Self-monitoring and self-management of oral anticoagulation.

BACKGROUND: The introduction of point-of-care devices for the management of patients on oral anticoagulation allows self-testing by the patient at home. Patients who self-test can either adjust their medication according to a pre-determined dose-INR (international normalized ratio) schedule (self-management), or they can call a clinic to be told the appropriate dose adjustment (self-monitoring). Increasing evidence suggests self-testing of oral anticoagulant therapy is equal to or better than standard monitoring. This is an updated version of the original review published in 2010. OBJECTIVES: To evaluate the effects on thrombotic events, major haemorrhages, and all-cause mortality of self-monitoring or self-management of oral anticoagulant therapy compared to standard monitoring. SEARCH METHODS: For this review update, we re-ran the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), 2015, Issue 6, the Cochrane Library, MEDLINE (Ovid, 1946 to June week 4 2015), Embase (Ovid, 1980 to 2015 week 27) on 1 July 2015. We checked bibliographies and contacted manufacturers and authors of relevant studies. We did not apply any language restrictions . SELECTION CRITERIA: Outcomes analysed were thromboembolic events, mortality, major haemorrhage, minor haemorrhage, tests in therapeutic range, frequency of testing, and feasibility of self-monitoring and self-management. DATA COLLECTION AND ANALYSIS: Review authors independently extracted data and we used a fixed-effect model with the Mantzel-Haenzel method to calculate the pooled risk ratio (RR) and Peto's method to verify the results for uncommon outcomes. We examined heterogeneity amongst studies with the Chi(2) and I(2) statistics and used GRADE methodology to assess the quality of evidence. MAIN RESULTS: We identified 28 randomised trials including 8950 participants (newly incorporated in this update: 10 trials including 4227 participants). The overall quality of the evidence was generally low to moderate. Pooled estimates showed a reduction in thromboembolic events (RR 0.58, 95% CI 0.45 to 0.75; participants = 7594; studies = 18; moderate quality of evidence). Both, trials of self-management or self-monitoring showed reductions in thromboembolic events (RR 0.47, 95% CI 0.31 to 0.70; participants = 3497; studies = 11) and (RR 0.69, 95% CI 0.49 to 0.97; participants = 4097; studies = 7), respectively; the quality of evidence for both interventions was moderate. No reduction in all-cause mortality was found (RR 0.85, 95% CI 0.71 to 1.01; participants = 6358; studies = 11; moderate quality of evidence). While self-management caused a reduction in all-cause mortality (RR 0.55, 95% CI 0.36 to 0.84; participants = 3058; studies = 8); self-monitoring did not (RR 0.94, 95% CI 0.78 to 1.15; participants = 3300; studies = 3); the quality of evidence for both interventions was moderate. In 20 trials (8018 participants) self-monitoring or self-management did not reduce major haemorrhage (RR 0.95, 95% CI, 0.80 to 1.12; moderate quality of evidence). There was no significant difference found for minor haemorrhage (RR 0.97, 95% CI 0.67 to 1.41; participants = 5365; studies = 13). The quality of evidence was graded as low because of serious risk of bias and substantial heterogeneity (I(2) = 82%). AUTHORS' CONCLUSIONS: Participants who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy. Thromboembolic events were reduced, for both those self-monitoring or self-managing oral anticoagulation therapy. A reduction in all-cause mortality was observed in trials of self-management but not in self-monitoring, with no effects on major haemorrhage.

A case of fixed drug eruption secondary to quinine in tonic water presenting to a sexual health clinic.

Fixed drug eruption (FDE) is a cutaneous drug reaction which occurs repeatedly at a given mucocutaneous site after exposure to the causative agent. Lesions typically occur on extremities, oral mucosa and genital skin. Quinine is a common food additive and is recognised as a rare cause of FDE. We report a case of FDE with oral and genital lesions presenting to a sexual health clinic due to quinine contained in tonic water.

Optimal loading dose of warfarin for the initiation of oral anticoagulation.

BACKGROUND: Warfarin is used as an oral anticoagulant. However, there is wide variation in patient response to warfarin dose. This variation, as well as the necessity of keeping within a narrow therapeutic range, means that selection of the correct warfarin dose at the outset of treatment is not straightforward. OBJECTIVES: To assess the effectiveness of different initiation doses of warfarin in terms of time in-range, time to INR in-range and effect on serious adverse events. SEARCH METHODS: We searched CENTRAL, DARE and the NHS Health economics database on The Cochrane Library (2012, Issue 4); MEDLINE (1950 to April 2012) and EMBASE (1974 to April 2012). SELECTION CRITERIA: All randomised controlled trials which compared different initiation regimens of warfarin. DATA COLLECTION AND ANALYSIS: Review authors independently assessed studies for inclusion. Authors also assessed the risk of bias and extracted data from the included studies. MAIN RESULTS: We identified 12 studies of patients commencing warfarin for inclusion in the review. The overall risk of bias was found to be variable, with most studies reporting adequate methods for randomisation but only two studies reporting adequate data on allocation concealment. Four studies (355 patients) compared 5 mg versus 10 mg loading doses. All four studies reported INR in-range by day five. Although there was notable heterogeneity, pooling of these four studies showed no overall difference between 5 mg versus 10 mg loading doses (RR 1.17, 95% CI 0.77 to 1.77, P = 0.46, I(2) = 83%). Two of these studies used two consecutive INRs in-range as the outcome and showed no difference between a 5 mg and 10 mg dose by day five (RR 0.86, 95% CI 0.62 to 1.19, P = 0.37, I(2 )= 22%); two other studies used a single INR in-range as the outcome and showed a benefit for the 10 mg initiation dose by day 5 (RR 1.49, 95% CI 1.01 to 2.21, P = 0.05, I(2 )= 72%). Two studies compared a 5 mg dose to other doses: a 2.5 mg initiation dose took longer to achieve the therapeutic range (2.7 versus 2.0 days; P < 0.0001), but those receiving a calculated initiation dose achieved a target range quicker (4.2 days versus 5 days, P = 0.007). Two studies compared age adjusted doses to 10 mg initiation doses. More elderly patients receiving an age adjusted dose achieved a stable INR compared to those receiving a 10 mg initial dose (and Fennerty regimen). Four studies used genotype guided dosing in one arm of each trial. Three studies reported no overall differences; the fourth study, which reported that the genotype group spent significantly more time in-range (P < 0.001), had a control group whose INRs were significantly lower than expected. No clear impacts from adverse events were found in either arm to make an overall conclusion. AUTHORS' CONCLUSIONS: The studies in this review compared loading doses in several different situations. There is still considerable uncertainty between the use of a 5 mg and a 10 mg loading dose for the initiation of warfarin. In the elderly, there is some evidence that lower initiation doses or age adjusted doses are more appropriate, leading to fewer high INRs. However, there is insufficient evidence to warrant genotype guided initiation.

Effect of UK policy on medical migration: a time series analysis of physician registration data.

BACKGROUND: Economically developed countries have recruited large numbers of overseas health workers to fill domestic shortages. Recognition of the negative impact this can have on health care in developing countries led the United Kingdom Department of Health to issue a Code of Practice for National Health Service (NHS) employers in 1999 providing ethical guidance on international recruitment. Case reports suggest this guidance had limited influence in the context of other NHS policy priorities. METHODS: The temporal association between trends in new professional registrations from doctors qualifying overseas and relevant United Kingdom government policy is reported. Government policy documents were identified by a literature review; further information was obtained, when appropriate, through requests made under the Freedom of Information Act. Data on new professional registration of doctors were obtained from the General Medical Council (GMC). RESULTS: New United Kingdom professional registrations by doctors trained in Africa and south Asia more than doubled from 3105 in 2001 to 7343 in 2003, as NHS Trusts sought to achieve recruitment targets specified in the 2000 NHS Plan; this occurred despite ethical guidance to avoid active recruitment of doctors from resource-poor countries. Registration of such doctors declined subsequently, but in response to other government policy initiatives. A fall in registration of South African-trained doctors from 3206 in 2003 to 4 in 2004 followed a Memorandum of Understanding with South Africa signed in 2003. Registrations from India and Pakistan fell from a peak of 4626 in 2004 to 1169 in 2007 following changes in United Kingdom immigration law in 2005 and 2006. Since 2007, registration of new doctors trained outside the European Economic Area has remained relatively stable, but in 2010 the United Kingdom still registered 722 new doctors trained in Africa and 1207 trained in India and Pakistan. CONCLUSIONS: Ethical guidance was ineffective in preventing mass registration by doctors trained in resource-poor countries between 2001 and 2004 because of competing NHS policy priorities. Changes in United Kingdom immigration laws and bilateral agreements have subsequently reduced new registrations, but about 4000 new doctors a year continue to register who trained in Africa, Asia and less economically developed European countries.

What are the basic self-monitoring components for cardiovascular risk management?

BACKGROUND: Self-monitoring is increasingly recommended as a method of managing cardiovascular disease. However, the design, implementation and reproducibility of the self-monitoring interventions appear to vary considerably. We examined the interventions included in systematic reviews of self-monitoring for four clinical problems that increase cardiovascular disease risk. METHODS: We searched Medline and Cochrane databases for systematic reviews of self-monitoring for: heart failure, oral anticoagulation therapy, hypertension and type 2 diabetes. We extracted data using a pre-specified template for the identifiable components of the interventions for each disease. Data was also extracted on the theoretical basis of the education provided, the rationale given for the self-monitoring regime adopted and the compliance with the self-monitoring regime by the patients. RESULTS: From 52 randomized controlled trials (10,388 patients) we identified four main components in self-monitoring interventions: education, self-measurement, adjustment/adherence and contact with health professionals. Considerable variation in these components occurred across trials and conditions, and often components were poorly described. Few trials gave evidence-based rationales for the components included and self-measurement regimes adopted. CONCLUSIONS: The components of self-monitoring interventions are not well defined despite current guidelines for self-monitoring in cardiovascular disease management. Few trials gave evidence-based rationales for the components included and self-measurement regimes adopted. We propose a checklist of factors to be considered in the design of self-monitoring interventions which may aid in the provision of an evidence-based rationale for each component as well as increase the reproducibility of effective interventions for clinicians and researchers.

Self-monitoring and self-management of oral anticoagulation.

BACKGROUND: The introduction of portable monitors (point-of-care devices) for the management of patients on oral anticoagulation allows self-testing by the patient at home. Patients who self-test can either adjust their medication according to a pre-determined dose-INR schedule (self-management) or they can call a clinic to be told the appropriate dose adjustment (self-monitoring). Several trials of self-monitoring of oral anticoagulant therapy suggest this may be equal to or better than standard monitoring. OBJECTIVES: To evaluate the effects of self-monitoring or self-management of oral anticoagulant therapy compared to standard monitoring. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE and CINAHL (to November 2007). We checked bibliographies and contacted manufacturers and authors of relevant studies. No language restrictions were applied. SELECTION CRITERIA: Outcomes analysed were thromboembolic events, mortality, major haemorrhage, minor haemorrhage, tests in therapeutic range, frequency of testing, and feasibility of self-monitoring and self-management. DATA COLLECTION AND ANALYSIS: The review authors independently extracted data. We used a fixed-effect model with the Mantzel-Haenzel method to calculate the pooled risk ratio (RR) and Peto's method to verify the results for uncommon outcomes. We examined heterogeneity amongst studies with the Chi(2) and I(2) statistics. MAIN RESULTS: We identified 18 randomized trials (4723 participants). Pooled estimates showed significant reductions in both thromboembolic events (RR 0.50, 95% CI 0.36 to 0.69) and all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89). This reduction in mortality remained significant after the removal of low-quality studies (RR 0.65, 95% CI 0.46 to 0.90). Trials of self-management alone showed significant reductions in thromboembolic events (RR 0.47, 95% CI 0.31 to 0.70) and all-cause mortality (RR 0.55, 95% CI 0.36 to 0.84); self-monitoring did not (thrombotic events RR 0.57, 95% CI 0.32 to 1.00; mortality RR 0.84, 95% CI 0.50 to 1.41). Self-monitoring significantly reduced major haemorrhages (RR 0.56, 95% CI 0.35 to 0.91) whilst self-management did not (RR 1.12, 95% CI 0.78 to 1.61). Twelve trials reported improvements in the percentage of mean INR measurements in the therapeutic range. No heterogeneity was identified in any of these comparisons. AUTHORS' CONCLUSIONS: Compared to standard monitoring, patients who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy. The number of thromboembolic events and mortality were decreased without increases in harms. However, self-monitoring or self-management were not feasible for up to half of the patients requiring anticoagulant therapy. Reasons included patient refusal, exclusion by their general practitioner, and inability to complete training.

Acceptability and psychological impact of out-of-office monitoring to diagnose hypertension: an evaluation of survey data from primary care patients.

BACKGROUND: Out-of-office blood pressure (BP) is recommended for diagnosing hypertension in primary care due to its increased accuracy compared to office BP. Moreover, being diagnosed as hypertensive has previously been linked to lower wellbeing. There is limited evidence regarding the acceptability of out-of-office BP and its impact on wellbeing. AIM: To assess the acceptability and psychological impact of out-of-office monitoring in people with suspected hypertension. DESIGN AND SETTING: A pre- and post-evaluation of participants with elevated (≥130 mmHg) systolic BP, assessing the psychological impact of 28 days of self-monitoring followed by ambulatory BP monitoring for 24 hours. METHOD: Participants completed standardised psychological measures pre- and post-monitoring, and a validated acceptability scale post-monitoring. Descriptive data were compared using χ2 tests and binary logistic regression. Pre- and post-monitoring comparisons were made using the paired t-test and Wilcoxon signed rank test. RESULTS: Out-of-office BP monitoring had no impact on depression and anxiety status in 93% and 85% of participants, respectively. Self-monitoring was more acceptable than ambulatory monitoring (n = 183, median 2.4, interquartile range [IQR] 1.9-3.1 versus median 3.2, IQR 2.7-3.7, P<0.01). When asked directly, 48/183 participants (26%, 95% confidence interval [CI] = 20 to 33%) reported that self-monitoring made them anxious, and 55/183 (30%, 95% CI = 24 to 37%) reported that ambulatory monitoring made them anxious. CONCLUSION: Out-of-office monitoring for hypertension diagnosis does not appear to be harmful. However, health professionals should be aware that in some patients it induces feelings of anxiety, and self-monitoring may be preferable to ambulatory monitoring.

Do advertisements for antihypertensive drugs in Australia promote quality prescribing? A cross-sectional study.

BACKGROUND: Antihypertensive medications are widely prescribed by doctors and heavily promoted by the pharmaceutical industry. Despite strong evidence of the effectiveness and cost-effectiveness of thiazide diuretics, trends in both promotion and prescription of antihypertensive drugs favour newer, less cost-effective agents. Observational evidence shows correlations between exposure to pharmaceutical promotion and less ideal prescribing. Our study therefore aimed to determine whether print advertisements for antihypertensive medications promote quality prescribing in hypertension. METHODS: We performed a cross-sectional study of 113 advertisements for antihypertensive drugs from 4 general practice-oriented Australian medical publications in 2004. Advertisements were evaluated using a quality checklist based on a review of hypertension management guidelines. Main outcome measures included: frequency with which antihypertensive classes were advertised, promotion of thiazide class drugs as first line agents, use of statistical claims in advertisements, mention of harms and prices in the advertisements, promotion of assessment and treatment of cardiovascular risk, promotion of lifestyle modification, and targeting of particular patient subgroups. RESULTS: Thiazides were the most frequently advertised drug class (48.7% of advertisements), but were largely promoted in combination preparations. The only thiazide advertised as a single agent was the most expensive, indapamide. No advertisement specifically promoted any thiazide as a better first-line drug. Statistics in the advertisements tended to be expressed in relative rather than absolute terms. Drug costs were often reported, but without cost comparisons between drugs. Adverse effects were usually reported but largely confined to the advertisements' small print. Other than mentioning drug interactions with alcohol and salt, no advertisements promoted lifestyle modification. Few advertisements (2.7%) promoted the assessment of cardiovascular risk. CONCLUSION: Print advertisements for antihypertensive medications in Australia provide some, but not all, of the key messages required for guideline-concordant care. These results have implications for the regulation of drug advertising and the continuing education of doctors.

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.

Global cardiovascular risk assessment in the primary prevention of cardiovascular disease in adults: systematic review of systematic reviews.

OBJECTIVE: To identify, critically appraise and summarise existing systematic reviews on the impact of global cardiovascular risk assessment in the primary prevention of cardiovascular disease (CVD) in adults. DESIGN: Systematic review of systematic reviews published between January 2005 and October 2016 in The Cochrane Library, EMBASE, MEDLINE or CINAHL databases, and post hoc analysis of primary trials. PARTICIPANTS, INTERVENTIONS, OUTCOMES: Systematic reviews of interventions involving global cardiovascular risk assessment relative to no formal risk assessment in adults with no history of CVD. The primary outcomes of interest were CVD-related morbidity and mortality and all-cause mortality; secondary outcomes were systolic blood pressure (SBP), cholesterol and smoking. RESULTS: We identified six systematic reviews of variable but generally of low quality (mean Assessing the Methodological Quality of Systematic Reviews 4.2/11, range 0/11 to 7/11). No studies identified by the systematic reviews reported CVD-related morbidity or mortality or all-cause mortality. Meta-analysis of reported randomised controlled trials (RCTs) showed small reductions in SBP (mean difference (MD) -2.22 mm Hg (95% CI -3.49 to -0.95); I2=66%; n=9; GRADE: very low), total cholesterol (MD -0.11 mmol/L (95% CI -0.20 to -0.02); I2=72%; n=5; GRADE: very low), low-density lipoprotein cholesterol (MD -0.15 mmol/L (95% CI -0.26 to -0.05), I2=47%; n=4; GRADE: very low) and smoking cessation (RR 1.62 (95% CI 1.08 to 2.43); I2=17%; n=7; GRADE: low). The median follow-up time of reported RCTs was 12 months (range 2-36 months). CONCLUSIONS: The quality of existing systematic reviews was generally poor and there is currently no evidence reported in these reviews that the prospective use of global cardiovascular risk assessment translates to reductions in CVD morbidity or mortality. There are reductions in SBP, cholesterol and smoking but they may not be clinically significant given their small effect size and short duration. Resources need to be directed to conduct high-quality systematic reviews focusing on hard patient outcomes, and likely further primary RCTs. TRIAL REGISTRATION NUMBER: CRD42015019821.

Patient use of blood pressure self-screening facilities in general practice waiting rooms: a qualitative study in the UK.

BACKGROUND: Blood pressure (BP) self-screening, whereby members of the public have access to BP monitoring equipment outside of healthcare consultations, may increase the detection and treatment of hypertension. Currently in the UK such opportunities are largely confined to GP waiting rooms. AIM: To investigate the reasons why people do or do not use BP self-screening facilities. DESIGN AND SETTING: A cross-sectional, qualitative study in Oxfordshire, UK. METHOD: Semi-structured interviews with members of the general public recruited using posters in GP surgeries and community locations were recorded, transcribed, and coded thematically. RESULTS: Of the 30 interviewees, 20% were hypertensive and almost half had self-screened. Those with no history of elevated readings had limited concern over their BP: self-screening filled the time waiting for their appointment or was done to help their doctor. Patients with hypertension self-screened to avoid the feelings they associated with 'white coat syndrome' and to introduce more control into the measurement process. Barriers to self-screening included a lack of awareness, uncertainty about technique, and worries over measuring BP in a public place. An unanticipated finding was that several interviewees preferred monitoring their BP in the waiting room than at home. CONCLUSION: BP self-screening appeared acceptable to service users. Further promotion and education could increase awareness among non-users of the need for BP screening, the existence of self-screening facilities, and its ease of use. Waiting room monitors could provide an alternative for patients with hypertension who are unwilling or unable to monitor at home.

Correlations of siblings' and mothers' utilisation of primary and hospital health care: a record linkage study in Western Australia.

A relationship between maternal and child use of general practitioners (GPs) has been shown to exist for some time, however, the reasons for this relationship are not clear and the extent to which this relationship extends to tertiary care is unknown. The aim of this study was to examine the relationships between the utilisation of health care by siblings and mothers over a 14 year period. A retrospective cohort study of 756 mothers and their 1494 children up to age 14 years was conducted in three general practices in Western Australia. Medicare claims and hospital morbidity records for 1984-1997 were linked using deterministic and probabilistic matching. Generalised Estimating Equations and correlations were used to examine the relationships between the utilisation of primary and hospital health care by family members. Significant correlations were found between hospital admissions of all participants and their GP visits, specialist visits, pathology and diagnostic imaging combined and hospital length of stay. There was a strong association between siblings' use of GPs. A child's rate of GP attendance increased with that of its mother. There was a weak but significant relationship between siblings' use of hospitals, and a child's hospital admission rate increased with that of its mother. It is concluded that there is a strong relationship between siblings' use of GPs and a weaker but still significant association between the hospital admissions of siblings. As expected, there were strong associations between mother and child visits to GPs. There was also an association between a mother's use of hospital and that of her children. This finding reduces the plausibility that the relationships found between utilisation of health care by siblings and mothers can be explained entirely by behavioural factors, and suggests the presence of intergenerational correlation of morbidity.

Early trauma management skills in Australian general practitioners.

BACKGROUND: General practitioners (GPs) have a role in the early management of major trauma in rural Australia. The Early Management of Severe Trauma (EMST) course fulfils their educational needs by providing skills for the systematic management of the seriously injured patient. However, with any skill there is a natural loss over time. This study surveyed GPs who have completed the EMST course to determine their confidence in trauma management. METHODS: A two-page survey was mailed in December 2004 to all GPs who had completed an EMST course from 1989 to 2004 and were currently residing in Western Australia. The survey consisted of background questions, open-ended questions regarding the EMST course and skills confidence ratings using visual analogue scales. The final sample size was 223. RESULTS: Response rate was 55%. GPs were least confident in carrying out diagnostic peritoneal lavage and cricothyroidotomy. They were most confident inserting i.v. cannulas and managing fluid replacement. Their confidence in some of these skills were related to the frequency of managing trauma patients but not to the interval since completing the EMST course. GPs found the systematic approach to trauma management and practical/procedural skills as the most relevant components of EMST. They felt that EMST could be improved with more accessible refresher courses and more practical/procedural skills. CONCLUSION: Most of these GPs were involved in rural hospital work where they may be required to manage seriously injured patients. They require regular refresher courses to maintain their confidence levels in treating seriously injured patients.

Assessing agreement of blood pressure-measuring devices in Tibetan areas of China: a systematic review.

BACKGROUND: The validity of blood pressure (BP)-measuring tools at very high altitudes is uncertain. Therefore, the objective of this review was to examine the degree of agreement of BP-measuring devices in Tibet. METHODS: We conducted electronic searches in Medline, Embase, Cinahl, Cochrane Library, Global Health Library and the ISI Web of Science. Randomised and observational studies were considered for inclusion. The methodological characteristics of included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 criteria. Our primary outcome was the difference in mean BP measurements between the new device and the gold standard. RESULTS: We identified three eligible studies, out of which two with a total of 162 participants were included. The studies differed in their methodology. One study reported significantly higher systolic blood pressure (SBP) measurement with electronic sphygmomanometer (Omron) compared with mercury sphygmomanometer (mean difference 5.8±4.7 mm Hg; p<0.001), with no significant difference in diastolic blood pressure (DBP) measurement (0.4±3.9 mm Hg; p=0.23). The second study reported mean differences of 1.0±5.9 mm Hg and -3.1±4.6 mm Hg for SBP and DBP, respectively. CONCLUSION: The limited evidence from published studies suggests that automated (Omron) BP monitors show a high degree of agreement for DBP when compared against mercury sphygmomanometer at high altitudes. However, the degree of such agreement for SBP is not consistent. Few studies assessing the validity of automated BP monitors at high altitudes have been conducted, and they differ in design and methodology. Further research assessing the suitability of BP-measuring instruments at high altitudes is therefore warranted.

Patient perceptions of the GP role in cancer management.

BACKGROUND: During the course of their cancer treatment, patients have to deal with a number of health professionals. We investigated patients' perceptions of the role of the general practitioner, with particular reference to GPs' ability to manage patients' cancer outside of the hospital setting. METHOD: We took a phenomenological approach, focussing on empowerment, and any central role of the GP. In depth interviews were conducted on the same haematological cancer patients over a 2 year period. Results were analysed for main themes regarding support and management of illness. RESULTS: Many patients had a long term relationship with an individual GP. They perceived GPs as providing a primarily supportive rather than treatment role outside of the hospital setting, and relied on them for clarification and reassurance. DISCUSSION: The personal, confiding relationship between the GP and cancer patient might be better exploited by specialists. Patients could feel more empowered in relation to their condition if provided with information by their GP that is more relevant and explicit. For this to occur, specialists must first provide GPs with timely and pertinent information about their cancer management.

Relationship between altitude and the prevalence of hypertension in Tibet: a systematic review.

INTRODUCTION: Hypertension is a leading cause of cardiovascular disease, which is the cause of one-third of global deaths and is a primary and rising contributor to the global disease burden. The objective of this systematic review was to determine the prevalence and awareness of hypertension among the inhabitants of Tibet and its association with altitude, using the data from published observational studies. METHODS: We conducted electronic searches in Medline, Embase, ISI Web of Science and Global Health. No gender or language restrictions were imposed. We assessed the methodological characteristics of included studies using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Two reviewers independently determined the eligibility of studies, assessed the methodology of included studies and extracted the data. We used meta-regression to estimate the degree of change in hypertension prevalence with increasing altitude. RESULTS: We identified 22 eligible articles of which eight cross-sectional studies with a total of 16 913 participants were included. The prevalence of hypertension ranged between 23% and 56%. A scatter plot of altitude against overall prevalence revealed a statistically significant correlation (r=0.68; p=0.04). Meta-regression analysis revealed a 2% increase in the prevalence of hypertension with every 100 m increase in altitude (p=0.06). The locations and socioeconomic status of subjects affected the awareness and subsequent treatment and control of hypertension. CONCLUSIONS: The results from cross-sectional studies suggest that there is a significant correlation between altitude and the prevalence of hypertension among inhabitants of Tibet. The socioeconomic status of the inhabitants can influence awareness and management of hypertension. Very little research into hypertension has been conducted in other prefectures of Tibet where the altitude is much higher. Further research examining the impact of altitude on blood pressure is warranted.

Randomized Controlled Trial of Shared Care for Patients With Cancer Involving General Practitioners and Cancer Specialists.

PURPOSE: We aimed to determine whether a shared care model (SCM) during chemotherapy treatment improved emotional well-being, empowerment, and prevalence of symptoms for people being treated for cancer. METHODS: People receiving chemotherapy for hematologic, breast, ovarian, or colorectal malignancies at two cancer centers were randomly assigned to receive SCM or standard care. The SCM involved a patient-held record, a project coordinator, routine contact between the patient and general practitioner/primary care physician, and primary care physician education. Participants completed the Hospital Anxiety and Depression Scale, the Mini-Mental Adjustment to Cancer, and an empowerment questionnaire before, in the middle of, and on completion of chemotherapy. The presence and severity of adverse effects of chemotherapy were recorded by patients in a symptom diary. RESULTS: Ninety-seven eligible participants were randomly allocated, less than half the intended recruitment. There were no significant differences between the groups for empowerment, symptom prevalence, or Mini-Mental Adjustment to Cancer scores. The proportion with clinical anxiety (Hospital Anxiety and Depression Scale anxiety score of ≥ 11) decreased over time in both groups (P = .013) but decreased more in the intervention group (P = .002). Depression was unchanged over time. CONCLUSION: Our study was limited by low recruitment and predominance of patients with breast cancer, and was underpowered for the main analyses. Results should therefore be interpreted with caution. Little benefit was seen for SCM in the majority of domains including empowerment, symptom prevalence, and psychological adjustment to cancer. The SCM showed efficacy in clinically anxious patients. Such interventions may be better implemented by using a targeted approach to identify at-need subgroups.

Apart from Medicare, what other work do GPs do?

BACKGROUND: Although Australian general practitioners are increasingly being encouraged to perform more non-Medicare funded work, little is known about the its extent or nature. METHOD: A cross sectional survey was sent to all 2107 potential GPs in Western Australia. RESULTS: The response rate was 480/1807 (27%). Nearly all GPs (95%) performed paid or unpaid non-Medicare work; 83% cared with non-Medicare payment for patients, averaging 6.5 hours per week. Paid nonpatient work (an average 4.3 hours per week, undertaken by 41% of GPs) was for divisions, teaching and research. Unpaid work was approximately 3.7 hours per week for patients, (mostly informal consultations and voluntary work) and 1.9 hours per week for nonpatient related activities (principally research, meetings and teaching). Overall GPs were satisfied with their job but were dissatisfied with government intrusion. The type and amount of non-Medicare funded work performed was not related to job satisfaction. CONCLUSION: General practitioners are involved in non-Medicare funded work to the extent of an average of 9.5 hours per week, including teaching, research and divisional activities.

Peer reviewed publication rates. An indication of research output.

BACKGROUND: The General Practice Evaluation Program (GPEP) funded general practice research between 1990-1999. We were interested in the publication rate of GPEP funded research as a measure of its research productivity. METHODS: A literature search and an email survey of GPEP researchers. We compared publication rates between the types of grants, types of institutions, and academic status of the authors. RESULTS: By June 2002, there were 201 peer reviewed articles in a range of 64 Australian and international peer reviewed journals from 99 projects (41% of completed or in progress projects, mean 2.3 per project), ranging from 0-22 per project. Forty-one investigators indicated they were in the process of writing for publication or plan to publish. They were more likely to publish with the support of a university. DISCUSSION: GPEP has achieved one of its major objectives--to contribute to evidence and knowledge about general practice. The publication rate indicates that Australian general practice research should still improve.

Home measurement of blood pressure and cardiovascular disease: systematic review and meta-analysis of prospective studies.

OBJECTIVE: Examine the relationship between home blood pressure (BP) and risk for all-cause mortality, cardiovascular mortality and cardiovascular events. METHODS: We conducted a systematic review and meta-analysis of prospective studies of home BP. Primary outcomes were all-cause mortality, cardiovascular mortality and cardiovascular events. We extracted hazard ratios and 95% confidence intervals (CIs) which were pooled with a random-effects model. Heterogeneity was assessed using the I statistic. RESULTS: We identified eight studies with 17 698 participants. Follow-up was 3.2-10.9 years. For all-cause mortality (n = 747) the hazard ratio for home BP was 1.14 (95% CI 1.01-1.29) per 10 mmHg increase in systolic BP compared to 1.07 (0.91-1.26) for office BP. For cardiovascular mortality (n = 193) the hazard ratio for home BP was 1.29 (1.02-1.64) per 10 mmHg increase in systolic BP compared to 1.15 (0.91-1.46) for office BP. For cardiovascular events (n = 699) the hazard ratio for home BP was 1.14 (1.09-1.20) per 10 mmHg increase in systolic BP compared to 1.10 (1.06-1.15) for office BP. In three studies which adjusted for office and home BP the hazard ratio was 1.20 (1.11-1.30) per 10 mmHg increase in systolic BP for home BP adjusted for office BP compared to 0.99 (0.93-1.07) per 10 mmHg increase in systolic BP for office BP adjusted for home BP. Diastolic results were similar. CONCLUSIONS: Home BP remained a significant predictor of cardiovascular mortality and cardiovascular events after adjusting for office BP suggesting it is an important prognostic variable over and above that of office BP.