Abstract-Low-dose thiazide-type diuretics are recommended as initial therapy for most hypertensive patients. Chlorthalidone has significantly reduced stroke and cardiovascular end points in several landmark trials; however, hydrochlorothiazide remains favored in practice. Most clinicians assume that the drugs are interchangeable, but their antihypertensive effects at lower doses have not been directly compared. We conducted a randomized, single-blinded, 8-week active treatment, crossover study comparing chlorthalidone 12.5 mg/day (force-titrated to 25 mg/day) and hydrochlorothiazide 25 mg/day (force-titrated to 50 mg/day) in untreated hypertensive patients. The main outcome, 24-hour ambulatory blood pressure (BP) monitoring, was assessed at baseline and week 8, along with standard office BP readings every 2 weeks. Thirty patients completed the first active treatment period, whereas 24 patients completed both. An order-drug-time interaction was observed with chlorthalidone; therefore, data from only the first active treatment period was considered.
To diagnose hypertension, multiple blood pressure (BP) measurements are recommended. We randomized patients into three groups: EMR-only (patients recorded BP measurements in an electronic medical record [EMR] web portal), EMR + reminders (patients were sent text message reminders to record their BP measurements in the EMR), and bi-directional text messaging (patients were sent a text message asking them to respond with their current BP). Subjects were asked to complete 14 measurements. Automated messages were sent to each patient in the bi-directional text messaging and EMR + reminder groups twice daily. Among 121 patients, those in the bi-directional text messaging group reported the full 14 measurements more often than both the EMR-only group (P < .001) and the EMR + reminders group (P = .038). Also, the EMR + reminders group outperformed the EMR-only group (P < .001). Bi-directional automated text messaging is an effective way to gather patient BP data. Text-message-based reminders alone are an effective way to encourage patients to record BP measurements.
ObjectivesGradual age-related cognitive deteriorations are common and are hypothesised to be partially attributable to declines in information-processing speed. The Iowa Healthy and Active Minds Study will evaluate the efficacy and effectiveness of a computerised visual processing speed training programme (Road Tour, Posit Science Corporation, San Francisco, California).Methods and analysisUsing a 3:3:4:4 ratio within two age strata (50–64 vs ≥65 years old), 681 men and women attending family care clinics were randomised to four treatment groups: 10 h of on-site Road Tour training, 10 h of on-site Road Tour training with 4 h of booster training at 11 months postrandomisation, 10 h of on-site attention control using computerised crossword puzzles (Boatload of Crosswords, Boatload Puzzles, LLC, Yorktown Heights, New York) and 10 h of at-home Road Tour training using the participant's personal computer. The primary outcome, visual processing speed, was assessed at randomisation and post-training (6–8 weeks postrandomisation), and is being reassessed at 1-year postrandomisation using the Useful Field of View test. Five secondary outcomes (Symbol Digit Modalities Test, Trail Making Tests A and B, Controlled Oral Word Association Test, Digit Vigilance Test, and the Stroop Colour and Word Test) were assessed at randomisation and will be reassessed at 1-year postrandomisation. Seven hypotheses will be tested using intent-to-treat analyses involving multiple linear, logistic, Poisson and negative binomial regression.Ethics and disseminationEthics approval was provided by the University of Iowa Institutional Review Board (IRB-03 protocol 200908789). All participants completed signed informed consent prior to enrolment. Road Tour is commercially available from Posit Science Corporation, which provided it to Iowa Healthy and Active Minds Study at no cost. All participants will receive a free copy of Road Tour for unlimited perpetual use at study completion.Clinical Trial Registration NumberNCT01165463.
ObjectivesInsufficient attention has been given to how information from computer-based clinical case simulations is presented, collected, and scored. Research is needed on how best to design such simulations to acquire valid performance assessment data that can act as useful feedback for educational applications. This report describes a study of a new simulation format with design features aimed at improving both its formative assessment feedback and educational function.MethodsCase simulation software (LabCAPS) was developed to target a highly focused and well-defined measurement goal with a response format that allowed objective scoring. Data from an eight-case computer-based performance assessment administered in a pilot study to 13 second-year medical students was analyzed using classical test theory and generalizability analysis. In addition, a similar analysis was conducted on an administration in a less controlled setting, but to a much large sample (n = 143), within a clinical course that utilized two random case subsets from a library of 18 cases.ResultsClassical test theory case-level item analysis of the pilot assessment yielded an average case discrimination of 0.37, and all eight cases were positively discriminating (range = 0.11–0.56). Classical test theory coefficient alpha and the decision study showed the eight-case performance assessment to have an observed reliability of σ = G = 0.70. The decision study further demonstrated that a G = 0.80 could be attained with approximately 3 h and 15 min of testing. The less-controlled educational application within a large medical class produced a somewhat lower reliability for eight cases (G = 0.53). Students gave high ratings to the logic of the simulation interface, its educational value, and to the fidelity of the tasks.ConclusionsLabCAPS software shows the potential to provide formative assessment of medical students' skill at diagnostic test ordering and to provide valid feedback to learners. The perceived fidelity of the performance tasks and the statistical reliability findings support the validity of using the automated scores for formative assessment and learning. LabCAPS cases appear well designed for use as a scored assignment, for stimulating discussions in small group educational settings, for self-assessment, and for independent learning. Extension of the more highly controlled pilot assessment study with a larger sample will be needed to confirm its reliability in other assessment applications.
Psychiatrists believe clinical preventive services are important and express interest in their delivery. Additional educational interventions are needed to train psychiatrists in clinical preventive services to avoid missed clinical opportunities for intervention in psychiatric populations that may have poor access to other medical care.
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