Improving hypertension control: a team approach in a primary care setting

BACKGROUND: Blood pressure (BP) control rates in the United States have not improved significantly during the past decade. There has been limited study of improvement efforts focusing on guideline implementation and changes in the model of care to address hypertension. METHODS: Five physician (MD)/registered nurse (RN)/licensed practical nurse (LPN) teams in a large community practice modified their care model in 1997 to manage hypertensive patients as part of guideline implementation efforts. The other 25 MD teams in the same setting practiced in the usual model, but were exposed to the guideline recommendations. BP control rates of patients in each group were assessed monthly. After nine months of testing the new care model, 10 additional teams adopted the model. RESULTS: In the pilot group, hypertension control rates showed statistically significant improvement from pre- (33.1%) to postimplementation (49.7%). After adjusting for age, this was significantly greater than the improvement in the control group (p = 0.033). Medication changes were more frequent in the pilot group (32.3%) than in the control group (27.6%); however, the differences were not statistically significant. A longitudinal examination of the hypertension patients in the study showed that improved BP control was sustained for at least 12 months. DISCUSSION: A change in the model of care for hypertensive patients within a primary care practice resulted in significant, sustainable improvement in BP control rates. These changes are consistent with the chronic care model developed by Wagner; practice redesign appeared to be the most important change.     

Intensive dialysis and blood pressure control: A review

The prevalence of hypertension in hemodialysis (HD) patients has increased over the years. In the early days of maintenance HD blood pressure (BP) control was achieved in most patients. As sessions were shortened, the prevalence of hypertension increased. Yet, in principle, dialysis is able to control hypertension. Today, in programs using long HD, most patients are normotensive without antihypertensive medication. The same is true for patients on daily dialysis, but not for those on short thrice‐weekly HD. In all studies reporting BP normalization, dry weight is regularly achieved. Why the poor control of hypertension now? At first sight the shortened session duration is the culprit. This is suggested by several epidemiologic observations and strongly supported by a prospective experience of changing the HD schedule (short to long HD or conversely) in the same group of patients. Recent studies, however, using strict volume control show that BP normalization can be obtained in conventional 3 x 4 hr/week dialysis with relatively low delivered Kt/V_urea. Therefore, prolonging the dialysis time and/or increasing the dialysis dose are not required to achieve BP control. Intensive dialysis most probably normalizes BP by getting the extracellular volume and the amount of sodium in the body back to normal. It acts in conjunction with a moderate dietary sodium restriction and the use of reasonably low dialysate sodium. With this approach improved BP control can be achieved in the vast majority of HD patients.     

The pivotal role of sodium balance in control of blood pressure in dialysis patients

In hemodialysis patients, as in patients with normal kidney function, sodium balance is the major determinant of changes in extracellular volume, and extracellular volume is an important determinant of blood pressure. The osmotic thresholds for thirst and ADH release are normal in kidney failure; pre‐dialysis serum sodium concentration shows a high index of individuality in oliguric hemodialysis patients. Non‐osmotic storage of sodium in vascular walls may also amplify the volume‐sensitivity of blood pressure. The variable relationship between volume removal and change in blood pressure described in clinical studies reflects a state of permanent volume expansion in those whose blood pressure does not fall, or rises, during dialysis, whereas those whose blood pressure falls during dialysis are those who approach normovolemia. Rigorous control of extracellular volume often results in perfect blood pressure control, but may be difficult to achieve safely other than with long, slow dialysis combined with dietary salt restriction.     

Automatic feedback control of relative blood volume changes during hemodialysis improves blood pressure stability during and after dialysis

Automatic feedback systems have been designed to control relative blood volume changes during hemodialysis (HD) as hypovolemia plays a major role in the development of dialysis hypotension. Of these systems, one is based on the concept of blood volume tracking (BVT). BVT has been shown to improve intra-HD hemodynamic stability. We first questioned whether BVT also improves post-HD blood pressure stability in hypotension-prone patients and second, whether BVT is effective in reducing the post-HD weight as many hypotension-prone patients are overhydrated because of an inability to reach dry weight. After a 3-week period on standard HD, 12 hypotension-prone patients were treated with two consecutive BVT treatment protocols. During the first BVT period of 3 weeks, the post-HD target weight was kept identical compared with the standard HD period (BVT-constant weight; BVT-cw). During the second BVT period of 6 weeks, we gradually tried to lower the post-HD target weight (BVT-reduced weight; BVT-rw). In the last week of each period, we studied intra-HD and 24 hr post-HD blood pressure behavior by ambulatory blood pressure measurement (ABPM). Pre- and post-HD weight did not differ between standard HD and either BVT-cw or BVT-rw. Heart size on a standing pre-dialysis chest X-ray did not change significantly throughout the study. There were less episodes of dialysis hypotension during BVT compared with standard HD (both BVT periods: p<0.01). ABPM data were complete in 10 patients. During the first 16 hr post-HD, systolic blood pressure was significantly higher with BVT in comparison with standard HD (both BVT periods: p<0.05). The use of BVT in hypotension-prone patients is associated with higher systolic blood pressures for as long as 16 hr post-HD. BVT was not effective in reducing the post-HD target weight in this patient group.     

Monitoring the social gradient: Inequalities in use of blood pressure monitors in the HUNT study

AimTo investigate the cross-sectional and longitudinal social gradient in use of blood pressure monitors, an innovative health technology.BackgroundThis is one of the first studies of social inequalities in the utilization of an end-user health technology in a universal health care context. The diffusion of innovation (DoI) and fundamental cause (FCT) theories predicts a widening of inequalities with the introduction of a new technology.Data and methodsTwo waves (N > 18,000) of the Nord-Trøndelag Health Study (HUNT), conducted in 1997 and 2008. Dependent variables were three self-reported indicators of blood pressure monitor use. Independent variables were educational attainment and income quartiles. Control variables were gender, age, and blood pressure.ResultsFor the blood pressure monitor variable from 1997, there was evidence of an educational gradient. No social inequalities were found for the 2008 monitor variable. When interacting socio-economic status with a survey wave dummy, results showed a social gradient from 1997 becoming smaller or non-significant in 2008. These results are supportive of the DoI and FCT, suggesting that the use of technology may initially generate health inequalities, which decrease as the technology is diffused across all social strata.     

Interdialytic blood pressure obtained by ambulatory blood pressure measurement and left ventricular structure in hypertensive hemodialysis patients

Unlike in subjects with normal renal function, the relationship between hypertension and cardiovascular morbidity and mortality in dialysis patients is still being debated. In order to clarify this issue, we performed 44-hour ambulatory blood pressure measurements (ABPM) during the interdialytic period in a group of 164 hypertensive patients, the blood pressure (BP) control based on conventional antihypertensive strategy previously, on chronic hemodialysis treatment in the Mediterranean region of Turkey. These results were then compared with their echocardiographic data. This is a cross-sectional analysis. The mean ABPM during 44 hours was close to the manually measured predialysis value, but there was a gradual increase in the ABPM values in the interdialytic period. When divided into a group with mild or no left ventricular hypertrophy (LVH) (45 patients) and severe LVH (119 patients), the latter had significantly higher BP levels in all separate periods, while the difference in predialysis BP was not significant. Patients with severe LVH had larger left atrium and left ventricular diameters, and consumed more antihypertensive drugs. Systolic BP during the night before dialysis showed the strongest relation to LVH, but interdialytic weight gain was also independently related to LVH. Yet, 56% of the patients with systolic BP <135 had severe LVH. There is not only an association between BP and presence of LVH, but it is shown that volume expansion is also an important independent determinant of LVH. This may explain the difficulty in identifying hypertension as a cardiac risk factor in these patients.     

基于PLC的闸门自动控制系统的设计与实现

在水利信息化的进程中，闸门安全、可靠的自动控制一直都是关注的焦点。针对闸门自动控制系统的控制需求，提出了基于远地控制层、集中控制层和现地控制层的三层控制体系结构，并采用先进的PLC以及现场总线技术加以实现，避免了传统集中控制带来的风险。该系统已经在通济堰渠首取水工程闸门工程中投入使用，取得了良好的运行效果。     

Measures of blood pressure and cognition in dialysis patients

There are few reports on the relationship of blood pressure with cognitive function in maintenance dialysis patients. The Cognition and Dialysis Study is an ongoing investigation of cognitive function and its risk factors in six Boston area hemodialysis units. In this analysis, we evaluated the relationship between different domains of cognitive function with systolic and diastolic blood pressure, pulse pressure, and intradialytic changes in systolic blood pressure, using univariate and multivariable linear regression models adjusted for age, sex, race, education, and primary cause of end‐stage renal disease. Among 314 participants, mean age was 63 years; 47% were female, 22% were African American, and 48% had diabetes. The mean (SD) of systolic blood pressure, diastolic blood pressure, pulse pressure, and intradialytic change in systolic blood pressure were 141 (21), 73 (12), 68 (15), and ?10 (24) mmHg, respectively. In univariate analyses, the performance on cognitive tests primarily assessing executive function and processing speeds was worse among participants with lower diastolic blood pressure and higher pulse pressure. These relationships were not statistically significant, however, in multivariable analyses. There was no association between cognitive function and systolic blood pressure or intradialytic change in systolic blood pressure in either univariate or multivariable analyses. We found no association between different measures of blood pressure and cognitive function in cross‐sectional analysis. Longitudinal studies are needed to confirm these results.     

Impact of the implementation of continuous construction method on pavement cracking performance

A continuous construction method (CCM) was proposed to decrease the reflective cracking generated from the cement-treated macadam base by reducing the shrinkage of base materials and improving the bond strength at the interface between the base layer and surface layer. Traditional 3–7 days of curing period of cement-treated macadam base was eliminated by CCM and the asphalt mixture can be paved immediately after the construction of cement-treated macadam base. An anti-cracking agent was developed and added into the cement-treated base materials to prolong the hydration process and improve the shrinkage performance of base materials. The influences of anti-cracking agent on the properties of cement-treated materials were analysed using laboratory tests. The generation of micro-expansion ettringite from cement system was investigated from the microscopic perspective using the scanning electronic microscope test. Test roads were constructed and contrasted to demonstrate the feasibility of this approach and showed a superior anti-cracking performance.     

空压机防喘振控制的设计和实现

简介离心式压缩机防喘振控制方案,介绍宝钢分公司7#空压机喘振线和控制线的确定,分析了7#空压机防喘振控制的实现方案以及存在的问题和改进措施。     

基于PLC的随速变压停车制动设计与实现

1∶1列车制动试验台能按不同速度、不同制动力和不同制动模式进行多次循环制动试验.随速变压停车制动设计通过1∶1列车制动试验台考察速度为200km/h的CRH2型动车组原装进口拖车轴装制动器的摩擦磨耗性能,利用LabVIEW与下位机PLC之间的串行通信.通过PLC进行PID调节,控制各种执行部件动作.实验表明,控制系统能够实现闸片在各个不同制动条件下达到随速变压停车制动.同时,上位机接收PLC返回的各种信号,可分别按照中国、美国铁路协会(AAR)、国际铁路联盟(UIC)、日本铁路标准(JRS)等标准对试验数据进行处理,得出相应的试验报表并打印出来.     

便携式无人机地面控制站设计与实现

为实现无人机状态监视、飞行操纵及机载任务设备控制,设计并搭建便携式无人机地面控制站。规划系统整体设计方案,提出采用USB接口技术设计完成系统的外部控制模块,解决系统便于携带的问题;利用Google Earth技术实现无人机状态实时监视,增强数据可读性。通过无人机飞行控制实验,表明该系统具有便携、人机界面友好、实时性强等优点,并具有功能扩展性。     

Impact of road traffic injuries on disability rates and long-term care costs in Spain

Road traffic injuries are one of the leading causes of increasing disability-adjusted life expectancy. We analyze long-term care needs associated with motor vehicle crash-related disability in Spain and conclude that needs attributable traffic injuries are most prevalent during victims’ mid-life years, they create a significant burden for both families and society as a whole given that public welfare programmes supporting these victims need to be maintained over a long time frame. High socio-economic costs of road traffic accidents (in Spain 0.04% of the GDP in 2008) are clearly indicative of the need for governments and policymakers to strengthen road accident preventive measures.     

小型四旋翼无人机飞行控制系统设计与实现

为进一步深入研究和开发小型四旋翼无人机搭建飞行控制实验系统,从硬件设计、软件开发和系统调试与飞行试验3个方面对搭建的小型四旋翼无人机飞行控制系统进行较为详细地阐述。飞行试验表明:所设计的飞行控制系统初步实现了对机体姿态的有效控制,为进一步研究自主飞行奠定了基础。     

一种新型自动跟踪控制系统的设计与实现

为了提高光伏发电的发电效率,降低发电成本,使用全新设计的传感器,设计了一种光伏自动跟踪控制系统。该系统所使用的传感器仅为四个光敏元件,几乎零成本。文中详细阐述了传感器的结构和工作原理、控制系统的设计以及系统控制的软件实现。试验结果证明,该系统能实现全天候全方位检测并迅速追踪到太阳的位置,有效的提高了跟踪系统的精确性。     

Impact of selected parameters on refrigerant flow boiling heat transfer and pressure drop in minichannels

This paper presents results concerning flow boiling heat transfer in a rectangular minichannel 1 mm deep, 40 mm wide and 360 mm long. The refrigerant flowing in the minichannel, Fluorinert FC-72, was heated by a thin foil microstructured on the side in contact with the fluid. Two types of microstructured surfaces were used: one with evenly distributed microcavities and the other with non-uniformly distributed minicavities. Liquid crystal thermography was applied to determine the temperature of the smooth side of the foil. The paper analyses mainly the impact of the microstructured heating surface and orientation of the minichanel on the heat transfer coefficient and two phase pressure drop. This required calculating the local values of heat transfer coefficient and measuring the pressure drop for different positions of the minichannel with enhanced heating wall. Moreover, the effects of selected thermal and flow parameters (mass flux density and inlet pressure), the geometric parameters, and the type of cooling liquid on the nucleate boiling heat transfer is studied. From the measurement results it is evident that applying a microstructured surface caused an increase in the heat transfer coefficient, which was approximately twice as high as that reported for the smooth surface. The highest values of the coefficient were observed for position 90° (the vertical minichannel) and position 0° (the horizontal minichannel), whereas the lowest were reported for position 180° (the horizontal minichannel). The experimental data concerning the two-phase flow pressure drop was compared with the calculation results obtained by applying nine correlations known from the literature. It is reported that most of the correlations can be used to predict the two-phase flow pressure drop gradient within an acceptable error limit (±30%) only for positions 90° and 135° (the vertical and inclined minichannels, respectively). The lowest agreement between the experimental data and the theoretical predictions was reported for the horizontal positions of the minichannel.     

Impact of safety belt use on road accident injury and injury type in Kuwait

The enactment of Kuwait's seat belt law in January 1994 provided an opportunity to examine the impact of seat belt use on road accident fatalities and injury types in this affluent Persian Gulf nation. Via a structured data form, the results of injurious/fatal road accidents for more than 1200 accident victims were gathered from the files of the six major government hospitals which treat most traffic accident victims. Statistical analysis of the data showed that seat belt use has had a positive effect in reducing both road traffic fatalities and multiple injuries in Kuwait. The use of seat belts has also affected the nature of the injuries resulting from road traffic accidents. Non-users of belts experienced higher frequencies of head, face, abdominal and limb injuries. Users of belts, on the other hand, suffered higher frequencies of neck and chest injuries. The interrelationship between the victim, his age, and the type of injuries resulting from road traffic accidents is also investigated.