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  • The evaluation of anaemia in an older primary care population: retrospective population-based study.

    14 March 2019

    Background: Anaemia is common in older people and the identification of potentially reversible haematinic deficiencies relies on appropriate investigation, often undertaken in primary care. Aim: To determine the laboratory prevalence of anaemia, the types of anaemia observed, and the biochemical and haematological investigations undertaken to characterise any associated haematinic abnormality in older primary care patients. Design & setting: A retrospective primary care based study of patients aged >65 years undergoing a full blood count in Oxfordshire, UK between 1 January 2012 and 31 December 2013. Method: Consecutive patients aged >65 years with a full blood count were identified retrospectively from a laboratory database. Patient demographics, number of blood tests and additional laboratory investigations requested were recorded. World Health Organisation (WHO) criteria were used to define anaemia. Results: In total 151 473 full blood counts from 53 890 participants were included: 29.6% of patients were anaemic. The majority had a normocytic anaemia (82.4%) and 46.0% of participants with anaemia had no additional investigations performed. The mean haemoglobin was lower in the anaemic group that underwent further investigation than those who did not (Hb 10.68 g/dl versus 11.24 g/dl, P<0.05): 33.2 % of patients with a microcytic anaemia (mean cell volume <80) did not have any markers of iron status measured. Conclusion: A large proportion of older adults in primary care with a recent blood test are anaemic, the majority with a normocytic anaemia, with evidence of inadequate investigation. Those with lower haemoglobin are more likely to be further investigated. Further work is needed to understand the approach to anaemia in older adults in primary care.

  • Corrigendum to “The feasibility and acceptability of self-testing for proteinuria during pregnancy: A mixed methods approach” [Pregn. Hypertens. 12 (2018) 161–168] (Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health (2018) 12 (161–168), (S2210778917301460), (10.1016/j.preghy.2017.11.009))

    20 March 2019

    © 2019 The Author(s) The authors regret the omission of the following In the Acknowledgements: “Lucy Mackillop was supported by the NIHR Oxford Biomedical Research Centre.” In the Affiliations: “NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust.” The authors would like to apologise for any inconvenience caused.

  • Association between heart rate variability and haemodynamic response to exercise in chronic heart failure.

    14 March 2019

    OBJECTIVES: Heart rate variability (HRV) and haemodynamic response to exercise (i.e. peak cardiac power output) are strong predictors of mortality in heart failure. The present study assessed the relationship between measures of HRV and peak cardiac power output. DESIGN: In a prospective observational study of 33 patients (age 54 ± 16 years) with chronic heart failure with reduced left ventricular ejection fraction (29 ± 11%), measures of the HRV (i.e. R-R interval and standard deviation of normal R-R intervals, SDNN) were recorded in a supine position. All patients underwent maximal graded cardiopulmonary exercise testing with non-invasive (inert gas rebreathing) cardiac output assessment. Cardiac power output, expressed in watts, was calculated as the product of cardiac output and mean arterial blood pressure. RESULTS: The mean RR and SDNN were 837 ± 166 and 96 ± 29 ms, peak exercise cardiac power output 2.28 ± 0.85 watts, cardiac output 10.34 ± 3.14 l/min, mean arterial blood pressure 98 ± 14 mmHg, stroke volume 91.43 ± 40.77 ml/beat, and oxygen consumption 19.0 ± 5.6 ml/kg/min. There was a significant but only moderate relationship between the RR interval and peak exercise cardiac power output (r = 0.43, p = 0.013), cardiac output (r = 0.35, p = 0.047), and mean arterial blood pressure (r = 0.45, p = 0.009). The SDNN correlated with peak cardiac power output (r = 0.42, p = 0.016), mean arterial blood arterial (r = 0.41, p = 0.019), and stroke volume (r = 0.35, p = 0.043). CONCLUSIONS: Moderate strength of the relationship between measures of HRV and cardiac response to exercise suggests that cardiac autonomic function is not good indicator of overall function and pumping capability of the heart in chronic heart failure.

  • How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure

    14 March 2019

    © Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ. Objective: To compare the effect of exercise regimens and medications on systolic blood pressure (SBP). Data sources: Medline (via PubMed) and the Cochrane Library. Eligibility criteria: Randomised controlled trials (RCTs) of angiotensin-converting enzyme inhibitors (ACE-I), angiotensin-2 receptor blockers (ARBs), β-blockers, calcium channel blockers (CCBs) and diuretics were identified from existing Cochrane reviews. A previously published meta-analysis of exercise interventions was updated to identify recent RCTs that tested the SBP-lowering effects of endurance, dynamic resistance, isometric resistance, and combined endurance and resistance exercise interventions (up to September 2018). Design: Random-effects network meta-analysis. Outcome: Difference in mean change from baseline SBP between comparator treatments (change from baseline in one group minus that in the other group) and its 95% credible interval (95% CrI), measured in mmHg. Results: We included a total of 391 RCTs, 197 of which evaluated exercise interventions (10 461 participants) and 194 evaluated antihypertensive medications (29 281 participants). No RCTs compared directly exercise against medications. While all medication trials included hypertensive populations, only 56 exercise trials included hypertensive participants (≥140 mmHg), corresponding to 3508 individuals. In a 10% random sample, risk of bias was higher in exercise RCTs, primarily due to lack of blinding and incomplete outcome data. In analyses that combined all populations, antihypertensive medications achieved higher reductions in baseline SBP compared with exercise interventions (mean difference 3.96 mmHg, 95% CrI 5.02 to 2.91). Compared with control, all types of exercise (including combination of endurance and resistance) and all classes of antihypertensive medications were effective in lowering baseline SBP. Among hypertensive populations, there were no detectable differences in the SBP-lowering effects of ACE-I, ARB, β-blocker and diuretic medications when compared with endurance or dynamic resistance exercise. There was no detectable inconsistency between direct and indirect comparisons. Although there was evidence of small-study effects, this affected both medication and exercise trials. Conclusions: The effect of exercise interventions on SBP remains under-studied, especially among hypertensive populations. Our findings confirm modest but consistent reductions in SBP in many studied exercise interventions across all populations but individuals receiving medications generally achieved greater reductions than those following structured exercise regimens. Assuming equally reliable estimates, the SBP-lowering effect of exercise among hypertensive populations appears similar to that of commonly used antihypertensive medications. Generalisability of these findings to real-world clinical settings should be further evaluated.

  • Oh (/o/) als ontvanger van informatie in sociale interactie

    14 March 2019

    Recently there has been an increased interest cross-linguistically in how speakers use interjections in everyday interaction. A particularly productive line of inquiry deals with what are known as change-of-state tokens, interjections with which speakers claim that there has been a shift in their cognitive state such as their knowledge, understanding, attention, etc. In this paper I explore the variability of the Dutch interjection oh /o/. Focusing on its use in response to informing turns, I argue that as a free-standing particle speakers use it to claim that the information in that prior turn was in some way unexpected: either because it contradicted what the speaker claimed he or she knew, or because it contradicted some presupposition that was encoded in an earlier question. I subsequently discuss the most frequent ways in which oh is combined with other turn components, showing how it is used to respond to announcements of valenced news, to do now-remembering, and to make claims of now-understanding. In closing I show that when oh prefaces additional turn components such as oké, each component deals with a different action-implication of the ongoing sequence and that oh is used to receive the information being conveyed.