Background Intravenous hydralazine is approved for the treatment of hypertensive emergency and widely used for hypertension associated with toxemia of pregnancy. As we had observed increased off-label use of this agent in area hospitals, we studied its use in a University teaching hospital. Methods Patients were identified prospectively between April and October 2010 from all hospitalized patients who had an order for intravenous hydralazine entered into the computerized physician order entry system. Clinician prescribers were unaware that this study was being conducted. Demographic and clinical information, including pre-treatment blood pressure (BP), change in BP and heart rate (HR) within 2 hours post-administration of hydralazine, concurrent and follow-up antihypertensive medications, and adverse events were obtained. Results There were 94 patients (mean age, 69 ± 18 years, 48% women, 89% with chronic hypertension) who received 201 intravenous hydralazine doses (mean dose of 11.4 ± 4.3 mg). Only 4 (2%) of patients had evidence of an urgent hypertensive condition (e.g., symptoms, target organ injury). Baseline BP was 175/82 ± 25/16 mmHg and following hydralazine was reduced by 24/9 ± 29/15 mmHg while HR increased by 4 ± 13 beats/min. Changes from baseline in BP were related to baseline BP: change in BP in the lower baseline range was −3 ± 20 mmHg while change observed in those with the highest range of baseline blood pressure was −35 ± 25 mmHg. Seventeen patients experienced an adverse event, the most common being hypotension (n=11). Conclusions Intravenous hydralazine is commonly prescribed for non-urgent cases of hypertension in the hospitalized patient. Changes in systolic BP, while related to baseline BP values, are nevertheless, highly variable. There is risk of hypotension associated with its use. There is evidence that this agent is not useful for many patients with hypertension in the hospital setting and may cause harm if used inappropriately.

Background Facility-based, multimonth dispensing of antiretroviral therapy (ART) for HIV could reduce burdens on patients and providers and improve retention in care. We assessed whether 6-monthly ART dispensing was non-inferior to standard of care and 3-monthly ART dispensing.Methods We did a pragmatic, cluster-randomised, unblinded, non-inferiority trial (INTERVAL) at 30 health facilities in Malawi and Zambia. Eligible participants were aged 18 years or older, HIV-positive, and were clinically stable on ART. Before randomisation, health facilities (clusters) were matched on the basis of country, ART cohort size, facility type (ie, hospital vs health centre), and region or province. Matched clusters were randomly allocated (1:1:1) to standard of care, 3-monthly ART dispensing, or 6-monthly ART dispensing using a simple random allocation sequence. The primary outcome was retention in care at 12 months, defined as the proportion of patients with less than 60 consecutive days without ART during study follow-up, analysed by intention to treat. A 2•5% margin was used to assess noninferiority. This study is registered with ClinicalTrials.gov, NCT03101592.

Respondents appeared balanced in their perceptions of this innovation and what it could realistically achieve. They were not indifferent to the many short and long-term problems that need to be resolved before it can be claimed to have become embedded in practice. The success of non-medical prescribing may depend on organizational support, coupled with a robust continuing professional development strategy for all nurse prescribers.

Data for liver transplant recipients (LTRs) regarding the benefit of care concordant with clinical practice guidelines for management of blood pressure (BP) are sparse. This paper reports on clinician adherence with BP clinical practice guideline recommendations and whether BP control is associated with mortality and cardiovascular events (CVEs) among LTRs. We conducted a longitudinal cohort study of adult LTRs who survived to hospital discharge at a large tertiary care network between 2010 and 2016. The primary exposure was a BP of <140/<90 mm Hg within year 1 of LT. Among 602 LTRs (mean age 56.7 years, 64% men), 92% had hypertension and 38% had new onset hypertension. Less than 30% of LTRs achieved a BP of <140/<90 mm Hg over a mean of 43.2 months. In multivariable models, adjusted for key confounders, BP control post‐LT compared with lack of control was associated with a significantly lower hazard of mortality (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.39, 0.87) and of CVEs (HR 0.65, 95% CI 0.43, 0.97). The association between BP control of <140/<90 mm Hg with improved survival and decreased CVEs in LTRs suggests that efforts to improve clinician adherence to BP clinical practice recommendations should be intensified.

While it is known that reproducibility of ambulatory blood pressure (BP) is superior to office BP in middle-aged subjects, little is known older age groups. Hence, we compared the long-term reproducibility of ambulatory and office BP readings in subjects over the age of 75 years. A cohort of 72 subjects 75-90 years of age (mean, 82 years at baseline) had repeat office and ambulatory blood pressures 2 years apart under similar conditions. On the same day, patients underwent office BP measurements by a semi-automated device and then by ambulatory BP monitoring. Awake and sleep periods were divided according to a diary kept by each patient. The agreement between studies was assessed using the standard deviation of the differences (SDD) and Bland-Altman plots. There were minimal mean changes in office, 24-hour, awake and sleep mean BP values between baseline and 2 years later. The SDDs between visits were lower for 24-hour BP compared to the office BP (11.7/5.9 mmHg versus 17.8/9.0 mmHg, p < 0.01). The SDD for 24-hour BP was also lower than the SDDs for the awake and sleep BP (p < 0.05). Nocturnal BPs defined by absolute values were more reproducible than categories of dippers and non-dippers. These data demonstrate that long-term reproducibility of 24-hour BP is superior to office measurements for very elderly subjects. In a clinical trial involving this age group, far fewer subjects would be required if 24-hour BP was the primary efficacy endpoint rather than the office BP.