Predictors of aspiration pneumonia: developing a new matrix for speech and language therapists.

INTRODUCTION: The contributing factors of aspiration pneumonia have been well documented. However, there are gaps in the literature regarding identifying the weight associated with each factor and the relationship between factors. METHOD: In this study, 20 potential predictors of aspiration pneumonia (with four additional variables) have been applied to historic Speech and Language Therapy records to greater understand the significance of each contributor of aspiration pneumonia. 152 cases with an oropharyngeal dysphagia, and a Speech and Language Therapy recommendation of eating and drinking with known aspiration and the associated potential risk of developing an aspiration pneumonia, were included in the data. These were inpatients and outpatients, and had various diagnoses but all had had a videofluoroscopy. RESULTS: Logistic regression analysis found seven factors that were individually significant in predicting the development of aspiration pneumonia with 84.93% sensitivity and 91.03% specificity DISCUSSION: Logistic regression and random forest analyses led to the proposal of a new matrix of predictors of aspiration pneumonia with respective scoring weights for individual and cumulative contributors (a direction for future research).

The diagnostic accuracy of multiparametric magnetic resonance imaging before biopsy in the detection of prostate cancer.

OBJECTIVES: To determine the extent to which clinically significant prostate cancer (csPCa) can be detected in a routine National Health Service setting in men with no previous biopsy, when multiparametric magnetic resonance imaging (mpMRI) is introduced into the diagnostic pathway. PATIENTS AND METHODS: In all, 1 090 mpMRIs were performed between July 2013 and April 2016 in biopsy-naïve men with an abnormal prostate-specific antigen level and/or digital rectal examination. Data were collected from patient records at the Royal Devon and Exeter NHS Foundation Trust. mpMRI Prostate Imaging Reporting and Data System (PI-RADS) scores were compared to transperineal or transrectal ultrasonography (TRUS)-guided biopsy findings as the reference standard. csPCa was defined as Gleason score of ≥3+4. The diagnostic accuracy of mpMRI was also assessed. RESULTS: The mpMRI was interpretable in 1 023 men and 792 underwent biopsy, of which 106 were transperineal. The median number of cores taken in transperineal and TRUS-guided biopsy were 10 and 6, respectively. The detection rate of csPCa was 37%; csPCa rose from 15% of PI-RADS 1 and 2 to 86% of PI-RADS 5. The sensitivity, negative predictive value, specificity, and positive predictive value were 82%, 85%, 59% and 54%, respectively. The study is limited by its retrospective nature and lack of reporting of follow-up for 'missed cancers'. Men with low mpMRI PI-RADS were also less likely to undergo biopsy. Whilst this selection bias may overestimate the detection rate of csPCa, this reflects the shared decisions patients and clinicians make in day-to-day practice outside of research centres. CONCLUSION: In a routine clinical setting, the higher the mpMRI PI-RADS, the greater the detection rate of csPCa in biopsy-naïve men. A normal mpMRI does not exclude csPCa; however, mpMRI may have utility in informing shared-decision making on whether to proceed to biopsy and subsequent treatment.

Assessing the accuracy of ultrasound estimation of gestational age during routine antenatal care in in vitro fertilization (IVF) pregnancies.

INTRODUCTION: In the UK an accurate gestational age is confirmed by ultrasound measured foetal crown rump length (CRL) at 11 + 2-14 + 1 weeks of gestation. The currently recommended Robinson and Fleming crown rump length reference chart was develop in 1975. Advances in ultrasound technology and standardized crown rump length measurement training could mean this is now out of date. Our study aimed to assess its accuracy in current routine antenatal care. METHODS: Retrospective data from 178 IVF pregnancies seen for routine antenatal care at a UK Regional Maternity Unit between 1 January 2006 and 1 January 2016 was retrieved. We compared ultrasound calculated crown rump length gestational age taken at the routine First Trimester Screening Clinic (FTSC) with the 'true' gestational age calculated from the known IVF fertilization date. RESULTS: We identified a systematic overestimation of gestational age by ultrasound using the currently recommended crown rump length reference chart when compared to IVF gestational age. The mean overestimation was 3.0 days (95% CI: 2.7 to 3.4), p < 0.001. A range of alternative ultrasound reference charts also generated a systematic overestimation, ranging from 1.6 to 2.9 days (p < 0.001, for each). CONCLUSIONS: The current crown rump length reference chart systematically overestimates gestational age by an average of three days when assessed in IVF pregnancies. A systematic overestimation was also identified in alternative crown rump length reference charts. These differences, although slight, were systematic with implications for the accuracy of gestational age estimation particularly in pregnancies at risk of pre-term delivery or growth restriction. Our findings need confirming in larger, non IVF cohorts and could lead to the need for an updated crown rump length reference chart.

3-phase Technicium-99m bone scanning in patients with pain in the hip region after cemented total hip replacement: a multicentre series of 100 cases.

INTRODUCTION: The aim of this study was to assess the benefit of a Technetium-99M (HDP) 3-phase bone scan (TPBS) as an additional diagnostic test in the evaluation of pain in the hip region following cemented total hip replacement (THR) surgery. METHODS: A retrospective study over a 24-month period was performed comprising 100 patients investigated with a TPBS. Investigations were summarised and analysed, and were classified as entirely normal, possibly abnormal, and definitely abnormal. RESULTS: 45% (45) of TPBSs were reported as being entirely normal, 50% (50) as possibly abnormal, and 5% (5) as definitely abnormal. During the 24-month study period 230 revision THR procedures were performed at our institution; 10% (24) were investigated with TPBS and 90% (206) were not. 29% (7/24) of patients investigated with a TPBS that subsequently underwent revision THR surgery had an entirely normal preoperative TPBS. 84% (38) with an abnormal TPBS were managed conservatively. A TPBS had a sensitivity of 29% (95% confidence interval (CI), 13%-51%) and a specificity of 50% (95% CI, 38%-62%) in the detection of infection, or loosening with concurrent infection. CONCLUSION: A TPBS should only be considered following clinical evaluation, serological investigation, diagnostic imaging and microbiological analysis of fluid obtained from arthrocentesis by a specialist revision arthroplasty surgeon. A TPBS may be useful in the situation where abnormal serology is present, but where repeated joint aspirations samples are inconclusive.

Pilot parallel randomised controlled trial of protective socks against usual care to reduce skin tears in high risk people: 'STOPCUTS'.

BACKGROUND: Skin tears are common in older adults and those taking steroids and warfarin. They are traumatic, often blunt injuries caused by oblique knocks to the extremities. The epidermis may separate from the dermis or both layers from underlying tissues leaving a skin flap or total loss of tissue, which is painful and prone to infection. 'Dermatuff™' knee-length socks containing Kevlar fibres (used in stab-proof vests and motorcyclists' clothing) aim to prevent skin tears. The acceptability of the socks and the feasibility of a randomised controlled trial (RCT) had not been explored. METHODS: In this pilot parallel group RCT, 90 people at risk of skin-tear injury from Devon care homes and primary care were randomised to receive the socks or treatment as usual (TAU). The pilot aimed to estimate parameters to inform the design of a substantive trial and record professionals' views and participants' acceptability of the intervention and of study participation. RESULTS: Participants were randomised from July 2013 and followed up until February 2015. Community participants were easier to recruit than care homes residents but were 10 years younger on average and more active. To recruit 90 participants, 395 had to be approached overall as 77% were excluded or declined. Seventy-nine participants (88%) completed the trial and 27/44 (61%) wore the socks for 16 weeks. There were 31 skin tear injuries affecting 18 (20%) of the 90 participants. The TAU group received more injuries, more repeated episodes, and larger tears with greater severity. Common daily diary reasons for not wearing the socks included perceived warmth in hot weather or not being available (holiday, in hospital, bed rest). Resource use data were obtainable and indicated that sock wearing gave a reduction in treatment costs whilst well-completed questionnaires showed improvements in secondary outcomes. CONCLUSIONS: This pilot trial has successfully informed the design and conduct of a future definitive cost-effectiveness RCT. It would need to be conducted in primary care with 880 active at-risk, elderly patients (440 per arm). Skin tear incidence and quality of life (from EQ5D5L) over a 4-month period would be the primary and secondary outcomes respectively. TRIAL REGISTRATION: ISRCTN, ISRCTN96565376.

Can clinical features be used to differentiate type 1 from type 2 diabetes? A systematic review of the literature.

OBJECTIVE: Clinicians predominantly use clinical features to differentiate type 1 from type 2 diabetes yet there are no evidence-based clinical criteria to aid classification of patients. Misclassification of diabetes is widespread (7-15% of cases), resulting in patients receiving inappropriate treatment. We sought to identify which clinical criteria could be used to discriminate type 1 and type 2 diabetes. DESIGN: Systematic review of all diagnostic accuracy studies published since 1979 using clinical criteria to predict insulin deficiency (measured by C-peptide). DATA SOURCES: 14 databases including: MEDLINE, MEDLINE in Process and EMBASE. The search strategy took the form of: (terms for diabetes) AND (terms for C-Peptide). ELIGIBILITY CRITERIA: Diagnostic accuracy studies of any routinely available clinical predictors against a reference standard of insulin deficiency defined by cut-offs of C-peptide concentrations. No restrictions on race, age, language or country of origin. RESULTS: 10,917 abstracts were screened, and 231 full texts reviewed. 11 studies met inclusion criteria, but varied by age, race, year and proportion of participants who were C-peptide negative. Age at diagnosis was the most discriminatory feature in 7/9 studies where it was assessed, with optimal cut-offs (>70% mean sensitivity and specificity) across studies being <30 years or <40 years. Use of/time to insulin treatment and body mass index (BMI) were also discriminatory. When combining features, BMI added little over age at diagnosis and/or time to insulin (<1% improvement in classification). CONCLUSIONS: Despite finding only 11 studies, and considerable heterogeneity between studies, age at diagnosis and time to insulin were consistently the most discriminatory criteria. BMI, despite being widely used in clinical practice, adds little to these two criteria. The criteria identified are similar to the Royal College of General Practitioners National Health Service (RCGP/NHS) Diabetes classification guidelines, which use age at diagnosis <35 years and time to insulin <6 m. Until further studies are carried out, these guidelines represent a suitable classification scheme. SYSTEMATIC REVIEW REGISTRATION: PROSPERO reference CRD42012001736.

Pilot randomised controlled trial of protective socks against usual care to reduce skin tears in high risk people "STOPCUTS": study protocol.

BACKGROUND: Skin tears are traumatic injuries occurring mostly on the extremities due to shearing and friction forces that separate the epidermis and the dermis from underlying tissues. They are common and occur mostly in older adults and those taking medications that compromise skin integrity. Pretibial skin tears can develop into leg ulcers, which require lengthy, expensive treatment to heal. Traumatic injuries are the second most common type of wounds after pressure ulcers in care homes and are the commonest reason for older adults to require the attention of a community nurse. Common causes of skin tear injuries are bumping into furniture and other obstacles, using mobility aids, transfer to/from wheelchairs, getting in and out of bed and falls. No effective preventative measures currently exist but knee-length, protective socks are now available that contain impact-resistant Kevlar fibres (of the type used in stab-proof vests) and cushioning layers underneath. METHODS/DESIGN: In this pilot parallel group, randomised controlled trial, 90 people at risk of skin-tear injury will be randomised with equal allocation to receive the intervention or usual care. They will be recruited from care homes and from the community via general practices and a research volunteer database. Pilot outcomes include recruitment, eligibility, attrition, ascertainment of injuries and completion of outcome measures. Acceptability of the intervention and of study participation will be explored using semi-structured interviews. The proposed primary outcome for the future definitive trial is skin tear-free days. Secondary outcomes are skin tear severity, health status, specific skin-tears quality of life, capability and fear of falling, measured at baseline and the end of the study and in the event of a skin tear. DISCUSSION: The results of this study will be used to inform the development and design of a future randomised controlled trial to assess the effectiveness and cost-effectiveness of a unique and innovative approach to skin tear prevention. Approval was granted by the NRES - Cornwall and Plymouth Research Ethics Committee (13/SW/013). Dissemination will include publication of quantitative and qualitative findings, and experience of public involvement in peer-reviewed journals. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN96565376.

Identifying clinical criteria to predict Type 1 diabetes, as defined by absolute insulin deficiency: a systematic review protocol.

INTRODUCTION: Management of a patient's diabetes is entirely dependent upon the type of diabetes they are deemed to have. Patients with Type 1 diabetes are insulin deficient so require multiple daily insulin injections, whereas patients with Type 2 diabetes still have some endogenous insulin production so insulin treatment is only required when diet and tablets do not establish good glycaemic control. Despite the importance of a correct diagnosis, classification of diabetes is based on aetiology and relies on clinical judgement. There are no clinical guidelines on how to determine whether a patient has Type 1 or Type 2 diabetes. We aim to systematically review the literature to derive evidence-based clinical criteria for the classification of the major subtypes of diabetes. METHODS AND ANALYSIS: We will perform a systematic review of diagnostic accuracy studies to establish clinical criteria that predict the subsequent development of absolute insulin deficiency seen in Type 1 diabetes. Insulin deficiency will be determined by reference standard C-peptide concentrations. Synthesis of criteria identified will be undertaken using hierarchical summary receiver operating characteristic curves. ETHICS AND DISSEMINATION: As this is a systematic review, there will be no ethical issues. We will disseminate results by writing up the final systematic review and synthesis for publication in a peer-reviewed journal and will present at national and international diabetes-related meetings.

Management of malignant pleural effusion associated with trapped lung syndrome.

Management of recurrent malignant pleural effusion associated with trapped lung syndrome remains problematic. An alternative treatment using a pleural catheter has been advocated. Between August 1999 and August 2002, 127 patients underwent thoracoscopy for malignant pleural effusion. Of these, 52 (41%) with trapped lung were managed by insertion of a pleural catheter. Mean age was 66 years (range, 42-89 years). The most frequent diagnosis was breast cancer. Spontaneous pleurodesis (drainage < 10 mL) occurred in 25 (48%) patients whose catheter was removed after 30 to 255 days (mean, 93.8 days). Symptomatic relief was achieved in 49 (94%) patients. Mean dyspnea score improved significantly from 3.0 to 1.9. Complications comprised catheter blockage, surgical emphysema, cellulitis, and loculated effusion in 2 patients each. Mean length of hospital stay was 3 days (range, 1-16 days). Median survival was 126 days (range, 10-175 days). We conclude that long-term placement of a pleural catheter provides effective palliation for malignant pleural effusion associated with trapped lung syndrome.

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 <0.9. There was negative correlation between systolic (Pearson's correlation coefficient - 0.378; P = 0.01) and diastolic (Pearson's correlation coefficient - 0.225; P = 0.05) magnitudes of IAD with ABPI. On tiptoe testing, 9/90 subjects (10%, 95% CI 4-16%) had a pressure drop > 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.

Measurement of cord insulin and insulin-related peptides suggests that girls are more insulin resistant than boys at birth.

OBJECTIVE: We aimed to examine sex differences in insulin and insulin propeptide concentrations at birth using validated cord blood collection. RESEARCH DESIGN AND METHODS: We tested the impact on insulin and insulin propeptides of taking 13 cord blood samples in heparin and EDTA and then centrifuging and separating plasma after 1, 2, 24, or 48 h at room temperature (heparin) or 4 degrees C (EDTA). Cord plasma insulin and insulin propeptides concentrations were measured in 440 babies and correlated with offspring anthropometry measured at birth. RESULTS: Cord insulin concentrations significantly decreased (74% those at baseline by 24 h; P = 0.01) in the samples taken in heparin and stored at room temperature, but those taken on EDTA and refrigerated remained stable for up to 48 h. Insulin propeptides were stable in both. Cord plasma insulin and insulin propeptides measured in EDTA were related to all measures of birth size and maternal glycemia and BMI (r > 0.11; P < 0.03 for all) and were higher in those delivered via caesarean section. Girls were lighter (3,497 vs. 3,608 g; P = 0.01) but had higher cord insulin (46.7 vs. 41.2 pmol/l; P = 0.031), total proinsulin (34.1 vs. 25.8 pmol/l; P < 0.001), and intact proinsulin (9.5 vs. 8.3 pmol/l; P = 0.004) concentrations than boys; this was further confirmed when cord insulin concentrations of boys and girls were compared after pair matching for birth weight (insulin 49.7 vs. 42.1 pmol/l; P = 0.004). CONCLUSIONS: When using appropriate sample collection methods, female newborns have higher insulin concentrations than male newborns, despite being smaller, suggesting intrinsic insulin resistance in girls.

The impact of maternal glycemia and obesity on early postnatal growth in a nondiabetic Caucasian population.

OBJECTIVE: Offspring of mothers with diabetes have increased birth weight and higher rates of obesity in early childhood. The relative role of maternal glycemia and maternal obesity is uncertain. We therefore studied the impact of maternal glycemia and maternal obesity on offspring birth measures and early postnatal growth in nondiabetic pregnancies. RESEARCH DESIGN AND METHODS: We studied 547 full-term singleton babies of nondiabetic parents. Data available included parental height and weight; maternal prepregnant weight; maternal fasting plasma glucose (FPG) at 28 weeks of gestation; and offspring weight and length at birth, 12 weeks of age, and 1 and 2 years of age. Relationships between parental and offspring measures were estimated using Pearson correlations. RESULTS: Maternal FPG was correlated with offspring birth weight (r = 0.25, P < 0.001), length (r = 0.17, P < 0.001), and BMI (r = 0.2, P < 0.001) but was not correlated with offspring growth at 12 weeks. Maternal prepregnancy BMI was significantly correlated with offspring weight (r = 0.26, P < 0.001), length (r = 0.12, P = 0.01), and BMI at birth (r = 0.26, P < 0.001) and remained correlated with offspring weight (r = 0.13-0.14, P = 0.007-0.002) and BMI (r = 0.14-0.19, P = 0.002 to <0.001) during the first 2 years. Paternal BMI was correlated with offspring weight from 12 weeks onwards (r = 0.11-0.22, P = 0.017 to <0.001), length (r = 0.10-0.12, P = 0.01-0.05), and BMI from 1 year onwards (r = 0.16-0.25, P = <0.001). CONCLUSIONS: In a nondiabetic cohort, the effect of maternal glycemia on birth weight is transitory, while the impact on growth of maternal BMI continues into early childhood. The independent association of paternal BMI with offspring postnatal growth suggests that the impact of parental BMI could be explained by genetic factors, shared environment, or both.

Assessing newborn body composition using principal components analysis: differences in the determinants of fat and skeletal size.

BACKGROUND: Birth weight is a composite of skeletal size and soft tissue. These components are likely to have different growth patterns. The aim of this paper is to investigate the association between established determinants of birth weight and these separate components. METHODS: Weight, length, crown-rump, knee-heel, head circumference, arm circumference, and skinfold thicknesses were measured at birth in 699 healthy, term, UK babies recruited as part of the Exeter Family Study of Childhood Health. Corresponding measurements were taken on both parents. Principal components analysis with varimax rotation was used to reduce these measurements to two independent components each for mother, father and baby: one highly correlated with measures of fat, the other with skeletal size. RESULTS: Gestational age was significantly related to skeletal size, in both boys and girls (r = 0.41 and 0.52), but not fat. Skeletal size at birth was also associated with parental skeletal size (maternal: r = 0.24 (boys), r = 0.39 (girls) ; paternal: r = 0.16 (boys), r = 0.25 (girls)), and maternal smoking (0.4 SD reduction in boys, 0.6 SD reduction in girls). Fat was associated with parity (first borns smaller by 0.45 SD in boys; 0.31 SD in girls), maternal glucose (r = 0.18 (boys); r = 0.27 (girls)) and maternal fat (r = 0.16 (boys); r = 0.36 (girls)). CONCLUSION: Principal components analysis with varimax rotation provides a useful method for reducing birth weight to two more meaningful components: skeletal size and fat. These components have different associations with known determinants of birth weight, suggesting fat and skeletal size may have different regulatory mechanisms, which would be important to consider when studying the associations of birth weight with later adult disease.

Evidence of genetic regulation of fetal longitudinal growth.

BACKGROUND: Genetic as well as environmental factors are important determinants of fetal growth but there have been few studies of the influence of paternal factors on fetal growth. AIM: To study the influence of paternal anthropometry on detailed measurements of offspring at birth. DESIGN: A prospective cohort study involving biochemistry, and anthropometry, of mothers and fathers at 28 weeks gestation, and detailed anthropometry of children within 24 h of birth. SUBJECTS: 567 White Caucasian singleton, non-diabetic, full term pregnancies recruited from central Exeter, UK. RESULTS: Paternal height, but not paternal BMI, was correlated with birth weight (r = 0.19) and with birth length (r = 0.33). This was independent of potential confounders and maternal height. All measurements of fetal skeletal growth including crown-rump, knee-heel and head circumference were associated with paternal height. Maternal height showed similar correlations with birth weight (r = 0.18) and birth length (r = 0.26). Maternal BMI was correlated with birth weight (r = 0.27) and birth length (r = 0.15). In a multifactorial analysis 38% of the variance in fetal height could be explained by gestation, sex, paternal height, maternal height, maternal glucose, maternal BMI, parity and maternal smoking. CONCLUSION: Paternal height has an independent influence on size at birth. This predominantly influences length and skeletal growth of the baby. In contrast to maternal obesity the degree of paternal obesity does not influence birth weight. This work suggests that there is genetic regulation of skeletal growth while the maternal environment predominantly alters the adiposity of the fetus.

Genetic cause of hyperglycaemia and response to treatment in diabetes.

BACKGROUND: Type 2 diabetes shows evidence of underlying heterogeneity. No studies have assessed whether different causes for diabetes change the response to oral hypoglycaemic therapy. In a few cases, patients with diabetes caused by mutations in the hepatocyte nuclear factor 1alpha (HNF-1alpha) gene have been described as sensitive to the hypoglycaemic effects of sulphonylureas. We aimed to see whether the glycaemic response to the sulphonylurea gliclazide and the biguanide metformin differed in HNF-1alpha diabetes and type 2 diabetes, and to investigate the mechanism for differences in sulphonylurea sensitivity. METHODS: We did a randomised crossover trial of glicazide and metformin in 36 patients, either with diabetes caused by HNF-1alpha mutations or type 2 diabetes, who were matched for body-mass index and fasting plasma glucose. The primary outcome was reduction in fasting plasma glucose. Analysis was by intention to treat. We assessed possible mechanisms for sulphonylurea sensitivity through insulin sensitivity, insulin secretory response to glucose and tolbutamide, and tolbutamide clearance. FINDINGS: Patients with HNF-1alpha diabetes had a 5.2-fold greater response to gliclazide than to metformin (fasting plasma glucose reduction 4.7 vs 0.9 mmol/L, p=0.0007) and 3.9-fold greater response to gliclazide than those with type 2 diabetes (p=0.002). Patients with HNF-1alpha diabetes had a strong insulin secretory response to intravenous tolbutamide despite a small response to intravenous glucose, and were more insulin sensitive than those with type 2 diabetes. Sulphonylurea metabolism was similar in both patient groups. INTERPRETATION: The cause of hyperglycaemia changes the response to hypoglycaemic drugs; HNF-1alpha diabetes has marked sulphonylurea sensitivity. This pharmacogenetic effect is consistent with models of HNF-1alpha deficiency, which show that the beta-cell defect is upstream of the sulphonylurea receptor. Definition of the genetic basis of hyperglycaemia has implications for patient management.

The differential blood pressure sign in general practice: prevalence and prognostic value.

BACKGROUND: Patients sometimes have differences of > or =20/10 mmHg in their blood pressure depending on which arm is measured. The prevalence and prognostic value of this finding in general practice are unknown. If these differences are due to peripheral vascular disease, these patients may be at increased risk of cardiovascular or cerebrovascular events. OBJECTIVE: Our aim was to establish the frequency and prognostic value of a blood pressure difference between arms in one rural general practice. METHODS: Paired blood pressure readings were collected from patients attending the surgery. The outcome measures of myocardial infarction, new diagnosis of angina, a cerebrovascular event or death were recorded prospectively. RESULTS: A total of 280 patients were examined, and of these 13.6% had a systolic blood pressure difference (SBPD) of > or =20 mmHg, and 23.2% a diastolic blood pressure difference (DBPD) of > or =10 mmHg. Eighty-three patients were followed-up for 5.6 years. Patients with a DBPD of > or =10 mmHg showed a mean event-free survival of 3.3 years [95% confidence interval (CI) 2.2-4.4] compared with 5.0 years (95% CI 4.7-5.3) for those with a DBPD of <10 mmHg (P < 0.0001). Patients with an SBPD of > or =20 mmHg showed a mean event-free survival of 3.5 years (95% CI 2.3-4.7) compared with 4.9 years (95% CI 4.5-5.2) for an SBPD of <20 mmHg (P = 0.043). CONCLUSIONS: During a single assessment of blood pressure, there will be a minority of patients with a difference of > or =20/10 mmHg between their right and left arms. Measurement of both arms is therefore necessary to diagnose and treat hypertension accurately. This study suggests an association between blood pressure difference and increased morbidity and mortality. Priority should be given to managing other risk factors aggressively in those patients with a reproducible blood pressure difference of > or =20/10 mmHg.