Developing and evaluating non-invasive healthcare technologies for a group of female participants from a socioeconomically disadvantaged area.

When compared to the general population, socioeconomically disadvantaged communities frequently experience compromised health. Monitoring the divide is challenging since standardized biomedical tests are linguistically and culturally inappropriate. The aim of this study was to develop and test a unique mobile biomedical testbed based on non-invasive analysis, as well as to explore the relationships between the objective health measures and subjective health outcomes, as evaluated with the World Health Organization Quality of Life survey. The testbed was evaluated in a socioeconomically disadvantaged neighborhood in Malmö, which has been listed as one of the twelve most vulnerable districts in Sweden. The study revealed that compared to conventional protocols the less intrusive biomedical approach was highly appreciated by the participants. Surprisingly, the collected biomedical data illustrated that the apparent health of the participants from the ethnically diverse low-income neighborhood was comparable to the general Swedish population. Statistically significant correlations between perceived health and biomedical data were disclosed, even though the dependences found were complex, and recognition of the manifest complexity needs to be included in further research. Our results validate the potential of non-invasive technologies in combination with advanced statistical analysis, especially when combined with linguistically and culturally appropriate healthcare methodologies, allowing participants to appreciate the significance of the different parameters to evaluate and monitor aspects of health.

Telehealth: improving maternity services by modern technology.

Hypertension is considered one of the most common medical disorders causing complexities in pregnancy. It could be a newly developed pregnancy-induced hypertension (PIH) or a pre-existing hypertension developing into superimposed pre-eclamptic toxaemia. PIH affects approximately 10% of pregnancies and can have a serious impact on both maternal and fetal well-being; hence requires frequent monitoring and timely intervention. National Institute for Health and Care Excellence (NICE) guidelines recommends once or twice weekly monitoring of blood pressure for such patients. The required frequent monitoring comes with certain implications for patients and healthcare services. An average patient with PIH would need to see her healthcare provider once or twice a week until delivery and 6 weeks thereafter. This certainly increases pressure on limited National Health Service (NHS) resources. Home-based monitoring using Telehealth technology can represent a potential solution for achieving good-quality care for the patient without increasing the workload for healthcare providers. We used 'Florence', a text-based technology platform to support home monitoring. We tested its acceptability, feasibility and safety to replace face-to-face appointments for blood pressure monitoring in selected patients with PIH. We implemented our project in three progressive phases using a plan, do, study, act methodology. Florence, telehealth technology was used for blood pressure monitoring instead of face-to-face appointments, and the effect of this innovative technology on the services and the patient experience was studied and necessary modifications were made before progression into the next phase. We recruited 75 patients over 12 months through the progressive phases and replaced around 800 face-to-face appointments by remotely supervised monitoring sessions with Florence successfully, with improved care and patient satisfaction. We also achieved better compliance with the NICE guidelines for blood pressure monitoring in PIH. Our project concluded that Telehealth can be a potential solution for improving care in maternity services, with lesser burden on NHS resources.

Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring.

BACKGROUND: Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients. METHODS: The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure. RESULTS: Interrupted time series analysis of EHR orders (npre = 493; npost = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (npre = 263; npost = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported. CONCLUSIONS: A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.

A comparison of first trimester blood pressures obtained at the time of first trimester pre-eclampsia screening and those obtained during prenatal care visits.

OBJECTIVE: To determine if enrollment blood pressures in a study on first trimester preeclampsia prediction significantly differed from those obtained during routine prenatal care visits in the first trimester. STUDY DESIGN: Women carrying a singleton gestation were prospectively enrolled in a first trimester study on preeclampsia prediction, and had systolic and diastolic blood pressure (SBP, DBP) measured at the time of enrollment. Blood pressure was also measured with the same technique by clinic nurses during the routine prenatal visits throughout the first trimester of pregnancy (9-14 weeks). The enrollment-BP (E-BP) and average first trimester-BP (aFT-BP) were compared using a paired samples t-test or Wilcoxon test, as appropriate. Smokers and patients on antihypertensive medications were excluded from the analysis. test. RESULTS: 644 women had prenatal care in the primary study center and met study criteria. The mean gestational age at study enrollment was 12.5 weeks. No significant difference was found between E-SBP and aFT-SBP (p = 0.10). Enrollment DBP and mean arterial pressure (MAP) were significantly lower than the aFT- DBP and -MAP (median DPB 67 vs 70 mm Hg and median MAP 83.7 vs 85 mmHg, respectively, p < 0.001). However, the difference was not clinically relevant (3 mmHg for DBP, and 1.3 mmHg for MAP). CONCLUSIONS: Blood pressures obtained in a setting of preeclampsia screening are not higher than those obtained during regular prenatal care in the first trimester. This suggests that the setting in which pre-eclampsia screening is performed is unlikely to be a confounder for blood pressure measurements and the risk assessment.

Validation of clinical prediction models: what does the "calibration slope" really measure?

BACKGROUND AND OBJECTIVES: Definitions of calibration, an aspect of model validation, have evolved over time. We examine use and interpretation of the statistic currently referred to as the calibration slope. METHODS: The history of the term "calibration slope", and usage in papers published in 2016 and 2017, were reviewed. The behaviour of the slope in illustrative hypothetical examples and in two examples in the clinical literature was demonstrated. RESULTS: The paper in which the statistic was proposed described it as a measure of "spread" and did not use the term "calibration". In illustrative examples, slope of 1 can be associated with good or bad calibration, and this holds true across different definitions of calibration. In data extracted from a previous study, the slope was correlated with discrimination, not overall calibration. Many authors of recent papers interpret the slope as a measure of calibration; a minority interpret it as a measure of discrimination or do not explicitly categorise it as either. Seventeen of thirty-three papers used the slope as the sole measure of calibration. CONCLUSION: Misunderstanding about this statistic has led to many papers in which it is the sole measure of calibration, which should be discouraged.

Nurses' and patients' experiences and preferences of the ankle-brachial pressure index and multi-site photoplethysmography for the diagnosis of peripheral arterial disease: A qualitative study.

Peripheral arterial disease is a global health problem, affecting around 20% of people aged over 60 years. Whilst ankle-brachial pressure index (ABPI) is regularly used for diagnosis, it has a number of limitations, which have presented a need for alternative methods of diagnosis. Multi-site photoplethysmography (MPPG) is one such method, but evidence of acceptability of both methods is lacking. This study aims to describe and compare preferences and experiences amongst nurses and patients of ABPI and MPPG use in primary care. We used qualitative research methods in the context of a clinical diagnostic study comparing ABPI with MPPG. Use of ABPI and MPPG by 13 nurses were observed with 51 patients across general practice surgeries in North-East England in 2015/16. Follow-up semi-structured interviews were conducted with 12 nurses and 27 patients. Data were thematically analysed. Two major themes were identified: (1) device preferences; (2) test discomfort and anxiety. There was a compelling preference for MPPG due to ease of use, speed of the test, patient comfort, and perceived device accuracy/objectivity. However some patients struggled to identify a preference, describing ambivalence to medical testing. ABPI was deemed uncomfortable and painful, particularly when the blood pressure cuff was inflated at the lower limbs. There was also evidence of anxiety amongst patients when their foot pulses were not identified using ABPI. Whilst ABPI is a non-invasive and routine procedure it was associated with a number of drawbacks in clinical practice. Nurses required considerable dexterity to employ the test, and it resulted in anxiety amongst some patients. Conversely, MPPG was deemed to be easier and quicker to use, and perceived to be less subjective. Should diagnostic accuracy and cost be comparable to ABPI, then the findings of this study suggest MPPG would be preferable to ABPI for patients as well as nurses.

Using the immediate blood pressure benefits of exercise to improve exercise adherence among adults with hypertension: a randomized clinical trial.

BACKGROUND: A single exercise session evokes immediate blood pressure (BP) reductions that persist for at least 24 h, termed postexercise hypotension (PEH). Self-monitoring of PEH may foster positive outcome expectations of exercise, and thus, enhance exercise adherence among adults with hypertension. PURPOSE: To compare the efficacy of self-monitoring of exercise (EXERCISE) versus exercise and PEH (EXERCISE + PEH) to improve exercise adherence and BP control among adults with hypertension. METHODS: Adults with high BP were randomized to EXERCISE (n = 12) or EXERCISE + PEH (n = 12). Participants underwent supervised, moderate intensity aerobic exercise training for 40-50 min/session, 3 days/week for 12 weeks and encouraged to exercise unsupervised at home at least 30 min/day, 1-2 days/week. EXERCISE + PEH also self-monitored BP before and after exercise. Adherence was calculated as [(no. of exercise sessions performed/no. of possible exercise sessions) × 100%]. BP was measured pre and posttraining. RESULTS: Healthy, middle-aged (52.3 ±â€Š10.8 years) men (n = 11) and women (n = 13) with hypertension (136.2 ±â€Š10.7/85.2 ±â€Š8.9 mmHg) completed exercise training with 87.9 ±â€Š12.1% adherence. EXERCISE + PEH demonstrated greater adherence to supervised training (94.3 ±â€Š6.6%) than EXERCISE (81.6 ±â€Š13.2%; P = 0.007). EXERCISE + PEH performed 32.6 ±â€Š22.5 min/week more unsupervised home exercise than EXERCISE (P = 0.004), resulting in greater exercise adherence (107.3 ±â€Š18.7%) than EXERCISE (82.7 ±â€Š12.2%; P = 0.002). Post versus pretraining BP was reduced -7.4 ±â€Š11.3/-4.9 ±â€Š9.9 mmHg (P < 0.025) with no statistical difference between EXERCISE (-5.2 ±â€Š13.3/-3.6 ±â€Š6.1 mmHg) and EXERCISE + PEH (-9.9 ±â€Š11.3/-6.1 ±â€Š6.9 mmHg; P > 0.344). CONCLUSION: The current study is the first to demonstrate that PEH self-monitoring is an efficacious tool to improve exercise adherence among a small sample of adults with hypertension. Future research among a larger, more diverse sample is needed to confirm these novel findings and determine whether EXERCISE + PEH translates to better BP control relative to EXERCISE self-monitoring alone.

Clinician accountability in a primary care clinic time-interval blood pressure measurements study: Practice implications.

BACKGROUND: Accurate blood pressure measurements (BPM) are important, as clinicians are tasked daily with using such measurements to make clinical diagnoses and patient care judgments. Research studies and controlled trials hold such measurements to a higher standard than everyday clinical practice. OBJECTIVE: The aim of this study was to evaluate difference in BPM outcomes of individuals in a clinic setting when clinicians collect BPM as usual vs BPM after 5- (USPSTF recommendation) and 10- minute (study unique intervention) timed rest interval. METHODS: A repeated-measures design was used to examine individual BPMs at the intervals of baseline, after a 5-minute rest interval post-baseline, and after a 10-minute rest interval post-baseline. Results Pairwise comparisons indicated that baseline SBP was the highest when compared to SBP measured at both 5- and 10-minutes post-baseline. SBP measured at 5-minutes was also significantly higher compared to SBP collected at 10-minutes post-baseline (ps < .05). For DBP, the repeated-measures ANOVA indicated that there was no significant difference across BPMs, F(2,198) = 1.25, p = .29. CONCLUSIONS: Results from this study revealed that implementing a 5-minute rest interval before BPMs are taken in a clinic setting produces a "clinically observable" reduction in the overall mean systolic BPs as seen at both 5- and 10-minute BPM intervals. It is important for all healthcare clinicians to recognize the importance of accurate BPM and the need to encourage better regulated BPM standard in everyday practice.

Patient experience of home and waiting room blood pressure measurement: a qualitative study of patients with recently diagnosed hypertension.

BACKGROUND: Out-of-office blood pressure (BP) measurement is advocated to confirm hypertension diagnosis. However, little is known about how primary care patients view and use such measurement. AIM: To investigate patient experience of out-of-office BP monitoring, particularly home and practice waiting room BP measurement, before, during, and after diagnosis. DESIGN AND SETTING: A cross-sectional, qualitative study with patients from two UK GP surgeries participating in a feasibility study of waiting room BP measurement. METHOD: Interviewees were identified from recent additions to the practice hypertension register. Interviews were recorded, transcribed, and coded thematically. RESULTS: Of 29 interviewees, 9 (31%) and 22 (76%) had used the waiting room monitor and/or monitored at home respectively. Out-of-office monitoring was used by patients as evidence of control or the lack of need for medication, with the printed results slips from the waiting room monitor perceived to improve 'trustworthiness'. The waiting room monitor enabled those experiencing uncertainty about their equipment or technique to double-check readings. Monitoring at home allowed a more intensive and/or flexible schedule to investigate BP fluctuations and the impact of medication and lifestyle changes. A minority used self-monitoring to inform drug holidays. Reduced intensity of monitoring was reported with both modalities following diagnosis as initial anxiety or patient and GP interest decreased. CONCLUSION: Home and practice waiting room measurements have overlapping but differing roles for patients. Waiting room BP monitors may be a useful out-of-office measurement modality for patients unwilling and/or unable to measure and record their BP at home.

Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services.

BACKGROUND: Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. "Virtual visits" are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit. OBJECTIVE: To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care. DESIGN: Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences. PARTICIPANTS: Primary care patients with hypertension. EXPOSURE: Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension. MAIN MEASURES: Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit. KEY RESULTS: Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140-160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, - 2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, - 0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]). CONCLUSIONS: Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

Biochemical Screening for Nonadherence Is Associated With Blood Pressure Reduction and Improvement in Adherence.

We hypothesized that screening for nonadherence to antihypertensive treatment using liquid chromatography-tandem mass spectrometry-based biochemical analysis of urine/serum has therapeutic applications in nonadherent hypertensive patients. A retrospective analysis of hypertensive patients attending specialist tertiary care centers was conducted in 2 European countries (United Kingdom and Czech Republic). Nonadherence to antihypertensive treatment was diagnosed using biochemical analysis of urine (United Kingdom) or serum (Czech Republic). These results were subsequently discussed with each patient, and data on follow-up clinic blood pressure (BP) measurements were collected from clinical files. Of 238 UK patients who underwent biochemical urine analysis, 73 were nonadherent to antihypertensive treatment. Their initial urinary adherence ratio (the ratio of detected to prescribed antihypertensive medications) increased from 0.33 (0-0.67) to 1 (0.67-1) between the first and the last clinic appointments. The observed increase in the urinary adherence ratio in initially nonadherent UK patients was associated with the improved BP control; by the last clinic appointment, systolic and diastolic BPs were ≈19.5 and 7.5 mm Hg lower than at baseline (P=0.001 and 0.009, respectively). These findings were further corroborated in 93 nonadherent hypertensive patients from Czech Republic-their average systolic and diastolic BPs dropped by ≈32.6 and 17.4 mm Hg, respectively (P<0.001), on appointments after the biochemical analysis. Our data show that nonadherent hypertensive patients respond to liquid chromatography-tandem mass spectrometry-based biochemical analysis with improved adherence and significant BP drop. Such repeated biochemical analyses should be considered as a therapeutic approach in nonadherent hypertensive patients.

White coat effect in hypertensive patients: the role of hospital environment or physician presence.

This study was to evaluate the role of hospital environment or physician presence for white coat effect (WCE) in hypertensive patients. At first, 54 hypertensive outpatients diagnosed on office blood pressure (OBP) were included for 2-week placebo run in. During the second week of the run in period, home BP was measured using electronic BP monitors for 5-7 days. Finally, 26 sustained hypertensive patients with home systolic BP/diastolic BP over 135/85 (but <180/110) mm Hg were enrolled for 8-week treatment of nifedipine controlled-release tablet. In the visit day, BP was measured by patient-self (OBP-p) or by doctor (OBP-d) according to order determined with randomization method. The self-BP measurement was performed in a reception room of hospital. The differences between home BP and OBP-d or OBP-p were calculated as WCE calculated on doctor-measurement (WCE-d) or WCE calculated on patient-measurement (WCE-p), respectively. The home and OBP were measured with the same BP device for each patient during the study period. In the total 54 outpatients received placebo, the WCE-d was similar to the WCE-p (for systolic BP 6.6 ± 14.4 vs. 6.8 ± 15.8 mm Hg, NS; for diastolic BP 3.3 ± 8.8 vs. 2.9 ± 9.2 mm Hg, NS). Meanwhile, the 26 sustained hypertensive patients had similar systolic WCE-d and WCE-p (4.8 ± 10.3 vs. 5.0 ± 12.2 mm Hg, NS) at placebo stage. Similarly, these values were comparable (3.0 ± 14.0 vs. 2.2 ± 14.4 mm Hg, NS) in treatment stage. Hospital environment plays a main role for the WCE in hypertensive patients.

Changing work stressors and coping resources influence blood pressure and hypertension incidence in a large OHSPIW cohort.

Psychosocial work environments may adversely influence blood pressure, but the benefits of altering these factors and introducing coping resources is unclear. We examined whether changing work stressors and coping resources affect the risk of hypertension and elevated BP. A total of 13,145 workers from the Occupational Health Study of Petroleum Industry Workers were included in this study. A baseline evaluation of work-related stress and coping resources was followed up in all participants after 12 years. The changes in task stressors and coping resources were measured using the Occupation Stress Inventory-Revised Edition, and changes in job control and organizational stressors were evaluated using the Instrument for Stress-Related Job Analysis (v. 6.0). Elevated hypertension incidence and BP were associated with increased task and organizational stressors, together with decreased job control and reduced coping resources. Gender-specific differences were observed in the factors influencing BP. The main risk factor was decreased self-care in males (3.11 mm Hg) and increased responsibility in females (2.84 mm Hg). The present study demonstrated that promoting such factors at the task-, individual-, and organizational level may help improve cardiovascular health.

Integrating Out-of-Office Blood Pressure in the Diagnosis and Management of Hypertension.

Guidelines for the diagnosis and monitoring of hypertension were historically based on in-office blood pressure measurements. However, the US Preventive Services Task Force recently expanded their recommendations on screening for hypertension to include out-of-office blood pressure measurements to confirm the diagnosis of hypertension. Out-of-office blood pressure monitoring modalities, including ambulatory blood pressure monitoring and home blood pressure monitoring, are important tools in distinguishing between normotension, masked hypertension, white-coat hypertension, and sustained (including uncontrolled or drug-resistant) hypertension. Compared to in-office readings, out-of-office blood pressures are a greater predictor of renal and cardiac morbidity and mortality. There are multiple barriers to the implementation of out-of-office blood pressure monitoring which need to be overcome in order to promote more widespread use of these modalities.

Blood pressure profile in pregnancy: The impact of its duration on results and patients' well-being.

BACKGROUND: A blood pressure profile (BPP) is often used to diagnose and manage hypertension in pregnancy. However, there is no consensus on the number and interval of blood pressure (BP) readings required. AIMS: To ascertain whether BP readings at 15-min interval over one hour yields clinically equivalent results to readings at 60-min interval over three hours. MATERIALS AND METHODS: Eighty unique women were recruited to this prospective study. Automated BP machines were used to take readings at 15-min interval over one hour and at 60-min interval over three hours. The mean systolic and diastolic BPs obtained using each regimen were calculated and compared. Women also completed a questionnaire to evaluate the psychosocial and financial impact of a prolonged outpatient investigation. RESULTS: BP readings from 67 patients were included for analysis. Clinical equivalence was assessed using the British Hypertension Society (BHS) validation criteria for comparing nonmercury devices to the gold-standard calibrated mercury device. Mean SBP readings for 54% (36/67), 90% (60/67) and 97% (65/67) and mean DBP readings for 73% (49/67), 94% (63/67) and 100% (67/67) were within 5, 10 and 15 mmHg agreement across the two time regimens which achieved grade B and grade A validation, respectively. A BPP was costly and stressful for women and affected their ability to attend work and look after other children. CONCLUSIONS: A BPP performed over one hour compared to over three hours yields clinically equivalent results, yet has psychosocial and financial advantages.

Comparison of Acceptability of Traditional and Novel Blood Pressure Measurement Methods.

BACKGROUND: Blood pressure (BP) monitor technology has developed significantly over the past years with the introduction of smaller and quieter home and ambulatory monitors that can both measure BP at night. The acceptability of different BP measurement methods using modern monitors is currently unknown. The purpose of this study was to compare patients' acceptability of traditional and novel BP measurement methods using up-to-date monitors. METHODS: A population sample of 223 participants underwent 4 office measurements on 2 occasions, a 24-hour ambulatory monitoring and 4 home measurements on 7 consecutive days with home nighttime (home-night) measurements on 2 nights. The acceptability of each method was evaluated with a questionnaire. Analysis of variance with post hoc Bonferroni correction was used to compare mean acceptability scores. RESULTS: Mean acceptability score, with a lower score indicating better acceptability, decreased from ambulatory (3.11±0.93) to home-night (2.74±0.81) to home (2.20±0.70) to office (1.95±0.63) measurements (P < 0.001 for all between-method comparisons). The largest between-method differences were observed in comfort of use and disturbance of everyday activities (P < 0.001). 73.1%, 31.8%, 1.3%, and 2.2% rated office, home, home-night, and ambulatory measurements as the most acceptable method, respectively. CONCLUSIONS: In the general population and under a research setting, office BP measurement was the method most preferred by the participants while home measurement was the second most preferred. Home-night measurement was slightly more preferred than ambulatory monitoring. However, before home-night BP measurement can be widely promoted as an alternative method for measuring nighttime BP, more evidence of its prognostic significance is needed.

Could Blood Pressure Phobia Go Beyond the White Coat Effect?

BACKGROUND: While it is known that excessive anxiety surrounding the measuring of blood pressure may preclude an accurate measurement, it is not known whether it could also lead to phobic avoidance behavior. METHODS: Self-reported information was collected on 125 individuals who made postings on 5 internet-based medical forums. RESULTS: Qualitative thematic analysis revealed that these individuals reported experiencing intense fear associated with the measuring of blood pressure, that was excessive or irrational and which contributed to avoidance of medical treatment and interference with life decisions. CONCLUSIONS: Based on these preliminary observations, we are speculating that these symptoms could be considered consistent with a diagnosis of a Specific Phobia. Investigations using quantitative methods, representative samples, and standardized clinical instruments need to be conducted before definitive conclusions can be reached.