Yan, Renfei. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2009. / Includes bibliographical references (leaves 69-77). / Abstract also in Chinese. / ABSTRACT --- p.I / ACKNOWLEDGEMENT --- p.V / LIST OF FIGURES --- p.VI / LIST OF TABLES --- p.VIII / LIST OF ABBREVIATIONS --- p.IX / Chapter CHAPTER 1. --- INTRODUCTION TO BLOOD PRESSURE MEASURING DEVICES AND EVALUATION STANDARDS --- p.1 / Chapter 1.1. --- Current situation on hypertension --- p.1 / Chapter A. --- Prevalence of hypertension --- p.1 / Chapter B. --- Low awareness of hypertension --- p.1 / Chapter 1.2. --- Calls for better management of hypertension --- p.2 / Chapter 1.3. --- Blood pressure measuring devices --- p.3 / Chapter A. --- Conventional devices and their limitations --- p.3 / Chapter B. --- Wearable cuff-less devices --- p.4 / Chapter 1.4. --- Evaluation of the wearable cuff-less devices --- p.6 / Chapter 1.5. --- Objectives of the thesis --- p.7 / Chapter 1.6. --- Structure of the thesis --- p.7 / Chapter CHAPTER 2. --- REVIEW ON CURRENT STANDARDS --- p.8 / Chapter 2.1. --- Introduction to current standards --- p.8 / Chapter A. --- AAMI standard --- p.8 / Chapter B. --- BHS protocol --- p.8 / Chapter C. --- ESH protocol --- p.9 / Chapter 2.2. --- Comparison of current standards --- p.9 / Chapter A. --- Evaluation scope --- p.9 / Chapter B. --- Validation protocol --- p.10 / Chapter C. --- Accuracy criteria --- p.10 / Chapter D. --- Testing reference --- p.13 / Chapter E. --- Recruitment of subjects --- p.13 / Chapter F. --- Ambulatory monitors --- p.14 / Chapter G. --- Special groups of population --- p.15 / Chapter H. --- Statistical considerations --- p.16 / Chapter 2.3. --- Major challenges for the evaluation of cuff-less devices --- p.17 / Chapter A. --- Lack of experimental data --- p.19 / Chapter B. --- Re-examination of the statistical considerations --- p.19 / Chapter C. --- Feature oriented design of the validation protocol --- p.19 / Chapter D. --- Selection of testing reference --- p.79 / Chapter CHAPTER 3. --- ERROR DISTRIBUTION MODEL --- p.21 / Chapter 3.1. --- Distribution assumption in current standards --- p.21 / Chapter 3.2. --- Distribution analysis from published reports --- p.22 / Chapter A. --- Methodology --- p.22 / Chapter B. --- Data analysis --- p.23 / Chapter C. --- Results --- p.23 / Chapter 3.3. --- Distribution analysis on a cuff-less device --- p.29 / Chapter A. --- Experiment --- p.29 / Chapter B. --- Data analysis --- p.31 / Chapter C. --- Results --- p.31 / Chapter 3.4. --- Discussion --- p.33 / Chapter A. --- Supporting evidence for t4 distribution --- p.33 / Chapter B. --- Implications for the application of t4 distribution --- p.34 / Chapter 3.5. --- Section Summary --- p.35 / Chapter CHAPTER 4. --- EVALUATION SCALE TO ASSESS THE ACCURACY --- p.36 / Chapter 4.1. --- Considerations for parameter selection --- p.37 / Chapter A. --- Outlying errors and system bias --- p.37 / Chapter B. --- Accuracy at different levels of blood pressure --- p.37 / Chapter 4.2. --- Description of selected parameters --- p.38 / Chapter 4.3. --- Theoretical relationship between “new´ح and “old´ح parameters --- p.38 / Chapter A. --- Mathematical relationship --- p.39 / Chapter B. --- Mapping relationship --- p.40 / Chapter 4.4. --- Assessment of accuracy at increasing blood pressure levels --- p.41 / Chapter A. --- Data transformation --- p.41 / Chapter B. --- Experimental study --- p.41 / Chapter 4.5. --- Discussion and application --- p.43 / Chapter A. --- Parameter selection --- p.43 / Chapter B. --- Sample size --- p.45 / Chapter C. --- Accuracy criteria --- p.46 / Chapter 4.6. --- Section summary --- p.47 / Chapter CHAPTER 5. --- FEATURE ORIENTED PROTOCOL DESIGN --- p.48 / Chapter 5.1. --- Rationale of accuracy assessment with BP change --- p.48 / Chapter 5.2. --- Experiment one --- p.49 / Chapter 5.3. --- Experiment two --- p.49 / Chapter 5.4. --- Data analysis --- p.49 / Chapter 5.5. --- Results --- p.50 / Chapter A. --- Experiment one --- p.50 / Chapter B. --- Experiment two --- p.52 / Chapter 5.6. --- Discussion --- p.58 / Chapter A. --- Difference between cuff-less and cuff-based devices --- p.58 / Chapter B. --- Correlation between accuracy and blood pressure changes --- p.58 / Chapter C. --- Inducement of blood pressure change --- p.59 / Chapter D. --- Other factors affect the accuracy --- p.60 / Chapter 5.7. --- Section summary --- p.61 / Chapter CHAPTER 6. --- PROPOSAL FOR THE EVALUATION OF WEARABLE CUFF-LESS DEVICES --- p.62 / Chapter 6.1. --- Scope --- p.62 / Chapter 6.2. --- Purpose --- p.62 / Chapter 6.3. --- Subject selection --- p.63 / Chapter 6.4. --- Main validation --- p.64 / Chapter A. --- Static test --- p.64 / Chapter B. --- Test with blood pressure change --- p.65 / Chapter C. --- Test after a certain period of time --- p.65 / Chapter 6.5. --- Data analysis and reporting --- p.66 / Chapter A. --- Statistical report --- p.66 / Chapter B. --- Graphical representation --- p.67 / Chapter 6.6. --- Conclusion and future work --- p.67 / REFERENCES --- p.69 / LIST OF PUBLICATIONS AND AWARDS --- p.78

The purpose of the study was to examine psychological and methodological factors which would predict the white coat effect (WCE). The WCE is defined as the difference (mm Hg) between ambulatory and office measured blood pressure (BP). Sixty three community volunteers participated in this study. Participants were divided into 3 Response style groups: (1) Office responders had ambulatory BP values which were lower than office BP, (2) Non responders showed a minimal difference between office and ambulatory BP, and (3) Home responders had significantly higher ambulatory BP compared to office BP. Participants were asked to have a series of BP readings taken by a physician, nurse and by themselves and participate in 24 hour ambulatory monitoring. State and trait self-report psychological measures were completed. Self measured BP was the most representative of ambulatory BP for the sample as a whole, and in particular for the Home responders. State anxiety, previously dismissed as mediating factor in the expression of the white coat effect, proved to discriminate between the groups. Office responders had significantly higher levels of state anxiety, directly related to BP measurements, compared to Home and Non responders. Habituation to the experience of having BP measured by a physician, and habituation of the anxiety prior to the BP measurement, was different among the three groups. Trait psychological variables did not distinguish group membership. Self measured systolic BP, state anxiety prior to self measured BP, habituation to physician measured BP and the anxiety preceding it, were entered as predictors variables in a discriminant function analyses. These variables were able to correctly classify group membership for 63% of the sample.

Blood pressure is one of the fundamental clinical measures. For more than 100 years, clinicians and researchers have used the mercury sphygmomanometer for blood pressure measurement. Environmental concern about mercury contamination has highlighted the need to find a replacement for traditional mercury sphygmomanometers. A number of currently used non-invasive blood pressure measurement methods have been studied in this research. The most commonly used automatic pressure monitoring method nowadays is the Oscillometric method. Height-based and Slope-based criteria are the two general means used to determine the systolic and diastolic pressures. However, these two criteria have many disputed points, making them debatable as a good standard for blood pressure measurement. For this reason, the auscultatory method continues to be the gold-standard for non-invasive blood pressure measurement. Current research uses a newly developed cuff with three different lengths of piezo film sensors and a pressure sensor to collect signals from the brachial artery. The objectives of the research are to process the measured signal from the sensors and develop a blood pressure measurement algorithm that will accurately determine the blood pressure noninvasively. Signal processing and heart beat / heart rate detection software have been developed. The best algorithm has been selected from three developed algorithms for further modification and validation. The final algorithm used two feed-forward Neural Networks to classify the acquired pressure signals into various regions of the pressure signals. The final algorithm has been tested on 258 measurements from 86 subjects. The testing result showed that the algorithm achieved grade A for both systolic and diastolic pressures according to the British Hypertension Society protocol. The mean differences (SD) between the observers and the developed algorithm were 1.44 (5.27) mmHg and 1.77 (6.17) mmHg for systolic and diastolic pressures, respectively, which also fulfilled the Association for the Advancement of Medical Instrumentation protocol. In conclusion, this algorithm was successfully developed and it is recommended for further clinical trial in a wider adult population. Further development of this algorithm also includes extending to other subgroups such as pregnant women, arrhythmia, diabetics and other subjects with diseases.

The purpose of the study was to examine psychological and methodological factors which would predict the white coat effect (WCE). The WCE is defined as the difference (mm Hg) between ambulatory and office measured blood pressure (BP). Sixty three community volunteers participated in this study. Participants were divided into 3 Response style groups: (1) Office responders had ambulatory BP values which were lower than office BP, (2) Non responders showed a minimal difference between office and ambulatory BP, and (3) Home responders had significantly higher ambulatory BP compared to office BP. Participants were asked to have a series of BP readings taken by a physician, nurse and by themselves and participate in 24 hour ambulatory monitoring. State and trait self-report psychological measures were completed. Self measured BP was the most representative of ambulatory BP for the sample as a whole, and in particular for the Home responders. State anxiety, previously dismissed as mediating factor in the expression of the white coat effect, proved to discriminate between the groups. Office responders had significantly higher levels of state anxiety, directly related to BP measurements, compared to Home and Non responders. Habituation to the experience of having BP measured by a physician, and habituation of the anxiety prior to the BP measurement, was different among the three groups. Trait psychological variables did not distinguish group membership. Self measured systolic BP, state anxiety prior to self measured BP, habituation to physician measured BP and the anxiety preceding it, were entered as predictors variables in a discriminant function analyses. These variables were able to correctly classify group membership for 63% of the sample. / Arts, Faculty of / Psychology, Department of / Graduate

Hypertension guidelines recommend out of office blood pressure (BP) measurement especially 24- hour ambulatory measurement (ABPM), to diagnose and manage hypertension but this is not routinely performed in kidney transplant units. This study was to determine if 24-hour ABPM, compared with office BP in kidney transplant recipients, would be more informative regarding BP management, and if pulse wave analysis (PWA) would assist in risk stratification. This study included patients older than 18 years, with working graft kidney for >12 months, and without problems affecting BP measurement and interpretation. After performing office BP measurements, a 24-hour ABPM with additional capability of calculating pulse wave velocity (PWV),augmentation index and central BP was undertaken. Patients were assessed for controlled hypertension, uncontrolled hypertension, masked hypertension, nocturnal hypertension, white coat hypertension, and dipping BP status. Data were analysed using standard statistical tests. Of 30 patients, 15 were Black Africans and 15 were of Mixed Ancestry with a mean age of 48.9 years. Seventeen patients were males and 36.7% had controlled hypertension, 30% uncontrolled hypertension, 6.7% white coat hypertension and 33.3% masked hypertension, of whom 70% had isolated nocturnal hypertension. 70% had a non-dipping, 26.7% a reverse dipping and only 3.3% had a normal dipping BP pattern. The mean difference between brachia! systolic BP and central systolic BP was 10.4 mm Hg, whereas PWV and augmentation index were similar to healthy populations. CONCLUSION: In kidney transplant recipients, 24-hour ABPM was superior to office BP in defining hypertensive status that qualified for modification of therapy but PWA did not contribute to risk assessment.

Data were collected from the initial symptom-limited maximal exercise tests of 161 patients without. diagnosed coronary heart disease (CHD). Subjects were grouped according to their systolic (SBP) and diastolic (DBP) blood pressure changes between the final two stages of exercise. / Master of Science

L'hypertension artérielle (HTA) est un problème de santé sérieux qui affecte 22% des canadiens et dont les complications sont nombreuses. Ces complications peuvent être diminuées par un diagnostic précoce et un traitement efficace et plusieurs auteurs affirment que l'exactitude de la mesure de la pression artérielle (PA) est la pierre angulaire pour établir le diagnostic et assurer un suivi adéquat. Quoique cette mesure soit réalisée très fréquemment, des études réalisées ailleurs qu'au Québec indiquent que les connaissances des infirmières à l'égard de la mesure de la PA sont insuffisantes pour des éléments reconnus comme ayant une influence significative sur les résultats de la mesure de la PA. À notre connaissance, aucune étude concernant les connaissances des infirmières n'a été publiée au Canada. Cette étude a donc pour but de décrire les connaissances théoriques et pratiques des infirmières pour la mesure de la PA en regard des recommandations du Programme éducatif canadien pour le contrôle de l'hypertension artérielle (2004) et comparer les relations entre ces variables. Une enquête par questionnaire auto administré pour décrire les connaissances théoriques ainsi qu'une observation directe par échantillonnage exhaustif pour décrire les connaissances pratiques ont été utilisées pour un premier échantillon de 50 infirmières. Une enquête postale transversale par échantillonnage aléatoire a été utilisée pour décrire les connaissances théoriques auprès d'un deuxième échantillon de 307 infirmières. Les outils ont été testés pour leur validité et leur fidélité dans le cadre de cette étude. L'étude a été approuvée par le comité d'éthique du centre de recherche clinique du CHUS. Les résultats quant aux données sociodémographiques démontrent que les infirmières ayant participé à l'une ou l'autre partie de l'étude sont semblables aux autres infirmières du Québec à l'égard du genre, de l'âge, du type d'emploi et de l'expérience. Elles sont toutefois statistiquement différentes pour le niveau de formation. Le score obtenu par les infirmières des deux échantillons pour le questionnaire sur les connaissances théoriques est de moins de 60%. On peut donc conclure qu'il existe des lacunes importantes en regard des connaissances théoriques acquises. Par ailleurs, ces infirmières croient dans de très fortes proportions posséder les connaissances théoriques et pratiques nécessaires à une mesure exacte de la PA. Pour les connaissances pratiques, le score global des infirmières est de 38%. Force est de croire que malgré le processus de mise à jour annuel et d'implantation des recommandations canadiennes, les connaissances pratiques des infirmières ne sont pas équivalentes au contenu de ces recommandations. Les infirmières qui détiennent un niveau de formation supérieur, celles qui ont lu les recommandations et celles qui ont suivi une formation continue sur la mesure de la PA obtiennent de résultats légèrement supérieurs aux autres infirmières. Considérant la fréquence avec laquelle les infirmières mesurent la PA et l'impact que peut avoir une mesure inexacte, il est important d'entreprendre dès maintenant des actions concrètes pour améliorer cette situation en mettant en place des formations continues régulières sur le sujet et en s'assurant que les programmes de formation initiale incluent une formation théorique et pratique fondée sur les recommandations en vigueur. Il semble également crucial de stimuler l'implantation des recommandations du PECH auprès des infirmières et d'évaluer l'impact de ces mesures par la suite.

Analysis of care in patients at risk for arterial hypertension in pharmacy IV. Author: Lada Kotlanová Tutor: PharmDr. Josef Malý, Ph.D. Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University in Prague Introduction and aim: Arterial hypertension (AH) belongs due to its pressure and atherosclerotic complications among very serious global health problems. The main goal of the therapy of AH is to prevent these complications, comprising early diagnosis and proper treatment plan. The aim of the study was to realize counselling in a pharmacy focused on clients with the risk of AH or already diagnosed AH. Metodology: Data were collected in a community pharmacy in Kralovice from September 2014 to January 2015. Prior to blood pressure measurement, the controlled interview was conducted with each client using special form which enabled to obtain important data from clients' history. Following data were obtained: socio-demographic characteristics of each client; their relationship to blood pressure measurement; risk factors of AH or atherosclerosis, respectively; disease history and use of drugs including food supplements. Results of blood pressure measurement, proposed intervention, or drug related problems were also subsequently recorded into the form thus...

Analysis of care in patients at risk for arterial hypertension in pharmacy III. Author: Petra Smíšková Tutor: PharmDr. Josef Malý, Ph.D. Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University in Prague Introduction: Arterial hypertension belongs to the most common diseases of cardiovascular system, not only in the Czech Republic. Therefore it is very important to focus on its prevention and early diagnostics before the stage of health complications shows up. Objectives: The aim of this thesis was to realize and evaluate consulting activities in pharmacy focused on patients who have high risks of arterial hypertension or have been already diagnosed with it. Methodology: Data were collected in a public pharmacy in Prague from the end of April 2013 until the beginning of April 2014. The actual blood pressure measurement was preceded by obtaining of answers to selected questions through controlled interview. Acquired statements were written into the printed forms. It was focused on particicipant's socio-demographic characteristics, his relationship to the blood pressure measurement; occurrence of risk factors of arterial hypertension, it means atherosclerosis; disease in the anamnesis and the usage of drugs including food supplements. The results of blood...

O diagnóstico, controle e prevenção das doenças cardiovasculares, dentre elas a Hipertensão Arterial, dependem obrigatoriamente da obtenção de valores de pressão arterial precisos. Para isso, é fundamental que a medida da pressão arterial seja realizada de maneira correta, padronizada e com aparelhos calibrados, para subsidiar condutas multidisciplinares assertivas e garantir a segurança do paciente. A literatura traz evidências de que o conhecimento dos profissionais de saúde está aquém das recomendações de diretrizes, e a prática nem sempre cumpre todas as etapas da técnica. Estudos sugerem que esse problema pode estar relacionado à formação profissional, com evidências de falhas no conhecimento teórico e prático entre estudantes da área da saúde. Por outro lado, exige-se do profissional, principalmente em Terapia Intensiva, conhecimentos e habilidades complexas, que incluem manuseio de equipamentos, materiais e medicamentos de alto custo, o que por vezes, se traduz em sobrecarga de trabalho, e execução de rotinas de forma automatizada. Partindo da hipótese de que uma intervenção educativa pode melhorar o conhecimento, e assim, favorecer a prática isenta de erros, o presente estudo avaliou o efeito de uma intervenção educativa sobre o conhecimento teórico e prático de profissionais de enfermagem (n=31) de Unidade Coronariana, relativos à medida indireta da pressão arterial, num hospital-escola no interior paulista. Trata-se de um estudo quasi- experimental, do tipo antes e depois, para determinar o conhecimento prático, utilizou- se check list validado, que avaliou a execução da técnica em simulação clínica. Para o conhecimento teórico, optou-se por elaborar e validar um questionário para a população de profissionais de enfermagem de Unidade Coronariana, por meio de um estudo metodológico de validação de conteúdo, semântica e pré-teste, pelo método DISABIKIDS®. A etapa de validação produziu um questionário de conhecimento teórico da medida indireta da PA, com 28 questões, sendo 8 de caracterização sociodemográfica, e 20 relativas às etapas da medida indireta da PA, baseadas nas principais diretrizes disponíveis. Em seguida, implementou-se a intervenção educativa, com estratégias expositivo-dialogadas, baseadas na Teoria do Arco de Maguerez, com a observação da realidade na prática simulada. Os resultados evidenciaram melhora estatisticamente significante no conhecimento teórico e prático após a intervenção, nas etapas de Preparo do cliente, Preparo do ambiente, Posição do cliente, Cuidados com os aparelhos, e Obtenção e Registro dos valores (p<0.05). Resultados indicaram que algumas etapas da medida indireta da pressão arterial são mais valorizadas na prática, em detrimento do respectivo conhecimento teórico. Por outro lado, há etapas cujo conhecimento teórico é satisfatório, porém a prática foi discrepante. O questionário validado nesse estudo representa um instrumento viável para estudos que visem determinar conhecimento teórico da medida indireta da pressão arterial em profissionais de saúde, em todos os níveis de atenção. A melhoria do conhecimento foi efetiva na teoria e na pratica simulada. Etapas voltadas à Posição do Cliente parecem estar sendo executadas de forma automatizada, enquanto que etapas voltadas à Checagem da calibração, Medida da circunferência braquial, Anotação sem arredondamento de valores, podem estar sendo negligenciadas, até mesmo por sobrecarga de rotinas, e necessitam especial atenção nas intervenções educativas e supervisão diária. A utilização da simulação contribuiu fortemente para o cumprimento dos objetivos propostos, proporcionou ao participante a oportunidade de autoavaliação, de maneira espontânea, e foi o canal de discussões sobre problemas da prática da medida indireta da pressão arterial. Discutiu-se a importância da medida indireta da pressão arterial isenta de erros, a responsabilidade individual, que deve contemplar o conhecimento sobre prazos de calibração de aparelhos. Além disso, discutiu-se o papel da instituição na busca de rotinas padronizadas e políticas voltadas à gestão de equipamentos. Diante desses achados, entende-se que uma intervenção educativa sobre a medida indireta da pressão arterial, voltada aos profissionais da saúde, aplicada de maneira sistemática, com periodicidade alinhada às diretrizes, representa grande possibilidade de melhoria do conhecimento, fornece subsídios para melhoria da qualidade da assistência, para os clientes e seus familiares, merecedores de todos os esforços possíveis na busca e obtenção da assistência e promoção do cuidado seguro e isento de erros / The diagnostics, prevention and control of cardiovascular diseases, among them arterial hypertension, depends wholesomely in obtaining precise blood pressure values. For this reason, it is paramount that blood pressure be measured correctly, in a standardized manner, and by using calibrated monitors and apparatuses to allow assertive multidisciplinary actions and guarantee patient safety. Medical literature brings evidence that health professional knowledge falls short of the necessary recommendations and directives, and procedures not always fulfill all technique requirements. Studies suggest that this problem might relate to professional qualification, attesting to some flaws in theoretical and practical understanding among health care students. On the other hand, it is demanded from the health professional, especially in Intensive Care Units, a complex understanding of abilities and knowledge, which include the handling of intricate machines, materials and high cost medication, frequently leading to work overload and the automated execution of work routines. Bearing in mind that an educational intervention might improve overall comprehension and understanding, thus, favoring error-free practices, this current study has evaluated the effects of an educational intervention on the theoretical and practical knowledge of nursing health professionals (n=31) in a Coronary Unit, concerning indirect blood pressure measurement in a teaching hospital in the state of São Paulo. It is a quasi- experimental study, type before and after, to determine practical knowledge, a validated checklist was used to evaluate technique execution under clinical simulation. For theoretical knowledge, a questionnaire was elaborated and validated for our Coronary Unit health professionals thought content validation, methodological studies, semantics and pre-tests using DISABIKIDS(TM) method. Validation stage produced a 28-question questionnaire of theoretical knowledge for indirect blood pressure measurement comprising 8 questions on social-demographics and 20 on indirect blood pressure measurement sequence, based upon the main available directives. Following this stage, an educational intervention with dialogue-expository strategies was implemented based upon Maguerez Arch Theory by observing reality in our simulated practice. The results evidenced statistically significant improvement in practical and theoretical knowledge following intervention in these stages: Client preparation, Environment preparation, Client positioning, Monitors and apparatus upkeep, Value registration and acquisition (p<0.05). Results indicate that some stages of blood pressure measurement are overvalued in practice, in detriment of acquired theoretical instruction. On the other hand, there are stages whose theoretical knowledge is satisfactory, but their practice discrepant. The validated questionnaire in this study represents a viable instrument for studies aimed at determining theoretical knowledge in indirect blood pressure measurement by health care professionals encompassing all their levels of action. Knowledge improvement was effective both in theoretical and simulated practices. Stages related to Client positioning seem to have been carried out mechanically, while stages related to Calibration check, Brachial circumference measurement, Non-rounded-value annotations might have been neglected by routine work overload, and require special attention during educational interventions and daily supervision. The use of simulation has strongly contributed to the fulfillment of the proposed objectives, allowed the participants to spontaneously evaluate themselves and was a channel of discussion about practical problems in indirect blood pressure measurement. The importance of error-free indirect blood pressure measurement was discussed, along with the health professional responsibility which must also contemplate knowledge about apparatus calibration frequency. Furthermore, the role of the institution was discussed in the search for standardized policies concerning equipment management. In the light of such findings, it can be understood that an educational intervention about indirect blood pressure measurement aimed at health professionals, systematically applied, frequency-aligned with the ongoing directives represents great possible knowledge improvement, subsidizes improvement in quality assistance for clients and their families, the well-deserving recipients of all possible efforts for high quality assistance and error-free health care