Search

Background: The use of correctly-sized blood pressure (BP) cuffs is important to ensure accurate measurement and effective management of hypertension. The goals of this study were to determine the proportions of pregnant women that would require small, adult, large, and extra-large (XL) cuff sizes, and to examine the demographic characteristics associated with need for a large or XL cuff., Methods: This cross-sectional study analyzed 1,176 pregnant women (≥18 years) included in the National Health and Nutrition Examination Survey (NHANES) 1999-2006 cycles. Recommended BP cuff sizes, based on American Heart Association recommendations, were categorized by mid-arm circumference: small adult (≤26 cm), adult (>26 to ≤34 cm), large (>34 to ≤44 cm), and extra-large (XL) (>44 cm)., Results: Among US pregnant women, recommended cuff sizes were: 17.9% small adult, 57.0% adult, and 25.1% for large or XL. About 38.5% of non-Hispanic Black, 21.6% of Mexican American and 21.0% of non-Hispanic White pregnant women required a large or XL cuff. About 81.8% of women in the highest quartile for BMI required large or XL cuffs, which was significantly higher than women in other quartiles., Conclusion: Roughly one out of every four pregnant women required large or XL BP cuffs. The requirement for large or XL cuffs was highest among non-Hispanic Black women and women with the highest BMI. For pregnant women, measuring the arm circumference and selecting an appropriately-sized cuff is important to facilitate accurate blood pressure monitoring and hypertension management., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: People with HIV (human immunodeficiency virus; PWH) have higher rates of cardiovascular disease than people without HIV. However, limited information exists about hypertension prevalence and associated risk factors in PWH., Methods: This cross-sectional study included adult patients in the 2022 IQVIATM Ambulatory Electronic Medical Record-US data. HIV was identified based on ≥2 HIV diagnosis codes or a positive HIV test. Hypertension was identified by diagnosis codes, ≥2 blood pressure (BP) readings ≥130/80 mm Hg, or an antihypertensive medication prescription. Among those with hypertension, control was defined as the most recent BP < 130/80 mm Hg. Logistic models using the marginal standardization method were used to estimate adjusted prevalence ratios (aPR) of hypertension and hypertension control among all patients and PWH specifically, controlling for covariates., Results: Of 7,533,379 patients, 19,102 (0.3%) had HIV. PWH had higher hypertension prevalence (66% vs. 54%, aPR:1.14, 95% CI: 1.13-1.15) compared with people without HIV. Among persons with hypertension, PWH were more likely to have controlled hypertension (aPR: 1.10, 95% CI: 1.07-1.13) compared with people without HIV. Among PWH, those from the South were more likely to have hypertension (aPR: 1.07, 95% CI: 1.02-1.12) than PWH from the Northeast, while Black PWH were less likely to have controlled hypertension (aPR: 0.72, 95% CI: 0.67-0.77) than White PWH., Conclusions: PWH were more likely to have hypertension than people without HIV. Geographic and racial disparities in hypertension prevalence and control were observed among PWH. Optimal care for PWH includes comprehensive strategies to screen for, prevent, and manage hypertension., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2024.)

Background: The COVID-19 pandemic prompted a rapid increase in telehealth use. However, limited evidence exists on how rural and urban residents used telehealth and in-person outpatient services to manage hypertension during the pandemic., Methods: This longitudinal study analyzed 701,410 US adults (18-64 years) in the MarketScan Commercial Claims Database, who were continuously enrolled from January 2017 through March 2022. We documented monthly numbers of hypertension-related telehealth and in-person outpatient visits (per 100 individuals), and the proportion of telehealth visits among all hypertension-related outpatient visits, from January 2019 through March 2022. We used Welch's two-tail t-test to differentiate monthly estimates by rural-urban status and month-to-month changes., Results: From February through April 2020, the monthly number of hypertension-related telehealth visits per 100 individuals increased from 0.01 to 6.05 (P < 0.001) for urban residents and from 0.01 to 4.56 (P < 0.001) for rural residents. Hypertension-related in-person visits decreased from 20.12 to 8.30 (P < 0.001) for urban residents and from 20.48 to 10.15 (P < 0.001) for rural residents. The proportion of hypertension-related telehealth visits increased from 0.04% to 42.15% (P < 0.001) for urban residents and from 0.06% to 30.98% (P < 0.001) for rural residents. From March 2020 to March 2022, the monthly average of the proportions of hypertension-related telehealth visits was higher for urban residents than for rural residents (10.19% vs. 6.96%; P < 0.001)., Conclusions: Data show that rural residents were less likely to use telehealth for hypertension management. Understanding trends in hypertension-related telehealth utilization can highlight disparities in the sustained use of telehealth to advance accessible health care., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2023.)

Background: Hypertension is an important risk factor for cardiovascular diseases. Electronic health records (EHRs) may augment chronic disease surveillance. We aimed to develop an electronic phenotype (e-phenotype) for hypertension surveillance., Methods: We included 11,031,368 eligible adults from the 2019 IQVIA Ambulatory Electronic Medical Records-US (AEMR-US) dataset. We identified hypertension using three criteria, alone or in combination: diagnosis codes, blood pressure (BP) measurements, and antihypertensive medications. We compared AEMR-US estimates of hypertension prevalence and control against those from the National Health and Nutrition Examination Survey (NHANES) 2017-18, which defined hypertension as BP ≥130/80 mm Hg or ≥1 antihypertensive medication., Results: The study population had a mean (SD) age of 52.3 (6.7) years, and 56.7% were women. The selected three-criteria e-phenotype (≥1 diagnosis code, ≥2 BP measurements of ≥130/80 mm Hg, or ≥1 antihypertensive medication) yielded similar trends in hypertension prevalence as NHANES: 42.2% (AEMR-US) vs. 44.9% (NHANES) overall, 39.0% vs. 38.7% among women, and 46.5% vs. 50.9% among men. The pattern of age-related increase in hypertension prevalence was similar between AEMR-US and NHANES. The prevalence of hypertension control in AEMR-US was 31.5% using the three-criteria e-phenotype, which was higher than NHANES (14.5%)., Conclusions: Using an EHR dataset of 11 million adults, we constructed a hypertension e-phenotype using three criteria, which can be used for surveillance of hypertension prevalence and control., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2023.)

Background: The American Heart Association (AHA) recommends cuff sizes of blood pressure (BP) monitoring devices based on patient arm circumference, which is critical for accurate BP measurement. This study aimed to assess cuff size variation across validated BP devices and to examine the degree of alignment with the AHA recommendations., Methods: Data on home BP devices were obtained from the US BP Validated Device Listing website and listed cuff sizes were compared against AHA recommendations: small adult (22-26 cm), adult (27-34 cm), large (35-44 cm), and extra-large (XL) (45-52 cm)., Results: There were 42 home validated BP devices from 13 manufacturers, and none offered cuffs that were aligned with the AHA recommendations. Over half of the devices (22, 52.4%) were compatible with only a broad-range cuff, generally excluding arm sizes larger than 44 cm. Only 5 devices from 4 manufacturers offered a cuff labeled "XL," and of these, only 3 devices had sizes that covered the AHA XL range. Terminology lacked consistency with manufacturers using: different labels to describe the same-sized cuffs (e.g., 22-42 cm was labeled "integrated," "standard," "adult," "large," and "wide range"); the same labels to describe differently sized cuffs (e.g., cuffs labeled "large" were sized 22-42 cm, 32-38 cm, 32-42 cm, 36-45 cm)., Conclusions: Manufacturers of US home BP devices employ inconsistent terminologies and thresholds for cuff sizes, and sizes were not aligned with AHA recommendations. This lack of standardization could pose challenges for clinicians and patients attempting to select a properly sized cuff to support hypertension diagnosis and management., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2023.)

Background: The COVID-19 pandemic disrupted healthcare in the United States and raised concerns about certain antihypertensives, and may have impacted both prescribing practices and access to blood pressure (BP) medications., Methods: We assessed trends in BP prescription fills before and during the first year of the COVID-19 pandemic, using cross-sectional data for BP fills and tablets in the IQVIA (IMS Health) National Prescription Audit® database. Drugs filled via retail (92% coverage), mail-order (78% coverage), and long-term care (72% coverage) channels from January 2018 through December 2020 were included. Data were projected nationally and by state., Results: Between 2.9 and 3.4 billion BP tablets were dispensed monthly until February 2020, increasing sharply to 3.8 billion in March 2020 and declining to 3.5 billion in April, then increasing at 3-month intervals until December 2020. The number of tablets per fill increased slightly over time, with the largest increase (from 66.7 to 68.6) during February-March, 2020. Tablets were dispensed through retail channels (99.7 billion), mail-order (14.7 billion), and long-term care (5.3 billion). Rates of patients initiating new medications decreased during 2020 compared to prior years. Fills did not vary significantly by drug class., Conclusions: A sharp increase in BP fills occurred with COVID-19 emergence, suggesting patients may have secured medications in preparation for potential access limitations. A decrease in new fills, indicating decreased initiation and/or modification of treatment regimens, suggests need for efforts to re-engage patients in the healthcare system and provide alternative ways to obtain medication refills and adjustments., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2023.)

Background: Hypertension, defined as blood pressure (BP) ≥130/80 mm Hg or antihypertensive medication use, affects approximately half of US adults, and appropriately sized BP cuffs are important for accurate BP measurement and hypertension management., Methods: This cross-sectional study analyzed 13,038 US adults (≥18 years) in the National Health and Nutrition Examination Survey 2015-March 2020 cycles. Recommended BP cuff sizes were categorized based on mid-arm circumference: small adult (≤26 cm), adult (>26 to ≤34 cm), large adult (>34 to ≤44 cm), and extra-large adult (>44 cm). Analyses were weighted and proportions were extrapolated to the US population., Results: Among US adults (246 million), recommended cuff sizes were: 6% (16 million) small adult, 51% adult (125 million), 40% large adult (98 million), and 3% extra-large adult (8 million). Among adults with hypertension (116 million), large or extra-large cuffs were needed by over half (51%) overall, including 65% of those aged 18-34 years and 84% of those with obesity (BMI ≥30 kg/m2). By race/ethnicity, the proportion needing a large or extra-large cuff was 57% of non-Hispanic Black adults, 54% of Hispanic adults, 51% of non-Hispanic White adults, and 23% of non-Hispanic Asian adults. Approximately 40% of adults with hypertension in Medicare needed a large or extra-large cuff, compared to 54% for private insurance and 53% for Medicaid., Conclusions: Over half of US adults with hypertension need a large or extra-large BP cuff., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2022.)

Background: Controlled blood pressure can prevent or reduce adverse health outcomes. Social and structural determinants may contribute to the disparity that despite equivalent proportions on antihypertensive medication, non-Hispanic Black (Black) adults have lower blood pressure control and more cardiovascular events than non-Hispanic White (White) adults., Methods: Data from 2013 to 2018 National Health and Nutrition Examination Survey were pooled to assess control among Black and White adults by antihypertensive medication use and selected characteristics using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Blood Pressure Guideline definition (systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg) among 4,739 adults., Results: Among those treated with antihypertensive medication, an estimated 34.9% of Black and 45.0% of White adults had controlled blood pressure. Control was lower for Black and White adults among most subgroups of age, sex, education, insurance status, usual source of care, and poverty-income ratio. Black adults had higher use of diuretics (28.5%-Black adults vs. 23.5%-White adults) and calcium channel blockers (24.2%-Black adults vs. 14.7%-White adults) compared with White adults. Control among Black adults was lower than White adults across all medication classes including diuretics (36.1%-Black adults vs. 47.3%-White adults), calcium channel blockers (30.2%-Black adults vs. 40.1%-White adults), and number of medication classes used., Conclusions: Suboptimal blood pressure control rates and disparities warrant increased efforts to improve control, which could include addressing social and structural determinants along with emphasizing implementation of the 2017 ACC/AHA Blood Pressure Guideline into clinical practice., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2022.)

Hypertension is highly prevalent in the United States, and many persons with hypertension do not have controlled blood pressure. Self-measured blood pressure monitoring (SMBP), when combined with clinical support, is an evidence-based strategy for lowering blood pressure and improving control in persons with hypertension. For years, there has been support for widespread implementation of SMBP by national organizations and the federal government, and SMBP was highlighted as a primary intervention in the 2020 Surgeon General's Call to Action to Control Hypertension, yet optimal SMBP use remains low. There are well-known patient and clinician barriers to optimal SMBP documented in the literature. We explore additional high-level barriers that have been encountered, as broad policy and systems-level changes have been attempted, and offer potential solutions. Collective efforts could modernize data transfer and processing, improve broadband access, expand device coverage and increase affordability, integrate SMBP into routine care and reimbursement practices, and strengthen patient engagement, trust, and access., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2021.)

Background: The 2017 American College of Cardiology / American Heart Association Guideline for blood pressure (BP) management newly classifies millions of Americans with elevated BP or stage 1 hypertension for recommended lifestyle modification alone (without pharmacotherapy). This study characterized these adults, including their cardiovascular disease risk factors, barriers to lifestyle modification, and healthcare access., Methods: This cross-sectional study examined nationally representative National Health and Nutrition Examination Survey data, 2013-2016, on 10,205 US adults aged ≥18, among whom 2,081 had elevated BP or stage 1 hypertension and met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone., Results: An estimated 22% of US adults (52 million) would be recommended for lifestyle modification alone. Among these, 58% were men, 43% had obesity, 52% had low-quality diet, 95% consumed excess sodium, 43% were physically inactive, and 8% consumed excess alcohol. Many reported attempting lifestyle changes (range: 39%-60%). Those who reported receiving health professional advice to lose weight (adjusted prevalence ratio 1.21, 95% confidence interval 1.06-1.38), reduce sodium intake (2.33, 2.00-2.72), or exercise more (1.60, 1.32-1.95) were significantly more likely to report attempting changes. However, potential barriers to lifestyle modification included 28% of adults reporting disability, asthma, or arthritis. Additionally, 20% had no health insurance and 22% had no healthcare visits in the last year., Conclusions: One-fifth of US adults met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone, and many reported attempting behavior change. However, barriers exist such as insurance gaps, limited access to care, and physical impairment., (© Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2020.)

Objectives: Anecdotal comparisons between rural and urban community pharmacy practice have been frequently reported. Therefore, a narrative systematic review was conducted to examine the published international evidence comparing the nature of services provided from community pharmacies in both settings. A comprehensive literature search was undertaken across four databases. The key criterion for inclusion was a comparison of practice, excluding dispensing and associated counselling. Definitions of 'rural' were specific to the country and publication year., Key Findings: The search yielded 3830 titles, from which 17 publications met the inclusion criteria. The studies investigated current or proposed services and included the provision of pharmaceutical care, public health activities and prescribing. Rural customers were more willing to seek advice and talked longer to the pharmacist, but not always. There was limited evidence that rural pharmacists provided more professional services and they appeared to have better working relationships with prescribers. Many of the authors challenged the validity of their own results, suggesting that other confounding factors accounted for the observed differences. In general, the statistical analyses reported were basic, with multivariate analyses being uncommon. There was some evidence that rural pharmacists were seemingly more willing to take on new professional roles and deliver a higher level of service. However, this conclusion is based on a small number of studies, often with a limited number of respondents and simplistic data analyses. Further high-quality research is required to ascertain and characterise any real differences between rural and urban settings in community pharmacy practice., (© 2019 Royal Pharmaceutical Society.)

Background: Delivery of cardiovascular disease (CVD) prevention programs by community pharmacists appears effective and enhances health service access. However, their capacity to implement complex behavioural change processes during patient counselling remains largely unexplored. This study aims to determine intervention fidelity by pharmacists for behavioural components of a complex educational intervention for CVD prevention. After receiving training to improve lifestyle and medicines adherence, pharmacists recruited 70 patients aged 50-74 years without established CVD, and taking antihypertensive or lipid lowering therapy. Patients received five counselling sessions, each at monthly intervals. Researchers assessed biomedical and behavioural risk factors at baseline and six months. Pharmacists documented key outcomes from counselling after each session. Most patients (86%) reported suboptimal cardiovascular diets, 41% reported suboptimal medicines adherence, and 39% were physically inactive. Of those advised to complete the intervention, 85% attended all five sessions. Pharmacists achieved patient agreement with most recommended goals for behaviour change, and overwhelmingly translated goals into practical behavioural strategies. Barriers to changing behaviours were regularly documented, and pharmacists reported most behavioural strategies as having had some success. Meaningful improvements to health behaviours were observed post-intervention. Findings support further exploration of pharmacists' potential roles for delivering interventions with complex behaviour change requirements., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To understand the factors influencing persistence with tiotropium in patients with chronic obstructive pulmonary disease (COPD)., Methods: Patients classified as 'persistent' or 'non-persistent' with tiotropium were identified from pharmacy dispensing records. Patients were compared for health status, beliefs and behaviours using data from questionnaires and interviews., Key Findings: Perceptions of the risks and benefits of medication, fear of worsening illness, and the GP's emphasis on the importance of the medication were key determinants of tiotropium persistence., Conclusions: Perceptions, attitudes and beliefs of patients and doctors influence persistence with tiotropium. These complex interactions need to be targeted to improve persistence with medicines in COPD., (© 2014 Royal Pharmaceutical Society.)

Objective: In aged-care facilities (ACFs) monitoring of warfarin can be logistically challenging and International Normalised Ratio (INR control) is often suboptimal. We aimed to determine whether an integrated information and communications technology system and the use of point-of-care (POC) monitors by nursing staff could improve the INR control of aged-care facility residents who take warfarin., Methods: Nursing staff identified residents who were prescribed warfarin in participating ACFs. A computer program (MedePOC) was developed to store and transmit INR results from the ACFs to general practitioners (GPs) for dosage adjustment. Nursing staff received training in the use of the CoaguChek XS point-of-care INR monitor and the MedePOC software. Following a run-in phase, eligible patients were monitored weekly for up to 12 weeks. The primary outcome was the change in the time in therapeutic range (TTR) in the intervention phase compared to the TTR in the 12 months preceding the study. All GPs, nursing staff and patients were surveyed for their experiences and opinions of the project., Key Findings: Twenty-four patients and 19 GPs completed the trial across six ACFs. The mean TTR for all patients improved non-significantly from 58.9 to 60.6% (P=0.79) and the proportion of INR tests in range improved non-significantly from 57.1 to 64.1% (P=0.21). The mean TTR improved in 14 patients (58%) and in these patients the mean absolute improvement in TTR was 23.1%. A post hoc analysis of the INR data using modified therapeutic INR ranges to reflect the dosage adjustment practices of GPs suggested that the intervention did lead to improved INR control. The MedePOC program and POC monitoring was well received by nursing staff., Conclusions: Weekly POC INR monitoring conducted in ACFs and electronic communication of the results and warfarin doses resulted in non-significant improvements in INR control in a small cohort of elderly residents. Further research involving modification to the communication strategy and a longer follow-up period is warranted to investigate whether this strategy can improve INR control and clinical outcomes in this vulnerable population., (© 2013 The Authors. IJPP © 2013 Royal Pharmaceutical Society.)

Background: Interpretive performance of screening mammography varies substantially by facility, but performance of diagnostic interpretation has not been studied., Methods: Facilities performing diagnostic mammography within three registries of the Breast Cancer Surveillance Consortium were surveyed about their structure, organization, and interpretive processes. Performance measurements (false-positive rate, sensitivity, and likelihood of cancer among women referred for biopsy [positive predictive value of biopsy recommendation {PPV2}]) from January 1, 1998, through December 31, 2005, were prospectively measured. Logistic regression and receiver operating characteristic (ROC) curve analyses, adjusted for patient and radiologist characteristics, were used to assess the association between facility characteristics and interpretive performance. All statistical tests were two-sided., Results: Forty-five of the 53 facilities completed a facility survey (85% response rate), and 32 of the 45 facilities performed diagnostic mammography. The analyses included 28 100 diagnostic mammograms performed as an evaluation of a breast problem, and data were available for 118 radiologists who interpreted diagnostic mammograms at the facilities. Performance measurements demonstrated statistically significant interpretive variability among facilities (sensitivity, P = .006; false-positive rate, P < .001; and PPV2, P < .001) in unadjusted analyses. However, after adjustment for patient and radiologist characteristics, only false-positive rate variation remained statistically significant and facility traits associated with performance measures changed (false-positive rate = 6.5%, 95% confidence interval [CI] = 5.5% to 7.4%; sensitivity = 73.5%, 95% CI = 67.1% to 79.9%; and PPV2 = 33.8%, 95% CI = 29.1% to 38.5%). Facilities reporting that concern about malpractice had moderately or greatly increased diagnostic examination recommendations at the facility had a higher false-positive rate (odds ratio [OR] = 1.48, 95% CI = 1.09 to 2.01) and a non-statistically significantly higher sensitivity (OR = 1.74, 95% CI = 0.94 to 3.23). Facilities offering specialized interventional services had a non-statistically significantly higher false-positive rate (OR = 1.97, 95% CI = 0.94 to 4.1). No characteristics were associated with overall accuracy by ROC curve analyses., Conclusions: Variation in diagnostic mammography interpretation exists across facilities. Failure to adjust for patient characteristics when comparing facility performance could lead to erroneous conclusions. Malpractice concerns are associated with interpretive performance.

We show that two distinct distributions of F-actin are present in the hyphal apex of the oomycete Achlya bisexualis, that have been chemically fixed with a combination of methylglyoxal and formaldehyde and stained with Alexa phalloidin. In approximately one half of the hyphae examined, an F-actin depleted zone within the apical F-actin cap was observed. The remaining hyphae had a continuous apical cap. In live, growing hyphae two types of cytoplasmic organization were observed at the tips, one in which a clear zone was present which may correlate with the F-actin depleted zone, and one where no such clear zone existed which may represent the continuous cap. We suggest that the F-actin depleted zone may be a structural component of the actin network in a subpopulation of oomycete hyphae and may be comparable to similar F-actin depleted zones at the apices of other tip growing cells such as pollen tubes and root hairs. This observation has implications with regard to models of hyphal extension. Hyphae fixed with formaldehyde alone showed continuous apical F-actin caps. Our ability to resolve the F-actin depleted zone likely reflects the cross-linking capabilities of methylglyoxal. The methylglyoxal-formaldehyde combination fixative gave more stained hyphae, brighter staining and more complete staining of F-actin compared to formaldehyde alone.

A sample of 761 subjects 70 years and over was drawn from general-practice records of a rural township. Each subject was assessed and followed for 1 year to determine the incidence of and factors related to falls. The fall rate (number of falls per 100 person-years) increased from 47 for those aged 70-74 years to 121 for those 80 years and over. There was no sex difference in fall rate but men were more likely than women to fall outside and at greater levels of activity. Twenty per cent of falls were associated with trips and slips but we found no evidence that inspection of homes and installation of safety features would have decreased the fall rate. Ten per cent of falls resulted in significant injury. Men who fell had an increased subsequent risk of death compared with those who did not fall (relative risk 3.2, 95% CI 1.7-6.0). Subsequent mortality was increased among women who fell but not to significant levels (relative risk 1.6, 95% CI 0.9-2.7).