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Objective: Hypertension is a recognized risk factor for the development of cognitive impairment and dementia in older adults. Aortic stiffness and altered haemodynamics could promote the transmission of detrimental high pressure pulsatility into the cerebral circulation, potentially damaging brain microvasculature and leading to cognitive impairment. We determined whether reservoir-excess pressure parameters were associated with cognitive function in people with hypertension (HT) and normotension (NT)., Methods: We studied 35 middle-aged and older treatment-naïve stage II/III HT (office systolic BP 176 ± 17 mmHg) and 35 age-, sex- and body mass index-matched NT (office systolic BP 127 ± 8 mmHg). Parameters derived from reservoir-excess pressure analysis including reservoir pressure integral (INTPR), excess pressure integral (INTXSP), systolic rate constant (SRC), diastolic rate constant (DRC) and pulse wave velocity (PWV) were calculated from an ensemble-averaged aortic pressure waveform derived from radial artery tonometry. Cognitive function was assessed using the Addenbrooke's Cognitive Examination Revised (ACE-R), Trail Making Test Part A (TMT-A) and Part B (TMT-B)., Results: All reservoir-excess pressure parameters were greater in HT than NT (all P  < 0.05). Greater INTXSP was associated with lower ACE-R score ( rs  = -0.31), longer TMT-A ( r  = 0.31) and TMT-B ( r  = 0.38). Likewise, greater DRC and PWV were also associated with lower ACE-R score ( rs  = -0.27 and rs  = -0.33), longer TMT-A ( r  = 0.51 and r  = 0.40) and TMT-B ( r  = 0.38 and r  = 0.32). Greater INTXSP, DRC and PWV are consistently associated with worse cognitive function in this study., Conclusions: These observations support a potential mechanistic link between adverse haemodynamics and a heightened risk of cognitive impairment in older adults with hypertension., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Current National Health Service policy in England encourages enhanced digital access in primary care service provision. In this study, we investigate 'digital facilitation' - that range of processes, procedures and personnel which seeks to support National Health Service primary care patients in their uptake and use of online services., Objectives: Identify, characterise and explore the potential benefits and challenges associated with different models of digital facilitation currently in use in general practice which are aimed at improving patient access to online services in general practice in England. Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions. Explore how patients with mental health conditions experience digital facilitation and gauge their need for this support., Design: Observational mixed-methods study (literature review, surveys, ethnographic observation and interviews); formal synthesis of findings., Setting: General practice in four regions of England., Participants: Practice survey: 156 staff. Patient survey: 3051 patients. Mental health survey: 756 patients. General practitioner patient survey: 3 million responders. Ethnographic case-studies: 8 practices; interviews with 36 staff, 33 patients and 10 patients with a mental health condition. Stakeholder interviews: 19 participants., Intervention: Digital facilitation as undertaken in general practice., Main Outcome Measures: Patient and practice staff reported use of, and views of, digital facilitation., Data Sources: Surveys, qualitative research; national General Practitioner Patient Survey (2019-22)., Review Methods: Scoping-review methodology applied to academic and grey literature published 2015-20., Results: While we did find examples of digital facilitation in routine practice, these often involved using passive or reactive modes of support. The context of COVID, and the necessary acceleration (at that time) of the move to a digital-first model of primary care, shaped the way digital facilitation was delivered. There was lack of clarity over where the responsibility for facilitation efforts lay; it was viewed as the responsibility of 'others'. Patients living with mental health conditions had similar needs and experiences regarding digital facilitation to other patients., Limitations: The context of the COVID pandemic placed limitations on the project. Fewer practices responded to the practice survey than anticipated; reconfiguration of general practices to support COVID measures was a key consideration during non-participant observation with social distancing and other measures still in place during fieldwork., Conclusions: Digital facilitation, while not a widely recognised concept, is important in supporting the move to a National Health Service with enhanced digital opportunities and enhanced digital access. General practice staff are allocating resources to provide such efforts in general practices in England. The establishment of clear lines of responsibility, the development of digital tools and platforms that work for patients and practice staff, and investment in staff time and training are needed if digital facilitation is to support the intended digital revolution., Future Work: We did not find one single dominant or preferred model of digital facilitation which might reasonably be considered to form the basis of an intervention to be tested. Rather, there is a need to co-develop such an intervention with patients, general practice staff and relevant policy experts. We outline a framework for a future evaluation of such an intervention., Study Registration: This study is registered as ResearchRegistry6523 (www.researchregistry.com/browse-the-registry#home/?view&#95;2&#95;search=Di-Facto&view&#95;2&#95;page=1) and PROSPERO CRD42020189019 (www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=189019)., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128268) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 32. See the NIHR Funding and Awards website for further award information.

Introduction: Chronic short sleep duration (i.e., <7 h sleep daily) could reduce the brain's ability to attenuate toxin and protein accumulation, which may contribute to Parkinson's disease (PD). The purpose of this study was to characterize the relationship between self-reported sleep duration from adolescence to adulthood and the age of diagnosis in people with PD. A secondary purpose was to characterize the interaction between sleep duration and physical activity through the lifespan on the age of PD diagnosis., Methods: A secondary data analysis was performed using the Fox Insight data set. Multiple regression analysis was used to determine the age range that sleep duration best predicted the age of diagnosis of PD. Hierarchical linear multiple regression was performed to assess if self-reported sleep duration, physical activity, and their interaction predicted the age of diagnosis for PD, after accounting for sociodemographic factors., Results: Both sleep (p < 0.001) and physical activity time (p = 0.013) significantly predicted the of age of onset of PD. In contrast, there was no evidence to support an interaction of sleep by physical activity on the age of diagnosis of PD. Sleep duration at 46-55 years maintained significance after controlling for education, income, race, ethnicity, and sex (p < 0.001). Weekly duration of time spent performing moderate-intensity physical activity was added as an input variable., Conclusion: Sleep duration significantly predicts the age of diagnosis of PD, with shorter sleep duration associated with a younger age of diagnosis of PD., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Health service policy in many jurisdictions is driving greater investment into digital primary care services. While some patients and practices may benefit, there are concerns that not all are able or wish to access primary care services online. "Digital facilitation" is the "range of processes, procedures, and personnel seeking to support patients in their uptake and use of online services" and may address such concerns., Objective: As part of a multimethod research program, we undertook surveys of practice staff and patients to gain insight into the support being offered by practices and explore patients' experiences of this support., Methods: General practices from 4 regions of England were sent a questionnaire exploring the modes of digital facilitation offered, the personnel involved in its delivery, and views on the motivations and drivers for providing support. Moreover, 12,822 patients registered with 62 general practices (predominantly those providing practice survey responses) were sent a questionnaire exploring their experiences of any support offered by their practice to use online services., Results: Almost one-third of practices (156/500, 31.2%) responded to the practice survey, with most reporting using passive modes of digital facilitation (eg, display, leaflets, and SMS text messages) and few using active modes (eg, offering tablets or computers or using practice champions). However, 90.9% (130/143) reported providing ad hoc support. Practices agreed that it was the responsibility of both the practice (105/144, 72.9%) and the wider National Health Service (118/143, 82.5%) to support patients in using online services and that providing such support benefited the practice (126/144, 87.5%) and their patients (132/144, 91.7%). Nearly a quarter of the patients (3051/12,822, 23.8%) responded to the patient survey, with few (522/3051, 17.11% or less) reporting awareness of any modes of digital facilitation apart from text messages and emails (1205/3051, 39.5%) and only 13.36% (392/2935) reporting receiving support to use online services. Adjusted logistic regression analyses showed that older patients had a lower likelihood of 4 outcomes: being aware of, or of using, digital facilitation efforts, or being told about or being helped to use online services (all P<.05), particularly with regard to being helped to use online services (adjusted odds ratio for patients aged 85 years versus those aged 55-64 years: 0.08, 95% CI 0.02-0.36). However, ethnic minority participants or those for whom their first language was not English had positive associations with these outcomes., Conclusions: General practices recognize that patients would benefit from support to access online services. However, the support provided is often passive or ad hoc, and patients were seldom aware of digital facilitation efforts that their practice provided. There is potential to increase engagement with online primary care services by providing more support for all patients, particularly to provide targeted support for older patients., (©Rachel Winder, John L Campbell, Nurunnahar Akter, Abodunrin Q Aminu, Jeffrey Lambert, Emma Cockcroft, Chloe Thomas, Christopher E Clark, Carol Bryce, Jon Sussex, Helen Atherton, Christine Marriott, Gary Abel. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 07.08.2024.)

Objective: To report a validation of the Riester Big Ben Square Desk Aneroid Sphygmomanometer according to the international protocol developed by the Working Group on Blood Pressure Monitoring of the European Society of Hypertension 2002 (ESH-IP 2002) in the interest of transparency. This legacy publication is intended to assure users that the device satisfied the requirements in place at that time., Methods: Performance of the device was assessed by participants' age, sex, arm circumference and entry SBP/DBP. Validation was performed in 33 participants. The sphygmomanometer was assessed according to the ESH-IP, which defines zones of accuracy compared to the mercury standard as ≤5, ≤10, ≤15 mmHg or more., Results: The mean (± SD) age was 50.5 ± 13.0 years, range 29-71 years, entry SBP 142.6 ± 23.7 mmHg, entry DBP 89.0 ± 17.8 mmHg. The device passed all the requirements listed and the validation protocol. The Riester Big Ben Square Desk aneroid sphygmomanometer slightly underestimated the observer-measured SBP, yet slightly overestimated DBP. The observer-device disagreement was -0.8 ± 6.4 mmHg SBP and +0.6 ± 4.0 mmHg DBP., Conclusion: These data show that the Riester Big Ben Square Desk aneroid sphygmomanometer fulfilled the ESH-IP 2002 requirements for the validation of BP monitors. It was on this basis that the British and Irish Hypertension Society recommended it for clinical use in the adult population., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Peripheral artery disease (PAD) is common and associated with future cardiovascular events. PAD is underdiagnosed, which limits opportunities to address secondary prevention of cardiovascular disease. It is unknown how closely guidelines for detection of PAD are followed in primary care., Aim: To survey GPs' attitudes to diagnosis and follow-up of patients with PAD., Design & Setting: Online survey of GPs in England and the Republic of Ireland (RoI)., Method: GPs' approaches to management of PAD were assessed using likelihood ratings (scales of 0-10) and discrete questions. Findings were summarised as proportions, or median and interquartile ranges (IQR)., Results: In total, 111 responses were analysed; 68 (61%) from England and 43 (39%) from the RoI. Considering a hypothetical patient at risk of PAD, likelihood of GPs enquiring about PAD symptoms (leg pains: 3/10 or erectile dysfunction: 2/10) was low. GPs in the RoI compared with GPs in England more often examined the heart (10/10 versus 7/10) or carotid vessels (5/10 versus 1/10). Lower limb pulses were palpated in response to symptoms or signs of PAD. In England 25% of practitioners, and in the RoI 55% of practitioners, reported that they do not measure ankle-brachial index (ABI)., Conclusion: Currently, detection of PAD is generally triggered by 'classical' leg claudication symptoms, while known vascular risk factors appear to elicit little consideration. ABI measurement is not performed by many practitioners, suggesting that a proportion of vascular referrals must be based on history and examination findings alone. Opportunities to recognise PAD are missed., (Copyright © 2024, The Authors.)

Background: Rural primary care practices struggle to employ and retain staff, and existing literature regarding recruitment and retention is focused on doctors. Shortages of qualified staff affect practice functioning, quality of care, and patient experience. Dispensing of medications is a rural service valued by patients. However, little is known about how dispensing services are valued by practices or related to the recruitment and retention of staff., Aim: To understand barriers to, and facilitators of, joining and remaining in rural dispensing practice employment, and to explore how rural practices value dispensing services., Design & Setting: Qualitative inquiry in rural primary care practices across England., Method: Semi-structured interviews with rural dispensing staff were undertaken, audio-recorded, transcribed verbatim, and analysed using framework analysis., Results: In total, 17 staff from 12 practices across England were interviewed between June and November 2021. Reasons for taking up employment in rural dispensing practices included perceived career autonomy, development opportunities, and preference for working and living in a rural setting. Skills required for dispensers' roles balanced against low wages were a barrier to recruitment. For nurses, barriers included perceived lack of knowledge around their role in rural care. Revenue from dispensing, opportunities for staff development, job satisfaction, and positive work environments drove retention of staff. However, negative perceptions of rural practice, travel difficulties, lack of applicants, and insufficient remuneration for roles were barriers to retention., Conclusion: Barriers to, and facilitators of, rural primary care recruitment and retention vary by role, and include factors unique to the rural setting., (Copyright © 2024, The Authors.)

Background: The National Health Service (NHS) and general practice are increasingly adopting digital services. These services can impact both positively and negatively upon patient experiences, and access to digital services is not equal amongst all groups. Within a wider project examining digital facilitation (the Di-Facto study) our team conducted a patient survey amongst English primary care practices aiming to investigate patient views of what supports uptake and use of web-based services. This paper reports on the analysis of the free-text responses from the patient survey., Methods: The Di-Facto patient survey was distributed to practices in eight clinical commissioning groups (CCGs) in England between 2021-2022. We examined free-text responses to two questions relating to access to primary care web-based and support for web-based services. We used qualitative reflexive thematic analysis based on a six-stage process to analyse responses., Results: Of the 3051 patients who responded to the Di-Facto survey, 2246 provided a free-text response. We present our findings in two major themes: systems and structures and their impact on use of web-based services, and 'what works for me', a description of how respondents described what worked, or did not work in terms of their interactions with web-based services. Respondents described how the technology, such as poor practice website design, confusion over multiple digital apps, data security and concerns about eConsultation offerings impacted on use of web-based services. Respondents described practice level barriers, such as a lack of or inconsistent provision, which prevented optimal use of web-based services. Respondents described personal and technical barriers that impacted on their use of digital services, and described which web-based services worked well for them. Respondents felt that web-based services were not a replacement for face-to-face interactions with a doctor., Conclusions: This analysis of free-text responses from a large patient survey highlights the system, practice, and person level barriers and facilitators to use of digital services in primary care. With an increasing push towards digital solutions in NHS primary care, practices should consider the design, rollout and communication of their web-based services to support patient access., (© 2024. The Author(s).)

Purpose: To inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening in a primary care setting for hypertension in adults aged 18 years and older. This protocol outlines the scope and methods for a series of systematic reviews and one overview of reviews., Methods: To evaluate the benefits and harms of screening for hypertension, the Task Force will rely on the relevant key questions from the 2021 United States Preventive Services Task Force systematic review. In addition, a series of reviews will be conducted to identify, appraise, and synthesize the evidence on (1) the association of blood pressure measurement methods and future cardiovascular (CVD)-related outcomes, (2) thresholds for discussions of treatment initiation, and (3) patient acceptability of hypertension screening methods. For the review of blood pressure measurement methods and future CVD-related outcomes, we will perform a de novo review and search MEDLINE, Embase, CENTRAL, and APA PsycInfo for randomized controlled trials, prospective or retrospective cohort studies, nested case-control studies, and within-arm analyses of intervention studies. For the thresholds for discussions of treatment initiation review, we will perform an overview of reviews and update results from a relevant 2019 UK NICE review. We will search MEDLINE, Embase, APA PsycInfo, and Epistemonikos for systematic reviews. For the acceptability review, we will perform a de novo systematic review and search MEDLINE, Embase, and APA PsycInfo for randomized controlled trials, controlled clinical trials, and observational studies with comparison groups. Websites of relevant organizations, gray literature sources, and the reference lists of included studies and reviews will be hand-searched. Title and abstract screening will be completed by two independent reviewers. Full-text screening, data extraction, risk-of-bias assessment, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers. Results from included studies will be synthesized narratively and pooled via meta-analysis when appropriate. The GRADE approach will be used to assess the certainty of evidence for outcomes., Discussion: The results of the evidence reviews will be used to inform Canadian recommendations on screening for hypertension in adults aged 18 years and older., Systematic Review Registration: This protocol is registered on PROSPERO and is available on the Open Science Framework (osf.io/8w4tz)., (© 2023. The Author(s).)

Competing Interests: Competing interests: None declared.

Biogeochemical sulfur cycling in sulfidic karst systems is largely driven by abiotic and biological sulfide oxidation, but the fate of elemental sulfur (S 0 ) that accumulates in these systems is not well understood. The Frasassi Cave system (Italy) is intersected by a sulfidic aquifer that mixes with small quantities of oxygen-rich meteoric water, creating Proterozoic-like conditions and supporting a prolific ecosystem driven by sulfur-based chemolithoautotrophy. To better understand the cycling of S 0 in this environment, we examined the geochemistry and microbiology of sediments underlying widespread sulfide-oxidizing mats dominated by Beggiatoa. Sediment populations were dominated by uncultivated relatives of sulfur cycling chemolithoautotrophs related to Sulfurovum, Halothiobacillus, Thiofaba, Thiovirga, Thiobacillus, and Desulfocapsa, as well as diverse uncultivated anaerobic heterotrophs affiliated with Bacteroidota, Anaerolineaceae, Lentimicrobiaceae, and Prolixibacteraceae. Desulfocapsa and Sulfurovum populations accounted for 12%-26% of sediment 16S rRNA amplicon sequences and were closely related to isolates which carry out autotrophic S 0 disproportionation in pure culture. Gibbs energy (∆G r ) calculations revealed that S 0 disproportionation under in situ conditions is energy yielding. Microsensor profiles through the mat-sediment interface showed that Beggiatoa mats consume dissolved sulfide and oxygen, but a net increase in acidity was only observed in the sediments below. Together, these findings suggest that disproportionation is an important sink for S 0 generated by microbial sulfide oxidation in this oxygen-limited system and may contribute to the weathering of carbonate rocks and sediments in sulfur-rich environments., (© 2023 The Authors. Geobiology published by John Wiley & Sons Ltd.)

Background: Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017., Objectives: To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease SEARCH METHODS: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied., Selection Criteria: We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation., Data Collection and Analysis: Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE., Main Results: We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar., Authors' Conclusions: This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services. Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery. Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Proper monitoring of fatigue and muscular damage may be used to decrease the high levels of cardiovascular disease, overuse musculoskeletal injuries, and workers compensation claims within the profession of firefighting. The purpose of this study was to examine muscle damage, muscular fatigue, and inflammation responses following a typical firefighting shift. Twenty-four professional firefighters completed two Physical Ability Tests to standardize the tasks typically performed in a day of work, and to elicit similar physiological responses. Participants were then monitored for 48 h. Prior to, and 48 h following the Physical Ability Tests, participants were evaluated for changes in strength, power, range-of-motion, as well as blood markers including myoglobin and c-reactive protein. Following the Physical Ability Tests, significant differences in myoglobin ( p < 0.05), grip strength ( p < 0.05), vertical jump ( p < 0.05), and sit-and-reach ( p < 0.05) were observed. No difference in c-reactive protein was observed ( p > 0.05). After 24 hours following a shift, firefighters exhibited decreased strength, power, and range-of-motion. This may lead to decreases in performance and an increased risk of injury.

Competing Interests: Competing interests: Interests were declared based on NICE’s policy on conflicts of interests (https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-interests-policy.pdf) and full statements are provided in the NICE guideline.

Introduction: The growing popularity of virtual reality devices and increasingly widespread distribution of VR products into the home exposes users to risk of bodily harm. Safety features are integrated into the devices themselves, but the burden of cautious use rests upon the end user. The purpose of this study is to quantify and describe the array of injuries and demographics effected by the burgeoning VR industry to inform and encourage mitigation strategies., Materials and Methods: The National Electronic Injury Surveillance System (NEISS) data was used to examine a nationwide sample of emergency department records from 2013 - 2021. Inverse probability sample weights for cases were applied to arrive at national estimates. NEISS data included consumer product injuries, patient age, sex, race and ethnicity, drug and alcohol involvement, diagnoses, injury descriptions, and emergency department disposition., Results: The first VR-related injury was reported in the NEISS data in 2017, and injuries were estimated to number 125. Incidents of VR-related injuries amplified as increased VR units sold, and by 2021, there was a 352% increase in VR injuries totaling a weighted estimate of 1,336 ED visits. The most common VR-related injury diagnosis is fracture (30.3%), followed by laceration (18.6%), contusion (13.9%), other (11.8%), and strain / sprain (10.0%). VR-related injuries involve the hand (12.1%), face (11.5%), finger (10.6%), and knee (9.0%), head (7.0%) and upper trunk (7.0%). Patients age 0-5 most commonly experienced injuries to the face (62.3%). Injuries in patients 6-18 were mostly to the hand (22.3%) and face (12.8%). Patients 19-54 experienced primarily injuries to the knee (15.3%), finger (13.5%), and wrist (13.3%). Patients aged 55 and older disproportionately experienced injuries in the upper trunk (49.1%) and upper arm (25.2%)., Conclusions: This is the first study to describe the incidence, demographics and characteristics of injuries from VR device use. Sales of home VR units continue to increase annually and the rapid increase in VR consumer injuries is being managed by emergency departments across the country. An understanding of these injuries will inform VR manufacturers, application developers, and users to promote safe product development and operation., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest to declare., (Copyright © 2023. Published by Elsevier Ltd.)

Introduction: Rural General Practice (GP) surgeries often struggle to employ and retain multidisciplinary team members. Existing research into rural recruitment and retention issues is limited, and usually focussed on doctors. Rural practices often rely on income from dispensing medications; little is known about how maintaining dispensing services contributes to the recruitment and retention of staff. This study aimed to understand the barriers and facilitators to working and remaining in rural dispensing practices, and to explore how the primary care team value dispensing services., Methods: We undertook semi-structured interviews with multidisciplinary team members of rural dispensing practices across England. Interviews were audio-recorded, transcribed and anonymised. Framework analysis was conducted using Nvivo 12., Results: Seventeen staff members (including GPs, practice nurses, practice managers, dispensers and administrative staff) from 12 rural dispensing practices across England were interviewed. Personal and professional reasons for taking up a role in a rural dispensing practice included perceived career autonomy and development opportunities, and preference for working and living in a rural setting. Key factors impacting retention of staff included revenue generated by dispensing, opportunities for staff development, job satisfaction and the positive work environment. Perceived challenges to retention were the balancing of the required skillset of dispensing with the wages available for the role, lack of skilled job applicants, travel difficulties and negative perceptions of rural primary care practice., Discussion: These findings will inform national policy and practice with the aim of providing further understanding of the drivers and challenges of working in rural dispensing primary care in England.

Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter-arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort. A number of 134678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib). On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs. 134.2 mmHg (p<0.01) and diastolic BP 82.7 vs. 82.6 mmHg (p<0.01), respectively. Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7813 (5.8%). Systolic IAD ≥ 15 mmHg 2980 (2.2%) and diastolic IAD ≥ 10 mmHg 7151 (5.3%). In total, there were 7595 (5.6%) and 8548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively. This study shows that a substantial prevalence of IAD exist in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasise the importance of undertaking bilateral BP measurement in routine clinical practice. This article is protected by copyright. All rights reserved., (This article is protected by copyright. All rights reserved.)

Background: Guidelines recommend measuring blood pressure (BP) in both arms, adopting the higher arm readings for diagnosis and management. Data to support this recommendation are lacking. We evaluated associations of higher and lower arm systolic BPs with diagnostic and treatment thresholds, and prognosis in hypertension, using data from the Inter-arm Blood Pressure Difference-Individual Participant Data Collaboration., Methods: One-stage multivariable Cox regression models, stratified by study, were used to examine associations of higher or lower reading arm BPs with cardiovascular mortality, all-cause mortality, and cardiovascular events, in individual participant data meta-analyses pooled from 23 cohorts. Cardiovascular events were modelled for Framingham and atherosclerotic cardiovascular disease risk scores. Model fit was compared throughout using Akaike information criteria. Proportions reclassified across guideline recommended intervention thresholds were also compared., Results: We analyzed 53 172 participants: mean age 60 years; 48% female. Higher arm BP, compared with lower arm, reclassified 12% of participants at either 130 or 140 mm Hg systolic BP thresholds (both P< 0.001). Higher arm BP models fitted better for all-cause mortality, cardiovascular mortality, and cardiovascular events (all P <0.001). Higher arm BP models better predicted cardiovascular events with Framingham and atherosclerotic cardiovascular disease risk scores (both P <0.001) and reclassified 4.6% and 3.5% of participants respectively to higher risk categories compared with lower arm BPs)., Conclusions: Using BP from higher instead of lower reading arms reclassified 12% of people over thresholds used to diagnose hypertension. All prediction models performed better when using the higher arm BP. Both arms should be measured for accurate diagnosis and management of hypertension., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: CRD42015031227.

Background: Systolic inter-arm differences (IAD) in blood pressure (BP) contribute independently to cardiovascular risk estimates. This can be used to refine predicted risk and guide personalised interventions., Aim: To model the effect of accounting for IAD in cardiovascular risk estimation in a primary care population free of pre-existing cardiovascular disease., Design & Setting: A cross-sectional analysis of people aged 40-75 years attending NHS Health Checks in one general practice in England., Method: Simultaneous bilateral BP measurements were made during health checks. QRISK2, atherosclerotic cardiovascular disease (ASCVD), and Framingham cardiovascular risk scores were calculated before and after adjustment for IAD using previously published hazard ratios. Reclassification across guideline-recommended intervention thresholds was analysed., Results: Data for 334 participants were analysed. Mean (standard deviation) QRISK2, ASCVD, and Framingham scores were 8.0 (6.9), 6.9 (6.5), and 10.7 (8.1), respectively, rising to 8.9 (7.7), 7.1 (6.7), and 11.2 (8.5) after adjustment for IAD. Thirteen (3.9%) participants were reclassified from below to above the 10% QRISK2 threshold, three (0.9%) for the ASCVD 10% threshold, and nine (2.7%) for the Framingham 15% threshold., Conclusion: Knowledge of IAD can be used to refine cardiovascular risk estimates in primary care. By accounting for IAD, recommendations of interventions for primary prevention of cardiovascular disease can be personalised and treatment offered to those at greater than average risk. When assessing elevated clinic BP readings, both arms should be measured to allow fuller estimation of cardiovascular risk., (Copyright © 2022, The Authors.)

Supplementation with cannabidiol (CBD) may expedite recovery when consumed after exercise. The purpose of this study was to determine if supplementation with CBD reduces inflammation and enhances performance following strenuous eccentric exercise in collegiate athletes. Twenty-four well-trained females (age = 21.2 ± 1.8 years, height = 166.4 ± 8 cm, weight = 64.9 ± 9.1 kg) completed 100 repetitions of unilateral eccentric leg extension to induce muscle damage. In this crossover design, participants were randomized to receive 5 mg/kg of CBD in pill form or a placebo 2 h prior to, immediately following, and 10 h following muscle damage. Blood was collected, and performance and fatigue were measured prior to, and 4 h, 24 h, and 48 h following the muscle damage. Approximately 28 days separated treatment administration to control for the menstrual cycle. No significant differences were observed between the treatments for inflammation, muscle damage, or subjective fatigue. Peak torque at 60°/s ( p = 0.001) and peak isometric torque ( p = 0.02) were significantly lower 24 h following muscle damage, but no difference in performance was observed between treatments at any timepoint. Cannabidiol supplementation was unable to reduce fatigue, limit inflammation, or restore performance in well-trained female athletes.

Background: Atrial fibrillation (AF) increases thromboembolism and stroke risk; this can be reduced by oral anticoagulation, but only if AF is detected. A portable, point-of-care device, capable of accurately detecting and identifying AF, could reduce workload and diagnostic delay by minimizing need for follow-up 12-lead electrocardiogram (ECGs)., Objective: To assess the diagnostic performance of the Plessey imPulse lead I ECG device compared with a 12-lead ECG in detecting AF., Methods: Cross-sectional diagnostic accuracy study. Participants underwent simultaneous 12-lead ECG and imPulse device recordings. The imPulse device reports AF to be "probable," "possible," "unlikely," or "uncontrolled AF unlikely." imPulse and ECG reference results were cross-tabulated; sensitivity, specificity, positive/negative predictive values, and positive/negative likelihood ratios with 95% confidence interval (CI) were estimated based on different imPulse device report categorizations and heart rate subgroups., Results: A total of 217 participants were recruited (mean age 70.2 [standard deviation 12.7]), 56% male, 57% outpatients, 43% inpatients) and 199 were included in analyses. AF was diagnosed on ECG for 41 of 199 (20.6%) participants and reported by imPulse as possible, probable, or uncontrolled AF unlikely present for 49 of 199 (24.6%). Sensitivity and specificity for imPulse detection of possible, probable, or uncontrolled AF unlikely vs unlikely, compared with ECG, were 80.5% (95% CI, 65.1%-91.2%) and 89.9% (84.1%-94.1%), respectively. When probable or uncontrolled AF unlikely were compared vs possible or unlikely AF, sensitivity and specificity were 63.4% (46.9%-77.9%) and 98.1% (94.6%-99.6%), respectively., Conclusion: The imPulse device has moderate sensitivity and good specificity compared with ECG AF detection in a hospital setting., (© 2022 Heart Rhythm Society.)

Background: Hypertension is a highly prevalent condition, with optimal treatment to BP targets conferring significant gains in terms of cardiovascular outcomes. Understanding why some patients do not achieve BP targets would be enhanced through greater understanding of their health-related quality of life (HRQoL). However, the only English language disease-specific instruments for measurement of HRQoL in hypertension have not been validated in accordance with accepted standards. It is proposed that the Spanish MINICHAL instrument for the assessment of HRQoL in hypertension could be translated, adapted and validated for use in the United Kingdom. The aim of the study was therefore to complete this process., Methods: The MINICHAL authors were contacted and the original instrument obtained. This was then translated into English by two independent English-speakers, with these versions then reconciled, before back-translation and subsequent production of a 2nd reconciled version. Thereafter, a final version was produced after cognitive debriefing, for administration and psychometric analysis in the target population of patients living in the Exeter area (Southwest UK) aged 18-80 years with treatment-naïve grade II-III hypertension, before, during and after 18 weeks' intensive treatment., Results: The English-language instrument was administered to 30 individuals (median age: 58.5 years, 53% male). Psychometric analysis demonstrated a floor effect, though no ceiling effect. Internal consistency for both state of mind (StM) and somatic manifestations (SM) dimensions of the instrument were acceptable (Cronbach's alpha = 0.81 and 0.75), as was test-retest reliability (ICC = 0.717 and 0.961) and construct validity, which was measured through co-administration with the EQ-5D-5L and Bulpitt-Fletcher instruments. No significant associations were found between scores and patient characteristics known to affect HRQoL. The EQ-5D-5L instrument found an improvement in HRQoL following treatment, with the StM and SM dimensions of the English language MINICHAL trending to support this (d = 0.32 and 0.02 respectively)., Conclusions: The present study details the successful English translation and validation of the MINICHAL instrument for use in individuals with hypertension. The data reported also supports an improvement in HRQoL with rapid treatment of grade II-III hypertension, a strategy which has been recommended by contemporaneous European guidelines. Trial registration ISRCTN registry number: 57475376 (assigned 25/06/2015)., (© 2022. The Author(s).)

Background: Left ventricular (LV) hypertrophy (LVH) in uncontrolled hypertension is an independent predictor of mortality, though its regression with treatment improves outcomes. Retrospective data suggest that early control of hypertension provides a prognostic advantage and this strategy is included in the 2018 European guidelines, which recommend treating grade II/III hypertension to target blood pressure (BP) within 3 months. The earliest LVH regression to date was demonstrated by echocardiography at 24 weeks. The effect of a rapid guideline-based treatment protocol on LV remodelling, with very early BP control by 18 weeks remains controversial and previously unreported. We aimed to determine whether such rapid hypertension treatment is associated with improvements in LV structure and function through paired cardiovascular magnetic resonance (CMR) scanning at baseline and 18 weeks, utilising CMR mass and feature tracking analysis., Methods: We recruited participants with never-treated grade II/III hypertension, initiating a guideline-based treatment protocol which aimed to achieve BP control within 18 weeks. CMR and feature tracking were used to assess myocardial morphology and function immediately before and after treatment., Results: We acquired complete pre- and 18-week post-treatment data for 41 participants. During the interval, LV mass index reduced significantly (43.5 ± 9.8 to 37.6 ± 8.3 g/m 2 , p < 0.001) following treatment, accompanied by reductions in LV ejection fraction (65.6 ± 6.8 to 63.4 ± 7.1%, p = 0.03), global radial strain (46.1 ± 9.7 to 39.1 ± 10.9, p < 0.001), mid-circumferential strain (- 20.8 ± 4.9 to - 19.1 ± 3.7, p = 0.02), apical circumferential strain (- 26.0 ± 5.3 to - 23.4 ± 4.2, p = 0.003) and apical rotation (9.8 ± 5.0 to 7.5 ± 4.5, p = 0.003)., Conclusions: LVH regresses following just 18 weeks of intensive antihypertensive treatment in subjects with newly-diagnosed grade II/III hypertension. This is accompanied by potentially advantageous functional changes within the myocardium and supports the hypothesis that rapid treatment of hypertension could improve clinical outcomes., Trial Registration: ISRCTN registry number: 57475376 (assigned 25/06/2015)., (© 2021. The Author(s).)

Undergraduate research is one of the most valuable activities an undergraduate can engage in because of its benefits, and studies have shown that longer experiences are more beneficial. However, prior research has illuminated that undergraduates encounter challenges that may cause them to exit research prematurely. These studies have been almost exclusively conducted at research-intensive (R1) institutions, and it is unclear whether such challenges are generalizable to other institution types. To address this, we extended a study previously conducted at public R1 institutions. In the current study, we analyze data from 1262 students across 25 public R1s, 12 private R1s, 30 master's-granting institutions, and 20 primarily undergraduate institutions (PUIs) to assess 1) to what extent institution type predicts students' decisions to persist in undergraduate research and 2) what factors affect students' decisions to either stay in or consider leaving their undergraduate research experiences (UREs) at different institution types. We found students at public R1s are more likely to leave their UREs compared with students at master's-granting institutions and PUIs. However, there are few differences in why students enrolled at different institution types consider leaving or choose to stay in their UREs. This work highlights the importance of studying undergraduate research across institutions.