Guideline for the diagnosis and management of hypertension in adults - 2016.

The National Heart Foundation of Australia has updated the Guide to management of hypertension 2008: assessing and managing raised blood pressure in adults (updated December 2010). Main recommendations For patients at low absolute cardiovascular disease risk with persistent blood pressure (BP) ≥ 160/100 mmHg, start antihypertensive therapy. The decision to treat at lower BP levels should consider absolute cardiovascular disease risk and/or evidence of end-organ damage, together with accurate BP assessment. For patients at moderate absolute cardiovascular disease risk with persistent systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, start antihypertensive therapy. Treat patients with uncomplicated hypertension to a target BP of < 140/90 mmHg or lower if tolerated. Changes in management as a result of the guideline Ambulatory and/or home BP monitoring should be offered if clinic BP is ≥ 140/90 mmHg, as out-of-clinic BP is a stronger predictor of outcome. In selected high cardiovascular risk populations, aiming for a target of < 120 mmHg systolic can improve cardiovascular outcomes. If targeting < 120 mmHg, close follow-up is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury. Why the changes have been made A 2015 meta-analysis of patients with uncomplicated mild hypertension (systolic BP range, 140-169 mmHg) demonstrated that BP-lowering therapy is beneficial (reduced stroke, cardiovascular death and all-cause mortality). A 2015 trial comparing lower with higher blood pressure targets in selected high cardiovascular risk populations found improved cardiovascular outcomes and reduced mortality, with an increase in some treatment-related adverse events.

How to measure home blood pressure: Recommendations for healthcare professionals and patients.

BACKGROUND: Home blood pressure (BP) monitoring is the self-measurement of BP in the home environment. It is complementary to 24-hour ambulatory BP, for better diagnosis and management of patients with high BP. Home BP monitoring is in widespread use, but variation in monitoring protocols could lead to inaccurate assessment of BP. OBJECTIVE: The aim of this article is to provide a practical guide (with resources) for patients and doctors on how to measure home BP according to a standardised, evidence-based protocol. DISCUSSION: Home BP should be measured using a validated, automatic BP device (preferably with memory storage), using an appropriately sized upper arm cuff. Measurements should be taken after five minutes of seated rest and before medication, food or vigorous exercise. BP should be recorded for seven days (five days minimum) in the morning and evening (two readings each). Overall, home BP is the average systolic and diastolic BP over seven days (excluding the first day); an average of ≥135/85 mmHg is indicative of hypertension.

Evaluating the prevention of premature cessation of exclusive breastfeeding in the general practice setting during the scheduled child immunisation consultation: a pilot study.

The purpose of this study was to test and evaluate the feasibility and clinical acceptability of the use of an infant feeding data collection tool during the scheduled childhood immunisation consultation, and to explore the appropriateness of this consultation as a site for a future intervention aiming to increase exclusive breastfeeding through the provision of advice and support to mothers. This descriptive exploratory (quantitative and qualitative) study used purposeful sampling to enrol five general practices in Hobart, Tasmania. General practitioners (GPs) and practice nurses (PNs) trialled and evaluated a paper-based data collection tool over a 6-week period from May through to June 2011. Twenty-two (13 GPs; 2 GP registrars and 7 PNs) participants trialled and evaluated the data collection tool (n = 54). From the evaluation questionnaire, field notes and informal interviews (n = 7), six conceptual headings emerged: setting; time pressures; resources and collaboration; mothers need to talk; professional exclusion; and lack of collaboration. The scheduled childhood immunisation consultation provides an opportunity for mothers and primary health practitioners to talk briefly about infant feeding and for the collection of infant feeding data. However, the immunisation consultation is not well suited to a breastfeeding support intervention as it is already very busy focusing on immunisation issues. Consideration should be given to the evaluation of a dedicated general practice/primary health 'infant feeding' consultation.

Management of hypertension in general practice--a qualitative needs assessment of Australian GPs.

BACKGROUND: This study aimed to identify strategies to improve the management of hypertension in general practice. METHODS: Four focus groups (25 general practitioners and general practice registrars) were conducted, recorded and transcribed. Common emerging themes were analysed by an iterative thematic process. RESULTS: Four main themes were identified: uncertainty about blood pressure measurement, achieving consensus in practice, accommodating patient differences and addressing systematic barriers. General practitioners want a more standardised approach to measuring and interpreting blood pressure with consistent, valid readings taken on one device that accurately measures patients blood pressure in the 'real world'. General practitioners want to be upskilled in specific areas related to hypertension management. DISCUSSION: To facilitate improvements in blood pressure management, the most pressing needs of this group of GPs is to reduce the uncertainty surrounding the measurement and interpretation of blood pressure readings. This study has identified that sections of existing hypertension guidelines need to be reviewed and implemented.

Barriers to diagnosing and managing hypertension - a qualitative study in Australian general practice.

BACKGROUND: Elevated blood pressure (BP) is a major modifiable risk factor. However hypertension still remains underdiagnosed, untreated or suboptimally treated. This study aimed to identify and explore barriers to initiating medication and treating elevated BP to target levels in the general practice setting. METHODS: Six focus groups involving 30 clinicians were audio recorded, transcribed in full and analysed for common emerging themes using an iterative thematic analysis. RESULTS: After making the decision to commence treatment, medication initiation was relatively straightforward. Clinical uncertainty about true underlying BP, distrust of measurement technology, and distrust of the evidence underpinning hypertension management were expressed. Patient age, gender and comorbidity influenced treatment strategy. Related themes included perceived patient attitude, clinical inertia, and patient centred care. Systems issues included lack of resources and lack of time. DISCUSSION: The management of an asymptomatic chronic disease within a patient centred, encounter based primary care context can be challenging.

New and old hotspots for rickettsial spotted fever acquired in Tasmania, 2012-2017.

OBJECTIVE: To describe the epidemiology and clinical characteristics of Tasmania-acquired rickettsial disease notified to the Department of Health in Tasmania from 2012 to 2017 inclusive. METHODS: Data on rickettsiosis cases acquired and notified in Tasmania between 1 January 2012 and 31 December 2017 were analysed descriptively. RESULTS: Eighteen cases of rickettsial infection notified in Tasmania 2012-17 and likely acquired in the state met one of three case definitions: 12 confirmed (67%), four probable (22%), and two possible (11%). The mean number of cases per year was 3.0 (population rate 0.6 per 100,000 population/year); 60% of cases occurred in November and December. Cases were more commonly older males. Fever, lethargy, and rash were commonly reported symptoms. Thirteen cases were likely acquired on Flinders Island, three around Great Oyster Bay and two in the Midlands. CONCLUSIONS: This study extends our knowledge of the epidemiology of rickettsial disease in Tasmania. This is the first account including confirmed cases acquired in the Midlands of Tasmania. Implications for public health: Increased knowledge and awareness of epidemiology of rickettsial infection in Tasmania is essential for timely diagnosis and appropriate treatment. These findings bear wider relevance outside Tasmania because visitors may also be at risk.

Oral corticosteroids--their place in the management of adhesive capsulitis.

The incidence of intrinsic disorders of the shoulder presenting in general practice has been estimated to be 14.7/1000 per year with adhesive capsulitis (also termed frozen shoulder, stiff painful shoulder or periarthritis) accounting for around 20% of cases (incidence 2.4/1000 per year), but occurring more frequently in the middle aged and those with diabetes. The aetiology of pathological findings of intra-articular inflammation and fibrosis is not known. Adhesive capsulitis is diagnosed clinically based on characteristic symptoms and signs: spontaneous onset of severe shoulder pain that interferes with activities of daily living and sleep, and progressive stiffness or restriction of both active and passive movements, especially elevation and external rotation.

Evaluating the effectiveness of public health interventions: the role and activities of the Cochrane Collaboration.

Public health decision makers, funders, practitioners, and the public are increasingly interested in the evidence that underpins public health decision making. Decisions in public health cover a vast range of activities. With the ever increasing global volume of primary research, knowledge and changes in thinking and approaches, quality systematic reviews of all the available research that is relevant to a particular practice or policy decision are an efficient way to synthesise and utilise research efforts. The Cochrane Collaboration includes an organised entity that aims to increase the quality and quantity of public health systematic reviews, through a range of activities. This paper aims to provide a glossary of the terms and activities related to public health and the Cochrane Collaboration.

Home blood pressure monitoring: Australian Expert Consensus Statement.

Measurement of blood pressure (BP) by a doctor in the clinic has limitations that may result in an unrepresentative measure of underlying BP which can impact on the appropriate assessment and management of high BP. Home BP monitoring is the self-measurement of BP in the home setting (usually in the morning and evening) over a defined period (e.g. 7 days) under the direction of a healthcare provider. When it may not be feasible to measure 24-h ambulatory BP, home BP may be offered as a method to diagnose and manage patients with high BP. Home BP has good reproducibility, is well tolerated, is relatively inexpensive and is superior to clinic BP for prognosis of cardiovascular morbidity and mortality. Home BP can be used in combination with clinic BP to identify 'white coat' and 'masked' hypertension. An average home BP of at least 135/85 mmHg is an appropriate threshold for the diagnosis of hypertension. Home BP may also offer the advantage of empowering patients with their BP management, with benefits including increased adherence to therapy and lower achieved BP levels. It is recommended that, when feasible, home BP should be considered for routine use in the clinical management of hypertension.

Ankle-Brachial Index determination and peripheral arterial disease diagnosis by an oscillometric blood pressure device in primary care: validation and diagnostic accuracy study.

OBJECTIVES: To determine the level of agreement between a 'conventional' Ankle-Brachial Index (ABI) measurement (using Doppler and mercury sphygmomanometer taken by a research nurse) and a 'pragmatic' ABI measure (using an oscillometric device taken by a practice nurse) in primary care. To ascertain the utility of a pragmatic ABI measure for the diagnosis of peripheral arterial disease (PAD) in primary care. DESIGN: Cross-sectional validation and diagnostic accuracy study. Descriptive analyses were used to investigate the agreement between the two procedures using the Bland and Altman method to determine whether the correlation between ABI readings varied systematically. Diagnostic accuracy was assessed via sensitivity, specificity, accuracy, likelihood ratios, positive and negative predictive values, with ABI readings dichotomised and Receiver Operating Curve analysis using both univariable and multivariable logistic regression. SETTING: Primary care in metropolitan and rural Victoria, Australia between October 2009 and November 2010. PARTICIPANTS: 250 persons with cardiovascular disease (CVD) or at high risk (three or more risk factors) of CVD. RESULTS: Despite a strong association between the two method's measurements of ABI there was poor agreement with 95% of readings within ±0.4 of the 0.9 ABI cut point. The multivariable C statistic of diagnosis of PAD was 0.89. Other diagnostic measures were sensitivity 62%, specificity 92%, positive predictive value 67%, negative predictive value 90%, accuracy 85%, positive likelihood ratio 7.3 and the negative likelihood ratio 0.42. CONCLUSIONS: Oscillometric ABI measures by primary care nurses on a population with a 22% prevalence of PAD lacked sufficient agreement with conventional measures to be recommended for routine diagnosis of PAD. This pragmatic method may however be used as a screening tool high-risk and overt CVD patients in primary care as it can reliably exclude the condition.

Opioids for osteoarthritis? Weighing benefits and risks: a Cochrane Musculoskeletal Group review.

Untreated pain is a major public health problem, but concerns about opioid misuse remain. This evidence-based look at when--or whether--opioids are indicated for OA patients will help you achieve the right balance.

It's in your hands: the value of handsearching in conducting systematic reviews of public health interventions.

BACKGROUND: While there is an emerging evidence base in public health, the evidence can often be difficult to find. Indexing of journals in MEDLINE has assisted those conducting systematic reviews to more easily identify published studies. However, information technology and the processes associated with indexing are not infallible. Studies may not be correctly marked by study design which may mean they are missed in the electronic searching process. Handsearching for evidence of intervention effectiveness has therefore become a recognized tool in the systematic review process. METHODS: Resources to guide handsearching activity currently are clinically focused, and may not be sensitive to the characteristics of public health studies where study terminology may differ. In response to this issue, the Cochrane Health Promotion and Public Health Field (the Field) developed and implemented a small study to recruit and support handsearchers from around the world to identify health promotion and public health trials and systematic reviews. A strategic framework was developed to recruit and support handsearchers to search six public health-related journals. RESULTS: In total, 131 trials and 21 systematic reviews were identified. The greatest value of handsearching was found to be in supplement editions and abstract sections of journals CONCLUSIONS: The study focused exclusively on indexed journals with the intention that tools and methods developed could be used to explore the potential for handsearching in non-indexed journals and for unpublished studies. The findings from this study will continue to support handsearching efforts and in doing so contribute to high quality systematic reviews of public health interventions.