Blood pressure variability: a new and unique risk factor

Blood pressure variability is a new and unique factor that is gaining more and more attention in the medical community. It refers to the fluctuation of blood pressure over time, and it can be caused by a variety of factors including stress, exercise, and even the time of day.

One important aspect of blood pressure variability is that it can be measured and tracked. This can be done through the use of a blood pressure monitor, which can be worn on the wrist or upper arm and measures blood pressure at regular intervals throughout the day. By tracking blood pressure variability, individuals and their healthcare providers can get a better understanding of their overall cardiovascular health and identify potential risk factors for conditions such as hypertension and heart disease.

Research has shown that blood pressure variability is a strong predictor of future cardiovascular events, such as heart attack and stroke. In fact, studies have shown that individuals with higher levels of blood pressure variability are at an increased risk for these types of events. For example, one study found that individuals with high blood pressure variability were 63% more likely to experience a stroke compared to those with low blood pressure variability (reference: “Blood Pressure Variability and Risk of Stroke: A Meta-Analysis”, Zhang et al., Stroke, 2012). Another study found that blood pressure variability was associated with a 2.5-fold increased risk of heart attack (reference: “Blood Pressure Variability and Risk of Myocardial Infarction: A Meta-Analysis”, Song et al., American Journal of Hypertension, 2014).

So what can be done to reduce blood pressure variability and the associated risks? One effective way is through lifestyle changes, such as eating a healthy diet, exercising regularly, and reducing stress. These changes can help to lower blood pressure and reduce fluctuations over time. In some cases, medication may also be necessary to manage blood pressure and reduce variability.

It is important to note that blood pressure variability is a complex and multifaceted issue, and further research is needed to fully understand its impacts on cardiovascular health. However, what is clear is that blood pressure variability is a unique and important factor that should be taken into consideration when evaluating an individual’s overall cardiovascular health. By tracking and managing blood pressure variability, individuals can take steps to improve their heart health and reduce their risk of future cardiovascular events.

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Making mRNA Vaccines Easy to Understand: Their Potential Role in Cancer Therapy

In recent years, mRNA vaccines have garnered significant attention due to their role in the fight against COVID-19. But mRNA vaccines have the potential to do much more than just prevent infectious diseases – they may also have a future role in cancer therapy.

But before we dive into the potential of mRNA vaccines in cancer therapy, let’s first understand what mRNA vaccines are and how they work.

What are mRNA Vaccines?

mRNA, or messenger ribonucleic acid, is a molecule that carries genetic information from DNA to the protein-making machinery of cells. Essentially, mRNA acts as a blueprint for the production of proteins in the body.

mRNA vaccines are a type of vaccine that use a small piece of genetic material (mRNA) to stimulate the body’s immune system to produce an immune response against a particular disease. Unlike traditional vaccines, which use weakened or inactivated forms of the disease-causing virus or bacteria, mRNA vaccines do not contain live pathogens. Instead, they use a small piece of the virus’s or bacteria’s genetic code, which is delivered to the body in the form of mRNA.

How Do mRNA Vaccines Work?

When an mRNA vaccine is administered, it enters cells and is translated into proteins. These proteins are then displayed on the surface of cells, where they are recognized by the immune system as foreign invaders. The immune system then mounts an immune response against the proteins, producing antibodies that can recognize and neutralize the virus or bacteria.

In addition to generating an immune response, mRNA vaccines can also stimulate the production of T cells, a type of immune cell that plays a key role in protecting the body against cancer and other diseases.

The Potential of mRNA Vaccines in Cancer Therapy

One of the major challenges in cancer treatment is the ability to specifically target and kill cancer cells while leaving healthy cells intact. Traditional cancer therapies, such as chemotherapy and radiation, often have significant side effects because they can damage healthy cells as well as cancer cells.

mRNA vaccines have the potential to overcome this challenge by selectively targeting cancer cells while leaving healthy cells unharmed. This is because mRNA vaccines can be designed to specifically target proteins that are found only on the surface of cancer cells, allowing the immune system to specifically attack the cancer cells while leaving healthy cells untouched.

In addition to their ability to selectively target cancer cells, mRNA vaccines have several other potential advantages as a cancer therapy. They can be produced quickly and at a low cost, and they have a good safety profile, with few side effects.

mRNA vaccines are still in the early stages of development as a cancer therapy, but there are several clinical trials underway that are investigating their use in a variety of cancer types, including breast, ovarian, and pancreatic cancer. While it will likely be several years before mRNA vaccines are approved for use in cancer therapy, the potential for this innovative approach is exciting and holds great promise for the future.

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Improving Patient Compliance with Medication

Medication compliance, or the extent to which patients take their prescribed medications as directed, is an important factor in ensuring that patients receive the full benefits of their treatment. However, many patients may not be compliant with their medication regimens for a variety of reasons, such as forgetfulness, fear of side effects, or difficulty affording the medication.

Non-compliance with medication can have serious consequences. When patients do not take their medications as prescribed, their symptoms may not improve or may even worsen, increasing their risk of complications and the need for more expensive or invasive treatments. Non-compliance can also lead to poor health outcomes and increased healthcare costs.

To improve medication compliance, a variety of strategies can be used. For example, patients can be given tools to help them remember to take their medications, such as pill organizers or smartphone reminders. Simplifying the dosing schedule and providing education about the medication and its benefits can also help increase compliance.

Healthcare providers play a critical role in improving medication compliance. They can provide support and education to patients, addressing any concerns or barriers to compliance, and collaborating with other members of the healthcare team to ensure that patients receive the medication and support they need.

In conclusion, medication compliance is an important factor in ensuring that patients receive the full benefits of their prescribed treatments. By implementing strategies to improve compliance and working together with healthcare providers, patients can be empowered to take their medications as directed and achieve better health outcomes.

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Medical Appraisal Template

The dust has finally settled with regards to the Medical Appraisal Template 2022.

GP Tools is proud to announce that the form has been implemented in its entirety.

There are significant changes from the MAG form and we feel that it is a return to the halcyon days of appraisal when box ticking was yet to be discovered.

  • Appraisal now centers around a holistic approach to the Doctor’s experience in the previous 12 months.
  • Copious reflection notes are no longer recommeded.
  • Discrete CPD and QIA logging are completely optional.
  • Unless absolutely necessary attachments and documentary evidence are not required.
  • Greater emphasis on the Doctor’s personal wellbeing and health.
  • Cutting down the time spent on filling in forms and box ticking.
  • A simpler and easy to understand layout.
  • Overview of CPD and QIA activities.
  • No longer credits or time spent to be documented.

The NHS England Appraisal Team have done a great job in making the process easier for Doctor’s and hopefully Revalidation Officers and LAT’s around the country will follow suit.

Medical Appraisal Template 2022

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Taking blood pressure tablets at bedtime, are they more effective?

Many media sources have reported that when taken at bedtime, blood pressure pills work better, reducing the risk of heart attack and early death.

It follows a large trial conducted through northern Spain general practices. It included about 20,000 people with high blood pressure (age 60 on average).

Half the people were told at bedtime to take their blood pressure tablets, and the other half at waking. These were followed up for an average of 6 years, during which time about one in ten suffered a heart attack, heart failure or stroke, or died from cardiovascular disease.

The study found that people who take their blood pressure tablets at bedtime the night blood pressure was significantly lower and 45% less likely to have one of these results.

The trial lend support past studies with similar findings. However, the trial just analysed Spaniards from white ethnic backgrounds. It also does not look at the effects of time on a certain blood pressure tablets. Therefore, as the researchers say, more studies are needed before we see whether the advice on how to take blood pressure medication should be changed.

Unless you are taking diuretics (water tablets), which may mean you have to get up a lot at night to urinate, there should be no negative effects from taking them at night. But it might be worth talking to the GP before making changes in how you take your medications, especially if you take several different medications.

What is the story’s origin?

This study was conducted by researchers from the University of Vigo and several other institutions in Spain. This project received financial support from the Spanish government and several other organizations.

The study was published in the peer-reviewed open European Heart Journal and is available for online access.

British media coverage of this study was widely accurate.

What kind of research was this?

This was a randomized controlled trial aimed to see whether it is better to take blood pressure tablets at bedtime or in the morning. A randomized trial is the best way to see the effectiveness of treatment for randomization have to balance differences in patient characteristics, such as health and lifestyle, which could affect the outcome.

One slight limitation is that the open-label trial (not blind) means patients and researchers are aware when they are taking their tablets.

An ideal design may have provided all the patients tablet morning and night, one set into the other drug and matching placebo (dummy tablets). However, the length of this trial will be extremely difficult. There could also be the risk of error (for example, patients taking placebo tablets 2 sets of the day and there is no cure them).

What did the research involve?

The trial was conducted between 2008 and 2018 in 40 general practices in northern Spain. This includes adults diagnosed with high blood pressure (hypertension) in accordance with the standards and criteria prescribed one or more blood pressure medications.

They recruited a total of 19 084 patients (mean 60 years, 56% male) who were told to take their medication at bedtime or in the morning. About a quarter of all patients recruited had type 2 diabetes, 43% were obese, 15% were smokers and 10% already have a past cardiovascular events such as heart attack. Patients wear different types of blood pressure medications.

Patients were followed up with clinical assessment at least once a year, which included blood tests and wore blood pressure monitors for 48 hours (ambulatory blood pressure monitoring). The main outcome of interest is the patients who experienced one or more:

  • heart attack
  • stroke
  • a procedure to open the heart arteries (like stent insertion)
  • heart failure
  • death from cardiovascular disease

They adjusted their analysis for the patient’s age, sex, cholesterol, initial blood pressure, smoking, diabetes and kidney disease.

What is the basis of the results?

During an average follow-up of 6 years, in 1752 adults (9%) had a major cardiovascular outcomes.

Patients who take their blood pressure tablets at bedtime had a 45% lower risk of any of these events (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.50 to .61). The researchers also found a decreased risk when they see each of the individual outcomes, such as heart attack or stroke.

Results of 48-hour blood pressure monitoring showed that patients taking their tablets at bedtime had lower blood pressure at night. There was no difference in daytime blood pressure between the two groups.

There was no difference between the groups in any of the side effects of treatment. There was also no difference in how many patients do not take their tablets should be, or when they should.

How did the researchers interpret the results?

The researchers concluded that drug-taking blood pressure on sleep results in improved control of blood pressure “and, most importantly, markedly reduced the occurrence of major cardiovascular disease events”.


It is a worthwhile experiment to investigate the best time to take blood pressure medication. It has certain powers of a very large sample size and long duration of follow-up, which is quite rare for a randomized trial.

They found that taking the medication at bedtime lowers blood pressure at night and reduce the risk of heart attacks and other cardiovascular events. They found these differences not only when looking at all the combined event, but each individual. This suggests that when you take the drugs makes a real difference. This lends support to previous trials that have had similar findings.

There are currently a variety of blood pressure medications do not have a strict prescription information at the time of the day they need to be taken, with the exception that diuretics (water tablets) are often taken in the morning to avoid the need to urinate frequently at night.

Despite the positive findings, there are some limitations to the trial. These include that the researchers were not able to analyze the effect of time for individual anti hypertensives. Also the study was held in mainly Spanish, exclusively white ethnic populations that may not be representative of other populations.

The researchers themselves acknowledge that their test results now need to be validated in other study populations. More conclusive findings might in the future lead to a change in the way anti hypertensives are prescribed.

The research

Hermida RC, Crespo JJ, Domínguez-Sardiña M, et al.

Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial

European Heart Journal. Published online October 22 2019

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Appraisal advice for a successful outcome

  1.  Don’t procrastinate and get advice early on about your pending appraisal.
  2.  Ask someone for help about what is on your mind. Usually this might be advice about what you are thinking of  submitting.
  3.  Look at some examples of submitted examples of appraisals.
  4.  Breaking down big goals into small goals. Starting to enter data into GP Tools , contacting your appraiser, etc.
  5. Avoid unnecessary work. It is not really necessary to scan and upload large amounts of evidence, unless particularly asked for. You only need to show notes if you have not written them into the toolkit. If you are submitting more than 15 documents per year you are wasting your time and effort in this process.
  6.  Avoid duplication of effort and avoid repeating yourself. Concentrate on being focussed.
  7.  4 domains of Good Medical Practice, sometimes can cause confusion. A great document for this is a GMC pdf discussing the four domains and their relevance to appraisal and revalidation.  Click here to download the PDF document
  8.  Quantifiying the amount of time you are spending on entering the data. SEAs/ QIAs shouldn’t take more than 15-20 minutes.
  9.  CPD log captures your CPD for the year. Should contain the date, number of hours, learning points. Having 1-2 learning points for each topic is enough. There is no need to scan everything on and it shouldn’t take more than 1 to 1.5 hours to convert all your notes into CPD data.
  10. Using a validated and accepted toolkit such as GP Tools to help you document your data. Use the mobile apps to collect your CPD data on the go.
  11. For MSF 360 feedback and patient surveys, remember to start early and allow a month for collection of your data and about a week for processing and collation of the responses into a report. Both types of feedback are free with GP Tools.successful appraisal

For more on this topic, watch a great video by Dr. Paula Wright:


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QRISK 3 – what’s new? a deeper look inside.

Qrisk logo

QRISK has been used in the general practice setting since 2007. It has been upgraded to QRISK 2. It is a 10 year cardiovascular risk tool. There is a proposal to upgrade to a newer version of the algorithm called QRISK 3. This has been outlined in a recent paper published by Julia Hippisley-Cox, professor of clinical epidemiology and general practice1,Carol Coupland, professor of medical statistics in primary care and Peter Brindle, evaluation and implementation theme lead, NIHR CLAHRC West. The paper was published in the 23rd May 2017 issue of the BMJ. BMJ 2017; 357 doi:

Currently QRISK 2 includes the ages of 25 to 84 and includes

  • Ethnicity
  • Deprivation (the Townsend score)
  • Systolic blood pressure
  • BMI
  • Total cholesterol/HDL ratio
  • Smoking
  • Family history of coronary artery disease in a first-degree relative aged less than 60
  • Type I diabetes
  • Type II diabetes
  • Treated hypertension
  • Rheumatoid arthritis
  • Atrial fibrillation
  • Chronic kidney disease (stage 4 or 5)

QRISK 3 will include the following additional factors:

  • Chronic kidney disease (stage 3, 4, or 5)
  • Systolic blood pressure variabilit
  • Migraine
  • Corticosteroid use
  • Systemic lupus erythematosus
  • Atypical psychotics
  • Severe mental illness,
  • Erectile dysfunction in men

Overall the calculator performed as the previous version. The new added risk factors were found to increase risk by about 10%, the only exception being HIV/AIDS.

You can use the new risk calculator here:


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2017/18 QOF update – Moderate to Severe Frailty

Electronic frailty index

The new 2017/18 Qof with the frailty index does away with the bureaucratic unplanned admissions direct enhanced service and replaces it with indentifying and managing the over 65s with moderate to severe frailty.

What is the electronic frailty index (eFI)?

The electronic Frailty Index (eFI), which has been developed by the  University of Leeds, TPP (System One), Bradford Teaching Hospitals NHS Foundation Trust, Bradford University and Birmingham University, is an evidence based criteria for identifying frail patients.

It is based upon 36 deficits comprising 2000 Read codes . The score is strongly predictive of adverse outcomes and has been validated in large international studies.

The eFI score is out of 36. For example if 9 deficits are present then the socre will be (9/36) or 0.25. In this way the following frailty categories can be defined:

eFI Score Category
0 – 0.12 Fit
0.13 – 0.24 Mild Frailty
0.25 – 0.36 Moderate Frailty
> 0.36 Severe Frailty
1. Fit (eFI score 0-0.12)– People who have no or few long-term conditions that are usually well controlled. This group would mainly be independent in day to day living activities.
2. Mild frailty (eFI score 0.13 –0.24) – People who are slowing up in older age and may need help with personal activities of daily living such as finances,shopping, transportation.
3. Moderate Frailty (eFI score 0.25 –0.36)–People who have difficulties with outdoor activities and may have mobility problems or require help withactivites such as washing and dressing.
4. Severe Frailty (eFI score > 0.36) – People who are often dependent for personal cares and have a range of long – term conditions/multimorbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within 6 – 12 months.
How to get the eFI score and the list of moderately and severely frail patients?
This should be built in to your electronic care record system already (EMIS and System One). Running the search will produce a list of your moderately and severely frail patients.
What your practice needs to do:

For those patients identified as living with severe frailty, practices should provide a clinical review, which should include an annual medication review and, where appropriate, discuss whether the patient has fallen in the last 12 months. Any other clinically-relevant intervention should also be provided. In addition, where a patient does not already have an enriched Summary Care Record (SCR) the practice will promote this seeking informed patient consent to activate the enriched SCR.

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Why GP Tools will never upsell.

Wikipedia defines Upselling as a sales technique whereby a seller induces the customer to purchase more expensive items, upgrades or other add-ons in an attempt to make a more profitable sale.

We believe that the whole revalidation industry that has sprouted out of nowhere is at its core built on upselling. If it were up us at GP Tools, we would provide this toolkit completely free to our users. Unfortunately, in the post-truth world that we live in, offering something for free implies a catch somewhere down the road or some other negative connotation.

Which is why we are not surprised when we receive emails from Doctors’ who have been somehow manaevred into buying unnecessary add-ons from other toolkit providers.

Our company ethos at it’s most basic level prevents us from engaging in predatory business practices such as upselling. Nowhere on the site will you ever be bombarded with messages forcing you to take out a learning module subscription, nor will we ever email you anything similar.

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