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1.  The Dinamap 1846SX automated blood pressure recorder: comparison with the Hawksley random zero sphygmomanometer under field conditions. 
STUDY OBJECTIVE--The aim was to compare the performance of the Dinamap 1846SX automated oscillometric blood pressure recorder with that of the Hawksley random zero sphygmomanometer during use under field study conditions. DESIGN--Two independent within subject measurement comparisons were made, one in adults and one in children, each conducted in three stages over several months while the Dinamap instruments were being used in epidemiological field surveys. SETTING--The studies were done in outpatients clinics (adults) and primary schools (children). PARTICIPANTS--141 adults (20-85 years) and 152 children (5-7 years) took part. MEASUREMENTS AND MAIN RESULTS--In adults a pair of measurements was made with each instrument, the order alternating for consecutive subjects. In children one measurements was made with each instrument, in random order. Measurements with the Dinamap 1846SX were higher than those with the random zero sphygmomanometer both in adults (mean difference 8.1 mm Hg; 95% CI 6.5 to 9.7 mm Hg) and in children (mean difference 8.3 mm Hg; 95% CI 6.9 to 9.7 mm Hg). Diastolic measurements were on average very similar both in adults and in children. The results were consistent at all three stages of both studies. The differences in systolic measurement were independent of blood pressure level. However, the extent of agreement in diastolic pressure depended on the diastolic blood pressure level; in both studies Dinamap diastolic measurements were higher at low diastolic pressures while random zero diastolic measurements were higher at high diastolic pressures. CONCLUSIONS--Systolic measurements made with the Dinamap 1846SX instrument are not directly comparable with those of the Hawksley random zero sphygmomanometer and are unlikely to be comparable with those of earlier Dinamap models. These differences have important implications for clinical practice and for comparisons of blood pressure measurement between epidemiological studies. However, the consistency of measurement by the Dinamap 1846SX over time suggests that the instrument may have a place in standardised blood pressure measurement in the research setting.
PMCID: PMC1059528  PMID: 1583434
2.  Optimising the accuracy of blood pressure monitoring in chronic kidney disease: the utility of BpTRU 
BMC Nephrology  2013;14:218.
Background
Accurate blood pressure monitoring is critical for the management of chronic kidney disease, but changes in management in secondary care clinics may be based on a single blood pressure reading, with a subsequent lack of accuracy. The aim of this study was to evaluate a fully automated sphygmomanometer for optimising the accuracy of blood pressure measurements in the setting of secondary care renal clinics.
Methods
Patients had routine blood pressure measurements with a calibrated DINAMAP PRO400 monitor in a clinical assessment room. Patients then underwent repeat assessment with a DINAMAP PRO400 monitor and BpTRU device and subsequent 24 hour ambulatory blood pressure monitoring (ABPM).
Results
The BpTRU systolic (± SD) reading (117.3 ± 14.1 mmHg) was significantly lower than the routine clinic mean systolic blood pressure (143.8 ± 15.5 mmHg; P < 0.001) and the repeat blood pressure taken with a DINAMAP PRO400 monitor in a quiet room (129.9 ± 19.9 mmHg; P < 0.001). The routine clinic mean diastolic (82.4 ± 11.2 mmHg) was significantly higher than the BpTRU reading (78.4 ± 10.0 mmHg; P < 0.001). Clinic BpTRU measurements were not significantly different to the daytime mean or overall mean of 24 hour ABPM.
Conclusions
In patients with CKD, routine clinic blood pressure measurements were significantly higher than measurements using a BpTRU machine in a quiet room, but there was no significant difference in this setting between BpTRU readings and 24 hour ABPM. Adjusting clinic protocols to utilise the most accurate blood pressure technique available is a simple manoeuvre that could deliver major improvements in clinical practice.
doi:10.1186/1471-2369-14-218
PMCID: PMC3852944  PMID: 24112304
3.  Validation study of the Dinamap ProCare 200 upper arm blood pressure monitor in children and adolescents 
Korean Journal of Pediatrics  2011;54(11):463-469.
Purpose
To validate the Dinamap ProCare 200 blood pressure (BP) monitor against a mercury sphygmomanometer in children 7 to 18 years old in accordance with the 2010 International Protocol of European Society of Hypertension (ESH-IP2) and the British Hypertension Society (BHS) protocol.
Methods
Forty-five children were recruited for the study. A validation procedure was performed following the protocol based on the ESH-IP2 and BHS protocols for children and adolescents. Each subject underwent 7 sequential BP measurements alternatively with a mercury sphygmomanometer and the test device by trained nurses. The results were analyzed according to the validation criteria of ESH-IP2.
Results
The mean (±SD) difference in the absolute BP values between test device and mercury sphygmomanometer readings was 1.85±1.65 mmHg for systolic BP (SBP) and 4.41±3.53 mmHg for diastolic BP (DBP). These results fulfilled the Association for the Advancement of Medical Instrumentation criterion of a mean±SD below 5±8 mmHg for both SBP and DBP. The percentages of test device-observer mercury sphygmomanometer BP differences within 5, 10, and 15 mmHg were 96%, 100%, and 100% for SBP, and 69%, 92%, and 100% for DBP, respectively, in the part 1 analysis; both SBP and DBP passed the part 1 criteria. In the part 2 analysis, SBP passed the criteria but DBP failed.
Conclusion
Although the Dinamap ProCare 200 BP monitor failed an adapted ESH-IP2, SBP passed. When comparing BP readings measured by oscillometers and mercury sphygmomanometers, one has to consider the differences between them, particularly in DBP, because DBP can be underestimated.
doi:10.3345/kjp.2011.54.11.463
PMCID: PMC3254892  PMID: 22253643
Blood pressure; Oscillometric device; Dinamap; Validation studies; International protocol
4.  Ankle blood pressure measured by automatic oscillotonometry: a comparison with Doppler pressure measurements. 
Oscillotonometry using Dinamap machine was investigated for the measurement of ankle and brachial blood pressures in our vascular practice. It was validated by comparison with intra-arterial pressure measured by transducer. Systolic ankle and brachial pressures in 43 patients were compared using the Dinamap and Doppler techniques, and significant correlation was found. Ankle and brachial systolic, diastolic and mean pressures and ankle/brachial pressure indices for all three pressures were measured in a group of 12 normal subjects supine at rest, and after treadmill exercise, and a range of normal values defined. The main limitation of the Dinamap is its failure to measure pressures below 50mmHg. The Dinamap technique is a noninvasive, simple, reproducible and quick method of measuring ankle and brachial pressures in vascular surgical practice.
PMCID: PMC2498533  PMID: 3426091
5.  Agreement between the Takeda UA-731 automatic blood pressure measuring device and the manual mercury sphygmomanometer: an assessment under field conditions in Newcastle upon Tyne, UK. 
STUDY OBJECTIVE: To assess agreement between two Takeda UA-731 automatic blood pressure measuring devices (referred to as machines A and B) and two manual mercury sphygmomanometers. DESIGN: A 'Y' connector attached each Takeda UA-731 to a manual mercury sphygmomanometer. Simultaneous measurements were made on adult subjects. SETTING: A population based cardiovascular disease survey in Newcastle upon Tyne, UK. PARTICIPANTS: Measurements on machine A were compared in 71 individuals (all women), and on machine B in 75 individuals (9 men, 66 women). The age range of subjects was 28 to 76 years and median ages were 59 years for machine A and 50 years for machine B. MAIN RESULTS: Blood pressure (mmHg) ranged from 72 to 212 systolic and 44 to 102 diastolic. Both Takedas gave significantly lower readings than the manual devices for systolic and diastolic pressures: differences were mean (SD: 95% CI) 3.7 mmHg (6.5: 2.2, 5.2) for machine A systolic, 2.3 mmHg (4.5: 1.3, 3.4) machine A diastolic; 1.8 mmHg (6.2: 0.4, 3.3) machine B systolic, and 1.8 (4.4: 0.8, 2.8) machine B diastolic. On the British Hypertension Society criteria, machine A was graded C on systolic measurements and B on diastolic; machine B was graded B on both systolic and diastolic measurements. CONCLUSIONS: The performance of these machines compares favourably with the Dinamap 8100, recently adopted for survey work by the Department of Health. The Takeda UA-731 looks promising for epidemiological survey work but before it can be fully recommended further evaluations are needed.
PMCID: PMC1060256  PMID: 8762392
6.  Evaluation of the accuracy of non-invasive automatic blood pressure monitors. 
Anesthesia Progress  1990;37(5):244-247.
Non-invasive automatic blood pressure monitors (BP-103N, DINAMAP 845XT, Finapres 2300) were compared with the auscultatory method. The blood pressure readings given by the oscillometric method (BP-103N, DINAMAP 845XT) were accurate and reproducible. Agreement with the auscultatory method was especially good for systolic pressure. For diastolic pressure readings, there was less agreement with the results of the auscultatory method. The finger arterial pressure method (Finapres 2300) occasionally displayed greater variability than the devices using the oscillometric method.
PMCID: PMC2148609  PMID: 2096748
7.  Comparison of direct and indirect blood pressure measurements in anesthetized dogs. 
The precision and accuracy of an indirect oscillometric blood pressure measurement technique (Dinamap 8100) was assessed in 11 anesthetized Beagle dogs weighing 8 to 11.5 kg. Direct blood pressure measurements were made by catheterization of the lingual artery, and simultaneous indirect measurements were determined by placing a cuff over the median artery (midradial area). Blood pressure measurements at 2 different planes of anesthesia (light and deep) were recorded in triplicate. At a light plane of anesthesia, the Dinamap 8100 underestimated diastolic and mean arterial pressure, and at a deep anesthetic plane overestimated systolic pressure. The indirect technique had good repeatability of systolic pressures. Regression analysis for the 2 techniques showed excellent correlation (r = 0.93). The results indicate that the indirect oscillometric blood pressure measurement technique provides a good estimate of systolic, diastolic, and mean arterial pressure in dogs weighing 8-11.5 kg.
PMCID: PMC1263773  PMID: 8521360
8.  Oscillometric blood pressure reference values of African full-term neonates in their first days postpartum 
Cardiovascular Journal of Africa  2009;20(6):344-347.
Background
Knowing the normative blood pressure (BP) in a newborn baby is important in order to identify abnormal BP readings. This study was done to determine normative BP values of Nigerian newborns, using the 8100 Dinamap monitor.
Methods
Consecutive full-term neonates delivered in a tertiary centre in Nigeria were recruited for the study. The babies’ systolic (SBP), diastolic (DBP) and mean arterial (MAP) blood pressures were measured within the first four days after birth.
Results
A total of 473 babies were recruited for the study. The mean SBP, DBP and MAP readings on day 1 were 66.8 ± 7.7, 38.5 ± 6.3 and 47.9 ± 6.3 mmHg, respectively. The day 1 SBP of babies > 4 kg were significantly higher than those who weighed < 2.5 and 2.5–4 kg (p = 0.01, p = 0.05), respectively.
Conclusion
This study provided current normative SBP, DBP and MAP values for Nigerian neonates. The BP readings compared with their Caucasian counterparts.
PMCID: PMC3721809  PMID: 20024474
9.  The Elag-Koln automatic blood pressure recorder. A clinical appraisal. 
British Heart Journal  1977;39(7):795-798.
The performance of an Elag-Koln semiautomatic blood pressure recorder was compared with the London School of Hygiene mercury sphygmomanometer in 24 subjects providing a wide range of blood pressure measurements. Readings with the two instruments correlated highly (for systole, r=0-99; for diastole phase 4, r=0-97; for diastole phase 5,r=0-98), and the slopes of the regressions did not differ significantly from unity. Elag-Koln measurements were higher for systole (mean difference 3-7 mmHg,P less than 0-001) and diastole phase 5 (mean difference 7-4 mmHg,P less than 0-001), but agreed closely with diastole phase 4 readings with the London School of Hygiene instrument. The Elag-Koln recorder tested was compact, easy to use, and had acceptable accuracy. This type of instrument deserves further testing to examine its suitability for general use.
Images
PMCID: PMC483318  PMID: 884029
10.  Measurement error in the Hawksley random zero sphygmomanometer: what damage has been done and what can we learn? 
BMJ : British Medical Journal  1993;306(6888):1319-1322.
The Hawksley random zero sphygmomanometer is used in all aspects of blood pressure research, from clinical trials to evaluation of new blood pressure recorders. It is designed to reduce observer bias in blood pressure measurement. The problem is that it also underestimates blood pressure. Furthermore, this was first reported more than two decades ago. In this paper Rónán Conroy and colleagues explore the consequences of using an inaccurate instrument for important research and why prestigious organisations like the World Health Organisation continue to use it.
Images
PMCID: PMC1677762  PMID: 8518574
11.  Factors related to total cholesterol and blood pressure in British 9 year olds. 
STUDY OBJECTIVE: To assess which factors are associated with total cholesterol concentration and blood pressure in 9 year olds, and to examine the extent to which a report of a heart attack in a close relative identifies children with a high total cholesterol value or high systolic blood pressure. DESIGN: This was a cross sectional study. SETTING: The analysis was based on 22 study areas from a representative English sample, 14 areas from a representative Scottish sample, and 20 areas from an inner city sample. PARTICIPANTS: There were 1987 children aged 8 or 9 whose blood pressure was measured and 1662 children whose total cholesterol was assessed. MEASUREMENTS AND MAIN RESULTS: Blood pressure was measured using the Dinamap 1846 automated sphygmomanometer and cholesterol using the Lipotrend C. Multiple regression analysis was used to examine the independent associations with each of the outcome variables. Either weight for height or sum of skinfolds measured in four sites was highly associated with the outcome measures in the study (p < 0.001). Fatter or overweight children had higher blood pressure and higher cholesterol concentrations. Child's height was also associated with the outcome measures in most of the analyses, but was positively related to blood pressure and negatively associated with cholesterol value. There was an association between diastolic blood pressure and area of residence as represented by the regional health authority (RHA), but the association was not the same as the association reported between coronary heart disease, standardised mortality ratio, and RHA. Children with low birth weight and those with shorter gestation had higher systolic blood pressure (p < 0.05 and p < 0.01 respectively), but not diastolic blood pressure. A report of a premature heart attack in a parent or a grandparent was not associated with higher cholesterol or blood pressure. CONCLUSIONS: Reducing obesity in children, together with the avoidance of smoking, may be an appropriate action to prevent coronary heart disease in adulthood. A report of heart disease in a close relative is an ineffective means of identifying children at greater risk of high cholesterol or blood pressure without other measurements from relatives.
PMCID: PMC1060341  PMID: 8944856
12.  Relation of arterial stiffness with gestational age and birth weight 
Archives of Disease in Childhood  2004;89(3):217-221.
Background: The cardiovascular risk of individuals who are born small as a result of prematurity remains controversial. Given the previous findings of stiffer peripheral conduit arteries in growth restricted donor twins in twin–twin transfusion syndrome regardless of gestational age, we hypothesised that among children born preterm, only those with intrauterine growth retardation are predisposed to an increase in cardiovascular risks.
Aim: To compare brachioradial arterial stiffness and systemic blood pressure (BP) among children born preterm and small for gestational age (group 1, n = 15), those born preterm but having birth weight appropriate for gestational age (group 2, n = 36), and those born at term with birth weight appropriate for gestational age (group 3, n = 35).
Methods: Systemic BP was measured by an automated device (Dinamap), while stiffness of the brachioradial arterial segment was assessed by measuring pulse wave velocity (PWV). The birth weight was adjusted for gestational age and expressed as a z score for analysis.
Results: The 86 children were studied at a mean (SD) age of 8.2 (1.7) years. Subjects from group 1, who were born at 32.3 (2.0) weeks' gestation had a significantly lower z score of birth weight (-2.29 (0.63), p<0.001), compared with those from groups 2 and 3. They had a significantly higher mean blood pressure (p<0.001) and their diastolic blood pressure also tended to be higher (p = 0.07). Likewise, their brachioradial PWV, and hence arterial stiffness, was the highest of the three groups (p<0.001). While subjects from group 2 were similarly born preterm, their PWV was not significantly different from that of group 3 subjects (p = 1.00) and likewise their z score of birth weight did not differ (-0.01 (0.71) v -0.04 (1.1), p = 1.00). Brachioradial PWV correlated significantly with systolic (r = 0.31, p = 0.004), diastolic (r = 0.38, p<0.001), and mean (0.47, p<0.001) BP, and with z score of birth weight (r = -0.43, p<0.001). Multiple linear regression identified mean BP and z score of birth weight as significant determinants of PWV.
Conclusion: The findings of the present study support the hypothesis that among children born preterm, only those with intrauterine growth retardation are disadvantaged as a result of increase in systemic arterial stiffness and mean blood pressure.
doi:10.1136/adc.2003.025999
PMCID: PMC1719813  PMID: 14977693
13.  Alcohol Intake and Blood Pressure: A Systematic Review Implementing a Mendelian Randomization Approach 
PLoS Medicine  2008;5(3):e52.
Background
Alcohol has been reported to be a common and modifiable risk factor for hypertension. However, observational studies are subject to confounding by other behavioural and sociodemographic factors, while clinical trials are difficult to implement and have limited follow-up time. Mendelian randomization can provide robust evidence on the nature of this association by use of a common polymorphism in aldehyde dehydrogenase 2 (ALDH2) as a surrogate for measuring alcohol consumption. ALDH2 encodes a major enzyme involved in alcohol metabolism. Individuals homozygous for the null variant (*2*2) experience adverse symptoms when drinking alcohol and consequently drink considerably less alcohol than wild-type homozygotes (*1*1) or heterozygotes. We hypothesise that this polymorphism may influence the risk of hypertension by affecting alcohol drinking behaviour.
Methods and Findings
We carried out fixed effect meta-analyses of the ALDH2 genotype with blood pressure (five studies, n = 7,658) and hypertension (three studies, n = 4,219) using studies identified via systematic review. In males, we obtained an overall odds ratio of 2.42 (95% confidence interval [CI] 1.66–3.55, p = 4.8 × 10−6) for hypertension comparing *1*1 with *2*2 homozygotes and an odds ratio of 1.72 (95% CI 1.17–2.52, p = 0.006) comparing heterozygotes (surrogate for moderate drinkers) with *2*2 homozygotes. Systolic blood pressure was 7.44 mmHg (95% CI 5.39–9.49, p = 1.1 × 10−12) greater among *1*1 than among *2*2 homozygotes, and 4.24 mmHg (95% CI 2.18–6.31, p = 0.00005) greater among heterozygotes than among *2*2 homozygotes.
Conclusions
These findings support the hypothesis that alcohol intake has a marked effect on blood pressure and the risk of hypertension.
Using a mendelian randomization approach Sarah Lewis and colleagues find strong support for the hypothesis that alcohol intake has a marked effect on blood pressure and the risk of hypertension.
Editors' Summary
Background.
High blood pressure (hypertension) is a common medical condition that affects nearly a third of US and UK adults. Hypertension has no symptoms but can lead to heart attacks or strokes. It is diagnosed by measuring blood pressure—the force that blood moving around the body exerts on the inside of large blood vessels. Blood pressure is highest when the heart is pumping out blood (systolic pressure) and lowest when it is filling up with blood (diastolic pressure). Normal blood pressure is defined as a systolic pressure of less than 130 millimeters of mercury (mmHg) and a diastolic pressure of less than 85 mmHg (a blood pressure of 130/85). A reading of more than 140/90 indicates hypertension. Many factors affect blood pressure, but overweight people and individuals who eat too much salty or fatty foods are at high risk of developing hypertension. Mild hypertension can often be corrected by lifestyle changes, but many people also take antihypertensive drugs to reduce their blood pressure.
Why Was This Study Done?
Another modifiable lifestyle factor thought to affect blood pressure is alcohol intake. Observational studies that ask people about their drinking habits and measure their blood pressure suggest that alcohol intake correlates with blood pressure, but they cannot prove a causal link because of “confounding”—other risk factors associated with alcohol drinking, such as diet, might also affect the study participant's blood pressures. A trial that randomly assigns people to different alcohol intakes could provide this proof of causality, but such a trial is impractical. In this study, therefore, the researchers have used “Mendelian randomization” to investigate whether alcohol intake affects blood pressure. An inactive variant of aldehyde dehydrogenase 2 (ALDH2; the enzyme that removes alcohol from the body) has been identified. People who inherit the variant form of this gene from both parents have an ALDH2 *2*2 genotype (genetic makeup) and become flushed and nauseated after drinking. Consequently, they drink less than people with a *1*2 genotype and much less than those with a *1*1 genotype. Because inheritance of these genetic variants does not affect lifestyle factors other than alcohol intake, an association between ALDH2 genotypes and blood pressure would indicate that alcohol intake has an effect on blood pressure without any confounding.
What Did the Researchers Do and Find?
The researchers identified ten published studies (mainly done in Japan where the ALDH2 gene variant is common) on associations between ALDH2 genotype and blood pressure or hypertension using a detailed search protocol (a “systematic review”). A meta-analysis (a statistical method for combining the results of independent studies) of the studies that had investigated the association between ALDH2 genotype and hypertension showed that men with the *1*1 genotype (highest alcohol intake) and those with the *1*2 genotype (intermediate alcohol intake) were 2.42 and 1.72 times more likely, respectively, to have hypertension than those with the *2*2 genotype (lowest alcohol intake). There was no association between ALDH2 genotype and hypertension among the women in these studies because they drank very little. Systolic and diastolic blood pressures showed a similar relationship to ALDH2 genotype in a second meta-analysis of relevant studies. Finally, the researchers estimated that for men the lifetime effect of drinking 1 g of alcohol a day (one unit of alcohol contains 8 g of alcohol in the UK and 14 g in the US; recommended daily limits in these countries are 3–4 and 1–2 units, respectively) would be an increase in systolic blood pressure of 0.24 mmHg.
What Do These Findings Mean?
These findings support the suggestion that alcohol has a marked effect on blood pressure and hypertension. Consequently, some cases of hypertension could be prevented by encouraging people to reduce their daily alcohol intake. Although the Mendelian randomization approach avoids most of the confounding intrinsic to observational studies, it is possible that a gene near ALDH2 that has no effect on alcohol intake affects blood pressure, since genes are often inherited in blocks. Alternatively, ALDH2 could affect blood pressure independent of alcohol intake. The possibility that ALDH2 could effect blood pressure independently of alcohol is intake made unlikely by the fact that no effect of genotype on blood pressure is seen among women who drink very little. Additional large-scale studies are needed to address these possibilities, to confirm the current finding in more people, and to improve the estimates of the effect that alcohol intake has on blood pressure.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050052.
The MedlinePlus encyclopedia has a page on hypertension (in English and Spanish)
The American Heart Association provides information for patients and health professionals about hypertension
The UK Blood Pressure Association provides information for patients and health professionals on all aspects of hypertension, including information about alcohol affects blood pressure
The Explore@Bristol science center (a UK charity) provides an alcohol unit calculator and information on the effects of alcohol
The International Center for Alcohol Policies provides drinking guidelines for countries around the world
doi:10.1371/journal.pmed.0050052
PMCID: PMC2265305  PMID: 18318597
14.  Size at Birth, Infant Growth, and Blood Pressure at 3 Years of Age 
The Journal of pediatrics  2007;151(6):670-674.
Objectives
Our aim was to determine the extent to which infant growth – in weight-for-length – from birth to 6 months is associated with systolic blood pressure (SBP) at 3 years, and to determine whether this association varies with birth size.
Study design
In 530 children from the prospective cohort Project Viva, we measured birth length and 6-month weight and length with research standard instruments and SBP at age 3 years with a Dinamap automated recorder. We derived weight-for-length z-scores (WFL-z) and analyzed data with mixed effect regression models.
Results
Mean (SD) WFL-z was 0.47(0.75) at birth and 0.70(0.96) at 6 months. Mean (SD) SBP at 3 years was 91.7(9.4) mmHg. After adjusting for confounding variables and birth WFL-z, child SBP was 1.0mmHg (95% CI 0.2, 1.8) higher for each z-score increment in 6-month WFL-z. SBP of children in the lowest birth WFL-z quartile and the highest 6-month WFL-z quartile was 5.5mmHg (95% CI 2.6, 8.4) higher than of children in the highest birth and lowest 6-month WFL-z quartiles.
Conclusions
More rapid increase in weight-for-length, a measure of adiposity, in the first 6 months of life is associated with higher early childhood systolic blood pressure, particularly in children who are thin at birth.
doi:10.1016/j.jpeds.2007.05.010
PMCID: PMC2278009  PMID: 18035150
Hypertension; epidemiology
15.  Arterial distensibility in children and teenagers: normal evolution and the effect of childhood vasculitis 
Archives of Disease in Childhood  2002;87(4):348-351.
Background: Polyarteritis nodosa is a necrotising vasculitis of the medium sized and small muscular arteries. The inflammatory and subsequent reparative processes may alter the arterial mechanical properties. The effect of vasculitic damage on arterial distensibility has never been explored however.
Aim: To determine the normal values and the effect of childhood vasculitis on arterial distensibility in children and teenagers.
Methods: Distensibility of the brachioradial arterial segment was studied using pulse wave velocity (PWV ∝1/√distensibility), in 13 children with polyarteritis nodosa at a median age of 11.8 (range 4.9–16) years. As a control group, 155 healthy schoolchildren (6–18 years, 81 boys) were studied. PWV was assessed using a photoplethysmographic technique; blood pressure was measured by an automatic sphygmomanometer (Dinamap). Data from patients were expressed as z scores adjusted for age and compared to a population mean of 0 by a single sample t test. Determinants of PWV in normal children were assessed by univariate and multivariate linear regression analyses.
Results: Age, height, weight, and systolic blood pressure correlated individually with the brachioradial PWV. Multivariate analysis identified age as the only independent determinant. Ten of the patients were in clinical remission, while three had evidence of disease activity at the time of study. The PWV in the patient group as a whole was significantly greater than those in healthy children (mean z score +0.99). Raised C reactive protein concentration (>2 mg/dl) in the three patients with active disease was associated with a higher PWV when compared to those in remission (z score +2.78 v +0.45). The diastolic blood pressure of the patients was higher than those of the controls (z score +1.04) while the systolic pressure was similar (z score -0.36).
Conclusions: PWV in the brachioradial arterial segment increases gradually during childhood independent of body weight, height, mass, and blood pressure. Increased PWV, and hence decreased distensibility, in this peripheral arterial segment occurs in polyarteritis nodosa and is amplified during acute inflammatory exacerbation.
doi:10.1136/adc.87.4.348
PMCID: PMC1763025  PMID: 12244018
16.  Physical activity, physical fitness, blood pressure, and fibrinogen in the Northern Ireland health and activity survey. 
STUDY OBJECTIVE: To investigate the relationship between physical activity, physical fitness, blood pressure, and fibrinogen. DESIGN: This was a cross sectional population study using a two stage probability sample. SETTING: Northern Ireland. PARTICIPANTS: A sample of 1600 subjects aged 16-74 years from the population of Northern Ireland. MAIN OUTCOME MEASURES: Physical activity profile from computer assisted interview using the Allied Dunbar national fitness survey scales. Physical fitness using estimation of VO2 max by extrapolation from submaximal oxygen uptake while walking on a motor driven treadmill. Systolic and diastolic blood pressure measured with a Hawksley random zero sphygmomanometer. Measurement of fibrinogen using the Clauss method. MAIN RESULTS: There were significant relationships between both current and past activity and blood pressure. These were of a magnitude that would have been clinically significant, but for the fact that, with the exception of the relationship between habitual activity and diastolic pressure (p = 0.03) and past activity and systolic pressure (p = 0.03) in men, they were not sustained after adjustment for the effect of age using analysis of variance. After adjustment for other potentially confounding factors using multiple regression, there was an inverse relationship between systolic blood pressure and past activity in men, so that those with a life-time of participation compared with a life-time of inactivity had a lower systolic blood pressure of 6 mmHg (p < 0.05). There was a highly significant (p < 0.001) inverse association between both systolic and diastolic blood pressure and physical fitness (VO2 max) which was not sustained after adjustment for possible confounding factors. There were relationships between fibrinogen and highest recorded activity (p < 0.001), habitual activity (p < 0.01), and past activity (p < 0.01) in men but no significant relationship in women. The relationship between fibrinogen and activity was no longer sustained after adjustment for possible confounding factors. There was a highly significant (p < 0.001) inverse relationship with physical fitness using VO2 max. This relationship was sustained after adjustment for possible confounding factors in both men (p < 0.05) and women (p < 0.001). CONCLUSIONS: There was a relationship between physical activity, physical fitness, and blood pressure but the relationship was greatly influenced by age. A reduction of 6 mmHg in systolic blood pressure associated with past activity is of clinical significance and supports the hypothesis that physical activity is of benefit in reducing cardiovascular risk. There was a lower level of fibrinogen in those who were most active but this relationship was not significant after adjustment for possible confounding factors. There was also a lower level of fibrinogen those who were most fit (VO2 max) and this relationship persisted even after adjustment for possible confounding factors.
PMCID: PMC1060280  PMID: 8935455
17.  Orthostatic hypotension before and after meal intake in diabetic patients and healthy elderly people 
Objectives:
The symptoms of orthostatic hypotension may be ignored or go unnoticed and may predispose some diabetic or elderly people to repeated falls and trauma, leading to immobility and prolongation of rehabilitation. The present investigation is concerned mainly with testing the reaction of the cardiovascular system in response to physiological stimuli, such as, standing upright from a supine position before and after meal intake in diabetic patients and the healthy Saudi population.
Materials and Methods:
Seventy-five healthy and 49 diabetic patients were selected for this study. Parameters of heart rate, systolic and diastolic blood pressures, and electrocardiograms (ECG) were obtained for each subject by Dinamap (an automatic recorder), after 10 minutes of rest in the supine position and then after one and two minutes of standing. All parameters were taken before and after an intake of a standard meal. The results were compared between the diabetic and non-diabetic groups, and between the elderly diabetic and the healthy elderly ≥ 65 year olds, and between the young adults ≤ 40 year olds and the elderly ≥ 65 year olds.
Results:
The postural changes of blood pressure and heart rate between the diabetic and non-diabetic groups, and between the elderly diabetic and the healthy elderly groups, were not significant. However, a highly significant postural drop in blood pressure, and an increase in the resting heart rate were recorded before and after a meal intake in the elderly compared to the young adults.
Conclusion:
The highly significant postural drop in blood pressure and increase in the resting heart rate in the elderly diabetic and healthy elderly people can be attributed to a defect in the arterial baroreceptors control of blood pressure and parasympathetic control of heart rate in this population.
doi:10.4103/2230-8229.94007
PMCID: PMC3326766  PMID: 22518354
Blood pressure; diabetic; elderly; heart rate; orthostatic hypotension
18.  Blood pressure centiles for Great Britain 
Archives of Disease in Childhood  2006;92(4):298-303.
Objective:
To produce representative cross-sectional blood pressure reference centiles for children and young people living in Great Britain.
Design:
Analysis of blood pressure data from seven nationally representative surveys: Health Surveys for England 1995–8, Scottish Health Surveys 1995 and 1998, and National Diet & Nutrition Survey 1997.
Methods:
Blood pressure was measured using the Dinamap 8100 with the same protocol throughout. Weight and height were also measured. Data for 11 364 males and 11 537 females aged 4–23 years were included in the analysis, after excluding 0.3% missing or outlying data. Centiles were derived for systolic, diastolic, mean arterial and pulse pressure using the lambda-mu-sigma (LMS) equations method.
Results:
Blood pressure in the two sexes was similar in childhood, rising progressively with age and more rapidly during puberty. Systolic pressure rose faster and was appreciably higher in adult men than in adult women. After adjustment for age, blood pressure was related more to weight than height, the effect being stronger for systolic blood pressure. Pulse pressure peaked at 18 years in males and 16 years in females.
Conclusions:
These centiles increase our knowledge of blood pressure norms in contemporary British children and young people. High blood pressure for age should be defined as blood pressure above the 98th centile, and high-normal blood pressure for age as blood pressure between the 91st and 98th centiles. The centiles identify children and young people with increased blood pressure, and will be of benefit to both clinical practice and research.
doi:10.1136/adc.2005.081216
PMCID: PMC2083671  PMID: 16905566
19.  Blood pressure centiles for Great Britain 
Archives of Disease in Childhood  2006;92(4):298-303.
Objective
To produce representative cross‐sectional blood pressure reference centiles for children and young people living in Great Britain.
Design
Analysis of blood pressure data from seven nationally representative surveys: Health Surveys for England 1995–8, Scottish Health Surveys 1995 and 1998, and National Diet & Nutrition Survey 1997.
Methods
Blood pressure was measured using the Dinamap 8100 with the same protocol throughout. Weight and height were also measured. Data for 11 364 males and 11 537 females aged 4–23 years were included in the analysis, after excluding 0.3% missing or outlying data. Centiles were derived for systolic, diastolic, mean arterial and pulse pressure using the latent moderated structural (LMS) equations method.
Results
Blood pressure in the two sexes was similar in childhood, rising progressively with age and more rapidly during puberty. Systolic pressure rose faster and was appreciably higher in adult men than in adult women. After adjustment for age, blood pressure was related more to weight than height, the effect being stronger for systolic blood pressure. Pulse pressure peaked at 18 years in males and 16 years in females.
Conclusions
These centiles increase our knowledge of blood pressure norms in contemporary British children and young people. High blood pressure for age should be defined as blood pressure above the 98th centile, and high‐normal blood pressure for age as blood pressure between the 91st and 98th centiles. The centiles identify children and young people with increased blood pressure, and will be of benefit to both clinical practice and research.
doi:10.1136/adc.2005.081216
PMCID: PMC2083671  PMID: 16905566
20.  Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial 
Objective To compare the quality and accuracy of manual office blood pressure and automated office blood pressure using the awake ambulatory blood pressure as a gold standard.
Design Multi-site cluster randomised controlled trial.
Setting Primary care practices in five cities in eastern Canada.
Participants 555 patients with systolic hypertension and no serious comorbidities under the care of 88 primary care physicians in 67 practices in the community.
Interventions Practices were randomly allocated to either ongoing use of manual office blood pressure (control group) or automated office blood pressure (intervention group) using the BpTRU device. The last routine manual office blood pressure (mm Hg) was obtained from each patient’s medical record before enrolment. Office blood pressure readings were compared before and after enrolment in the intervention and control groups; all readings were also compared with the awake ambulatory blood pressure.
Main outcome measure Difference in systolic blood pressure between awake ambulatory blood pressure minus automated office blood pressure and awake ambulatory blood pressure minus manual office blood pressure.
Results Cluster randomisation allocated 31 practices (252 patients) to manual office blood pressure and 36 practices (303 patients) to automated office blood pressure measurement. The most recent routine manual office blood pressure (149.5 (SD 10.8)/81.4 (8.3)) was higher than automated office blood pressure (135.6 (17.3)/77.7 (10.9)) (P<0.001). In the control group, routine manual office blood pressure before enrolment (149.9 (10.7)/81.8 (8.5)) was reduced to 141.4 (14.6)/80.2 (9.5) after enrolment (P<0.001/P=0.01), but the reduction in the intervention group from manual office to automated office blood pressure was significantly greater (P<0.001/P=0.02). On the first study visit after enrolment, the estimated mean difference for the intervention group between the awake ambulatory systolic/diastolic blood pressure and automated office blood pressure (−2.3 (95% confidence interval −0.31 to −4.3)/−3.3 (−2.7 to −4.4)) was less (P=0.006/P=0.26) than the difference in the control group between the awake ambulatory blood pressure and the manual office blood pressure (−6.5 (−4.3 to −8.6)/−4.3 (−2.9 to −5.8)). Systolic/diastolic automated office blood pressure showed a stronger (P<0.001) within group correlation (r=0.34/r=0.56) with awake ambulatory blood pressure after enrolment compared with manual office blood pressure versus awake ambulatory blood pressure before enrolment (r=0.10/r= 0.40); the mean difference in r was 0.24 (0.12 to 0.36)/0.16 (0.07 to 0.25)). The between group correlation comparing diastolic automated office blood pressure and awake ambulatory blood pressure (r=0.56) was stronger (P<0.001) than that for manual office blood pressure versus awake ambulatory blood pressure (r=0.30); the mean difference in r was 0.26 (0.09 to 0.41). Digit preference with readings ending in zero was substantially reduced by use of automated office blood pressure.
Conclusion In compliant, otherwise healthy, primary care patients with systolic hypertension, introduction of automated office blood pressure into routine primary care significantly reduced the white coat response compared with the ongoing use of manual office blood pressure measurement. The quality and accuracy of automated office blood pressure in relation to the awake ambulatory blood pressure was also significantly better when compared with manual office blood pressure.
Trial registration Clinical trials NCT 00214053.
doi:10.1136/bmj.d286
PMCID: PMC3034423  PMID: 21300709
21.  Patient self-monitoring of blood pressure in general practice: the 'inverse white-coat' response. 
Self-monitoring of blood pressure may give a truer estimate of usual blood pressure than readings by a doctor in the surgery, and may save time for health professionals. This study aimed to determine the accuracy of self-monitoring in the surgery using a wrist oscillometric sphygmomanometer (Omron RX). One hundred and seventy-three patients were taught to record their own blood pressure with the Omron RX. One hundred and nineteen patients recorded three self-measurements at monthly intervals, and their readings were compared with those of an experienced nurse using the Omron RX and a mercury sphygmomanometer. On average, patients' readings were higher than the nurse's readings (mean difference in phase 1 = systolic pressure 4.7 +/- 13.1 mmHg, diastolic pressure 2.7 +/- 9.3 mmHg [both P < 0.001]). Only half of the patients' readings were within 10 mmHg systolic and 5 mmHg diastolic of the nurse's readings. The readings by the nurse using both devices did not differ.
PMCID: PMC1314549  PMID: 14694700
22.  HYPERTENSION IN THE EASTERN PROVINCE OF SAUDI ARABIA: RESULTS OF A SCREENING CAMPAIGN 
Objective:
To estimate the prevalence of hypertension through a screening campaign in the Eastern Province of Saudi Arabia, and examine its association with lifestyle factors.
Research Design and Methods:
In 2004, all Saudi residents in the Eastern Province, aged 30 years and above were invited to participate in a screening campaign for the early detection of diabetes and hypertension. Blood pressure was recorded by trained nurses using a mercury sphygmomanometer, based on the recommendations of (JNC- VII). A positive screening test for hypertension was defined as systolic and/or diastolic blood pressure of ≥ 140 and 90 mm Hg, respectively. Subjects who had positive screening tests were asked to come on the following day for a confirmation of the reading. Hypertension was considered if there was a persistent reading of systolic and/or diastolic blood pressure of ≥ 140 and 90 mmHg after confirmation, or when there was history of a previous diagnosis.
Results:
21% of the sample was positive from previous history or screening. After confirmation, the prevalence of hypertension dropped to 15.6%, pre-hypertension was 3.7%, whereas the prevalence of undiagnosed hypertension was 2.8%. The prevalence rose with age. It was higher in women than in men of all age groups and in all sectors of the eastern province, although the mean systolic and diastolic BP was higher in men than women. It was higher with lower education, in widows and divorcees than others (P<0.0001).
Conclusion:
The yield of the screening for abnormal blood pressure was high. Systematic follow-up of subjects with abnormal screening results is vital.
PMCID: PMC3377128  PMID: 23012174
Hypertension; Screening; Saudi Arabia
23.  Agreement of Blood Pressure Measurements between Random-Zero and Standard Mercury Sphygmomanometers 
The random-zero sphygmomanometer has been widely used in observational studies and clinical trials for blood pressure measurement. We examined the agreement of blood pressure measurements between random-zero and standard mercury sphygmomanometers among 2,007 Chinese study participants aged 15–60 years. Three blood pressure readings were obtained by trained observers using random-zero and standard mercury sphygmomanometers, respectively, in a random order. Overall, blood pressure readings obtained using the random-zero device were significantly lower than those obtained with the standard mercury sphygmomanometer, with a mean difference ranging from −3.0 to −2.7 mm Hg for systolic and −1.4 to −0.9 mm Hg for diastolic blood pressure (all p <0.01). Correlation coefficients between mean blood pressure measurements obtained using the random-zero and standard mercury sphygmomanometers were high (0.90 for systolic and 0.85 for diastolic blood pressure, both p< 0.0001). In conclusion, our study indicated that there was strong agreement between blood pressure measurements obtained using the random-zero and standard mercury sphygmomanometers although blood pressure values were on average lower with the random-zero sphygmomanometer.
doi:10.1097/MAJ.0b013e31816956ac
PMCID: PMC2587170  PMID: 19011391
blood pressure measurements; random-zero sphygmomanometer; standard mercury sphygmomanometer; agreement
24.  Field evaluation of the Copal UA-231 automatic sphygmomanometer. 
Automated sphygmomanometers should be evaluated in field studies before being recommended for epidemiological use. In this study an automated sphygmomanometer, the Copal UA-231, was evaluated on the basis of duplicate blood pressure measurements, one with this machine and one with a Hawksley random zero machine, taken on 1536 participants in a health survey. The Copal-random zero differences had a mean of 2.3 mm Hg for systolic blood pressure and 1.9 mm Hg for diastolic pressure, the Copal reading higher than the random zero. The standard deviations of these differences were similar to the standard deviations of the differences between two random zero measurements taken on subjects in a separate survey. However, Copal-random zero differences varied systemically with blood pressure levels. In this study a 10 mm Hg increase in systolic blood pressure was associated with a 1.22 mm Hg increase in the Copal-random zero difference and a 10 mm Hg increase in diastolic blood pressure was associated with a 1.15 mm Hg increase in the Copal-random zero difference. The Copal UA-231 is recommended for use in field surveys, but it should be recognised that a small systematic increase in Copal-random zero difference with increasing blood pressure may complicate interpretation of epidemiological associations.
PMCID: PMC1052759  PMID: 3256572
25.  Seaweed intake and blood pressure levels in healthy pre-school Japanese children 
Nutrition Journal  2011;10:83.
Background
Few studies have examined whether dietary factors might affect blood pressure in children. We purposed to investigate whether seaweed intake is associated with blood pressure level among Japanese preschool children.
Methods
The design of the study was cross-sectional and it was conducted in autumn 2006. Subjects were healthy preschoolers aged 3-6 years in Aichi, Japan. Blood pressure and pulse were measured once by an automated sphygmomanometer, which uses oscillometric methods. Dietary data, including seaweed intake, were assessed using 3-day dietary records covering 2 consecutive weekdays and 1 weekend day. Of a total of 533 children, 459 (86.1 percent) agreed to be enrolled in our study. Finally, blood pressure measurement, complete dietary records and parent-reported height and weight were obtained for 223 boys and 194 girls.
Results
When we examined Spearman's correlation coefficients, seaweed intake was significantly negatively related to systolic blood pressure in girls (P = 0.008). In the one-way analysis of covariance for blood pressure and pulse after adjustments for age and BMI, the boys with the lowest, middle and highest tertiles of seaweed intake had diastolic blood pressure readings of 62.8, 59.3 and 59.6 mmHg, respectively (P = 0.11, trend P = 0.038). Girls with higher seaweed intake had significantly lower systolic blood pressure readings (102.4, 99.2 and 96.9 mmHg for girls with the lowest, middle and highest tertiles of seaweed intake, respectively; P = 0.037, trend P = 0.030).
Conclusion
Our study showed that seaweed intake was negatively related to diastolic blood pressure in boys and to systolic blood pressure in girls. This suggests that seaweed might have beneficial effects on blood pressure among children.
doi:10.1186/1475-2891-10-83
PMCID: PMC3199754  PMID: 21827710
blood pressure; child, preschool; diet records; seaweed; nutrition

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