AB1203 DAS28 (DISEASE ACTIVITY SCORE) ELEVATIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA) WHO HAVE COMORBID FIBROMYALGIA ARE EXPLAINED BY ELEVATED TENDER JOINT COUNTS AS MUCH AS BY ELEVATED PATIENT GLOBAL ASSESSMENT

Background

DAS28 (disease activity score 28) is elevated in the 20-30% of patients with rheumatoid arthritis (RA) who have comorbid fibromyalgia (FM), largely on the basis of tender joint count (TJC) and patient global assessment (PATGL) [rather than swollen joint count (SJC) or erythrocyte sedimentation rate (ESR)].1 High DAS28 in the absence of clinical inflammatory activity may suggest inappropriate treatment escalation and/or changes in a treat-to-target approach. Some reports suggest removal of PATGL from criteria for remission2.

Objectives

We analyzed the 4 DAS28-ESR component measures in reports of FM+ or FM- RA patients, to recognize the possible contribution of each to elevated DAS28 in patients with FM.

Methods

We reviewed reports from a meta-analysis of elevated DAS28 in RA patients with comorbid FM,1 and conducted a PubMed search for further reports of DAS28-ESR in FM+ or FM- RA patients in routine care. We analyzed reports that presented the 4 individual DAS-28-ESR components in FM+ vs FM- RA patients, calculated overall medians of published mean or median results, and calculated ratios of each component measure in FM+ and FM- patients.

Results

Eleven reports were identified. Mean disease duration was 5-12.8 years. Median DAS28-ESR of means/medians in FM+ RA patients was 5.3, and >5.1 in 9 of 11 studies, suggesting high disease activity (moderate in 2 studies) (Table 1). By contrast, median DAS28-ESR of means/medians in FM- RA patients was 4.1, moderate (3.2–5.1) in all 11 studies (Table 1). Medians of individual DAS28-ESR components were 28.5 vs 26 for ESR, 3.25 vs 3 for SJC, 12.3 vs 5.5 for TJC, and 62.7 vs 40 for PATGL in FM+ vs FM- RA patients, respectively. Ratios of DAS28 components in FM +/FM - patients were 2.7 for TJC, 1.6 for PATGL, 1.1 for ESR, and 1.0 for SJC.

Table 1.

DAS28 and component measures In RA patients who have or do not have comorbid fibromyalgia and ratio of means in the two groups (FM+/FM-)

MEASURESDAS28ESRSJCTJCPATGLSTUDYFM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM-FM-FM-FM-FM-FM-FM-FM-FM-FM-Ranzolin5.4, 4.01.329*,251.163.5*,2.0*1.79.5*,3*3.276*,40*1.92009Pollard6, 4.31.439,271.44.0,4.0117,62.866,401.62010Toms5.3, 3.71.439.4,28.51.44.9,3.01.614.1,2.94.960.4,32.61.82010Zammurrad 20135.3, 3.91.338.9,311.22.8,1.71.613.1,4.13.262.7,381.6Nawito5.6, 4.51.238.2,41.80.92.8,3.00.912.3,4.52.738.2,41.80.92013Ghib5.6, 4.61.223,221.15.0,6.00.815,5.52.766,44.51.52015*Joharatnam4.8, 4.41.119,171.11.0,1.0111,61.870,421.62015*Mian5.2, 4.11.320.5,19.11.11.8,2.80.615.6,7.32.157,49.51.12016Chakr5.3, 3.91.328.5,261.13.9,2.4*1.610*,3*3.356.5*,31.5*1.82017Salaffi4.5, 3.81.224,320.73.0,4.00.712,6280,701.12018*Provan5.2, 4.21.223,211.18.4,6.41.310.7,6.41.755,301.82019Median-11 Studies5.3, 4.11.328.5,261.13.2,5.3112.3,5.52.762.7,401.6

* All values were reported means other than medians noted by asterisk (*).

Conclusion

Mean DAS28-ESR indicated high vs moderate disease activity in 9 of 11 FM+ RA patient groups vs all 11 FM- RA groups, respectively. Among the 4 DAS28 component measures, TJC differed most in FM+ vs FM- RA patients followed by PATGL, while SJC and ESR were similar in both groups. The impact of TJC likely is underestimated as the DAS28 formula weights TJC twice as SJC. Elevated DAS28 in the absence of inflammation in RA FM+ patients may result as much or more from TJC as from PATGL.

References

[1]Duffield et al Rheumatology (Oxford). 2018;57(8):1453-1460.

[2]Ferreira et al J Rheumatol. 2021.

Disclosure of Interests

None declared

AB0174 MOST RHEUMATOID ARTHRITIS PATIENTS IN POST–2010 REPORTS FROM ROUTINE CARE REMAIN IN DAS28, CDAI OR RAPID3 MODERATE ACTIVITY/SEVERITY, NOT LOW/REMISSION: EXPLAINED IN PART BY LIMITS OF INDICES AND/OR STRATEGIES FOR DIAGNOSIS AND TREATMENT?

Background

Availability of powerful biological agents to treat rheumatoid arthritis (RA) has led to a strategy of treat-to-target toward remission or low disease activity according to a quantitative index, although higher levels of disease activity according to shared decisions are recognized as appropriate for certain patients.1 Substantial improvement in patient status was documented quantitatively in 2000 compared to 1985,2 maintained in 20083 and 20104, but few reports in recent years compare patient status in routine care to earlier data.

Objectives

To analyze post-2010 reports concerning mean or median or categories of DAS28, CDAI, and RAPID3 to depict patient status, and compared to pre-2011 reports.

Methods

PubMed searches were conducted for 2011-2021 reports for “DAS28 (disease activity score) categories not trial,” and repeated twice, replacing “DAS28” with “CDAI” (clinical disease activity index) and “RAPID3” (routine assessment of patient index data). Activity/severity levels for high, moderate, low, and remission, respectively, are: DAS28 (0-10) >5.1, 3.2–5.1, 2.6–3.2, ≤2.6; CDAI (0-76) >22, 10.1–22, 2.9-10, ≤2.8; RAPID3 (0-30) >12, 6.1–12, 3.1-6, ≤3.0. Mean and/or median DAS28, CDAI, or RAPID3, and/or proportions of patients who were in remission, low, moderate, and high activity/severity were compiled. Results were compared to 3 pre-2011 reports, 2 of which included all 3 indices.2-4

Results

Results from 1985 vs 2000 indicate >50% improvement in swollen joints and physical function,2 maintained in 20083 and 20104 (data not shown). The search identified 32 reports with 98 comparisons of 1, 2, or 3 indices for mean or median levels or activity/severity categories (Table). Analyses of 57 means or medians indicated 10 high, 39 moderate, 8 low; for DAS28-ESR 2, 18, 2; for DAS28-CRP 1, 6, 3; for CDAI 4, 9, 3; and for RAPID3 3, 6, 0 (Table). Analyses of 41 reports of comparisons of disease activity/severity categories indicated more high/moderate in 35 vs low/remission in 6, 1 of 5 for DAS28–CRP and 5 of 15 for CDAI (Table). Remission according to DAS28, CDAI, or RAPID3 was reported in 17.1%, 10.2%, and 13.7% of patients, respectively, and low activity/severity or remission in 33.3%, 39.6%, and 29.7%, respectively (data not shown).

Table 1.

Means and/or Medians and categories of DAS28-ESR, DAS28-CRP, CDAI and RAPID3.

Index:# of compa-risonsDAS28-ESRDAS28-CRPCDAIRAPID3Mean/Median of IndexTotal means and medians572210169High activity/severity102143Moderate activity/severity3918696Low activity/severity82330Remission00000Categories of High or Moderate Activity/Severity vs Low or RemissionTotal classified by categories41125159High or Moderate>Low or Remission35124109Low or Remission>High or Moderate60150

Conclusion

Most RA patients in post 2011 reports from routine care were in moderate activity according to means or medians or categories, unchanged from 2008 and 2010. Only a minority were classified as in remission or low activity/severity. Optimal RA treatment may require modification of treatment goals, further recognition of differences between patients in clinical trials and routine care, and possible new strategies for earlier identification of RA patients for treatment, in addition to new therapeutic agents.

References

[1]Smolen JS et al. Ann Rheumatic Dis. 2010;69(4):631-7.

[2]Pincus T et al. Arthritis and Rheumatism. 2005;52(4):1009-19.

[3]Pincus T et al. J Rheumatol. 2008;35(11):2136-47.

[4]Pincus T et al. Arthritis Care & Research. 2010;62(2):181-9.

Disclosure of Interests

None declared

Hooded broadcast sprayer for particle drift reduction

BACKGROUND

There is renewed interest amongst crop protection professionals and regulators in the adoption of spray hoods to further reduce pesticide off-target movement during applications. Although the benefits of sprayer hoods have been reported since the early 1950s, adoption has been relatively low among farmers and applicators. The objective of this study was to evaluate the effectiveness of spray hoods in reducing pesticide drift of spray solutions from nozzles typically used for herbicide applications in row crops with tolerance to dicamba or 2,4-D.

RESULTS

Hooded applications substantially reduced spray drift potential across all treatment scenarios compared to conventional applications. Hooded applications using the AIXR nozzle without drift-reducing adjuvant (DRA) had a similar area under the drift curve (31.5) compared to conventional applications (open sprayer) using the TTI nozzle with DRA (27.7), despite the major droplet size differences between these treatments (D_V50  = 447.5 and 985 μm, respectively).

CONCLUSION

These results indicate that the adoption of spray hoods combined with proper nozzle selection, and the use of DRAs can substantially reduce spray drift potential during pesticide applications. The use of this technology can be complementary to other drift-reducing technologies. © 2021 Society of Chemical Industry.

FRI0517 POSSIBLE EARLY DETECTION OF ADVERSE EVENTS USING A STRUCTURED, STANDARD, 60-SYMPTOM CHECKLIST ON A MULTIDIMENSIONAL HEALTH ASSESSMENT QUESTIONNAIRE (MDHAQ)

Background:

Adverse events of medications are reported to account for 5% of hospital admissions in the USA, including 10% in the elderly, despite extensive warnings to patients by health professionals and pharmacies concerning the problem. Some adverse events are relatively obvious, such as a severe rash or severely abnormal laboratory test. However, many adverse events are common symptoms, such as headache or fatigue, which may not necessarily be recognized as adverse events, particularly in elderly patients with many comorbidities. In clinical trials and other clinical research, a structured, standard, protocol-driven symptom checklist is recorded according to the “scientific method.” In routine care, by contrast, recognition and recording of adverse events is elicited by health professionals at patient encounters or contact initiated by patients between visits, as “subjective” medical history information, which may be highly variable. Use of a standard symptom checklist on an electronic patient questionnaire has been reported in oncology, pulmonology and other specialties, but not in rheumatology. A multidimensional health assessment questionnaire (MDHAQ) includes a standard 60-symptom checklist, to recognize comorbidities, provide a review of systems, and serve on a fibromyalgia assessment screening tool (FAST3) as a clue to identify patients with fibromyalgia. The MDHAQ 60–symptom checklist can identify new symptoms after initiation of a medication which may be adverse events.

Objectives:

To analyze an MDHAQ 60-symptom checklist as a cost-effective approach to recognize medication-associated adverse events.

Methods:

All patients at one site complete an MDHAQ at each visit, which includes a standard, structured 60-symptom checklist, in addition to RAPID3 (routine assessment of patient index data) and FAST3. Paper MDHAQs from routine care are scanned into an Epic electronic medical record (EMR) and copied into a data repository for retrospective analyses. A list of common adverse events of many specific DMARDs (disease-modifying antirheumatic drugs) and biological agents used to treat rheumatoid arthritis (RA) was compiled from websites of the FDA, pharmaceutical companies, and Up-to-date.® Most listed symptoms are found on the structured MDHAQ 60-symptom checklist. A retrospective review of scanned MDHAQs at the first visit was conducted to recognize the presence or absence of self-reported symptoms which were listed as common adverse events for specific DMARDs on the MDHAQ 60-symptom checklist, using simple descriptive statistics. Only methotrexate (Mtx) is presented here due to space limitations.

Results:

All symptoms listed as adverse events of specific DMARDs were reported at higher frequencies in 379 DMARD-treated RA patients or 153 Mtx-treated patients, compared to 149 DMARD-naïve patients (Table). More than 30% of DMARD-treated patients reported headache and/or unusual fatigue, 27% anxiety; 10-20% cough, dizziness, hair loss, nausea, skin rash or hives, stomach pain or cramps, eye problems, and/or weight loss; and 5-10% diarrhea, fever, and/or mouth sores (Table). Similar proportions were seen for Mtx-treated patients, although anxiety and cough were not listed as specific adverse events.

Conclusion:

The MDHAQ symptom checklist may prove valuable to detect adverse events of high-risk medications, including on an electronic MDHAQ, which could be completed at home for 12 weeks after initiation of a new medication as a cost-effective approach for early detection of adverse events.

Symptom listed on MDHAQ/MEDI60DMARD naïveN=149(28%)DMARD treatedN=379(72%)MethotrexateN=153(29%)Headache28%36%36%Unusual fatigue31%33%34%Anxiety23%27%Cough16%18%Dizziness14%18%20%Hair loss10%17%19%Nausea11%13%18%Skin rash or hives11%14%13%Stomach pain/cramps9%16%15%Eye problems9%13%14%Anorexia/weight loss10%16%17%Diarrhea5%9%8%Fever5%8%7%Mouth sores3%7%8%

Disclosure of Interests:

Kyle Schroeder: None declared, Sara Abu Mehsen: None declared, Isabel Castrejon: None declared, Theodore Pincus Shareholder of:

Dr. Pincus holds a copyright and trademark on MDHAQ and RAPID3 for which he receives royalties and license fees from profit-making organizations, all of which are used to support further development of quantitative clinical measures for patients and health professionals.

AB1194 STRIKING DIFFERENCES IN THE COURSE OF OSTEOARTHRITIS (OA) COMPARED TO RHEUMATOID ARTHRITIS (RA) OVER THE FIRST 24 MONTHS OF RHEUMATOLOGY CARE AT ONE PRIVATE PRACTICE SETTING

Background:

Recent reports indicate that disease burden in osteoarthritis (OA) is similar to or greater than in rheumatoid arthritis (RA) when an identical measure is used to assess patients with either disease, generally an MDHAQ/RAPID3 (multidimensional health assessment questionnaire/routine assessment of patient index data). The data suggest that a traditional view that RA is more severe than OA no longer is valid at this time. One concern is that similar disease burdens in OA vs RA may result entirely from superior treatments for RA, and RA may be considerably more severe than OA at initial presentation.

Objectives:

To analyze MDHAQ disease burden in patients with OA vs RA at initial visit and at 24-month follow-up in routine care at a single solo-rheumatologist private practice setting.

Methods:

All patients at this setting complete an MDHAQ at each visit in the waiting area, prior to seeing the rheumatologist. The MDHAQ includes three 0-10 scores for physical function, pain visual numeric scale (VNS), and patient global VNS, which may be compiled into a 0–30 RAPID3, as well as a 0-10 fatigue VNS, and 0-16 rheumatoid arthritis disease activity index (RADAI) self-report painful joint count. Mean MDHAQ scores were analyzed for all 73 OA and 116 RA patients seen for an initial visit between 2011 and 2017. Mean scores at initial and 24-month visits were compared for all 25 OA and 63 RA patients seen at 24 month (21-27 month) follow-up visits, using paired t tests.

Results:

Mean MDHAQ scores at first visit were similar for all 73 OA and 116 RA patients, and also for 25 OA and 63 RA patients who were also seen 24 months later, e.g., mean RAPID3 was 12.0-14.2. However, mean changes over 2 years were strikingly different in OA versus RA patients (Table). Almost all mean scores in OA were somewhat higher, while all mean scores in RA were clinically and statistically significantly improved at 24 months, e.g., mean RAPID3 worsened from 13.0 to 15.2 (+2.2 units, 17%) in OA patients, compared to improvement from 12.5 to 8.2 (-4.3 units, -34%) in RA patients. The smallest mean change in RA patients involved the joint count (7.7 to 6.1, -21%) (Table), suggesting possible control of inflammation, but continued damage to specific joints. An important limitation is that the data do not include follow-up on patients not seen over the 24 month “window,” because of substantially better or poorer status, joint surgery, or other reasons, although the data present an accurate characterization of one rheumatology practice setting.

Mean values of patient MDHAQ scores in patients with OA or RA at first visit and 24-month follow-up

MDHAQ score:OA first visit of those seen at 24 months(n=25)OA 24- month visit (n=25)% change, over 24 monthsRA first visit of those seen at 24 months(n=63)RA 24- month visit (n=63)% change, over 24 monthsRAPID313.015.2+2.2, +17%12.58.2-4.3, -34%Function0.810.77-0.04, -5%0.710.50-0.21, -29%Pain5.26.4+1.2, +23%5.13.2-1.9, -37%Patient global5.15.9+0.8, +16%5.13.3-1.8, -35%Fatigue4.14.4+0.3, +7%4.83.5-1.3, -27%Pt joint count7.57.8+0.3, +4%7.76.1-1.6, -21%

Abbreviations: MDHAQ=multidimensional health assessment questionnaire, OA=osteoarthritis, RA=rheumatoid arthritis, RAPID3=routine assessment of patient index data.

In change data, negative numbers indicate improvement, positive numbers indicate worsening.

Conclusion:

Mean MDHAQ/RAPID3 scores were similar in RA or OA at the initial visit. Over 24 months, scores worsened slightly in OA and improved considerably in RA, resulting in considerably poorer status in OA versus RA, likely reflecting superior treatments for RA vs OA. At an individual level, patients with primary OA may have better or poorer status than patients with primary RA. Nonetheless, at a group level, the severity of disease burden in OA appears similar to RA, and becomes greater over the next 24 months, likely as a result of better treatments. The severity of OA is underrated, suggesting a need for increased resources for research toward better treatments for OA.

Disclosure of Interests:

Kyle Schroeder: None declared, Theodore Pincus Shareholder of:

Dr. Pincus holds a copyright and trademark on MDHAQ and RAPID3 for which he receives royalties and license fees from profit-making organizations, all of which are used to support further development of quantitative clinical measures for patients and health professionals., Martin Bergman Shareholder of: Johnson & Johnson – stockholder, Consultant of: AbbVie, BMS, Celgene Corporation, Genentech, Janssen, Merck, Novartis, Pfizer, Sanofi – consultant, Speakers bureau: AbbVie, Celgene Corporation, Novartis, Pfizer, Sanofi – speakers bureau

Education, Training and Ongoing Updating for High-Quality Cancer Care: Programs and Technology for Tumor Boards and Case Discussions

Background: The rapid advance in new knowledge of cancer etiology, creation of treatment guidelines, new technologies and medicines into routine practice and the need to understand cost and efficacy that underlie policy are daunting. Remaining current must be accomplished on top of increasingly busy clinical care requirements and patient numbers requires novel solutions. Education and training opportunities are available from professional societies, cancer programs, paid courses and written reviews, though person-to-person mentorship and expert opinion are vital to navigate the vast amount of information. Aim: To provide experience-based insight into addressing the challenge for professionals to maintain one's expertise in cancer care in countries at all income levels. Methods: The International Cancer Expert Corps and partner organizations are establishing a global and multisectoral network that builds human capacity and capability to establish sustainable cancer programs that function at world-class standards ( www.iceccancer.org ). The model utilizes in-person, in-country visits along with ongoing connectivity through telemedicine video conferences. The pioneering education Chartrounds program ( www.chartrounds.com ) is an example of initiative taken by those “in the field” which began in the U.S. and has recently expanded to include separate Web sites for India, Africa, and Latin America. Results: Chartrounds.com, a free Web-based conferencing platform providing disease-site based educational peer review sessions, exemplifies how global expertise can be shared, altruistic education is willingly provided by world-renowned experts and a method of providing practice changing education is possible while the responsibility for the decision-making and treatment implementation remain with the individual treatment center. Weekly experience by Chartrounds and ICEC is defining the complexity of telecommunications, especially problematic with low capacity bandwidth that tests the capacity for effective teleconferences requiring high-quality voice and image data. Conclusion: The enormous body of knowledge needed by cancer practitioners to provide state-of-the-art cancer care requires creative solutions for education, mentorship and telecommunications. That major research institutions such as the National Cancer Institute has invested in developing TELESYNERGY enhances the quality of cancer care and research that are necessary at the global level. Newer platforms are rapidly emerging and artificial intelligence and machine learning will soon assist with education and quality assurance tasks. For UICC members, recognizing present and emerging solutions is critical to best invest in resources and necessary personnel skill-sets to “leapfrog” into the newer enabling technology and approaches to help bring the best possible cancer care into resource-limited environments. The content is the personal opinion of the authors and not their organizations.

The role and impact of community health workers in childhood obesity interventions: a systematic review and meta-analysis

Childhood obesity increases the risk for poor health during childhood, as well as for adult obesity and its associated comorbidities. Children from racial/ethnic minority groups or who live in poverty experience elevated rates of obesity. One potential method for reducing childhood obesity disparities is to involve community health workers (frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served). The purpose of this systematic review and meta-analysis was to explore the role and effectiveness of community health workers in childhood obesity interventions. Eleven studies met inclusion criteria, of which nine were eligible for inclusion in the meta-analysis. Results demonstrated that community health workers played various roles in childhood obesity interventions in the home, clinic, school, and community setting. Interventions focused primarily on children from underserved populations. Meta-analytic findings demonstrated a small but significant impact on BMIz and BMI percentile (BMIz [7 studies]: -0.08, 95% CI: -0.15, -0.01, p = 0.03, I2  = 39.4%; BMI percentile [2 studies]: -0.25, 95% CI: -0.38, -0.11, p < 0.01, I2  = 0%). Findings from this review demonstrate that partnering with community health workers may be an important strategy for reducing childhood obesity disparities and advancing health equity.

Workforce Capacity and Capability Building Through Metrics-Based Mentoring Partnerships

Background: Globally, cancer is the second leading cause of death. Low- and middle-income countries (LMICs) especially lack the sufficient healthcare and oncology workforces needed to screen, diagnose and treat individuals with cancer. While traditional academic and training programs designed to produce healthcare professionals in these countries fill a critical role, few programs exist that maintain, develop, and increase the knowledge, skills, and professional performance of current healthcare and oncology workforces. Mentoring partnerships and twinning programs can provide ongoing education and training that strengthen and build workforce capacity and capability for the full scope of cancer care. Aim: The goal is to achieve resource-appropriate multimodality cancer-care using guideline- and protocol-based education and training and also to develop the capability to conduct world quality research. The model utilizes in-person, in-country site visits lasting from several weeks to months and ongoing connectivity through weekly telemedicine video conferences. Methods: The International Cancer Expert Corps (ICEC) and partner organizations are establishing a network of global and multisectoral partnerships that builds human capacity and capability needed to establish sustainable cancer programs that function at world-class standards. The three-fold mentor-mentee approach ( www.iceccancer.org ) is built by 1) enlisting hubs of expertise to include academic medical centers/universities, private practices and an ICEC Central Hub, 2) enrolling the breadth of expert-mentors needed from a university, practice, professional society and interested individuals, and 3) identifying centers in LMICs - clinics/hospitals/and other care delivery sites in underserved areas, and associates - physicians/allied healthcare workers- seeking mentoring and education. Results: Recent implementation of the ICEC 5-Step Progression Plan provides guidance and serves as an assessment tool for measuring progress between the hubs-centers programs and expert-associate. Twinning programs (hubs-ICEC centers) have been established in multiple sites worldwide including in Africa, Asia and Eurasia. Conclusion: Implementation of the ICEC 5-Step Progression Plan provides a platform from which to track the current stages and progress of twinning mentor-mentee programs, and to evaluate new programs. This information guides the programs and also provides metric-based investment in global health. Critically as the skills in associates and ICEC centers grows, they achieve expert-mentor status and centers become hubs to serve the surrounding regions, thereby enabling geometric growth in cancer care to meet the needs of the growing global burden of cancer. The content is the personal opinion of the authors and not their organizations.

Spray particle drift mitigation using field corn (Zea mays L.) as a drift barrier

BACKGROUND

Herbicide particle drift reduces application efficacy and can cause severe impacts on nearby vegetation depending on the herbicide mode of action, exposure level, and tolerance to the herbicide. A particle drift mitigation effort placing windbreaks or barriers on the field boundaries to reduce off-target movement of spray particles has been utilized in the past. The objective of this research was to evaluate the effectiveness of field corn (Zea mays L.) at different heights as a particle drift barrier.

RESULTS

Applications with a non-air inclusion flat fan nozzle (ER11004) resulted in greater particle drift when compared with an air inclusion nozzle (TTI11004). Eight rows of corn were used as barriers (0.91, 1.22, and 1.98 m height) which reduced the particle drift for both nozzles, especially at shorter downwind distances. Applications with the ER11004 nozzle without corn barriers had 1% of the applied rate (D99 ) predicted to deposit at 14.8 m downwind, whereas this distance was reduced (up to 7-fold) when applications were performed with corn barriers. The combination of corn drift barriers and nozzle selection (TTI11004) provided satisfactory particle drift reduction when the D99 estimates were compared with those for applications with the ER11004 nozzle without corn barriers (up to 10-fold difference).

CONCLUSION

The corn drift barriers were effective in reducing particle drift from applications with the ER11004 and the TTI11004 nozzles (Fine and Ultra Coarse spray classifications, respectively). The corn drift barrier had appropriate porosity and width as the airborne spray was captured within its canopy instead of deflecting up and over it. © 2018 Society of Chemical Industry.

Prediction of Cardiovascular Risk in Hemodialysis Patients by Data Mining

Objectives: The objective of this work was to contribute to the development, validation and application of data mining methods for prediction in decision support systems in medicine. The particular focus was on the prediction of cardiovascular risk factors in hemodialysis patients, specifically the interventricular septum (IVS) thickness of the heart of individual patients as an important quantitative indicator to diagnose left ventricular hypertrophy. The work was based on data from 63 long-term hemodialysis patients of the KfH Dialysis Centre in Jena, Germany.

Methods: The approach applied is based on data mining methods and involves four major steps: data based clustering, cluster based rule extraction, rulebase construction and cluster and rule based prediction. The methods employed include crisp and fuzzy algorithms. At each step, logical and medical validation of results was carried out. Different sets of randomly selected patient data were used to train, test and optimize the clusterbases and rulebases for prediction.

Results: Using the best clusterbase/rulebase combination designed, the IVS thickness cluster (‘small’ or ‘large’) was predicted correctly for 30 of the 35 patients with known IVS values in the training data set; no patient was predicted incorrectly and 5 were parity predicted. For the test data set, 4 of the 6 patients with known IVS values were predicted correctly, no patient incorrectly and 2 parity. These results did not substantially differ from those obtained using the second best clusterbase/rulebase combination which was finally recommended for use based on further performance criteria. The prediction of the IVS thickness clusters of the 22 patients with unknown IVS values also yielded good results that were (and could only be) validated by a medical individual risk assessment of these patients.

Conclusions: The approach applied proved successful for the cluster and rule based prediction of a quantitative variable, such as IVS thickness, for individual patients from other variables relevant to the problem. The results obtained demonstrate the high potential of the approach and the methods developed and validated to support decision-making in hemodialysis and other fields of medicine by individual risk prediction.

Rapid response to climate change in a marginal sea

The Mediterranean Sea is a mid-latitude marginal sea, particularly responsive to climate change as reported by recent studies. The Sicily Channel is a choke point separating the sea in two main basins, the Eastern Mediterranean Sea and the Western Mediterranean Sea. Here, we report and analyse a long-term record (1993–2016) of the thermohaline properties of the Intermediate Water that crosses the Sicily Channel, showing increasing temperature and salinity trends much stronger than those observed at intermediate depths in the global ocean. We investigate the causes of the observed trends and in particular determine the role of a changing climate over the Eastern Mediterranean, where the Intermediate Water is formed. The long-term Sicily record reveals how fast the response to climate change can be in a marginal sea like the Mediterranean Sea compared to the global ocean, and demonstrates the essential role of long time series in the ocean.

[Posttraumatic disorders in patients with schizophrenia spectrum disorders]

BACKGROUND

The findings of international studies suggest high rates of interpersonal violence and posttraumatic stress disorder (PTSD) among patients with schizophrenia spectrum disorders. Only few studies, however, have so far been conducted in the German-speaking countries.

OBJECTIVES

The aim of our study was to determine the prevalence of lifetime experiences of interpersonal violence and comorbid PTSD among inpatients in a German university hospital.

METHOD

In N = 145 consecutively admitted patients with schizophrenia spectrum disorders (67 % male) the structured trauma interview (STI) was used to assess experiences of interpersonal violence and the structured clinical interview for DSM-IV (SCID) to assess comorbid PTSD.

RESULTS

Sexual violence under the age of 16 years was reported by 17 % of the patients (women 27 %, men 12 %). Approximately one third (32 %) reported physical violence by parental figures (women 38 %, men 29 %). At least one form of early violence (sexual or physical) was reported by half of the women (48 %) and one third of the men (34 %). Negative sexual experiences later in life were reported by 17 %, physical violence by 38 % and at least one of these forms by 48 % of the patients. In total two thirds of all patients (66 %) reported experiences of violence during their lifetime. The prevalence of acute PTSD was 12 %. Another 9 % of patients had a subsyndromal PTSD.

CONCLUSION

The present study confirmed the high rates of experiences of interpersonal violence and comorbid PTSD in a German sample of patients with schizophrenia spectrum disorders. Violence and it's consequences should therefore be routinely assessed and the full spectrum of trauma-specific therapies should be integrated into the treatment of this group of patients.

The self-pressurising air-Q® Intubating Laryngeal Airway for airway maintenance during anaesthesia in adults: a report of the first 100 uses

The self-pressurising air-Q® Intubating Laryngeal Airway is a new, commercially available, supraglottic airway device that incorporates a self-regulating periglottic cuff. In this retrospective review, we describe our initial clinical experience using the device in 100 patients. The ease and number of insertion attempts, airway seal pressure, device positioning, intubation success and oropharyngeal morbidity were recorded. The air-Q Intubating Laryngeal Airway was successfully inserted in all 100 patients and functioned adequately as a primary airway in 70 of the 72 patients in which it was used for this purpose. The median (interquartile range [range]) airway seal pressure was 22 (19-29, [10-40]) cmH2O. Intubation via the air-Q Intubating Laryngeal Airway was successful in 28 of 29 (97%) patients. Eleven percent of patients complained of sore throat postoperatively before discharge. In our series, the air-Q Intubating Laryngeal Airway performed adequately as a primary airway during anaesthesia with respect to ease of insertion, adequacy of airway maintenance and as a conduit for intubation in both anticipated and unanticipated difficult airways. Although our initial experience is positive, further investigation with larger numbers of observations are needed as the upper limits of the 95% confidence intervals for device failure (the worst failure rate the clinician could expect) are still high.

A high-resolution real-time forecasting system for predicting the fate of oil spills in the Strait of Bonifacio (western Mediterranean Sea)

The Strait of Bonifacio is a long and narrow area between Corsica and Sardinia. To manage environmental emergencies related to the spill of oil from vessels, an innovative forecasting system was developed. This tool is capable of operationally predicting the dispersion of hydrocarbon spills in the coastal area of the Bonifacio Strait, either from an instantaneous or continuous spill and either in forward or backward mode. Experimental datasets, including ADCP water current measurements and the trajectories of drifter buoys released in the area, were used to evaluate the accuracy of this system. A comparison between the simulation results and experimental data revealed that both the water circulation and the surface transport processes are accurately reproduced by the model. The overall accuracy of the system in reproducing the transport of an oil spill at sea was estimated for both forward and backward prediction mode and in relation to different forecasting time lags.

Biotemplated silica and titania nanowires: synthesis, characterization and potential applications

A simple biotemplating method for the synthesis of silica (SiO2) and titania (TiO2) nanowires was designed on a fibrillar protein (alpha-synuclein) template. The diameter of SiO2 and TiO2 nanowires could be varied, between 20-100 nm, by varying the processing conditions. The nanowires were characterized by energy dispersive spectroscopy (EDS) and electron energy loss spectroscopy (EELS). Due to their high surface area and porosity, the nanowires were tested for potential applications in enzymatic biosensor design.

In vivo tissue sampling of embryonic resorption sites using ultrasound guided biopsy

In the polytocous European brown hare (Lepus europaeus) more than 23% of all successful implantations undergo embryonic resorption. The objective of the study was to establish a minimally invasive ultrasound guided biopsy technique to collect embryonic resorption tissue in vivo. The sampled material was genetically analysed to determine paternity and the sex of the embryo. Female hares were either mated or artificially inseminated and pregnancy was confirmed by ultrasound on day six post ovulation. Subsequent embryonic development was ultrasonographically monitored on a regular basis to detect embryos undergoing resorption. Cell material of the resorption site was collected under ultrasonographic control via transabdominal biopsy of the placenta or aspiration of resorption fluid. To avoid breathing movements during the biopsy, the animals were intubated and a short apnoea was evoked by assisted ventilation. The presence of embryonic cells in the biopsy material was confirmed by microsatellite analysis in 11 of the fluid samples (n = 28) and six of the placental samples (n = 8). The lower success rate in the fluid samples was attributed to the abundance of maternal cells which was confirmed by the analysis of fluid sample smears. Male sex of the embryos undergoing resorption was detected by SRY analysis for ten of the fluid samples and for one of the placental samples. The two biopsy techniques did not have any negative impact on the prenatal development of the healthy siblings nor did it influence the future breeding performance of the females that were biopsied.

Evaluation of effectiveness of combined sewer overflow control measures by operational data

The effect of combined sewer overflow (CSO) control measures should be validated during operation based on monitoring of CSO activity and subsequent comparison with (legal) requirements. However, most CSO monitoring programs have been started only recently and therefore no long-term data is available for reliable efficiency control. A method is proposed that focuses on rainfall data for evaluating the effectiveness of CSO control measures. It is applicable if a sufficient time-series of rainfall data and a limited set of data on CSO discharges are available. The method is demonstrated for four catchments of the Berlin combined sewer system. The analysis of the 2000-2007 data shows the effect of CSO control measures, such as activation of in-pipe storage capacities within the Berlin system. The catchment, where measures are fully implemented shows less than 40% of the CSO activity of those catchments, where measures have not yet or not yet completely been realised.

[Five-year survival rate of the Allofit titanium press-fit cup]

BACKGROUND

The Allofit titanium press-fit cup has become the best-selling cementless acetabular implant in Germany, with approximately 30,000 implants sold in 2007. However, only a limited number of scientific publications - mostly from the development centres in Austria - support this success on the market.

METHODS

At our institution in 1999-2000, 174 total hip replacements were performed using the Allofit cementless press-fit cup. At a mean follow-up of 5.3 years (range 40-85 months), 154 patients were evaluated clinically and radiographically, representing a follow-up rate of 89%.

RESULTS

The 5-year survival rate was 98.1% (95% CI: 95.8-100%), with revision for any reason as an end point. Three cups were revised (aseptic loosening with one, and two septic complications). The average Harris hip score was 89.1+/-13.7 in all unrevised patients.

CONCLUSION

We confirm the excellent survival rates of the Allofit cup as reported by the development centres, supporting the ongoing use of the cup at our institution.

In vivo investigation of the inflammatory response against allylamine plasma polymer coated titanium implants in a rat model

Titanium (Ti) is an established biomaterial for bone replacement. However, facilitation of osteoblast attachment by surface modification with chemical groups could improve the implant performance. Therefore, this study aimed to evaluate the effect of a plasma polymerized allylamine (PPAAm) layer on the local inflammation in a rat model. Three series (RM76AB, RM78AB, RM77AB) of PPAAm-treated Ti plates were prepared using different plasma conditions. Twelve male LEW.1A rats received one plate of each series and one uncoated control plate implanted into the back musculature. After 7, 14 and 56 days, four rats were euthanized to remove the implants with surrounding tissue. Total monocytes/macrophages, tissue macrophages, T-cells and MHC-class-II-positive cells were morphometrically counted. On day 14, the macrophage/monocyte number was significantly higher for the controls than for the PPAAm samples. On day 56, the RM76AB and RM78AB samples had significantly lower numbers than RM77AB and the controls. The same was found for the tissue macrophages. No change over time and no differences between the implants were found for the T-cells. For the number of MHC-class-II-positive cells, a significant decrease was found only for the RM78AB implants between day 14 and day 56. Physico-chemical analysis of the PPAAm implants revealed that the RM77AB implants had the lowest water absorption, the highest nitrogen loss and the lowest oxygen uptake after sonication. These results demonstrate that the PPAAm samples and the controls were comparable regarding local inflammation, and that different plasma conditions lead to variations in the material properties which influence the tissue reaction.

Conduction Properties Of Decellularized Nerve Biomaterials

The purpose of this study is to optimize poly(3,4,-ethylenedioxythiophene) (PEDOT) polymerization into decellular nerve scaffolding for interfacing to peripheral nerves. Our ultimate aim is to permanently implant highly conductive peripheral nerve interfaces between amputee, stump, nerve fascicles and prosthetic electronics. Decellular nerve (DN) scaffolds are an FDA approved biomaterial (Axogen ) with the flexible tensile properties needed for successful permanent coaptation to peripheral nerves. Biocompatible, electroconductive, PEDOT facilitates electrical conduction through PEDOT coated acellular muscle. New electrochemical methods were used to polymerize various PEDOT concentrations into DN scaffolds without the need for a final dehydration step. DN scaffolds were then tested for electrical impedance and charge density. PEDOT coated DN scaffold materials were also implanted as 15-20mm peripheral nerve grafts. Measurement of in-situ nerve conduction immediately followed grafting. DN showed significant improvements in impedance for dehydrated and hydrated, DN, polymerized with moderate and low PEDOT concentrations when they were compared with DN alone (a ≤ 0.05). These measurements were equivalent to those for DN with maximal PEDOT concentrations. In-situ, nerve conduction measurements demonstrated that DN alone is a poor electro-conductor while the addition of PEDOT allows DN scaffold grafts to compare favorably with the "gold standard", autograft (Table 1). Surgical handling characteristics for conductive hydrated PEDOT DN scaffolds were rated 3 (pliable) while the dehydrated models were rated 1 (very stiff) when compared with autograft ratings of 4 (normal). Low concentrations of PEDOT on DN scaffolds provided significant increases in electro active properties which were comparable to the densest PEDOT coatings. DN pliability was closely maintained by continued hydration during PEDOT electrochemical polymerization without compromising electroconductivity.

The HSG procedure for modelling integrated urban wastewater systems

Whilst the importance of integrated modelling of urban wastewater systems is ever increasing, there is still no concise procedure regarding how to carry out such modelling studies. After briefly discussing some earlier approaches, the guideline for integrated modelling developed by the Central European Simulation Research Group (HSG - Hochschulgruppe) is presented. This contribution suggests a six-step standardised procedure to integrated modelling. This commences with an analysis of the system and definition of objectives and criteria, covers selection of modelling approaches, analysis of data availability, calibration and validation and also includes the steps of scenario analysis and reporting. Recent research findings as well as experience gained from several application projects from Central Europe have been integrated in this guideline.

[Special features of procedures in paediatric orthopaedics]

To get good to excellent results in paediatric orthopaedics perioperative pain treatment is essential. Guidelines are in general similar to those for adults. Some special features should be taken into account. Differences are reduced possibilities of communication in the early years, different pharmacokinetics and a different perception of pain itself. A multimodal approach has proven to be very effective: workflow tailored to children's needs, ambiance appropriate for children and pharmacological analgesia. Children and parents have to be informed carefully about procedures, hospital setting and pain therapy in the first session. Pain therapy is orientated to the reversed WHO pain treatment scheme completed by surface and regional anaesthesia. After discharge pain treatment has to be administered. This article presents concepts of perioperative analgesia.

Over-the-counter medications for acute cough in children and adults in ambulatory settings

BACKGROUND

Acute cough due to upper respiratory tract infection (URTI) is a common symptom. Non-prescription over-the-counter (OTC) medicines are frequently recommended as a first-line treatment, but there is little evidence as to whether these drugs are effective.

OBJECTIVES

To assess the effects of oral OTC cough preparations for acute cough.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4); MEDLINE (January 1966 to January Week 1, 2007); EMBASE (January 1974 to January 2007); and the UK Department of Health National Research Register (June 2007).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing oral OTC cough preparations with placebo in children and adults suffering from acute cough in ambulatory settings. We considered all cough outcomes and second outcomes of interest were adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened potentially relevant citations and independently extracted data and assessed study quality. Quantitative analysis was performed where appropriate.

MAIN RESULTS

Twenty five trials (17 in adults, 8 in children) involving 3492 people (2876 adults and 616 children) were included. RESULTS OF STUDIES IN ADULTS: Six trials compared antitussives with placebo and had variable results. Two trials compared the expectorant, guaifenesin with placebo, one indicated significant benefit whereas the other did not. One trial found that a mucolytic reduced cough frequency and symptom scores. Two studies examined antihistamine-decongestant combinations and found conflicting results. Three studies compared other combinations of drugs with placebo and indicated some benefit in reducing cough symptoms. Three trials found antihistamines were no more effective than placebo in relieving cough symptoms. RESULTS OF STUDIES IN CHILDREN: Antitussives (two studies), antihistamines (two studies), antihistamine decongestants (two studies) and antitussive/bronchodilator combinations (one study) were no more effective than placebo. No studies using expectorants met our inclusion criteria. The results of one trial favoured active treatment with mucolytics over placebo. One trial tested two paediatric cough syrups and both preparations showed a 'satisfactory response' in 46% and 56% of children compared to 21% of children in the placebo group.

AUTHORS' CONCLUSIONS

There is no good evidence for or against the effectiveness of OTC medicines in acute cough. The results of this review have to be interpreted with caution due differences in study characteristics and quality. Studies often showed conflicting results with uncertainty regarding clinical relevance. Higher quality evidence is needed to determine the effectiveness of self-care treatments for acute cough.

Consideration of online rainfall measurement and nowcasting for RTC of the combined sewage system

In Berlin, Germany, the demand for enhanced protection of the environment and the growing economic pressure have led to an increased application of control concepts within the sewage system. A global control strategy to regulate the pumpage of the combined sewage system to the treatment plant was developed and evaluated in a theoretical study. The objective was to reduce CSO. In this paper an extension of the existing control algorithm by information from online rainfall measurement and radar nowcasting is described. The rainfall information is taken into account by two additive terms describing the predicted volume from rainfall runoff. On the basis of numerical simulation the potential of these two complementary forecast terms in the global control algorithm to further reduce CSO is evaluated. The investigations are based on long-time simulations that are conducted with the dynamic flow routing model InfoWorks for three subcatchments of the Berlin drainage system. The results show that at the current Berlin system a CSO reduction of only 0.8% is possible. The effect of the forecast terms is limited by operational constraints. Limits are set to both, the delivery from each individual pump station and the total pumpage to the treatment plant.

How can adherence to lipid-lowering medication be improved? A systematic review of randomized controlled trials

OBJECTIVE

Poor patient adherence to lipid-lowering medication is a major contributory factor in the lack of success in treating hyperlipidaemia. The objective of this review was to assess the effect of adherence-enhancing interventions for lipid-lowering medication.

DESIGN

Systematic review of randomized controlled trials (RCTs).

DATA SOURCES

Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycInfo and CINAHL for all-language publications in November 2005. Direct contact with authors of included RCTs.

METHODS

Two reviewers extracted data independently and assessed studies according to criteria outlined by the Cochrane Reviewers' Handbook.

RESULTS

Nine RCTs were included in the review. Substantial between-study heterogeneity made pooling of data inappropriate. Four out of nine RCTs reported significantly improved adherence rates. The interventions associated with improved adherence were simplification of drug regimen (absolute increase 11%), patient information and education (13%) and intensified patient care (8.6% and 24%). Duration of follow-up was short, ranging from 2 to 24 months. No clear pattern emerged with regard to different classes of lipid-lowering drugs and adherence levels.

CONCLUSIONS

Intensified patient care appears to be the most promising intervention in terms of improved adherence to lipid-lowering drugs. Numbers of trials are low and evidence is sparse. Important aspects to be addressed in future studies are long-term follow-up, effect of improved adherence on serum lipid levels and concurrent, economic evaluation of adherence-enhancing strategies.

Interventions used to improve control of blood pressure in patients with hypertension

BACKGROUND

It is well recognized that patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals--a condition labeled as "uncontrolled" hypertension. The optimal way in which to organize and deliver care to patients who have hypertension so that they reach treatment goals has not been clearly identified.

OBJECTIVES

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension.

SEARCH STRATEGY

All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), Medline and Embase from June 2000.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring; (2) educational interventions directed to the patient; (3) educational interventions directed to the health professional; (4) health professional (nurse or pharmacist) led care; (5) organisational interventions that aimed to improve the delivery of care; (6) appointment reminder systems. Outcomes assessed were: (1) mean systolic and diastolic blood pressure; (2) control of blood pressure; (3) proportion of patients followed up at clinic

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook.

MAIN RESULTS

56 RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2 mmHg, -11.7/-6.5 mmHg, -10.6/-7.6 mmHg for 3 strata of entry blood pressure) and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure (weighted mean difference (WMD): -2.0 mmHg, 95%CI: -2.7 to -1.4 mmHg, respectively. Appointment reminders increased the proportion of individuals who attended for follow-up. RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Health professional (nurse or pharmacist) led care may be a promising way of delivering care, with the majority of RCTs being associated with improved blood pressure control, but requires further evaluation.

AUTHORS' CONCLUSIONS

Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels.

Interventions used to improve control of blood pressure in patients with hypertension

BACKGROUND

It is well recognized that patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labeled as "uncontrolled" hypertension. The optimal way in which to organize and deliver care to patients who have hypertension so that they reach treatment goals has not been clearly identified.

OBJECTIVES

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension.

SEARCH STRATEGY

All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), Medline and Embase from June 2000.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systems. Outcomes assessed were: (1) mean systolic and diastolic blood pressure( 2) control of blood pressure (3) proportion of patients followed up at clinic.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook.

MAIN RESULTS

56 RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2 mmHg, -11.7/-6.5 mmHg, -10.6/-7.6 mmHg for 3 strata of entry blood pressure) and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure (weighted mean difference (WMD): -2.0 mmHg, 95%CI: -2.7 to -1.4 mmHg, respectively. Appointment reminders increased the proportion of individuals who attended for follow-up. RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Health professional (nurse or pharmacist) led care may be a promising way of delivering care, with the majority of RCTs being associated with improved blood pressure control, but requires further evaluation.

AUTHORS' CONCLUSIONS

Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels.

Relationship between medication adherence and blood pressure in primary care: prospective study

There is good evidence from randomised trials (RCTs) that treating high blood pressure is effective in reducing cardiovascular risk, but people with high blood pressure can find it difficult to take antihypertensive medication regularly. The relationship between adherence and achieved blood pressure is far from clear.

Interventions used to improve control of blood pressure in patients with hypertension

BACKGROUND

It is well recognized that patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals- a condition labeled as "uncontrolled" hypertension. The optimal way in which to organize and deliver care to patients who have hypertension so that they reach treatment goals has not been clearly identified.

OBJECTIVES

To determine the effectiveness of interventions to improve control of blood pressure in patients with elevated blood pressure. To evaluate the ability of reminders to improve the follow-up of patients with elevated blood pressure.

SEARCH STRATEGY

All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), Medline and Embase from June 2000.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systems. OUTCOMES ASSESSED WERE: (1) mean systolic and diastolic blood pressure (2) control of blood pressure (3) proportion of patients followed up at clinic.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook.

MAIN RESULTS

59 RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organized system of regular review linked to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2 mmHg, -11.7/-6.5 mmHg, -10.6/-7.6 mmHg for 3 strata of entry blood pressure) and all-cause mortality at five years follow-up (6.38% versus 7.78%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure (weighted mean difference (WMD): -2.03 mmHg, 95%CI: -2.69 to -1.38 mmHg, respectively. Appointment reminders increased the proportion of individuals who attended for follow-up. RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Health professional (nurse or pharmacist) led care may be a promising way of delivering care, with the majority of RCTs being associated with improved blood pressure control, but requires further evaluation.

AUTHORS' CONCLUSIONS

Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a systematic stepped care approach when patients do not reach target blood pressure levels.