Objective To systematically review studies quantifying the associations of long term (clinic), mid-term (home), and short term (ambulatory) variability in blood pressure, independent of mean blood pressure, with cardiovascular disease events and mortality.Data sources Medline, Embase, Cinahl, and Web of Science, searched to 15 February 2016 for full text articles in English.Eligibility criteria for study selection Prospective cohort studies or clinical trials in adults, except those in patients receiving haemodialysis, where the condition may directly impact blood pressure variability. Standardised hazard ratios were extracted and, if there was little risk of confounding, combined using random effects meta-analysis in main analyses. Outcomes included all cause and cardiovascular disease mortality and cardiovascular disease events. Measures of variability included standard deviation, coefficient of variation, variation independent of mean, and average real variability, but not night dipping or day-night variation.Results 41 papers representing 19 observational cohort studies and 17 clinical trial cohorts, comprising 46 separate analyses were identified. Long term variability in blood pressure was studied in 24 papers, mid-term in four, and short-term in 15 (two studied both long term and short term variability). Results from 23 analyses were excluded from main analyses owing to high risks of confounding. Increased long term variability in systolic blood pressure was associated with risk of all cause mortality (hazard ratio 1.15, 95% confidence interval 1.09 to 1.22), cardiovascular disease mortality (1.18, 1.09 to 1.28), cardiovascular disease events (1.18, 1.07 to 1.30), coronary heart disease (1.10, 1.04 to 1.16), and stroke (1.15, 1.04 to 1.27). Increased mid-term and short term variability in daytime systolic blood pressure were also associated with all cause mortality (1.15, 1.06 to 1.26 and 1.10, 1.04 to 1.16, respectively).Conclusions Long term variability in blood pressure is associated with cardiovascular and mortality outcomes, over and above the effect of mean blood pressure. Associations are similar in magnitude to those of cholesterol measures with cardiovascular disease. Limited data for mid-term and short term variability showed similar associations. Future work should focus on the clinical implications of assessment of variability in blood pressure and avoid the common confounding pitfalls observed to date.Systematic review registration PROSPERO CRD42014015695.

The application of precision medicine requires in-depth characterisation of a patient's tumours and the dynamics of their responses to treatment. We used next-generation sequencing of cfDNA to monitor therapy responses of a metastatic vaginal mucosal melanoma and show that cfDNA can be used to monitor tumour evolution and subclonal responses to therapy even when biopsies are not available.

Looked after children represent a vulnerable group in society, many of whom are exposed to maltreatment, particularly in the form of relational trauma, prior to placement with a foster family. Challenging behaviours can place foster placements at risk and looked after children often confront the possibility of placement breakdown. A carer's capacity to retain a robust understanding of the children in their care as autonomous individuals with needs, feelings and thoughts may reveal to be important in enabling them to respond more effectively to the worrying or disruptive behaviour they might experience. The Reflective Fostering Programme (RFP) is a new group-based programme aiming to support foster carers of children aged 4-11.This innovative development follows calls by NICE and other organisations to help improve outcomes for children in care, by improving resources to their carers. The RFP is rooted in evidence drawn from the field of contemporary attachment and mentalizing research, which indicates that children who have a carer high in reflective functioning tend to have more favourable outcomes in terms of social-emotional wellbeing. It also draws on the evidence that looking after a child who has impaired capacity to mentalize as a result of early relational trauma has an impact on the carer's capacity to mentalize and respond sensitively to the child (Ensink et al., 2015). This paper sets out the rationale for the RFP, outlines its key elements, and concludes by outlining future service implementation and a planned feasibility study examining this approach. Key wordsMentalization, reflective fostering, foster carers, looked after children, interventions IntroductionThe number of looked after children in England and Wales has been growing steadily in the last few years. In March 2016 there were 70,440 children in care, up by 5% compared to 2012 2 (Department for Education [DfE], 2016). Additionally, there has been a move away from residential and toward fostering placements, with three-quarters of looked after children placed with foster carers (DfE, 2016). This is in recognition of the fact that children develop best in the context of stable, predictable relationships, with present and available caregivers, and that foster care is in many ways the most important 'intervention' that can be offered to a child who is not able to live with their birth family (National Institute for Health and Care Excellence [NICE], 2013).Despite the clear advantages of foster care, children in such placements can place great demand on carers, who aren't always provided with sufficient training and ongoing support to cope with the various demands of the role (Bunday et al., 2015; Gurney-Smith et al., 2017;Schofield et al., 2000;Sinclair et al., 2000). More than 45% of looked after children have a diagnosable mental health disorder-five times the prevalence of mental health disorder among children in the general population (NICE, 2013). Experiences of neglect and trauma are common within this group of children, but...

Although self-monitoring of blood pressure is common among people with hypertension, little is known about how general practitioners (GPs) use such readings. This survey aimed to ascertain current views and practice on self-monitoring of UK primary care physicians. An internet-based survey of UK GPs was undertaken using a provider of internet services to UK doctors. The hyperlink to the survey was opened by 928 doctors, and 625 (67%) GPs completed the questionnaire. Of them, 557 (90%) reported having patients who self-monitor, 191 (34%) had a monitor that they lend to patients, 171 (31%) provided training in self-monitoring for their patients and 52 (9%) offered training to other GPs. Three hundred and sixty-seven GPs (66%) recommended at least two readings per day, and 416 (75%) recommended at least 4 days of monitoring at a time. One hundred and eighty (32%) adjusted self-monitored readings to take account of lower pressures in out-of-office settings, and 10/5 mm Hg was the most common adjustment factor used. Self-monitoring of blood pressure was widespread among the patients of responding GPs. Although the majority used appropriate schedules of measurement, some GPs suggested much more frequent home measurements than usual. Further, interpretation of home blood pressure was suboptimal, with only a minority recognising that values for diagnosis and on-treatment target are lower than those for clinic measurement. Subsequent national guidance may improve this situation but will require adequate implementation.

BackgroundAmbulatory and/or home monitoring are recommended in the UK and the US for the diagnosis of hypertension but little is known about their acceptability.AimTo determine the acceptability of different methods of measuring blood pressure to people from different minority ethnic groups.Design and settingCross-sectional study with focus groups in primary care in the West Midlands.MethodPeople of different ethnicities with and without hypertension were assessed for acceptability of clinic, home, and ambulatory blood pressure measurement using completion rate, questionnaire, and focus groups.ResultsA total of 770 participants were included, who were white British (n = 300), South Asian (n = 241), and African Caribbean (n = 229). White British participants had significantly higher successful completion rates across all monitoring modalities compared with the other ethnic groups, especially for ambulatory monitoring: white British (n = 277, 92% [95% confidence interval [CI] = 89% to 95%]) versus South Asian (n = 171, 71% [95% CI = 65% to 76%], P<0.001) and African Caribbean (n = 188, 82% [95% CI = 77% to 87%], P<0.001), respectively. There were significantly lower acceptability scores for minority ethnic participants across all monitoring methods compared with white British participants. Focus group results highlighted self-monitoring as most acceptable and ambulatory monitoring least acceptable without consistent differences by ethnicity. Clinic monitoring was seen as inconvenient and anxiety provoking but with the advantage of immediate professional input.ConclusionReduced acceptability and completion rates among minority ethnic groups raise important questions for the implementation and interpretation of blood pressure monitoring. Selection of method of blood pressure monitoring should take into account clinical need, patient preference, and potential cultural barriers to monitoring.