of mono versus combination
therapies.
A standardised protocol for recording study BP measurements is applied. Specifically,
after an initial rest period of approximately 5 min, three systolic and diastolic BP
measurements separated by one-minute intervals, are obtained in the sitting position
using an appropriate size cuff and an automated BP monitor approved by the Therapeutic
Goods Administration of Australia. Aberrant readings are defined as those whereby the
difference between the lowest and highest of the three seated readings is ≥10 mm Hg
(systolic) or ≥5 mm Hg (diastolic). When this occurs, thepatient isrested for anadditional
3 min and another set of three readings are taken for study documentation.
As also shown in Fig. 1, all patients undergo baseline assessment of their absolute
CVD risk [19] and identification of their ideal risk factor levels (including their
individualised BP target according to the presence or absence of target organ damage
and/or established CVD [1]). Eligible patients then commence a standard 28 day run-in
period of treatment with open-label, oral valsartan 80 mg per day, with a mandatory BP
check 14 days after the initiation of treatment to determine the need for “rescue
randomisation” (if systolic BP is N180 mm Hg or clinically indicated). In addition to
standardising initial anti-hypertensive therapy, this phase of the study permits the
application of combination therapy at the point of randomisation. All other anti-
hypertensive treatments are ceased at the commencement of this run-in phase of the
study. Those who achieve their target BP at either their 14 or 28 day visit take no
further part in the study. If, however, BP remains sub-optimal after the 28-day run-in
period, patients are randomised to usual care or to the study intervention comprising an
intensive BP management strategy using titrated treatment regimens which include three
alternate forms of valsartan-based therapy (VIPER-BP intervention).
For those randomised to usual care (Group 1), GPs apply their usual pattern of patient
visitsandtreatmentstrategiestoachievetheirindividualisedBPtarget, withafinalstudyvisit
at week 26. Those randomised to the VIPER-BP intervention (Group 2) follow an intensive 6
to 18 week period of BP management (with a final study visit at week 26). Within Group 2,
patients are further randomised to treatment according to the following algorithms of open-
label, oral valsartan-based therapy: Group 2a (initial mono-therapy arm) — GPs initially
utilise valsartan 160 mg per day for 6 weeks, followed by (if required) dose titrations every
4 weeks thereafter until week 14 (valsartan 320 mg per day, then valsartan 320 mg plus
hydrochlorothiazide[HCTZ]12.5 mg perdayand thenvalsartan320 mg plus HCTZ25 mgper
day — maximal dose). For patients not at BP target at week 18 (after 4 weeks on the maximal
dose), triple or alternative therapy is considered for the remainder of the study follow-up
period; Group 2b (initial combination therapy arm) — GPs initially utilise single pill
combination products of either valsartan plus HCTZ or valsartan plus amlodipine for an initial
6 weeks of therapy (based on the treating GPs preference), with dose titrations (if required)
every 4 weeks thereafter until week 10. If the HCTZ combination is preferred, the schedule
followed isvalsartan 80 mg plus HCTZ 12.5 mg, then valsartan 160 mg plus HCTZ12.5 mg per
day, and then valsartan 160 mg plus HCTZ 25 mg per day (maximal dose). If the amlodipine
combination is chosen, the treatment strategy followed is valsartan 80 mg plus amlodipine
5 mg per day, valsartan 160 mg plus amlodipine 5 mg, and then valsartan 160 mg plus
amlodipine 10 mg — maximal dose. For those patients not at BP target at week 14 (after
4 weeks on the maximal dose of either regimen), triple or alternative therapy is considered
for the remainder of the study follow-up period.
4.4. Study endpoints
The primary endpoint is the percentage of patients randomised to the usual care
treatment group versus the VIPER-BP intervention treatment group who have achieved their
pre-specified (individualised NHFA criteria [1] — see Table 1) BP target at 26 weeks.
Secondary endpoints include change in mean sitting systolic and diastolic BP from baseline
(visit 4)to26 weeks(visit9),rateofadverseeventsattributabletoanti-hypertensivetherapy
and the proportion of “early responders” who achieve individualised BP control (recorded at
pre-specified study visits) after one or two adjustments in anti-hypertensive therapy. During
the 26 week follow-up period, changes in absolute CVD risk [19], health state [20], mental
health [21,22], evidence of end-organ damage, self-care and treatment compliance will also
be assessed. Major clinical end-points (at 26 weeks) are all-cause mortality and fatal and
non-fatal cardiovascular events (e.g. acute myocardial infarction, stroke and heart failure).
The proportion of patients (and GPs) who adhere to the VIPER-BP intervention (in respect to
drug titration and regular follow-up) will also be determined in addition to the potential
correlation between adherence to the intervention and degree of BP control.
4.5. Study power
We established a 7% absolute difference in individualised BP control at 26 weeks as
the minimum clinically significant difference between groups. Based on findings from
the literature [10], we anticipate that up to 12% difference (approximately 20% relative
difference when assuming a baseline rate of 50% control in the usual care arm of the
study) will be observed between groups. Given inherent uncertainties in the rate of
patient recruitment, the “conversion” of run-in to randomised patients and completion
of 26 week follow-up, a conservative approach to calculating the requisite sample size
was applied. Fig. 2 shows that assuming a two-sided alpha level of 0.05 and adjusting
for 2:1 randomisation for study intervention versus usual care, 1800 subjects who
complete 26 week follow-up will provide N80% power to detect a minimal 7% absolute
difference in BP control at 26 weeks on the basis that 50% of those allocated to usual
care are at their individualised target within this time point. In practice, we aim to
initially randomise up to 2250 subjects to achieve this target. However as demonstrated in
Fig. 2, a total of 1500–1800 subjects with complete follow-up will provide sufficient study
power to detect an 8–9% difference between groups at 85% study power.
5. Preliminary profile of study patients
By November 2010, a total of 2157 potentially eligible patients had
been subjected to initial screening. Of these, 1965 (91%) were entered into
the 28 day valsartan 80 mg “run-in” phase. Subsequently, 257 patients
achieved their individual BP target (13%) whilst at the other end of the
spectrum, 62 patients (3.2%) required a rescue randomisation for
markedly elevated BP. Of the remainder (n=361), 217 were still in the
run-in phase and 144 had prematurely withdrawn from the study; this
included 33 adverse events (1.7% of run-in patients) and two serious
adverse events. Thus, 1285 patients have been randomised to usual care
(n=435) or the VIPER-BP intervention (n=850). Of those randomised,
797 (62%) were male who were on average 3 years younger than female
patients (mean age 58±12 versus 61±12 years; pb0.05) and 63% (810)
had previous treatment for hypertension ceased at study run-in.
319S. Stewart et al. / International Journal of Cardiology 153 (2011) 317–322
4. Calculated BP targets (systolic/diastolic BP) were as follows: 125/75 mm
Hg (18% with proteinuria), 130/80 mm Hg (55% with diabetes or CVD)
and 140/90 mm Hg (27% without CVD or renal dysfunction). Mean
systolic and diastolic BP on randomisation was 148±15/88±11 mm Hg
with similar BP profiles for men and women respectively (148±15/88±
11 versus 148±18/87±10 mm Hg).
6. Discussion
To our knowledge, this study (incorporating a combined pharma-
cological and disease management approach to BP management using
computerised support) represents the largest of its kind in Australia
and indeed worldwide. Although there have been many large
Fig. 1. VIPER-BP study schema. Legend: GP, General Practitioner; CVD, cardiovascular disease; BP, blood pressure; NHFA, National Heart Foundation of Australia; HT, hypertension;
SBP, systolic blood pressure; Tx, treatment.
320 S. Stewart et al. / International Journal of Cardiology 153 (2011) 317–322
5. hypertension trials [14–16] with a major focus on the efficacy of
different combinations of pharmacological therapy (including the
ANBP2 Study in Australia [23]), there is a paucity of large-scale, multi-
centre studies combining pharmacological treatment with a structured
approach to management. As identified previously, there is sufficient
evidence to suggest that a step-wise, vigorous approach to the primary
care management of hypertension will provide improved BP control [10].
However, we have strong evidence, both from community-based studies
[3,4] and our direct survey of Australian GPs that a heterogeneous
approach to the management of hypertension has meant that the “rule of
halves” still applies; close to 50% of those treated for hypertension remain
hypertensive. Unfortunately, if we apply more rigorous BP targets to
prevent end-organ damage and subsequent morbidity and mortality [1],
such a treatment gap is likely to be wider. In support of a more aggressive
approach to hypertension management, results from both the VALUE
[14,16] and ACCOMPLISH [15] trials suggest there are potential
advantages to achieving BP control sooner and that early application of
combination therapies are more likely to achieve this goal.
There are many challenges when engaging extremely busy GPs to
undertake a clinical research program such as VIPER-BP, particularly
smaller GP clinics where the capacity to support additional research
activities is limited. This is compounded by our attempt to apply a more
structured and uniformed approach to BP management. In order to
streamline clinical management according to the study protocol and
provide GPs with a practical tool that is relevant beyond the study, we
developed and applied the Baker IDI CVD Risk Assessment and Management
Tool that provides computer-based profiling for individual patients. This
identifies their key primary and secondary prevention goals (where
appropriate) and recommends incremental anti-hypertensive therapy
according to the patient's BP. It is interesting to note that many of the
prerequisites for progressing through the study rely upon the type of
individual profiling inherent to current guidelines (e.g. lipid profile and
albumin–creatinine ratio) [1,19]. However, many patients recruited are
being profiled (via the assessment tool) in this way for the first time.
Recruitment rates thus far demonstrate that achieving the target number
of patients will be challenging, yet still attainable, whilst retaining
statistical power to examine the primary endpoint.
The VIPER-BP Study is an innovative study of intensive BP
management in primary care that combines the application of more
intensive and aggressive anti-hypertensive therapy with structured BP
management to more rapidly attain and sustain individualised BP targets
in otherwise hypertensive individuals. Preliminary data suggest that we
have recruited a representative cohort of Australian GPs with the capacity
to recruit a sufficiently large cohort of eligible patients. If the primary
endpoint analysis favours the studyintervention, the VIPER-BP Studymay
have profound implications for the primary care management of elevated
BP to reduce the enormous burden imposed by hypertension-related
disease (particularly chronic heart failure) in Australia [7] and other high
Table 1
Australian treatment targets for optimal BP management [1].
⁎ Specific lower BP targets have not been established for other high-risk groups (e.g.
those with peripheral arterial disease, those with familiar hypercholesterolemia or
those at high absolute risk of cardiovascular disease) due to the current lack of
evidence from clinical trials. Targets will be set when evidence becomes available.
Fig. 2. Projected power of the VIPER-BP Study (primary endpoint). Legend: The shaded area shows the predicted range of patients subject to complete 26-week follow-up for
determination of the primary endpoint. The star shows that 1750 patients with complete 26-week follow-up will provide an estimated study power of 85% to detect an 8% absolute
difference between groups (assuming a 2-sided alpha of 0.05).
321S. Stewart et al. / International Journal of Cardiology 153 (2011) 317–322
6. income countries where the population burden of chronic heart disease
remains the number one health priority [24]. It may also be applicable to
low-to-middle income countries [8,9] where effective primary care
management of hypertension may avert an epidemic of hypertensive
heart disease.
Acknowledgement
We gratefully acknowledge all GP Investigators for participating in
the VIPER-BP Study and thank the Study Nurse Coordinators for
assisting with recruitment, the scheduling of visits and completion of
study forms. We thank Karen Best, VIPER-BP Clinical Trial Manager,
and Astrid Cuncins-Hearn, Fiona Howard, Andrew Sloane and Mitch
Kirkman for overseeing the execution of the Study and for their site
liaison. Sincere thanks to Anny Tandyo, Malika Senaratna, Nerolie
Strickland, Ann Nadonza and the Data Management Centre at Baker IDI
for database design, data programming and the ongoing processing and
verification of study data.
The authors of this manuscript have certified that they comply
with the Principles of Ethical Publishing in the International Journal of
Cardiology [25].
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