Journal articles
Clark C, Albsri A, Omboni S, McDonagh S, Fletcher B, McManus R, Shappard J (In Press). Hypertension: evidence for effective detection and management through pharmacy. The Pharmaceutical journal
McDonagh S, Clark CE (In Press). Inter-arm differences in blood pressure: a brief summary. Diabetes and Primary Care, 21
Clark C, Thomas D, Llewellyn D, Ferrucci L, Bandinelli S, Campbell J (In Press). Systolic inter-arm blood pressure difference and risk of cognitive decline in the elderly: cohort study. British Journal of General Practice
Norris M, Poltawski L, Calitri RA, Shepherd A, Dean S (In Press). The acceptability and experience of a functional training programme (ReTrain) in community dwelling stroke survivors in South West England: a qualitative study. BMJ Open
Samarasekera EJ, Clark CE, Kaur S, Patel RS, Mills J, Guideline Committee (2023). Cardiovascular disease risk assessment and reduction: summary of updated NICE guidance.
BMJ,
381 Author URL.
McDonagh STJ, Dalal H, Moore S, Clark CE, Taylor RS (2023). Cochrane corner: centre versus telemedicine approaches to cardiac rehabilitation. Heart
McDonagh ST, Dalal H, Moore S, Clark CE, Dean SG, Jolly K, Cowie A, Afzal J, Taylor RS (2023). Home-based versus centre-based cardiac rehabilitation.
Cochrane Database Syst Rev,
10(10).
Abstract:
Home-based versus centre-based cardiac rehabilitation.
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.
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Clark CE (2023). Hypertension and hypotension: getting the balance right.
Br J Gen Pract,
73(726), 6-7.
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Cross R, McDonagh S, Cockcroft E, Turner M, Isom M, Lambourn R, Campbell J, Clark CE (2023). Recruitment and retention of staff in rural dispensing practice.
Rural Remote Health,
23(1).
Abstract:
Recruitment and retention of staff in rural dispensing practice.
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.
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McDonagh S, Cross R, Masoli J, Konya J, Abel G, Sheppard J, Jakubowski B, Bhanu C, Fordham J, Turner K, et al (2023). UNDERSTANDING MEASUREMENT OF POSTURAL HYPOTENSION: a NATIONWIDE SURVEY OF PRIMARY CARE PRACTICE IN ENGLAND. Journal of Hypertension, 41(Suppl 3).
Clark C, McDonagh S, Cross R, Masoli J, Konya J, Abel G, Sheppard J, Jakubowski B, Bhanu C, Fordham J, et al (2023). Understanding Measurement of postural hypotension: a nationwide survey of primary care practice in England.
Br J Gen Pract,
73(suppl 1).
Abstract:
Understanding Measurement of postural hypotension: a nationwide survey of primary care practice in England.
BACKGROUND: Postural hypotension (PH), the drop in blood pressure (BP) on standing, is associated with falls, all-cause mortality and cognitive decline. PH diagnostic criteria require lying-to-standing BP measurements. PH Prevalence in older adults is 20%, however, it is infrequently recorded in primary care records, suggesting PH testing and/or recording is under-utilised in this setting. AIM: to understand current PH measurement and management by primary care practitioners in England. METHOD: Clinical Research Networks circulated an online survey to primary care clinicians involved in measurement of BP. Demographics and responses were summarised as percentages, or median and inter-quartile ranges (IQR), as appropriate. The survey remains open until 30 November 2022; full results will be presented at the conference. RESULTS: to date, there are 669 replies (341 doctors, 179 nurses, 70 healthcare assistants, 23 pharmacists, 56 other roles); median age 45 (IQR 38 to 53), 72% female. Overall, 597 (89%) responders check for PH, predominantly when symptoms are present (98%). Less common reasons to check include patients being over 80 (24%), Parkinson's disease (21%), hypertension reviews (18%), medication reviews (12%) or diabetes reviews (11%). Sitting-to-standing BP measurements are common (77%); only 22% use lying-to-standing. Only 64% ensure a rest period before sitting or lying BP measurement and only 1 (IQR 1 to 2) standing BP measurement is made, usually (66%) within the first minute of standing. CONCLUSION: Interim findings suggest that most PH assessments in primary care do not meet current guideline criteria. Full findings from this survey are expected to inform and influence future national guidelines.
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McDonagh S, Sheppard J, Warren F, Boddy K, Farmer L, Shore H, Williams P, Lewis P, Fordham AJ, Martin U, et al (2022). ARM BASED ON LEG BLOOD PRESSURES (ABLE-BP): CAN SYSTOLIC LEG BLOOD PRESSURE MEASUREMENTS PREDICT BRACHIAL BLOOD PRESSURE? AN INDIVIDUAL PARTICIPANT DATA META-ANALYSIS. Journal of Hypertension, 40(Suppl 1), e8-e9.
Konya J, Neal RD, Clark C, Bearman D, Campbell J (2022). Can early cancer detection be improved in deprived areas by involving community pharmacists?.
Br J Gen Pract,
72(717), 153-154.
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Wander GS, McDonagh STJ, Rao MS, Alagesan R, Mohan JC, Bhagwat A, Pancholia AK, Viswanathan M, Chopda MB, Purnanand A, et al (2022). Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian Primary Care.
J Clin Hypertens (Greenwich)Abstract:
Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian Primary Care.
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
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Wander GS, McDonagh STJ, Rao MS, Alagesan R, Mohan JC, Bhagwat A, Pancholia AK, Viswanathan M, Chopda MB, Purnanand A, et al (2022). Clinical relevance of double‐arm blood pressure measurement and prevalence of clinically important inter‐arm blood pressure differences in Indian primary care.
The Journal of Clinical Hypertension,
24(8), 993-1002.
Abstract:
Clinical relevance of double‐arm blood pressure measurement and prevalence of clinically important inter‐arm blood pressure differences in Indian primary care
AbstractHypertension 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 134 678 (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 < .01) and diastolic BP 82.7 vs 82.6 mmHg (p < .01), respectively.Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7,813 (5.8%). Systolic IAD ≥ 15 mmHg 2,980 (2.2%) and diastolic IAD ≥ 10 mmHg 7,151 (5.3%). In total, there were 7,595 (5.6%) and 8,548 (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 exists in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasize the importance of undertaking bilateral BP measurement in routine clinical practice.
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Jordan AN, Anning C, Wilkes L, Ball C, Pamphilon N, Clark CE, Bellenger NG, Shore AC, Sharp ASP, Valderas JM, et al (2022). Cross-cultural adaptation of the Spanish MINICHAL instrument into English for use in the United Kingdom. Health and Quality of Life Outcomes, 20(1).
Leach B, Parkinson S, Gkousis E, Abel G, Atherton H, Campbell J, Clark C, Cockcroft E, Marriott C, Pitchforth E, et al (2022). Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review.
Journal of Medical Internet Research,
24(7), e33911-e33911.
Abstract:
Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review
. Background
. The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation—referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services—may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear.
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. Objective
. This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation.
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. Methods
. Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach.
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. Results
. A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients’ trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation.
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. Conclusions
. Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations.
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. Trial Registration
. PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019
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Clark CE, Warren FC, Boddy K, McDonagh STJ, Moore SF, Teresa Alzamora M, Ramos Blanes R, Chuang S-Y, Criqui MH, Dahl M, et al (2022). Higher Arm Versus Lower Arm Systolic Blood Pressure and Cardiovascular Outcomes: a Meta-Analysis of Individual Participant Data from the INTERPRESS-IPD Collaboration.
Hypertension,
79(10), 2328-2335.
Abstract:
Higher Arm Versus Lower Arm Systolic Blood Pressure and Cardiovascular Outcomes: a Meta-Analysis of Individual Participant Data from the INTERPRESS-IPD Collaboration.
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
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McDonagh STJ, Norris B, Fordham AJ, Greenwood MR, Richards SH, Campbell JL, Clark CE (2022). Inter-arm blood pressure difference and cardiovascular risk estimation in primary care: a pilot study.
BJGP Open,
6(3).
Abstract:
Inter-arm blood pressure difference and cardiovascular risk estimation in primary care: a pilot study.
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.
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McDonagh STJ, Rhodes S, Warren FC, Keenan S, Pentecost C, Keeling P, James M, Taylor RS, Clark CE (2022). Performance of the imPulse device for the detection of atrial fibrillation in hospital settings. Cardiovascular Digital Health Journal, 3(4), 171-178.
McDonagh STJ, Sheppard JP, Warren FC, Boddy K, Farmer L, Shore H, Williams P, Lewis PS, Baumber R, Fordham J, et al (2021). Arm Based on LEg blood pressures (ABLE-BP): can systolic leg blood pressure measurements predict systolic brachial blood pressure? Protocol for an individual participant data meta-analysis from the INTERPRESS-IPD Collaboration.
BMJ Open,
11(3), e040481-e040481.
Abstract:
Arm Based on LEg blood pressures (ABLE-BP): can systolic leg blood pressure measurements predict systolic brachial blood pressure? Protocol for an individual participant data meta-analysis from the INTERPRESS-IPD Collaboration
IntroductionBlood pressure (BP) is normally measured on the upper arm, and guidelines for the diagnosis and treatment of high BP are based on such measurements. Leg BP measurement can be an alternative when brachial BP measurement is impractical, due to injury or disability. Limited data exist to guide interpretation of leg BP values for hypertension management; study-level systematic review findings suggest that systolic BP (SBP) is 17 mm Hg higher in the leg than the arm. However, uncertainty remains about the applicability of this figure in clinical practice due to substantial heterogeneity.AimsTo examine the relationship between arm and leg SBP, develop and validate a multivariable model predicting arm SBP from leg SBP and investigate the prognostic association between leg SBP and cardiovascular disease and mortality.Methods and analysisIndividual participant data (IPD) meta-analyses using arm and leg SBP measurements for 33 710 individuals from 14 studies within the Inter-arm blood pressure difference IPD (INTERPRESS-IPD) Collaboration. We will explore cross-sectional relationships between arm and leg SBP using hierarchical linear regression with participants nested by study, in multivariable models. Prognostic models will be derived for all-cause and cardiovascular mortality and cardiovascular events.Ethics and disseminationData originate from studies with prior ethical approval and consent, and data sharing agreements are in place—no further approvals are required to undertake the secondary analyses proposed in this protocol. Findings will be published in peer-reviewed journal articles and presented at conferences. A comprehensive dissemination strategy is in place, integrated with patient and public involvement.PROSPERO registration numberCRD42015031227.
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Clark CE, McDonagh STJ, McManus RJ, Martin U (2021). COVID-19 and hypertension: risks and management. A scientific statement on behalf of the British and Irish Hypertension Society.
J Hum Hypertens,
35(4), 304-307.
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Jordan A, Anning C, Wilkes L, Ball C, Pamphilon N, Clark CE, Bellenger NG, Shore AC, Sharp ASP, Valderas JM, et al (2021). Cross-Cultural Adaptation of the Spanish MINICHAL Instrument into English for Use in the United Kingdom.
Abstract:
Cross-Cultural Adaptation of the Spanish MINICHAL Instrument into English for Use in the United Kingdom
Abstract
. 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, using a cohort of patients enrolled in an 18-week programme for the treatment of grade II-III hypertension. 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. Results: the final version of the instrument was administered to 30 individuals with grade II/III hypertension before and after 18 weeks’ intensive treatment. 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 EQ5d5L and Bulpitt-Fletcher instruments. No significant associations were found between scores and patient characteristics known to affect HRQoL. The EQ5D5L 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).
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Burnier M, Prejbisz A, Weber T, Azizi M, Cunha V, Versmissen J, Gupta P, Vaclavik J, Januszewicz A, Persu A, et al (2021). Hypertension healthcare professional beliefs and behaviour regarding patient medication adherence: a survey conducted among European Society of Hypertension Centres of Excellence. Blood Pressure, 30(5), 282-290.
Clark CE (2021). Inter-arm blood pressure difference, when is it a useful risk marker for cardiovascular events?. Journal of Human Hypertension, 36(2), 117-119.
Bauersachs R, Brodmann M, Clark C, Debus S, De Carlo M, Gomez-Cerezo JF, Madaric J, Mazzolai L, Ricco J-B, Sillesen H, et al (2021). International public awareness of peripheral artery. disease.
Vasa,
50(4), 294-300.
Abstract:
International public awareness of peripheral artery. disease
Summary: Background: Peripheral artery disease (PAD) of the lower limbs is a common condition with considerable global burden. Some country-specific studies suggest low levels of public awareness. To our knowledge public awareness of PAD has never been assessed simultaneously in several countries worldwide. Patients and methods: This was an international, general public, internet-based quantitative survey assessing vascular health and disease understanding. Questionnaires included 23 closed-ended multiple-choice, Likert scale and binary choice questions. Data were collected from 9,098 survey respondents from nine countries in Europe, North and Latin America during May-June 2018. Results: Overall, familiarity with PAD was low (57% of respondents were “not at all familiar”, and 9% were “moderately” or “very familiar”). Knowledge about PAD health consequences was limited, with 55% of all respondents not being aware of limb consequences of PAD. There were disparities in PAD familiarity levels between countries; highest levels of self-reported awareness were in Germany and Poland where 13% reported to be “very” or “moderately” familiar with PAD, and lowest in Scandinavian countries (5%, 3% and 2% of respondents in Norway, Sweden and Denmark, respectively). There were disparities in awareness according to age. Respondents aged 25–34 were most familiar with PAD, with 12% stating that they were “moderately” or “very” familiar with the condition, whereas those aged 18–24 were the least familiar with PAD (7% “moderately” or “very” familiar with PAD). In the 45–54, 55–64 and 65+ age groups, 9% said they were “moderately” or “very” familiar with the term. There was no important gender-based difference in PAD familiarity. Conclusions: on an international level, public self-reported PAD awareness is low, even though PAD is a common condition with considerable burden. Campaigns to increase PAD awareness are needed to reduce delays in diagnosis and to motivate people to control PAD risk factors.
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Gomez-Cano M, Wiering B, Abel G, Campbell JL, Clark CE (2021). Medication adherence and clinical outcomes in dispensing and non-dispensing practices: a cross-sectional analysis.
Br J Gen Pract,
71(702), e55-e61.
Abstract:
Medication adherence and clinical outcomes in dispensing and non-dispensing practices: a cross-sectional analysis.
BACKGROUND: Most patients obtain medications from pharmacies by prescription, but rural general practices can dispense medications. The clinical implications of this difference in drug delivery are unknown. This study hypothesised that dispensing status may be associated with better medication adherence. This could impact intermediate clinical outcomes dependent on medication adherence in, for example, hypertension or diabetes. AIM: to investigate whether dispensing status is associated with differences in achievement of Quality and Outcomes Framework (QOF) indicators that rely on medication adherence. DESIGN AND SETTING: Cross-sectional analysis of QOF data for 7392 general practices in England. METHOD: QOF data from 1 April 2016 to 31 March 2017 linked to dispensing status for general practices with list sizes ≥1000 in England were analysed. QOF indicators were categorised according to whether their achievement depended on a record of prescribing only, medication adherence, or neither. Differences were estimated between dispensing and non-dispensing practices using mixed-effects logistic regression, adjusting for practice population age, sex, deprivation, list size, single-handed status, and rurality. RESULTS: Data existed for 7392 practices; 1014 (13.7%) could dispense. Achievement was better in dispensing practices than in non-dispensing practices for seven of nine QOF indicators dependent on adherence, including blood pressure targets. Only one of ten indicators dependent on prescribing but not adherence displayed better achievement; indicators unrelated to prescribing showed a trend towards higher achievement by dispensing practices. CONCLUSION: Dispensing practices may achieve better clinical outcomes than prescribing practices. Further work is required to explore underlying mechanisms for these observations and to directly study medication adherence rates.
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Jordan AN, Fulford J, Gooding K, Anning C, Wilkes L, Ball C, Pamphilon N, Mawson D, Clark CE, Shore AC, et al (2021). Morphological and functional cardiac consequences of rapid hypertension treatment: a cohort study.
Journal of Cardiovascular Magnetic Resonance,
23(1).
Abstract:
Morphological and functional cardiac consequences of rapid hypertension treatment: a cohort study
Abstract
. 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.
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. 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.
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. 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/m2, 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).
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. 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).
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Abstract.
McDonagh STJ, Mejzner N, Clark CE (2021). Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis.
BMC Family Practice,
22(1).
Abstract:
Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis
Abstract
. Background
. Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups.
.
. Methods
. Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale.
.
. Results
. One thousand eight hundred sixteen studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14–20%; I2 = 99%) for 34 community cohorts, 19% (15–25%; I2 = 98%) for 23 primary care cohorts and 31% (15–50%; I2 = 0%) for 3 residential care or nursing homes cohorts (P = 0.16 between groups). By condition, prevalences were 20% (16–23%; I2 = 98%) with hypertension (20 cohorts), 21% (16–26%; I2 = 92%) with diabetes (4 cohorts), 25% (18–33%; I2 = 88%) with Parkinson’s disease (7 cohorts) and 29% (25–33%, I2 = 0%) with dementia (3 cohorts), compared to 14% (12–17%, I2 = 99%) without these conditions (P < 0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P < 0.01, P = 0.13, respectively; R2 = 36%). PH prevalence was not affected by blood pressure measurement device (P = 0.65) or sitting or supine resting position (P = 0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P = 0.01) irrespective of study quality (P = 0.04).
.
. Conclusions
. PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH.
. PROSPERO:CRD42017075423.
.
Abstract.
Masoli JAH, Todd OM, Clark CE (2021). Systolic blood pressure and outcomes in frail older adults.
British Journal of Hospital Medicine,
82(5), 1-4.
Abstract:
Systolic blood pressure and outcomes in frail older adults
Hypertension is diagnosed in the majority of older people with frailty, in whom blood pressure prognosis is not well understood. This editorial describes recent evidence on blood pressure and outcomes in older people with frailty.
Abstract.
Clark C, Warren F, Boddy K, McDonagh S, Moore S, Goddard J, Reed N, Turner M, Alzamora MT, Ramos Blanes R, et al (2020). Associations Between Systolic Interarm Differences in Blood Pressure and Cardiovascular Disease Outcomes and Mortality: Individual Participant Data Meta-Analysis, Development and Validation of a Prognostic Algorithm: the INTERPRESS-IPD Collaboration. Hypertension, n/a, 1-12.
Lewis PS, Chapman N, Chowienczyk P, Clark C, Denver E, Lacy P, Martin U, McManus R, Neary A, Sheppard J, et al (2020). Correction: Oscillometric measurement of blood pressure: a simplified explanation. A technical note on behalf of the British and Irish Hypertension Society (Journal of Human Hypertension, (2019), 33, 5, (349-351), 10.1038/s41371-019-0196-9).
Journal of Human Hypertension,
34(3).
Abstract:
Correction: Oscillometric measurement of blood pressure: a simplified explanation. A technical note on behalf of the British and Irish Hypertension Society (Journal of Human Hypertension, (2019), 33, 5, (349-351), 10.1038/s41371-019-0196-9)
This Article was originally published under Nature Research’s License to Publish, but has now been made available under a [CC BY 4.0] license. The PDF and HTML versions of the Article have been modified accordingly.
Abstract.
Clark CE, McDonagh STJ, McManus RJ (2020). Measurement of blood pressure in people with atrial fibrillation (vol 33, pg 763, 2019).
JOURNAL OF HUMAN HYPERTENSION,
34(6), 476-476.
Author URL.
Sheppard JP, Lacy P, Lewis PS, Martin U (2020). Measurement of blood pressure in the leg—a statement on behalf of the British and Irish Hypertension Society. Journal of Human Hypertension, 34(6), 418-419.
Gomez-Cano M, Wiering B, Abel G, Campbell J, Clark C (2020). Medication adherence and clinical outcomes in dispensing and non-dispensing practices: a cross-sectional analysis. British Journal of General Practice
McDonagh STJ, Mejzner N, Clark CE (2020). Prevalence of Postural Hypotension in Primary, Community and Institutional Care: a Systematic Review and Meta-Analysis.
Abstract:
Prevalence of Postural Hypotension in Primary, Community and Institutional Care: a Systematic Review and Meta-Analysis
Abstract
. Background: Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care despite these associated risks. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups.Methods: a systematic review, meta-analyses and meta-regression were undertaken. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean prevalence of PH were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment of included studies was undertaken using an adapted version of the Newcastle-Ottawa Scale.Results: 1816 studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%) in the community, 19% (15-25%) in primary care and 31% (15-50%) in residential care or nursing homes (P=0.16 between groups). By condition, prevalences were 20% (16-24%) with hypertension, 21% (16-26%) with diabetes, 25% (18-33%) with Parkinson’s disease and 29% (25-33%) with dementia, compared to 14% (12-17%) without these conditions (P<0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P<0.01, P=0.13, respectively; R2=36%). PH prevalence was not affected by blood pressure measurement device (P=0.65) or sitting or supine resting position (P=0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P=0.01) irrespective of study quality (P=0.04).Conclusions: the prevalence of PH in populations relevant to primary care is substantial. The definition used is important when testing for PH. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of postural hypotension.PROSPERO: CRD42017075423.
Abstract.
McDonagh STJ, Mejzner N, Clark CE (2020). Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis.
Abstract:
Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis
Abstract
. Background: Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups.
Methods: Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale.
Results: 1816 studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%; I2=99%) for community cohorts, 19% (15-25%; I2=98%) for 23 primary care cohorts and 31% (15-50%; I2=0%) for 3 residential care or nursing homes cohorts (P=0.16 between groups). By condition, prevalences were 20% (16-23%; I2=98%) with hypertension (20 cohorts), 21% (16-26%; I2=92%) with diabetes (4 cohorts), 25% (18-33%; I2=88%) with Parkinson’s disease (7 cohorts) and 29% (25-33%; I2=0%) with dementia (3 cohorts), compared to 14% (12-17%; I2=99%) without these conditions (P<0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P<0.01, P=0.13, respectively; R2=36%). PH prevalence was not affected by blood pressure measurement device (P=0.65) or sitting or supine resting position (P=0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P=0.01) irrespective of study quality (P=0.04).
Conclusions: PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH.
PROSPERO:CRD42017075423.
Abstract.
Jordan AN, Anning C, Wilkes L, Ball C, Pamphilon N, Clark CE, Bellenger NG, Shore AC, Sharp ASP (2020). Rapid treatment of moderate to severe hypertension using a novel protocol in a single-centre, before and after interventional study.
J Hum Hypertens,
34(2), 165-175.
Abstract:
Rapid treatment of moderate to severe hypertension using a novel protocol in a single-centre, before and after interventional study.
Rapid treatment to target in hypertension may have beneficial effects on long-term outcomes. This has led to a new recommendation in the 2018 European hypertension guidelines for patients with grade II/III hypertension to be treated to target within three months. However, whether it is feasible and safe to quickly manage treatment-naïve grade II/III hypertension to target was unclear. We examined this using a single-centre before and after interventional study, treating newly diagnosed, never-treated, grade II/III hypertensive patients with a daytime average systolic ABP ≥ 150 mmHg to target within 18 weeks. The proportion at office target BP at 18 weeks was determined, together with office and ambulatory BP change from baseline to after the intervention. The protocol was designed to maximise medication adherence, including a low threshold for treatment adaptation. Safety was evaluated through close monitoring of adverse events and protocol discontinuation. Fifty-five participants were enrolled with 54 completing the protocol. 69 ± 12.3% were at office target BP at their final visit, despite a high average starting BP of 175/103 mmHg, as a consequence of significant reductions in both office and ambulatory BP. of those at office target BP, 51% were above target on ambulatory measurement. Adherence testing demonstrated that 92% of participants were adherent to treatment at their final visit. Therefore we conclude that the accelerated management of treatment-naïve grade II/III hypertension is feasible and safe to implement in routine practice and there is no evidence to suggest it causes harm. Further large-scale randomised studies of rapid, adaptive treatment, including a cost-effectiveness analysis, are required.
Abstract.
Author URL.
Sheppard JP, Lacy P, Chapman N, Clark C, McManus RJ (2020). Reporting of the Meditech ABPM-06 ambulatory blood pressure device validation study. Blood Pressure Monitoring, 25(1), 59-60.
Clark CE, Masoli J, Warren FC, Soothill J, Campbell JL (2020). Vitamin D and COVID-19 in older age: evidence versus expectations. British Journal of General Practice, 71(702), 10-11.
Clark CE, McDonagh STJ, McManus RJ (2019). Accuracy of automated blood pressure measurements in the presence of atrial fibrillation: systematic review and meta-analysis.
J Hum Hypertens,
33(5), 352-364.
Abstract:
Accuracy of automated blood pressure measurements in the presence of atrial fibrillation: systematic review and meta-analysis.
Atrial fibrillation (AF) affects ~3% of the general population and is twice as common with hypertension. Validation protocols for automated sphygmomanometers exclude people with AF, raising concerns over accuracy of hypertension diagnosis or management, using out-of-office blood pressure (BP) monitoring, in the presence of AF. Some devices include algorithms to detect AF; a feature open to misinterpretation as offering accurate BP measurement with AF. We undertook this review to explore accuracy of automated devices, with or without AF detection, for measuring BP. We searched Medline and Embase to October 2018 for studies comparing automated BP measurement devices to a standard mercury sphygmomanometer contemporaneously. Data were extracted by two reviewers. Mean BP differences between devices and mercury were calculated, where not reported and compared; meta-analyses were undertaken where possible. We included 13 studies reporting 14 devices. Mean systolic and diastolic BP differences from mercury ranged from -3.1 to + 6.1/-4.6 to +9.0 mmHg. Considerable heterogeneity existed between devices (I2: 80 to 90%). Devices with AF detection algorithms appeared no more accurate for BP measurement with AF than other devices. A previous review concluded that oscillometric devices are accurate for systolic but not diastolic BP measurement in AF. The present findings do not support that conclusion. Due to heterogeneity between devices, they should be evaluated on individual performance. We found no evidence that devices with AF detection measure BP more accurately in AF than other devices. More home or ambulatory automated BP monitors require validation in populations with AF.
Abstract.
Author URL.
McDonagh S, Clark C (2019). CVD risk factors: new evidence, new approaches?. Primary Care Cardiovascular Journal
Clark CE, McDonagh STJ, McManus RJ, Blood Pressure Measurement Working Party of the British and Irish Hypertension Society (2019). Measurement of blood pressure in people with atrial fibrillation.
J Hum Hypertens,
33(11), 763-765.
Author URL.
Lewis PS, Chapman N, Chowienczyk P, Clark C, Denver E, Lacy P, Martin U, McManus R, Neary A, Sheppard J, et al (2019). Oscillometric measurement of blood pressure: a simplified explanation. A technical note on behalf of the British and Irish Hypertension Society. Journal of Human Hypertension, 33(5), 349-351.
Clark CE, Thomas D, Warren F, Llewellyn D, Ferrucci L, Campbell J (2018). Detecting Risks of Postural Hypotension (DROP): derivation and validation of a prediction score for primary care. BMJ Open
Clark CE, Sims L (2018). Hypertension care: sharing the burden with pharmacists.
Br J Gen Pract,
68(675), 458-459.
Author URL.
Clark C, Boddy K, Warren F, McDonagh S, Taylor R, Aboyans V, Cloutier L, McManus R, Shore A, Campbell J, et al (2018). INTER-ARM DIFFERENCES IN BLOOD PRESSURE AND MORTALITY: INDIVIDUAL PATIENT DATA META-ANALYSIS AND DEVELOPMENT OF a PROGNOSTIC ALGORITHM (INTERPRESS-IPD COLLABORATION). Canadian Journal of Cardiology, 34(10).
Clark C, Smith L, Cloutier L, Konya J, Todkar S, McDonagh S, Clark O, Glynn L, Taylor R, Campbell J, et al (2018). INTERVENTIONS TO IMPROVE CONTROL OF HYPERTENSION; WHAT WORKS (AND WHAT DOESN’T): SYSTEMATIC REVIEW AND META-REGRESSION. Canadian Journal of Cardiology, 34(10), s130-s131.
McManus R, Lacy P, Clark C, Chapman N, Lewis P (2018). Reporting of blood pressure monitor validation studies. Blood Pressure Monitoring, 23(4), 214-215.
Clark CE, Boddy K, Warren FC, Taylor RS, Aboyans V, Cloutier L, McManus RJ, Shore AC, Campbell JL (2017). Associations between interarm differences in blood pressure and cardiovascular disease outcomes: protocol for an individual patient data meta-analysis and development of a prognostic algorithm.
BMJ Open,
7(6).
Abstract:
Associations between interarm differences in blood pressure and cardiovascular disease outcomes: protocol for an individual patient data meta-analysis and development of a prognostic algorithm.
INTRODUCTION: Individual cohort studies in various populations and study-level meta-analyses have shown interarm differences (IAD) in blood pressure to be associated with increased cardiovascular and all-cause mortality. However, key questions remain, such as follows: (1) What is the additional contribution of IAD to prognostic risk estimation for cardiovascular and all-cause mortality? (2) What is the minimum cut-off value for IAD that defines elevated risk? (3) is there a prognostic value of IAD and do different methods of IAD measurement impact on the prognostic value of IAD? We aim to address these questions by conducting an individual patient data (IPD) meta-analysis. METHODS AND ANALYSIS: This study will identify prospective cohort studies that measured blood pressure in both arms during recruitment, and invite authors to contribute IPD datasets to this collaboration. All patient data received will be combined into a single dataset. Using one-stage meta-analysis, we will undertake multivariable time-to-event regression modelling, with the aim of developing a new prognostic model for cardiovascular risk estimation that includes IAD. We will explore variations in risk contribution of IAD across predefined population subgroups (eg, hypertensives, diabetics), establish the lower limit of IAD that is associated with additional cardiovascular risk and assess the impact of different methods of IAD measurement on risk prediction. ETHICS AND DISSEMINATION: This study will not include any patient identifiable data. Included datasets will already have ethical approval and consent from their sponsors. Findings will be presented to international conferences and published in peer reviewed journals, and we have a comprehensive dissemination strategy in place with integrated patient and public involvement. PROSPERO REGISTRATION NUMBER: CRD42015031227.
Abstract.
Author URL.
Schwartz CL, Clark C, Koshiaris C, Gill PS, Greenfield SM, Haque SM, Heer G, Johal A, Kaur R, Mant J, et al (2017). Interarm Difference in Systolic Blood Pressure in Different Ethnic Groups and Relationship to the “White Coat Effect”: a Cross-Sectional Study. American Journal of Hypertension, 30(9), 884-891.
Clark CE (2017). The interarm blood pressure difference: Do we know enough yet?.
J Clin Hypertens (Greenwich),
19(5), 462-465.
Author URL.
Mejzner N, Clark CE, Smith LF, Campbell JL (2017). Trends in the diagnosis and management of hypertension: repeated primary care survey in South West England.
Br J Gen Pract,
67(658), e306-e313.
Abstract:
Trends in the diagnosis and management of hypertension: repeated primary care survey in South West England.
BACKGROUND: Previous surveys identified a shift to nurse-led care in hypertension in 2010. In 2011 the National Institute for Health and Care Excellence (NICE) recommended ambulatory (ABPM) or home (HBPM) blood pressure (BP) monitoring for diagnosis of hypertension. AIM: to survey the organisation of hypertension care in 2016 to identify changes, and to assess uptake of NICE diagnostic guidelines. DESIGN AND SETTING: Questionnaires were distributed to all 305 general practices in South West England. METHOD: Responses were compared with previous rounds (2007 and 2010). Data from the 2015 Quality and Outcomes Framework (QOF) were used to compare responders with non-responders, and to explore associations of care organisation with QOF achievement. RESULTS: One-hundred-and-seventeen practices (38%) responded. Responders had larger list sizes and greater achievement of the QOF target BP ≤150/90 mmHg. Healthcare assistants (HCAs) now monitor BP in 70% of practices, compared with 37% in 2010 and 19% in 2007 (P
Abstract.
Author URL.
Clark CE, Taylor RS, Butcher I, Stewart MC, Price J, Fowkes FGR, Shore AC, Campbell JL (2016). Inter-arm blood pressure difference and mortality: a cohort study in an asymptomatic primary care population at elevated cardiovascular risk.
Br J Gen Pract,
66(646), e297-e308.
Abstract:
Inter-arm blood pressure difference and mortality: a cohort study in an asymptomatic primary care population at elevated cardiovascular risk.
BACKGROUND: Differences in blood pressure between arms are associated with increased cardiovascular mortality in cohorts with established vascular disease or substantially elevated cardiovascular risk. AIM: to explore the association of inter-arm difference (IAD) with mortality in a community-dwelling cohort that is free of cardiovascular disease. DESIGN AND SETTING: Cohort analysis of a randomised controlled trial in central Scotland, from April 1998 to October 2008. METHOD: Volunteers from Lanarkshire, Glasgow, and Edinburgh, free of pre-existing vascular disease and with an ankle-brachial index ≤0.95, had systolic blood pressure measured in both arms at recruitment. Inter-arm blood pressure differences were calculated and examined for cross-sectional associations and differences in prospective survival. Outcome measures were cardiovascular events and all-cause mortality during mean follow-up of 8.2 years. RESULTS: Based on a single pair of measurements, 60% of 3350 participants had a systolic IAD ≥5 mmHg and 38% ≥10 mmHg. An IAD ≥5 mmHg was associated with increased cardiovascular mortality (adjusted hazard ratio [HR] 1.91, 95% confidence interval [CI] = 1.19 to 3.07) and all-cause mortality (adjusted HR 1.44, 95% CI = 1.15 to 1.79). Within the subgroup of 764 participants who had hypertension, IADs of ≥5 mmHg or ≥10 mmHg were associated with both cardiovascular mortality (adjusted HR 2.63, 95% CI = 0.97 to 7.02, and adjusted HR 2.96, 95% CI = 1.27 to 6.88, respectively) and all-cause mortality (adjusted HR 1.67, 95% CI = 1.05 to 2.66, and adjusted HR 1.63, 95% CI = 1.06 to 2.50, respectively). IADs ≥15 mmHg were not associated with survival differences in this population. CONCLUSION: Systolic IADs in blood pressure are associated with increased risk of cardiovascular events, including mortality, in a large cohort of people free of pre-existing vascular disease.
Abstract.
Author URL.
Clark CE, Taylor RS, Shore AC, Campbell JL (2016). Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysis.
Br J Gen Pract,
66(652), e838-e847.
Abstract:
Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysis.
BACKGROUND: Various prevalence figures have been reported for inter-arm differences in blood pressure (IAD); variation may be explained by differing population vascular risk and by measurement method. AIM: to review the literature to derive robust estimates of IAD prevalence relevant to community populations. DESIGN AND SETTING: Systematic review and meta-analysis. METHOD: MEDLINE, Embase, and CINAHL were searched for cross-sectional studies likely to represent general or primary care populations, reporting prevalence of IAD and employing a simultaneous method of measurement. Using study-level data, pooled estimates of mean prevalence of systolic IADs were calculated and compared using a random effects model. RESULTS: Eighty IAD studies were identified. Sixteen met inclusion criteria: pooled estimates of prevalence for systolic IAD ≥10 mmHg were 11.2% (95% confidence interval [CI] = 9.1 to 13.6) in hypertension, 7.4% (95% CI = 5.8 to 9.2) in diabetes, and 3.6% (95% CI = 2.3 to 5.0) for a general adult population (P
Abstract.
Author URL.
Clark C, Thomas D, Warren F, Llewellyn D, Ferrucci L, Campbell J (2016). [OP.3C.04] PREDICTING POSTURAL HYPOTENSION, FALLS, AND COGNITIVE IMPAIRMENT: THE INCHIANTI STUDY.
J Hypertens,
34 Suppl 2Abstract:
[OP.3C.04] PREDICTING POSTURAL HYPOTENSION, FALLS, AND COGNITIVE IMPAIRMENT: THE INCHIANTI STUDY.
OBJECTIVE: over three million people aged over 65 fall each year in the UK. Postural hypotension (PH) is a risk factor for falls. It is associated with excess mortality, and may affect cognition. PH is not routinely checked for in UK clinical practice. We studied the InCHIANTI dataset to derive and validate a simple prediction tool designed to facilitate identification of subjects to be checked for PH. DESIGN AND METHOD: InCHIANTI is a population-based study of ageing. It recruited subjects from population registries in Chianti, Italy in 1998 and they were followed up triennially. Blood pressure (BP) at recruitment was measured after resting supine, and one and three minutes after standing, using a mercury sphygmomanometer. Systolic PH was defined as a > = 20 mmHg fall in supine BP on standing. Subjects were randomised to derivation or validation cohorts; allocation was undertaken blinded to PH status and medical history. Candidate predictor variables identified from literature searches were tested for univariable cross sectional associations with PH using χ2 tests. Those with significant associations were entered into multivariable linear regression models, and used to derive simple and weighted prediction scores (DROP scores). DROP scores were tested in the validation cohort for prediction of PH, future falls, cognitive decline and mortality rates. RESULTS: PH was present in 56/726 (7.7%) of the derivation cohort and 45/727 (6.2%) of the validation cohort (p = 0.25). PH was associated with age > = 65, falls in the preceding year, diabetes, previous stroke, hypertension and Parkinson's disease. A simple score summing numbers of these variables performed equally well as weighted scores (AUROC 0.67 (0.59 to 0.74); p
Abstract.
Author URL.
Clark C, Shore A, Taylor R, Campbell J (2015). 1C.08: THE INTER-ARM DIFFERENCE IN BLOOD PRESSURE AND MORTALITY: SYSTEMATIC REVIEW AND META-ANALYSIS.
J Hypertens,
33 Suppl 1Abstract:
1C.08: THE INTER-ARM DIFFERENCE IN BLOOD PRESSURE AND MORTALITY: SYSTEMATIC REVIEW AND META-ANALYSIS.
OBJECTIVE: We previously reported the association of inter-arm differences in blood pressure measurements (IAD) with increased cardiovascular and all-cause mortality. Several new large cohorts have been reported since our 2012 meta-analysis. We have therefore updated our meta-analyses to take account of these new data. DESIGN AND METHOD: Systematic review and meta-analysis: Medline, Embase and CINAHL were searched for studies reporting survival data in association with IAD. Study level hazard ratios (HR) were extracted for systolic IADs >=10mmHg and >=15mmHg, and pooled using generic inverse variance in a random effects model. Statistical heterogeneity was assessed using the I statistic. RESULTS: Searches to 12th November 2014 identified 3514 unique citations. Eighty full texts were assessed, and 13 studies (reporting data for 14 unique cohorts) contributed to the analyses, Median follow up ranged from 3 to 13 years. Five cohorts employed a simultaneous method of IAD measurement; the remainder used sequential measurements. Ten cohorts were recruited from community populations, including one hypertensive and one diabetic cohort. Four were selected hospital cohorts at increased vascular risk.Cardiovascular mortality was greater with an IAD >=10mmHg (HR 1.9 (95%CI 1.3 to 2.6; 7 cohorts, 13815 participants; I = 45%) and an IAD >=15mmHg (HR 1.7 (1.2 to 2.4; 9 cohorts; 18241 participants; I = 30%). For all-cause mortality HRs were 1.4 (1.2 to 1.8; 10 cohorts, 17709 participants; I = 62%) for IAD >=10mmHg and 1.4 (1.1 to 1.7; 12 cohorts, 18714 participants; I = 46%) for IAD >=15mmHg. Heterogeneity between studies could be accounted for by stratification according to underlying population cardiovascular risk, with higher HRs seen in populations at elevated risk; cardiovascular mortality with an IAD >=10mmHg: HR 1.4 (1.1 to 1.8; I = 0%) for community based cohorts compared to 3.8 (2.2 to 6.6; I = 0%) for those at elevated cardiovascular risk (p = 0.001; Figure).(Figure is included in full-text article.) CONCLUSIONS: : New studies confirming the association of an IAD with increased cardiovascular and all-cause mortality are consistent with previously published findings. Risks associated with an IAD rise in association with the underlying vascular risk of the population studied.
Abstract.
Author URL.
Clark CE (2015). Difference in blood pressure measurements between arms: methodological and clinical implications.
Curr Pharm Des,
21(6), 737-743.
Abstract:
Difference in blood pressure measurements between arms: methodological and clinical implications.
Differences in blood pressure measurements between arms are commonly encountered in clinical practice. If such differences are not excluded they can delay the diagnosis of hypertension and can lead to poorer control of blood pressure levels. Differences in blood pressure measurements between arms are associated cross sectionally with other signs of vascular disease such as peripheral arterial disease or cerebrovascular disease. Differences are also associated prospectively with increased cardiovascular mortality and morbidity and all cause mortality. Numbers of publications on inter-arm difference are rising year on year, indicating a growing interest in the phenomenon. The prevalence of an inter-arm difference varies widely between reports, and is correlated with the underlying cardiovascular risk of the population studied. Prevalence is also sensitive to the method of measurement used. This review discusses the prevalence of an inter-arm difference in different populations and addresses current best practice for the detection and the measurement of a difference. The evidence for clinical and for vascular associations of an inter-arm difference is presented in considering the emerging role of an inter-arm blood pressure difference as a novel risk factor for increased cardiovascular morbidity and mortality. Competing aetiological explanations for an inter-arm difference are explored, and gaps in our current understanding of this sign, along with areas in need of further research, are considered.
Abstract.
Author URL.
Clark CE, Aboyans V (2015). Interarm blood pressure difference: more than an epiphenomenon.
Nephrol Dial Transplant,
30(5), 695-697.
Author URL.
Clark C, Smith L, Cloutier L, Glynn L, Clark O, Taylor R, Campbell J (2015). LB01.01: ALLIED HEALTH PROFESSIONAL-LED INTERVENTIONS FOR IMPROVING CONTROL OF BLOOD PRESSURE IN PATIENTS WITH HYPERTENSION: a COCHRANE SYSTEMATIC REVIEW AND META-ANALYSIS.
J Hypertens,
33 Suppl 1Abstract:
LB01.01: ALLIED HEALTH PROFESSIONAL-LED INTERVENTIONS FOR IMPROVING CONTROL OF BLOOD PRESSURE IN PATIENTS WITH HYPERTENSION: a COCHRANE SYSTEMATIC REVIEW AND META-ANALYSIS.
OBJECTIVE: Nurse or pharmacist-led care may improve control of hypertension. We have undertaken a new Cochrane review of evidence for allied health professional led interventions in the management of hypertension. DESIGN AND METHOD: We searched multiple bibliographic databases to October 2013 for randomised controlled trials. We included any nursing, pharmacist, or allied health professional-led intervention designed to improve control of blood pressure (BP), compared to usual management of hypertension.Primary outcome measures were change in systolic BP, achievement of study target BP and use of antihypertensive medication. Two authors independently assessed studies for inclusion, extracted data, and assessed risk of bias using Cochrane criteria. Intervention effects were pooled using odds ratios (OR) or mean differences (MD). RESULTS: We identified 579 potential unique citations; 234 full-texts were assessed, and 98 papers met the inclusion criteria. Overall, half the risk of bias judgments across studies were rated as low risk.Compared to usual care, greater falls in systolic BP were seen for both nurse-led interventions (MD -3.8mmHg (95% CI: -5.6 to -2.0); 28 studies, 10573 participants) and pharmacist-led interventions (MD -7.6mmHg (-9.7 to -5.4); 30 studies, 6504 participants, p
Abstract.
Author URL.
Clark C, Smith L, Glynn L, Cloutier L, Clark O, Taylor R, Campbell J (2015). LB02.01: CHANGES IN BLOOD PRESSURE IN PATIENTS WITH HYPERTENSION RECEIVING USUAL CARE IN RANDOMISED CONTROLLED TRIALS. FINDINGS FROM a SYSTEMATIC REVIEW AND META-ANALYSIS.
J Hypertens,
33 Suppl 1Abstract:
LB02.01: CHANGES IN BLOOD PRESSURE IN PATIENTS WITH HYPERTENSION RECEIVING USUAL CARE IN RANDOMISED CONTROLLED TRIALS. FINDINGS FROM a SYSTEMATIC REVIEW AND META-ANALYSIS.
OBJECTIVE: on reviewing the evidence for allied health professional led interventions in the management of hypertension, we observed that blood pressure (BP) also falls within the usual care arms of included studies. Therefore we have undertaken further analysis to quantify the change in blood pressure in control arms of BP intervention studies included in the review. DESIGN AND METHOD: We used data from our Cochrane review (A115) that included 58 randomised controlled trials in 6897 patients identified in searches up to October 2013. This review included any nurse, pharmacist, or allied health professional-led intervention designed to improve control of BP, compared to usual management of hypertension.We used the primary outcome of change in systolic and diastolic BP from baseline to final follow up reported in usual care control arms of included trials. Changes in BP were expressed as weighted mean differences pooled using generic inverse variance taking account of within patient correlation. RESULTS: Mean systolic BP fell by -3.9mmHg (95% CI: -5.5 to -2.4) and diastolic BP fell by -2.7mmHg (-3.4 to -1.9) during usual care. Heterogeneity between studies was marked (systolic I2 = 97% and diastolic I2 = 94%). Usual care consisted of routine care only (45 trials) or enhancement with educational support for health professionals or patients (13 trials). Type of usual care did not account for observed heterogeneity, however restricting analyses to 24 high quality studies indicated a trend towards greater BP reductions with enhanced usual care compared to routine care only: diastolic -4.6mmHg (-6.5 to -2.7) for enhanced vs. -1.9mmHg (-3.1 to -0.7; p = 0.02) for routine care and systolic -6.9mmHg (-11.5 to -2.2) for enhanced vs. -4.2mmHg (-6.9 to -1.6; p = 0.33) for routine care. CONCLUSIONS: Statistically and clinically significant reductions in BP were seen in the control arms of BP intervention studies in this review, with greater reductions when usual care is enhanced within studies. Further work to establish whether this finding can be generalised to other BP intervention studies is required. This trend should be considered when interpreting BP intervention studies and in designing future interventions.
Abstract.
Author URL.
Clark C, Thomas D, Ferrucci L, Campbell J (2015). LB02.09: DETECTING RISK OF POSTURAL HYPOTENSION IN THE ELDERLY (DROP-HE): THE INCHIANTI STUDY.
J Hypertens,
33 Suppl 1, e87-e88.
Abstract:
LB02.09: DETECTING RISK OF POSTURAL HYPOTENSION IN THE ELDERLY (DROP-HE): THE INCHIANTI STUDY.
OBJECTIVE: Postural hypotension (PH) is a risk factor for falls, and associated with excess mortality. Recommendations on testing for PH vary: NICE (2011) advises checking in the presence of falls or symptoms whilst ESH/ESC (2013) advises checking in elderly and diabetics. It is recommended that blood pressure (BP) is measured both 1 and 3 minutes after standing; this is seldom done in clinical practice. We studied the InChianti dataset to identify associations of PH that could inform clinical practice. DESIGN AND METHOD: the InCHIANTI study is a population-based study established to understand causes of walking difficulties in older persons. Subjects were randomly selected from population registries in the Chianti area of Italy in 1998; they underwent extensive baseline interviews and examinations, and are being followed up triennially. BP at recruitment was measured supine and after one and three minutes standing with a mercury sphygmomanometer. Systolic PH was defined as a >=20mmHg fall in supine BP on standing. Survival with or without PH was analysed and Cox proportional hazard ratios (HRs) calculated. Univariable cross sectional associations for PH were analysed using χ2 tests. Potentially significant associations (P=65 years, any fall in the previous year, and previous diagnoses of hypertension, stroke or angina. A simple scoring system of 0 to 5 according to the presence of each of these variables suggested numbers needed to screen of 11 for a score of 2 and 8 for a score of 3 (figure). CONCLUSIONS: the likelihood of PH can be predicted from existing medical history. Presence of diabetes is not a predictor of PH in this cohort. Further work is underway to refine and validate the DROP score.(Figure is included in full-text article.).
Abstract.
Author URL.
Jenkinson CE, Asprey A, Clark CE, Richards SH (2015). Patients' willingness to attend the NHS cardiovascular health checks in primary care: a qualitative interview study.
BMC Family Practice,
16(1).
Abstract:
Patients' willingness to attend the NHS cardiovascular health checks in primary care: a qualitative interview study
Background: the NHS Cardiovascular Health Check (NHSHC) programme was introduced in England in 2009 to reduce cardiovascular disease mortality and morbidity for all patients aged 40 to 74 years old. Programme cost-effectiveness was based on an assumed uptake of 75% but current estimates of uptake in primary care are less than 50%. The purpose of this study was to identify factors influencing patients' willingness to attend an NHSHC. For those who attended, their views, experiences and their future willingness to engage in the programme were explored. Method: Telephone or face-to-face interviews were conducted with patients who had recently been invited for an NHSHC by a letter from four general practices in Torbay, England. Patients were purposefully sampled (by gender, age, attendance status). Interviews were audio recorded, transcribed verbatim and analysed thematically. Results: 17 attendees and 10 non-attendees were interviewed. Patients who attended an NHSHC viewed it as worthwhile. Proactive attitudes towards their health, a desire to prevent disease before they developed symptoms, and a willingness to accept screening and health check invitations motivated many individuals to attend. Non-attendees cited not seeing the NHSHC as a priority, or how it differed from regular monitoring already received for other conditions as barriers to attendance. Some non-attendees actively avoided GP practices when feeling well, while others did not want to waste health professionals' time. Misunderstandings of what the NHSHC involved and negative views of what the likely outcome might be were common. Conclusion: While a minority of non-attendees simply had made an informed choice not to have an NHSHC, improving the clarity and brevity of invitational materials, better advertising, and simple administrative interventions such as sending reminder letters, have considerable potential to improve NHSHC uptake.
Abstract.
Clark CE, Horvath IA, Taylor RS, Campbell JL (2014). Doctors record higher blood pressures than nurses: systematic review and meta-analysis.
Br J Gen Pract,
64(621), e223-e232.
Abstract:
Doctors record higher blood pressures than nurses: systematic review and meta-analysis.
BACKGROUND: the magnitude of the 'white coat effect', the alerting rise in blood pressure, is greater for doctors than nurses. This could bias interpretation of studies on nurse-led care in hypertension, and risks overestimating or overtreating high blood pressure by doctors in clinical practice. AIM: to quantify differences between blood pressure measurements made by doctors and nurses. DESIGN AND SETTING: Systematic review and meta-analysis using searches of MEDLINE, CENTRAL, CINAHL, Embase, journal collections, and conference abstracts. METHOD: Studies in adults reporting mean blood pressures measured by doctors and nurses at the same visit were selected, and mean blood pressures extracted, by two reviewers. Study risk of bias was assessed using modified Cochrane criteria. Outcomes were pooled across studies using random effects meta-analysis. RESULTS: in total, 15 studies (11 hypertensive; four mixed hypertensive and normotensive populations) were included from 1899 unique citations. Compared with doctors' measurements, nurse-measured blood pressures were lower (weighted mean differences: systolic -7.0 [95% confidence interval {CI} = -4.7 to -9.2] mmHg, diastolic -3.8 [95% CI = -2.2 to -5.4] mmHg). For studies at low risk of bias, differences were lower: systolic -4.6 (95% CI = -1.9 to -7.3) mmHg; diastolic -1.7 (95% CI = -0.1 to -3.2) mmHg. White coat hypertension was diagnosed more frequently based on doctors' than on nurses' readings: relative risk 1.6 (95% CI =1.2 to 2.1). CONCLUSIONS: the white coat effect is smaller for blood pressure measurements made by nurses than by doctors. This systematic difference has implications for hypertension diagnosis and management. Caution is required in pooling data from studies using both nurse- and doctor-measured blood pressures.
Abstract.
Author URL.
Clark CE, Steele AM, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL (2014). Interarm Blood Pressure Difference in People with Diabetes: Measurement and Vascular and Mortality Implications a Cohort Study.
DIABETES CARE,
37(6), 1613-1620.
Author URL.
Clark CE, Smith LFP, Glynn LG, Taylor RS, Campbell JL, Cloutier L (2013). Allied health professional-led interventions for improving control of blood pressure in patients with hypertension: systematic review and meta-analysis.
JOURNAL OF HUMAN HYPERTENSION,
27(10), 641-641.
Author URL.
Clark CE (2013). Four-Limb Blood Pressure Measurement a Research Tool Looking for Clinical Use.
HYPERTENSION,
61(6), 1146-1147.
Author URL.
Clark CE, Steele AM, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL (2013). The inter-arm blood pressure difference in people with diabetes: measurement, vascular, and mortality implications.
JOURNAL OF HUMAN HYPERTENSION,
27(10), 645-645.
Author URL.
Campbell J, Clark CE, Taylor RS, Shore AC, Ukoumunne OC (2012). Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta analysis. Lancet
Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL (2012). Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis (vol 379, pg 905, 2012).
LANCET,
380(9838), 218-218.
Author URL.
Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL (2012). Erratum: Association of a diff erence in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis (The Lancet (2012) 379 (905-914). The Lancet, 380(9838).
Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL (2012). Interarm blood pressure difference and vascular disease - Authors reply. The Lancet, 380(9836), 24-25.
Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL (2012). Interarm blood pressure difference and vascular disease Reply.
LANCET,
380(9836), 24-25.
Author URL.
Clark C, Smith L, Taylor R, Campbell J (2012). Response to Carey and Courtenay. Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis. Diabet Med, 29(1), 155-156.
Clark CE, Taylor RS, Shore AC, Campbell JL (2012). The difference in blood pressure readings between arms and survival: primary care cohort study.
BMJ,
344Abstract:
The difference in blood pressure readings between arms and survival: primary care cohort study.
OBJECTIVE: to determine whether a difference in systolic blood pressure readings between arms can predict a reduced event free survival after 10 years. DESIGN: Cohort study. SETTING: Rural general practice in Devon, United Kingdom. PARTICIPANTS: 230 people receiving treatment for hypertension in primary care. INTERVENTION: Bilateral blood pressure measurements recorded at three successive surgery attendances. MAIN OUTCOME MEASURES: Cardiovascular events and deaths from all causes during a median follow-up of 9.8 years. RESULTS: at recruitment 24% (55/230) of participants had a mean interarm difference in systolic blood pressure of 10 mm Hg or more and 9% (21/230) of 15 mm Hg or more; these differences were associated with an increased risk of all cause mortality (adjusted hazard ratio 3.6, 95% confidence interval 2.0 to 6.5 and 3.1, 1.6 to 6.0, respectively). The risk of death was also increased in 183 participants without pre-existing cardiovascular disease with an interarm difference in systolic blood pressure of 10 mm Hg or more or 15 mm Hg or more (2.6, 1.4 to 4.8 and 2.7, 1.3 to 5.4). An interarm difference in diastolic blood pressure of 10 mm Hg or more was weakly associated with an increased risk of cardiovascular events or death. CONCLUSIONS: Differences in systolic blood pressure between arms can predict an increased risk of cardiovascular events and all cause mortality over 10 years in people with hypertension. This difference could be a valuable indicator of increased cardiovascular risk. Bilateral blood pressure measurements should become a routine part of cardiovascular assessment in primary care.
Abstract.
Author URL.
Clark CE, McManus R (2012). The use of highly structured care to achieve blood pressure targets.
BMJ-BRITISH MEDICAL JOURNAL,
345 Author URL.
Clark CE (2011). Inter-arm blood pressure measurement needs to be practical and accurate.
Am J Hypertens,
24(11), 1189-1190.
Author URL.
Clark CE, Smith LFP, Harding G, Taylor RS, Campbell JL (2011). Nurse led hypertension clinics: evolving ahead of the evidence?.
JOURNAL OF HUMAN HYPERTENSION,
25(10), 630-630.
Author URL.
Clark CE, Smith LFP, Taylor RS, Campbell JL (2011). Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis.
Diabet Med,
28(3), 250-261.
Abstract:
Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis.
BACKGROUND: Previous reviews demonstrate uncertainty about the effectiveness of nurse-led interventions in the management of hypertension. No specific reviews in diabetes have been identified. We have systematically reviewed the evidence for effectiveness of nurse-led interventions for people with diabetes mellitus. METHODS: in this systematic review and meta-analysis, searches of Medline, Embase, CINAHL and the Cochrane Central Trials register were undertaken to identify studies comparing any intervention conducted by nurses in managing hypertension in diabetes with usual doctor-led care. Additional citations were identified from papers retrieved and correspondence with authors. Outcome measures were absolute systolic and diastolic blood pressure, change in blood pressure, proportions achieving study target blood pressure and proportions prescribed anti-hypertensive medication. RESULTS: Eleven studies were identified. Interventions included adoption of treatment algorithms, nurse-led clinics and nurse prescribing. Meta-analysis showed greater reductions in blood pressure in favour of any nurse-led interventions (systolic weighted mean difference -5.8 mmHg, 95% CI -9.6 to -2.0; diastolic weighted mean difference -4.2 mmHg, 95% CI -7.6 to -0.7) compared with usual doctor-led care. No overall superiority in achievement of study targets or in the use of medication was evident for any nurse-based interventions over doctor-led care. CONCLUSIONS: There is some evidence for improved blood pressure outcomes with nurse-led interventions for hypertension in people with diabetes compared with doctor-led care. Nurse-based interventions require an algorithm to structure care and there is some preliminary evidence for better outcomes with nurse prescribing. Further work is needed to elucidate which nurse-led interventions are most effective.
Abstract.
Author URL.
Clark CE, Taylor RS, Shore AC, Campbell JL (2011). Systolic inter-arm blood pressure difference is associated with increased cardiovascular and all-cause mortality in hypertension: meta-analysis.
JOURNAL OF HUMAN HYPERTENSION,
25(10), 633-633.
Author URL.
Clark CE, Arnold E, Lasserson TJ, Wu T (2010). Herbal interventions for chronic asthma in adults and children: a systematic review and meta-analysis.
Prim Care Respir J,
19(4), 307-314.
Abstract:
Herbal interventions for chronic asthma in adults and children: a systematic review and meta-analysis.
AIMS: to assess the efficacy of herb and plant extracts in the management of asthma. METHOD: Systematic review and meta-analysis. Multiple database searches identified randomised placebo controlled trials of herbal interventions reporting at least one primary outcome measure. Where possible data were combined for meta-analysis. Primary outcome measures were lung function, exacerbations and reduction in corticosteroid use. Secondary outcome measures were symptoms and symptom scores, use of reliever medications, changes in rates of consultation and adverse effects. RESULTS: Twenty-six studies reporting on 20 herbal preparations were included. Two of six studies reporting change in FEV1 were positive. Little data was available on frequency of exacerbations. For primary outcomes single studies of Boswellia, Mai-Men-Dong-Tang, Pycnogenol, Jia-Wei-Si-Jun-Zi-Tang and Tylophora indica showed potential to improve lung function, and a study of 1.8-Cineol (eucalyptol) showed reduced daily oral steroid dosage. CONCLUSIONS: Improvements in symptoms were not strongly supported by objective changes. Most trials were of small sample size, short duration, and poor methodology. Further adequately powered trials are needed to assess these compounds. Such trials should conform to CONSORT guidance, report standardised spirometry, and use validated symptom and severity scores. No recommendations for herbal treatment of asthma can be made from the current evidence.
Abstract.
Author URL.
Clark CE, Smith LFP, Taylor RS, Campbell JL (2010). Nurse led interventions to improve control of blood pressure in people with hypertension: Systematic review and meta-analysis.
BMJ (Online),
341(7771).
Abstract:
Nurse led interventions to improve control of blood pressure in people with hypertension: Systematic review and meta-analysis
Objective: to review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study. Design: Systematic review and meta-analysis. Data sources: Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. Study selection: Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults. Data extraction: Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken. Data synthesis: Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference -8.2 mm Hg, 95% confidence interval -11.5 to -4.9), nurse prescribing showed greater reductions in blood pressure (systolic -8.9 mm Hg, -12.5 to -5.3 and diastolic -4.0 mm Hg, -5.3 to -2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic -4.8 mm Hg, 95% confidence interval -7.0 to -2.7 and diastolic -3.5 mm Hg, -4.5 to -2.5). Conclusions: Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.
Abstract.
Clark CE, Smith LFP, Taylor RS, Campbell JL (2010). Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis.
BMJ,
341Abstract:
Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis.
OBJECTIVE: to review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. STUDY SELECTION: Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults. DATA EXTRACTION: Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken. DATA SYNTHESIS: Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference -8.2 mm Hg, 95% confidence interval -11.5 to -4.9), nurse prescribing showed greater reductions in blood pressure (systolic -8.9 mm Hg, -12.5 to -5.3 and diastolic -4.0 mm Hg, -5.3 to -2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic -4.8 mm Hg, 95% confidence interval -7.0 to -2.7 and diastolic -3.5 mm Hg, -4.5 to -2.5). CONCLUSIONS: Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.
Abstract.
Author URL.
Clark CE, Smith LFP, Taylor RS, Campbell JL (2010). Nurse-led management of hypertension.
Br J Gen Pract,
60(572).
Author URL.
Clark CE, Campbell JL (2009). Hypertension guidelines.
BRITISH JOURNAL OF GENERAL PRACTICE,
59(563), 448-449.
Author URL.
Clark CE, Greaves CJ, Evans PH, Dickens A, Campbell JL (2009). Inter-arm blood pressure difference in type 2 diabetes: a barrier to effective management?.
Br J Gen Pract,
59(563), 428-432.
Abstract:
Inter-arm blood pressure difference in type 2 diabetes: a barrier to effective management?
BACKGROUND: Previous studies have identified a substantial prevalence of a blood pressure difference between arms in various populations, but not patients with type 2 diabetes. Recognition of such a difference would be important as a potential cause of underestimation of blood pressure. AIM: to measure prevalence of an inter-arm blood pressure difference in patients with type 2 diabetes, and to estimate how frequently blood pressure measurements could be erroneously underestimated if an inter-arm difference is unrecognised. DESIGN OF STUDY: Cross-sectional study. SETTING: Five surgeries covered by three general practices, Devon, England. METHOD: Patients with type 2 diabetes underwent bilateral simultaneous blood pressure measurements using a validated protocol. Mean blood pressures were calculated for each arm to derive mean systolic and diastolic differences, and to estimate point prevalence of predefined magnitudes of difference. RESULTS: a total of 101 participants were recruited. Mean age was 66 years (standard deviation [SD] = 13.9 years); 59% were male, and mean blood pressure was 138/79 mmHg (SD = 15/10 mmHg). Ten participants (10%; 95% confidence interval [CI] = 4 to 16) had a systolic inter-arm difference > or =10 mmHg; 29 (29%; 95% CI = 20 to 38) had a diastolic difference >/=5 mmHg; and three (3%; 95% CI = 0 to 6) a diastolic difference > or =10 mmHg. No confounding variable was observed to account for the magnitude of an inter-arm difference. CONCLUSION: a systolic inter-arm difference > or =10 mmHg was observed in 10% of patients with diabetes. Failure to recognise this would misclassify half of these as normotensive rather than hypertensive using the lower-reading arm. New patients with type 2 diabetes should be screened for an inter-arm blood pressure difference.
Abstract.
Author URL.
Arnold E, Clark CE, Lasserson TJ, Wu T (2008). Herbal interventions for chronic asthma in adults and children.
Cochrane Database of Systematic Reviews(1).
Abstract:
Herbal interventions for chronic asthma in adults and children
Background: Herb and plant based preparations are a popular treatment for asthma, although there remain concerns as to their efficacy and safety. In Western societies, motivations for using such treatments may be both positive and negative, with their perceived safety and dissatisfaction with conventional medicine among them. In China such treatments are more commonly used and many compounds considered 'conventional' are derived from herbs or plants. Objectives: to assess the efficacy and safety of herb and plant extracts in the management of chronic asthma. Search strategy: the Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, EMBASE and AMED were searched with pre-defined terms. Searches are current as of February 2007. Selection criteria: Randomised placebo controlled trials of any herb or plant extract were eligible. Study participants had to have a primary diagnosis of asthma. Studies in both adults and children were eligible for the review. Data collection and analysis: Two reviewers assessed studies for suitability. Data were extracted and double-checked. Main results: Twenty-seven studies (29 experimental groups) met the review entry criteria, randomising a total of 1925 participants. The studies identified assessed the effects of 21 different herbal preparations. Study quality varied considerably, and the sample sizes were often small. For primary outcomes (exacerbations, steroids use and lung function measurements): Two out of six studies reporting change in FEV1 were positive, with very few data available on the frequency of exacerbations. One study which did report these data was negative. Health-related quality of life was only measured in one trial. Authors' conclusions: the evidence base for the effects of herbal treatments is hampered by the variety of treatments assessed, poor reporting quality of the studies and lack of available data. The data that are available from the studies provide only a small insight into the long-term efficacy and harm profiles of these treatments. The absence of common endpoint measurements limits the validity of our findings further. Positive findings in this review warrant additional well-designed trials in this area. Copyright © 2008 the Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Abstract.
Clark CE, Campbell JL (2008). The interarm blood pressure difference.
HYPERTENSION,
52(2), E15-E15.
Author URL.
Clark CE (2007). Screening for peripheral vascular disease [5]. British Journal of General Practice, 57(541).
Clark CE, Campbell JL, Powell RJ, Thompson JF (2007). The inter-arm blood pressure difference and peripheral vascular disease: cross-sectional study.
Fam Pract,
24(5), 420-426.
Abstract:
The inter-arm blood pressure difference and peripheral vascular disease: cross-sectional study.
BACKGROUND: a blood pressure (BP) difference between the upper limbs is often encountered in primary care. Knowledge of its prevalence and importance in the accurate measurement of BP is poor, representing a source of error. Current hypertension guidelines do not emphasize this. OBJECTIVES: to establish the prevalence of an inter-arm blood pressure difference (IAD) and explore its association with other indicators of peripheral vascular disease (PVD) in a hypertensive primary care population. METHODS: This was a cross-sectional study. Primary care, one rural general practice, was the setting of the study. The methods were controlled simultaneous measurement of brachial BPs, ankle-brachial pressure index (ABPI) and tiptoe stress testing in 94 subjects. RESULTS: in all, 18 of 94 [19%, 95% confidence interval (CI) 11-27%] subjects had mean systolic inter-arm difference (sIAD) > or =10 mmHg and seven of 94 (7%, 95% CI 2-12%) had mean diastolic inter-arm difference (dIAD) > or =10 mmHg. Nineteen of 91 (20%, 95% CI 12-28%) had a reduced ABPI. or =20%. CONCLUSIONS: an IAD and asymptomatic PVD are common in a primary care hypertensive population. Magnitude of the IAD is inversely correlated with ABPI, supporting the hypotheses that IADs are causally linked to PVD, and that IAD is a useful marker for the presence of PVD. Consequently, detection of an IAD should prompt the clinician to screen subjects for other signs of vascular disease and target them for aggressive cardiovascular risk factor modification.
Abstract.
Author URL.
Clark CE, Campbell JL, Powell RJ (2007). The interarm blood pressure difference as predictor of cardiovascular events in patients with hypertension in primary care: cohort study.
J Hum Hypertens,
21(8), 633-638.
Abstract:
The interarm blood pressure difference as predictor of cardiovascular events in patients with hypertension in primary care: cohort study.
Objectives of this study were to measure the prevalence of a difference in blood pressure (BP) between arms and determine whether a difference is associated with increased risk of cardiovascular events or death. A prospective cohort study of 247 patients with hypertension was undertaken in one rural general practice in England. The main outcome measures were mean difference in BP between arms and new episodes of myocardial infarction, cerebrovascular event, onset of angina or peripheral vascular disease or death. A total of 57/247 (23%) patients had a mean difference in systolic BP between arms of >or=10 mm Hg and 8/247 (3%) had a mean difference of >or=20 mm Hg. A total of 15/247 (6%) patients had a mean difference in diastolic BP between arms of >or=10 mm Hg. Survival analysis after 4.7 years (range 3.3-5.9) showed a shorter mean survival time without event or death for patients with a difference in systolic BP of >or=10 mm Hg compared with a difference of
Abstract.
Author URL.
Clark CE, Campbell JL, Evans PH, Millward A (2006). Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review.
J Hum Hypertens,
20(12), 923-931.
Abstract:
Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review.
A blood pressure (BP) difference between arms was first reported over 100 years ago. Knowledge of its prevalence and relevance to the accurate measurement of BP remains poor. Current hypertension guidelines do not emphasise it. The objectives of this study were to establish the best estimate of prevalence of the inter-arm difference (IAD) in the population, to consider its implications for accurate BP measurement and treatment, and to discuss its aetiology and potential as a risk marker for cardiovascular disease. Systematic literature review was carried out. The data sources were Medline EMBASE and CINAHL databases, and Index of Theses. Studies reporting prevalence rates of IAD were retrieved and considered for inclusion against explicit methodological criteria. Point prevalence rates were extracted and weighted mean prevalence rates calculated. The main outcome measures were weighted mean prevalences of systolic IAD > or =10 and > or =20 mm Hg and of diastolic IAD > or =10 mm Hg. Thirty-one studies were identified. Most had methodological weaknesses; only four met the inclusion criteria. Pooled prevalences of the IAD from these four studies were 19.6% systolic > or =10 mm Hg (95% CI 18.0-21.3%), 4.2% systolic > or =20 mm Hg (95% CI 3.4-5.1%) and 8.1% diastolic > or =10 mm Hg (95%CI 6.9-9.2%). In conclusion, an IAD is present in a substantial number of patients and should be looked for whenever diagnosis and treatment depend on accurate measurements of BP. The importance of an IAD should be better emphasised in current hypertension management guidelines. There is evidence associating an IAD with peripheral vascular disease, raising the possibility that its presence may predict cardiovascular events.
Abstract.
Author URL.
Clark CE (2003). Use of salmeterol/fluticasone combination (Seretide) in an asthma clinic: a pragmatic open study from primary care.
Primary Care Respiratory Journal,
12(3), 86-89.
Abstract:
Use of salmeterol/fluticasone combination (Seretide) in an asthma clinic: a pragmatic open study from primary care
Aims: the salmeterol/fluticasone combination inhaler (Seretide) has been shown to be effective in the management of asthma by randomised controlled trials. This study examined whether it was also effective in clinical use in primary care. Methods: Patients attending the surgery asthma clinic with persistent symptoms despite regular inhaled corticosteroid therapy were offered Seretide. Outcome measures were symptom scores, peak flow measurements, prescriptions for relief bronchodilators, mean daily inhaled steroid dosage, and asthma treatment costs. Patients were assessed at baseline, 9 and 19 months, comparing Seretide users with other asthma clinic attenders. Results: Fifty patients were studied, 20 started Seretide. Symptom scores at entry were higher for Seretide patients than the comparison group (total score 4.2 vs 1.5; p
Abstract.
Clark CE, Smith LFP (2002). Clinical governance and education: the views of clinical governance leads in the South West of England.
British Journal of Clinical Governance,
7(4), 261-266.
Abstract:
Clinical governance and education: the views of clinical governance leads in the South West of England
This qualitative study examined the views of clinical governance leads in South West England on the development of clinical governance, and its relationship to education in primary care. Information was obtained from semi-structured interviews with clinical governance leads, and supplementary methods were used to confirm key findings. Four principal themes emerged: education, support, barriers, and evolution. Education is central to achieving the clinical governance agenda. There is a range of educational needs within primary care and these must be integrated into practice professional development plans, which will be shaped by national and local priorities. A need for PCG clinical governance tutors to support this process emerged. A range of supporting mechanisms was identified, as were barriers: principally inadequate resources and a rigid agenda imposed from above. Existing educationalists will need to change their role within the new structures, and this should be an evolutionary rather than a revolutionary process.
Abstract.
Clark CE, Powell RJ (2002). The differential blood pressure sign in general practice: prevalence and prognostic value.
FAMILY PRACTICE,
19(5), 439-441.
Author URL.
Clark CE (2001). Difference in blood pressure between arms might reflect peripheral vascular disease [7]. British Medical Journal, 323(7309), 399-400.
Clark C (2000). Are β-blockers ever safe in asthma? Practice audit and literature search triggered by the use of a significant event audit.
Asthma in General Practice,
8(1), 7-8.
Abstract:
Are β-blockers ever safe in asthma? Practice audit and literature search triggered by the use of a significant event audit
Aim: to audit an adverse event in an asthmatic patient, namely, the prescription of a β-blocker. Method: Significant event auditing, and Medline and EMBASE/Excerpta Medica literature searches, Results: Fourteen asthmatics (3.3% of the asthmatics on the practice list) were identified as ever having received a β-blocker. In all cases the history of asthma pre-dated the prescription of the β-blocker. These data and results of the literature search lead to discussion of the medicolegal implications of the event and possible changes to future management. Conclusions: a significant event audit can provide an appropriate forum for reviewing care of an asthmatic patient, β-blockers are still prescribed for asthmatics despite the well known hazards, and the incidence of this is probably under-reported. The literature suggests that no β-blocker can be safely started in an asthmatic patient in general practice.
Abstract.
Furness J, Fearby S, Clough JB, Clark CE, Coote JM, Silver DAT, Halpin DMG (2000). Asthma after childhood pneumonia. BMJ, 321(7271).
Clark CE, Coote JM, Silver DAT, Halpin DMG (2000). Asthma after childhood pneumonia - Reply.
BRITISH MEDICAL JOURNAL,
321(7271), 1290-1290.
Author URL.
Furness J, Fearby S, Clough JB, Clark CE, Coote JM, Silver DAT, Halpin DMG (2000). Asthma after childhood pneumonia [7] (multiple letters). British Medical Journal, 321(7271), 1289-1290.
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320(7248), 1514-1516.
Author URL.
Clark CE, Bourne S (1999). Practice information on audiotape for visually-impaired patients.
BRITISH JOURNAL OF GENERAL PRACTICE,
49(438), 67-68.
Author URL.
Clark CE (1999). Time to go public on performance? [2]. British Journal of General Practice, 49(449).
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Respir Med,
87(3), 227-228.
Author URL.