Disciplinary power on daily practices of nurses and physicians in the hospital.

To understand power relations, it is important to consider that power is an attribute, and whoever has it at a given moment is in the condition of dominant and whoever is under its exercise is dominated. Moreover, we must consider that these positions are interchangeable, changing when relations of force change. Power relations represent the pursuit of supremacy through knowledge, with struggles for better positioning in the social structure. In this study, we analyze the effects of disciplinary power on daily practices of nurses and physicians in the hospital environment, more specifically in intensive care units. From the perspective of disciplines, power is exercised in a discreet, modest, calculated and permanent way, through the establishment of rules and norms. In this context, despite the strong appreciation of a medical-centered model, it is observed that nurses gain visibility through knowledge and the defense of institutional norms and rules, which can generate tensions in daily professional practices.

Development of a hidradenitis suppurativa patient decision aid.

BACKGROUND: Patient decision aids (PDAs) are tools that facilitate informed shared decision-making between patients and health care providers. To address a previously identified need in treatment decision-making in hidradenitis suppurativa (HS), we developed an HS-PDA. METHODS: Development of the HS-PDA was based on International Patient Decision Aids Standards. Evidence was derived from the North American Clinical Management Guidelines for HS. RESULTS: Content from guidelines was transformed into patient-friendly language and reviewed by three physicians and two patient representatives. Feedback on HS-PDA content, presentation and practicality was obtained from 7 HS patients and 5 physicians. Revisions were made following thematic analysis. All patients felt the content on treatment options contained the right amount of information and 5 found it helpful to see these options contextualized to their values. Each stated they would use the HS-PDA during treatment decision-making. Three and four physicians respectively indicated the content was accurate and language was patient-friendly. LIMITATIONS: Small sample sizes may limit generalizability. CONCLUSION: This HS-PDA was developed in accordance with international standards based on current HS guidelines with input from patients and physicians. It is available online without cost.

MEthods of ASsessing blood pressUre: identifying thReshold and target valuEs (MeasureBP): a review & study protocol.

Despite progress in automated blood pressure measurement (BPM) technology, there is limited research linking hard outcomes to automated office BPM (OBPM) treatment targets and thresholds. Equivalences for automated BPM devices have been estimated from approximations of standardized manual measurements of 140/90 mmHg. Until outcome-driven targets and thresholds become available for automated measurement methods, deriving evidence-based equivalences between automated methods and standardized manual OBPM is the next best solution. The MeasureBP study group was initiated by the Canadian Hypertension Education Program to close this critical knowledge gap. MeasureBP aims to define evidence-based equivalent values between standardized manual OBPM and automated BPM methods by synthesizing available evidence using a systematic review and individual subject-level data meta-analyses. This manuscript provides a review of the literature and MeasureBP study protocol. These results will lay the evidenced-based foundation to resolve uncertainties within blood pressure guidelines which, in turn, will improve the management of hypertension.

Impact of choosing the closest rather than the mean auscultatory blood pressure value on the European Society of Hypertension International Protocol device validation results.

OBJECTIVE: When calculating the difference between alternating auscultatory reference standard (ARS) and the automated device-under-test (DUT) blood pressure (BP) measurements, the European Society of Hypertension International Protocol (ESH-IP) allows investigators to choose the closest ARS value to the DUT value, rather than using the mean of the ARS readings [which is mandated by the International Organization for Standardization (ISO)]. The impact of this rule on ESH-IP validation study results is unknown and was assessed. DESIGN AND METHODS: Nine alternating BP measurements performed according to the ISO protocol were obtained in 94 subjects. The impact of using the closest rather than the mean ARS reading on mean error, SD of the difference, and proportion of readings with DUT-ARS differences within 5, 10, and 15 mmHg was determined. RESULTS: Mean age was 58.6 ± 18.3 years, screening BP was 126.4/77.7 mmHg, and arm circumference was 32.0 ± 4.7 cm. DUT-ARS difference was 0.0 ± 5.3/-0.5 ± 5.0 mmHg using the closest ARS and -0.2 ± 6.5/-0.7 ± 5.9 mmHg using the mean ARS. When using the closest rather than the mean ARS value, the proportion of systolic readings with absolute DUT-ARS differences ≤5 mmHg was 73% (vs. 60% for the mean ARS method), ≤10 mmHg was 93% (vs. 88%), and ≤15 mmHg was 99% (vs. 98%). Corresponding values for diastolic BP were 73% (vs. 62%) for differences ≤5 mmHg, 94% (vs. 91%) for ≤10 mmHg, and 99% (vs. 99%) for ≤15 mmHg. CONCLUSION: Using the closest rather than the mean ARS value results in more favourable validation study results and increases likelihood of passing.

Impact of a hidradenitis suppurativa patient decision aid on treatment decision making: A randomized controlled trial.

BACKGROUND: Patient decision aids are tools that facilitate shared decision making when clinical evidence and patient values and preferences inform the process. Evidence-based guidelines have been developed for clinicians in hidradenitis suppurativa management. To address treatment decision-making needs of hidradenitis suppurativa patients, we developed a hidradenitis suppurativa patient decision aid. OBJECTIVE: To assess the efficacy of the hidradenitis suppurativa patient decision aid during treatment decision making. METHODS: An online, participant-blinded, parallel-group, randomized controlled trial of the hidradenitis suppurativa patient decision aid versus Mayo Clinic hidradenitis suppurativa website content (Mayo) was conducted with hidradenitis suppurativa patients. Outcomes were knowledge, decisional conflict, and preparation for decision making. RESULTS: Forty participants fulfilled inclusion criteria and were randomized to hidradenitis suppurativa patient decision aid or Mayo. In the hidradenitis suppurativa patient decision aid group, data from 16 and 15 participants were analyzed at phases 1 and 2, respectively. In the Mayo group, data from 15 and 13 participants were analyzed at phases 1 and 2, respectively. Increased knowledge (P < .01) and preparation for decision making (P < .01), as well as reduced decisional conflict (P < .01), were observed in the hidradenitis suppurativa patient decision aid compared with the Mayo group. LIMITATIONS: The online methodology and recruitment from online hidradenitis suppurativa support groups limits generalizability of findings. CONCLUSION: A hidradenitis suppurativa patient decision aid increased knowledge and preparation for decision making and reduced decisional conflict.

Recognition and management of hypertension by nurses: action in patients with diabetes is critical.

The Canadian Hypertension Education Program (CHEP), Canadian Hypertension Society, Blood Pressure Canada, Canadian Diabetes Association, College of Family Physicians of Canada, Canadian Pharmacists Association, Heart and Stroke Foundation of Canada, and the Canadian Council of Cardiovascular Nurses issued a recent call for all health care professionals in Canada to double their efforts to assist patients with diabetes in maintaining target blood pressures (Campbell et al., 2009b). Blood pressure (B/P) in diabetic individuals should be less than 130 mmHg systolic and less than 80 mmHg diastolic (CHEP 2009). Considering recognition and treatment of hypertension in people with diabetes can result in reductions in disability and death, control of hypertension must become an interdisciplinary priority. Maintaining B/P less than 130/80 mmHg requires lifestyle modification as the cornerstone to treatment and often two or more B/P medications (Campbell et al., 2009a). The cost of multiple drugs required for B/P control in diabetic individuals is one of the few treatments estimated to reduce overall health costs and related cardiovascular disease complications (Gillies, Abrams, & Lambert, 2007). Nurses are essential partners in assessing and assisting diabetic patients and all patients with hypertension to reduce overall cardiovascular risks. Nurses may also be key practitioners in assessing and monitoring patient difficulties with adherence to lifestyle or pharmacological interventions (Jayasinghe, 2009; McLean et al., 2008). Individualized lifestyle counselling and treatment modification are recommended to maintain target B/P and treat dysglycemia, dyslipidemia, smoking or any other cardiovascular risks in diabetic individuals.

Accuracy of oscillometric blood pressure algorithms in healthy adults and in adults with cardiovascular risk factors.

BACKGROUND: Fixed-ratio and slope-based algorithms are used to derive oscillometric blood pressure (BP). However, a paucity of published data exists assessing the accuracy of these methods. Our objective was to determine the accuracy of fixed-ratio and slope-based algorithms in healthy adults and in adults with cardiovascular risk factors. PATIENTS AND METHODS: Overall, 85 healthy adults (age≥18 years) and 85 adults with cardiovascular risk factors were studied. Three oscillometric and four two-observer mercury-based auscultation measurements were performed in each, according to International Standards Organization 2013 methodology. Two fixed-ratio algorithms and one slope-based algorithm were applied to process oscillometric waveform envelopes and derive oscillometric BP. Paired and unpaired t-tests were used to compare mean oscillometric BP within and between each group, respectively. RESULTS: For healthy adults, mean age was 50.3±17.8 years, mean arm circumference was 30.4±3.8 cm, and 62% were female. In the cardiovascular risk group, mean age was 63.8±12.4 years, mean arm circumference was 31.9±4.2 cm, and 62% were female. For systolic BP, the fixed-ratio algorithms produced the lowest mean error and narrowest SD. For diastolic BP, mean errors were similar for all three algorithms, but the fixed-ratio algorithms had higher precision. The comparison of healthy adults and those with cardiovascular risk factor showed high variability for systolic and diastolic BP (SD: 8.113.9 mmHg). CONCLUSION: In both healthy adults and in those with cardiovascular risk factors, the fixed-ratio technique performed better than the slope-based algorithm. High between-group variability indicates that subject-specific algorithms may be needed.

Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.

Nurses managing high blood pressure in patients with diabetes in community pharmacies.

Physicians in the Edmonton, Alberta, area may soon have some help in identifying and managing blood pressure. The study SCRIP-HTN aims to evaluate the effect of a community-based nurse and pharmacist active screening team on blood pressure management in patients with diabetes. The primary outcome measure is blood pressure change over six months. As of March 2007, this randomized control trial has been completed and is currently being analyzed. Recent studies suggest that as few as one in eight people with diabetes have their blood pressure controlled (McLean, Simpson, McAlister, & Tsuyuki, 2006b), and that one of the major barriers to control is that patients simply do not see their physician (Hutchison, Abelson, Woodward, & Norman, 1996). Nurses have the knowledge, skills and caring, as well as breadth and diversity to contribute to client care management of hypertension. Nurses are often a critical conduit of high-quality health information within their families, neighbourhoods and communities. Nurses have an excellent opportunity to proactively affect the care and outcomes of patients with diabetes that are hypertensive.

2007 Hypertension Education Program (CHEP) recommendations: management of hypertension by nurses.

Recent data from the World Health Organization (WHO) indicate that nearly one billion people in the world are suffering from hypertension. Forecasts suggest that, with the aging of the population, this number could reach 1.5 billion by 2025 (Kearney, Whelton, & Reynolds, 2005). In developed countries, more than one in five adults have hypertension (Vasan, Beiser, Seshadri, Larson, Kannel, & D'Agostino, 2002). Statistics for Canada reveal that fewer than 15% of those diagnosed with hypertension are adequately controlled (Joffres, Hamet, MacLean, L'italien, & Fodor, 2001). Part of the effort to improve hypertension detection, assessment and treatment is an annual process to produce and update evidence-based recommendations for the management of hypertension and to implement the recommendations (Zarnke, Campbell, McAlister, & Levine, 2000; Campbell, Nagpal, & Drouin, 2001). The most up-to-date 2007 Canadian recommendations for the assessment and management of hypertension are presented. Contemporary nursing practice requires that nurses take responsibility and a role in the primary prevention, detection and treatment of hypertension.

Should patients with higher blood pressure variability be excluded from validation studies? An assessment of the '12/8' rule.

To limit the inclusion of participants with increased blood pressure (BP) variability and presumably to avoid potential bias, the International Standards Organization BP device validation standard recommends exclusion of patients with a BP variability of more than 12/8 mmHg across reference readings. This '12/8 rule' is based on expert consensus and lacks empirical justification. In a post-hoc analysis of a study comparing two types of cuff designs carried out according to the International Standards Organization standard, we divided the study sample into patients who did not have (n=79) and patients who had (n=55) more than 12/8 mmHg variability. Patients with more than 12/8 mmHg variability were older and had a higher prevalence of diabetes (41.8 vs. 22.8%; P=0.02) and hypertension (43.6 vs. 29.1%; P=0.08). The mean systolic BP differences between the two cuff designs were not significantly different in participants who did not show more than 12/8 mmHg variability versus those who did (2.2±3.5 vs. 3.1±3.4; mean difference of differences -0.9±3.4; P=0.14). Similarly, the mean diastolic BP differences were not significantly different in participants who did not have more than 12/8 mmHg variability versus those who did (1.5±2.2 vs. 1.4±2.6; mean difference of differences 0.1±2.4; P=0.82). A limitation of our analysis is that the original study data focused on a comparison of different cuff designs and not formal validation of a specific device. Therefore, replication of these findings is warranted. Nevertheless, our findings do not support the use of the 12/8 rule and indicate that this rule may be promoting unnecessarily homogenous study samples, limiting external generalizability, and needlessly increasing workload and expense.

An Assessment of the Accuracy of Home Blood Pressure Monitors When Used in Device Owners.

OBJECTIVE: To examine the accuracy of home blood pressure (BP) devices, on their owners, compared to auscultatory reference standard BP measurements. METHODS: Eighty-five consecutive consenting subjects ≥18 years of age, who owned an oscillometric home BP device (wrist or upper-arm device), with BP levels between 80-220/50-120 mm Hg, and with arm circumferences between 25-43 cm were studied. Pregnancy and atrial fibrillation were exclusion criteria. Device measurements from each subject's home BP device were compared to simultaneous 2-observer auscultation using a mercury sphygmomanometer. Between-group mean comparisons were conducted using paired t-tests. The proportion of patients with device-to-auscultatory differences of ≥5, 10, and 15 mm Hg were tabulated and predictors of systolic and diastolic BP differences were identified using linear regression. RESULTS: Mean age was 66.4 ± 11.0 years, mean arm circumference was 32.7 ± 3.7 cm, 54% were female and 78% had hypertension. Mean BPs were 125.7 ± 14.0/73.9 ± 10.4 mm Hg for home BP devices vs. 129.0 ± 14.7/72.9 ± 9.3 for auscultation (difference of -3.3 ± 7.3/0.9 ± 6.1; P values <0.0001 for systolic and 0.17 for diastolic). The proportion of devices with systolic or diastolic BP differences from auscultation of ≥5, 10, and 15 mm Hg was 69%, 29%, and 7%, respectively. Increasing arm circumference was a statistically significant predictor of higher systolic (parameter estimate 0.61 per cm increase; P value 0.004) and diastolic (0.38; 0.03) BP. CONCLUSIONS: Although mean differences from 2-observer auscultation were acceptable, when tested on their owners, most home BP devices were not accurate to within 5 mm Hg. Ensuring acceptable accuracy of the device-owner pairing should be prioritized.

Hypertension in Russia: Changes Observed After 4 Years of a Comprehensive Health System Improvement Program in the Yaroslavl Region.

Rates of cardiovascular mortality and morbidity in Russia have been among the highest in Europe. A comprehensive health system improvement program targeting better diagnosis and control of hypertension was undertaken in the Yaroslavl Region of Russia. This initiative was a joint program between clinicians, the Department of Health and Pharmacy of the Yaroslavl Region, and Novartis Pharma LLC. From 2011 to 2014, the blood pressure control rate improved substantially (94% relative improvement), the percentage of patients with a systolic blood pressure ≥180 mm Hg decreased (from 10% to 5%), and there was a reduction in stroke incidence rate from 4.6 to 3.7 per 1000 population. During this same period, significant changes were made to the way hypertension was diagnosed and treated across all regional government polyclinics, and the use of antihypertensive therapies increased.

Hypertension management research priorities from patients, caregivers, and healthcare providers: A report from the Hypertension Canada Priority Setting Partnership Group.

Patient- and stakeholder-oriented research is vital to improving the relevance of research. The authors aimed to identify the 10 most important research priorities of patients, caregivers, and healthcare providers (family physicians, nurses, nurse practitioners, pharmacists, and dietitians) for hypertension management. Using the James Lind Alliance approach, a national web-based survey asked patients, caregivers, and care providers to submit their unanswered questions on hypertension management. Questions already answered from randomized controlled trial evidence were removed. A priority setting process of patient, caregiver, and healthcare providers then ranked the final top 10 research priorities in an in-person meeting. There were 386 respondents who submitted 598 questions after exclusions. Of the respondents, 78% were patients or caregivers, 29% lived in rural areas, 78% were aged 50 to 80 years, and 75% were women. The 598 questions were distilled to 42 unique questions and from this list, the top 10 research questions prioritized included determining the combinations of healthy lifestyle modifications to reduce the need for antihypertensive medications, stress management interventions, evaluating treatment strategies based on out-of-office blood pressure compared with conventional (office) blood pressure, education tools and technologies to improve patient motivation and health behavior change, management strategies for ethnic groups, evaluating natural and alternative treatments, and the optimal role of different healthcare providers and caregivers in supporting patients with hypertension. These priorities can be used to guide clinicians, researchers, and funding bodies on areas that are a high priority for hypertension management research for patients, caregivers, and healthcare providers. This also highlights priority areas for improved knowledge translation and delivering patient-centered care.

Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.

Treatment and blood pressure control in 47,964 people with diabetes and hypertension: a systematic review of observational studies.

BACKGROUND: Many patients with diabetes also have hypertension, greatly increasing their risk for cardiovascular disease. It has been suggested that hypertension is poorly treated in those with diabetes. OBJECTIVE: To examine treatment and control of hypertension in people with diabetes. DATA SOURCES: Data sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, Web of Science, clinical evidence and government health and statistical Web sites. METHOD: Databases were systematically reviewed and hand searches of the bibliographies of relevant studies (1990 to 2004) were conducted. Two investigators selected studies and extracted the data independently. RESULTS: A total of 44 studies (77,649 subjects with diabetes, 47,964 [62%] of whom also had hypertension) were included. While 83% (range 32% to 100%) of patients with hypertension received drug therapy, only 12% (range 6% to 30%) had their blood pressure (BP) controlled to 130/85 mmHg or less. While BP control rates differed by definition of control (those studies with the least stringent definitions for BP control--160/90 mmHg or less--reported mean control rates of 37%), treatment and control rates did not differ appreciably between countries or health care settings. CONCLUSIONS: Fewer than one in eight people with diabetes and hypertension have adequately controlled BP, with remarkable uniformity across studies conducted in a variety of settings. There is an urgent need for multidisciplinary, community-based approaches to manage these high-risk patients.