Hypertension is a major cause of morbidity and mortality and its control has important clinical and socio-economic benefits to the family and community. Unfortunately, the extent of blood pressure (BP) control and its potential predictors in hypertensive patients in many rural communities in low-resource settings are largely unknown. This study assessed the extent of uncontrolled BP and its predictors amongst hypertensive patients accessing primary health care in a rural community in South Africa.This cross-sectional study included 422 randomly selected hypertensive patients. Demographic and clinical data were collected using structured face-to-face questionnaire supplemented by respondents’ clinical records.n = 286, 67.8%) and diabetes  were the most common comorbidities. Treatment adherence was achieved in only 36.3% and BP was controlled to target in 50.2% of the respondents. Significant predictors of uncontrolled BP were poor treatment adherence , obesity compared with normal weight and overweight  and being a diabetic .Obesity plus overweight . We also propose the use of Community-Based Physical and Electronic Reminding and Tracking System (CB-PERTS) to address poor treatment adherence. This clinic serves a predominantly rural population of over 132 000 inhabitants and accepts patient referrals from 10 PHC clinics in the district for various primary health care services. Data collection was from November 2015 to January 2016.19 All newly diagnosed hypertensive patients with no previous follow up, too ill to answer questions or needed urgent treatment were excluded. According to the clinic records, the estimated number of hypertensive patients seen yearly is approximately 12 000. The minimum required sample size (n) was estimated using the following equation:17All hypertensive patients 18 years and above, accessing care at the study setting, were eligible participants. Hypertension was defined as systolic BP ≥ 140 and diastolic BP ≥ 90 mmHg following repeated measurements.Z is the critical value for a 95% confidence level, e is the considered acceptable margin of error of 5% and P is the assumed proportion of 50% of those with poorly controlled BP in the population of patients with 422 eligible participants who were systematically selected at random.20 Thus, on each day of the data collection, every eligible third hypertensive patient was recruited.where 21 but with some modifications to the specific context of the setting and to supplement the respondents’ clinical notes in line with the study objectives. Data on demography , lifestyle choices , duration of treatment and adherence 21 were collected.The survey instrument was a validated questionnaire that had been used previously2), BMI category ,22 comorbid illness , antihypertensive drugs therapy  and BP measured in each occasion during at least two different clinic visits. The BP, height and weight were measured during clinic visit on the day of the data collection by the triaging healthcare staff as part of the routine process of care. Specifically, BP was measured using a validated and regularly calibrated automated device, and this is in line with the current South African Hypertension Practice Guidelines.10 The measurements were taken from the arm of each study participant at rest using an appropriate size cuff. During the measurement, the patient was seated, his or her shoulders supported on the backrest of the chair, legs not crossed, feet placed on the floor and neither the patient nor the healthcare professional was talking. The average of the BP reading from the previous visit and that obtained on the day of data collection/interview were recorded and used as a measure of BP control. The BP measurement were in line with the existing local and international hypertension protocols and guidelines.19 The BP control targets were based on both the guidelines of the International Society of Hypertension and the South African Hypertension Society.19 These target BP in the study setting at the time of the study were < 140/90 mmHg for uncomplicated hypertension and ≤ 130/80 mmHg for those with comorbidity such as diabetes and chronic kidney disease (CKD).20 Data on measures of CKD, diabetes and dyslipidaemia, as documented in the patients’ files at the time of initial diagnosis were also extracted. In line with the South African Hypertension Guidelines, CKD was defined as estimated glomerular filtration rate (eGFR)  <  60  mL/min, which was obtained from the laboratory values of creatinine and calculation of the estimated GFR using MDRD formula. Dyslipidaemia was defined as total fasting cholesterol > 5.1 mmol/L.10Data were collected from Patients’ clinical notes on body mass index  version 24.0 . All categorical data were presented as frequencies and percentages. Normality check was performed on continuous variables to identify patterns of data distribution. Normally distributed continuous data were presented as mean and standard deviation (s.d.). Independent variables were initially tested for association with BP control using the Chi-square test. Statistically significant variables found in the bivariate analyses were included stepwise in a multivariate logistic regression analysis to determine the factors that remained associated with control of BP when entered into the model alongside the other variables that were shown to be significant. Statistical significance was set at Permission to conduct the study was given by the Sedibeng District health services. Ethical approval was granted by the Ethics Committees of the University of the Witwatersrand, South Africa (certificate number: M150859) and University of Liverpool, United Kingdom (certificate number: 7-16-2015-01). Study participants gave informed consent before they were enrolled. All personal patient information was de-identified at source and codes used for all participants, thereby, preserving their anonymity.n = 229) were men of mean age 59.4 (s.d. = 12.0) years. Whilst women  had a mean age 59.7 (s.d. = 12.3) years. Over half of the participants were unemployed  and the majority had either primary  or secondary school education . The details of the demographic characteristics of the participants are shown in Of the 422 hypertensive patients’ who participated in the study, all were black people, slightly over half  kg/m2. A total of 54% (n = 228) and 50.9% (n = 215) had diabetes and dyslipidaemia, respectively. Target BP control, irrespective of comorbidities, was achieved in 50.2% of patients. Mean systolic BP was 138.7 mmHg (s.d. = 15.9) for men and 140.3 mmHg (s.d. = 17.5) for women. Mean diastolic BP was 84.4 mmHg (s.d. = 9.8) for men and 84.8 mmHg (s.d. = 10.9) for women.n = 71, 16.8%), 83.1% did this less than three times a week with an exercise duration of < 30 min in 47 (66.2%). Most of the respondents  did not drink alcohol, but of those 32.0% (n = 135) who did, 104 (77.0%) .0 only occasionally on less than a weekly basis. The majority of participants  reported that they smoked or used tobacco products.n = 405, 96.0%) with the commonest pattern being three or more . However, the majority of patients  were not fully adherent with the hypertensive treatment, with the mean duration of treatment being 10.0 (s.d. = 7.6) years in women and 8.5 (s.d. = 6.8) years in men.21 In this table, the reply of ‘none of the time’ to 13 of the 14 items on this scale was achieved by over 90% of the respondents in only six of the 13 items or questions in the scale, signifying poor adherence. However, adherence to follow up appointments was good because almost all the respondents (97.5%) answered ‘all of the time’ to the remaining one question on the scale: ‘how often do you make the next appointment before you leave the clinic’.p = 0.019) and their BMI category (p < 0.001). Uncontrolled BP was also associated with the presence of certain comorbid conditions: bronchial asthma (p = 0.011), diabetes (p < 0.001) and CKD (p = 0.041). In addition, the number of drugs prescribed (p = 0.01), the correct combination of drugs (p = 0.025) and adherence to treatment (p < 0.001) were found to be associated with uncontrolled BP.Preliminary analysis using the Chi-square test indicated that uncontrolled BP was significantly associated with two demographic factors: the sex of the patient (p < 0.001) and the presence of diabetes  clearly contribute to the association with uncontrolled BP, the major factor was the lack of adherence to treatment .These factors were therefore included in the multivariate logistic regression analysis to identify which ones were most likely to indicate possible uncontrolled BP. Body mass index, diabetes and treatment adherence remained in the model following stepwise elimination of those factors that were not significant in the model. The odds ratios (ORs) of obesity when compared with normal weight and overweight independently were not significantly different, and the BMI category was reconsidered as a dichotomous variable normal weight and overweight as compared with obesity. The multivariate logistic regression analysis showed the association between the determinant factors and uncontrolled BP . Althoug24 in one of the first nationally representatives estimates of the burden of hypertension and extent of hypertensive care in South Africa. Similar to what we found, almost half of the treated patients are not controlled.24 It is important to emphasise that although most studies of BP control in South Africa have reported lower control rates,12 with the exception of a 57.0 % BP control rate reported by Onwukwe and Omole,9 we are of the opinion that our control rate is still unsatisfactory. This is because of the fact that almost half of the respondents whose BP was not controlled to recommended levels could be predisposed to various cardiovascular complications and these have important public health implications such as stroke, congestive heart failure, peripheral vascular disease and CKD.8 This lack of BP control occurred despite the observation that the prescribed antihypertensive medications combinations were appropriate in most patients (96%) and in line with the existing treatment guidelines and consistent with previous studies.12This study found that BP was controlled to target in 50.2% of the hypertensive patients, all of whom were black people and accessing PHC. Our finding is in line with the BP control report by Berry et al.19 Specifically, the Creole Clinical Trial that was performed on black patients in sub-Saharan Africa emphasises the compelling need to use appropriate combination therapy to treat hypertension.25 In that study, amlodipine combined with hydrochlorothiazide or perindopril was found to be more efficacious than perindopril combined with hydrochlorothiazide in reducing BP to optimal levels.25 In African Americans, achieving optimal BP control goals with these antihypertensive drugs combinations is very hard according to the evidence from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.27 This is because of a combination of factors such as dietary pattern, predisposition to increased salt sensitivity and treatment resistant hypertension, which effectively raises their BP medication requirements resulting in suboptimal control of the BP.27 In those with resistant hypertension, the use of spironolactone have been found to improve BP control, and when a thiazide or thiazide such as diuretic is indicated, chlorthalidone or indapamide have been shown to be more efficacious than hydrochlorothiazide in lowering BP.28 A total of 84% of the patients in this study had comorbid diabetes, heart failure and CKD either alone or in combination, thus, requiring a compelling use of an ACE-I for effective and optimum treatment.10 Apart from its recommended use in the control of BP preferably in combination with amlodipine in uncomplicated hypertension, the compelling rationale for the use of ACE-I is to slow or halt the progression of microvascular complications associated with diabetes, heart failure or CKD.29In this study notably, the participants were essentially black patients. The frequency of use of the first-line antihypertensive drugs were enalapril, an ACE-I (87.9%); amlodipine, a CCB (71.3%), and hydrochlorothiazide, a thiazide diuretics (60.2%). We found that these drugs were used in appropriate combinations in 96% of the patients and appropriate drug combination is recommended in the current South African hypertension treatment and other international guidelines.19 In this study, we do not have full data on the optimisation of doses of the antihypertensive medications used by the patients or the actual reasoning for the preference to use a particular antihypertensive drug.Optimisation of prescribed antihypertensive medication is currently supported by evidence because patients who are not receiving the correct dose and combination of their medications finds it difficult to achieve optimal BP control.18 Specifically, in terms of behaviour, the HBM is a health behaviour theoretical framework that can be used to explain why people take actions to control their illness such as hypertension and to suggest/design interventions against it.18 In practice, the constructs of the HBM are perceived susceptibility, severity, benefits, barriers, cues to actions and self-efficacy.17 Although this study was not designed to use these constructs to predict BP control, however, it is assumed that it can be used to design interventions against the predictors of BP control emanating from the study.18 This is because evidence from the use of the HBM as a behavioural change framework for disease conditions indicates that people’s beliefs about whether or not they are susceptible to a disease such as hypertension and their perceptions of the benefits of trying to avoid it, influences their readiness to act, which includes accepting interventions directed at risk reductions for the disease.18Risk perception to uncontrolled BP and poor adherence to recommended treatment for hypertension may be a health behavioural issue, which is well rooted in the HBM and can be used to design interventions to address it.30 The subsequent observation that lack of adherence to treatment is the most significant factor associated with uncontrolled BP  also confirms previous findings.31 Factors affecting adherence to treatment includes pill burden (resulting from lack of use of fixed or single dose pill combinations) and medication side effects especially cough and angioedema when an ACE-I such as enalapril is used.33 Specifically, in this study, we did not directly assess the side effect of drugs but have a direct and quantifiable data on pill burden because almost 70% of the patients were prescribed three or more different antihypertensive pills that were not in fixed dose combinations: a major failure in the public health sector in South Africa. It is important to emphasise that in line with other international treatment guidelines, current local guidelines on treatment of hypertension recommends the use of fixed or single dose pills to help patients deal with the issue of poor medication adherence and control of BP.19 Unfortunately, fixed dose combination of antihypertensive pills are presently not available in the South African Public health sector, therefore, patients are made to depend on multiple pills, which potentially predisposes them to poor adherence. Furthermore, in our study, as previously expressed, we assessed adherence including its underlying contributors such as medication side effects (indirect assessment) and pill burden (direct assessment) by the use of the 14-item or questions in the validated Hill-Bone compliance (adherence) scale.21 This adherence scale is relatively subjective, non-invasive and cost-effective tool that also has its limitations.21 However, it is important to emphasise that the difficulty in accurately assessing adherence to hypertensive treatment is well-documented in literature and this has led to the suggestion for the use of combination of methods.33 Based on this, direct measurement of ingested antihypertensive drugs in blood or urine as performed in a study in the United Kingdom and Czech Republic appears to be the best method to accurately assess and document adherence and its effect on BP control.34 Unfortunately, because of economic cost and invasive nature of this biochemical method of assessing adherence, we were unable to fit it into our study methods.33 Furthermore, given that the relatively subjective method that we used appears to be less accurate compared with the biochemical method, our reported level of adherence in relation to BP control needs to be interpreted with caution. This becomes more imperative as many of the questions in the 14-item Hill-Bone compliance scale actually assesses hypertension treatment behaviour rather than adherence based on actual ingestion of the antihypertensive drug.21 This may be an indication of why our reported level of adherence to treatment is very poor whilst actual BP control reached a modest 50.2% threshold. However, as already indicated, our reported BP control rate is in line with a previous finding in South Africa.24In our study, only 36.3% of the respondents were fully adherent to hypertensive treatment and this is consistent with previous reports.36 In line with previous studies, both are associated with prolonged poor BP control8 and in practice has socio-economic consequences of increasing the healthcare costs of treatment and productive workforce disability.35 Specifically, we found that obesity compared with normal weight and overweight was a strong predictor  of uncontrolled BP, which is consistent with observations from previous studies.37 Also, consistent with the findings of Reboldi et al.,38 54% of the patients in this study had comorbid diabetes. This was also shown to be a risk factor for uncontrolled BP  and is similar to the reports by Duggirala et al.39 and Morgado et al.31 Diabetes is a regularly implicated risk factor for nephropathy, retinopathy and neuropathy,39 indicating the need for regular screening for these conditions in primary care. Also, approximately 10% of patients in our study had comorbid renal disease, which was not associated with uncontrolled BP. However, this finding needs to be interpreted with caution as a previous study revealed that silent renal disease not usually diagnosed/identified at screening was present in 25% of hypertensive men and 6% of women.40 This calls for concern, especially, if the number of patients with renal disease (CKD) in this study is extrapolated to a population level as there are usually large costs and other public health consequences associated with managing these patients.Comorbid obesity and diabetes observed in this study, appear to be common in South Africa and tend to be important factors for cardiovascular disease.42 In this study, it was observed that a few participants (16.8%) were meeting exercise goals and alcohol intake was extremely low (32%). Surprisingly, we found that 82.5% either smoke or use tobacco products, which is a leading risk factor for cardiovascular events including hypertension. However, it is important to note that the link between smoking/use of tobacco and BP is debatable and according to the recommendations of the South African Hypertension guideline, in people who are already hypertensive, cessation of use of tobacco products does not readily translate to a drop in systolic BP.10 This is in contrast to other life style modifications such as moderate weight loss, use of Dietary Approaches to Stop Hypertension (DASH) diet, reduction in salt/sodium use, physical activity and moderation of alcohol intake, which result in varying degrees of reduction in systolic BP in people who are already hypertensive.10 On the strength of our findings, the historical role that lifestyle modifications play in the adjunctive management of cardiovascular diseases including hypertension needs to be re-enforced during patients’ encounters with attending PHC clinicians, and the HBM may be useful in this circumstance.18There is overwhelming evidence showing that lifestyle choices associated with inadequate physical activity, habitual smoking and excessive alcohol intake , are major public health concerns because of their associations with raised BP and its exacerbations.15 The interview aspect of the study including the responses to the items in the Hill-Bone compliance (adherence) scale was mainly based on self-report, which may not only create a form of information bias but being a cross-sectional design, cannot infer causation.43 This may be a plausible explanation for the disparity between the level of BP control and treatment adherence. However, the use of evidence-based BP control targets and measurements taken in the clinic from patients, and the combination of face-to-face interview and patients’ clinical records for data collection, may have helped to ensure greater certainty in these aspects of the data.Our findings may not be generally applicable to other racial groups in South Africa, as only black patients were studied and there may be peculiar demographic and clinical differences in BP control that would need to be tested and compared with other racial groups.10 In addition, apart from the constructs of the HBM that can be used to screen for risk perceptions for hypertension and barriers to treatment adherence, which is necessary for the design of interventions, an additional measure to prevent poor adherence to treatment in patients with chronic conditions such as hypertension is Community-Based Physical and Electronic Reminding and Tracking System (CB-PERTS). This is for use in patients identified in the clinic to have poor treatment adherence. The components of CB-PERTS in authors’ view will include: (1) scheduled home visits by community healthcare workers to encourage adherence, (2) supportive interview and (3) establishing an electronic alert system such as mobile phones that may be used by a patient to notify the healthcare professional about any difficulty with treatment adherence or used by healthcare professional to remind a patient about the need for treatment adherence . Incidentally, our proposal on the use of digital system to assist in managing chronic hypertension is supported by WHO recommendation.44 We recognise that a previous study (STAR) in South Africa that used the digital system (mobile-phone short message system) strategy produced minimal changes in adherence.45 In contrast, our proposal is a combination of three strategies, which include the use of the mobile-phone digital system, and we are of the view that it may produce a different result if it is given an opportunity for a trial in primary care. Additional study is underway to implement/assess the effectiveness of the CB-PERTS in improving treatment adherence.We align with the recommendations of the South African Hypertension treatment guidelines for the use of fixed dose or single pill combinations to reduce pill burden in patients.This study, which used a combination of interview supplemented by clinical records, found that BP was controlled to target in approximately half of the hypertensive patients. Adherence to treatment may be the most important objective in the PHC setting for hypertensive patients. Whilst it is known that the HBM can be used to design interventions against observed predictors of uncontrolled BP including poor adherence to treatment, CB-PERTS as proposed in this report should be tested and brought to use if found effective in improving treatment adherence. Hypertensive patients with diabetes and or obesity require special consideration, as these conditions appear to be an independent risk factor for uncontrolled BP. Therefore, there is a need for regular screening, health education and promotion initiatives including behavioural change interventions aimed at the identified risk factors and predictors of uncontrolled BP in primary care, and this is in line with the health belief model.


Home blood pressure measurement (HBPM) has the advantage of measuring blood pressure (BP) multiple times over a long period. HBPM effectively diagnoses stress-induced transient BP elevations , insufficient BP control throughout the day , and even BP variability. In most cases, HBPM may increase self-awareness of BP, increasing the compliance of treatment. Cumulative evidence has reported better improved predictive values of HBPM in cardiovascular morbidity and mortality than office BP monitoring. In this position paper, the Korean Society of Hypertension Home Blood Pressure Forum provides comprehensive information and clinical importance on HBPM. Home blood pressure monitoring (HBPM) has three characteristics: (1) monitoring is performed by the patients themselves; (2) measurements are performed at the home; (3) an automatic blood pressure (BP) device is used rather than a conventional manometer. These traits result in several advantages and limitations.First, self-monitoring means that healthcare professionals do not take part in the measurement. BP may be elevated due to conscious or unconscious anxiety in the presence of healthcare providers. This phenomenon is known as the white coat effect, which is the reason for diagnosing hypertension in some persons and leading to unnecessary medication. The white coat effect can be avoided if the patients measure their own BP. During this process, the patient should take the initiative, and this includes purchasing a device to self-monitor. This may eventually improve disease awareness and treatment compliance. However, a correct understanding of the monitoring method and continuous training require non-healthcare professionals to self-monitor their BP. Since most people consider purchasing a BP manometer only after being advised by a physician, it is necessary for physicians to firstly recognize the importance of HBPM. In addition, if reliable education on HBPM is not provided to healthcare professionals and patients, reliable BP data may not be obtained.Second, monitoring BP at home has the advantage of obtaining accurate BP measurements while avoiding the anxiety that patients may experience when they visit a medical facility. Also, mean BP and trends in BP fluctuation can be obtained with repeated monitoring. However, whether the BP at rest represents a person's overall risk of cardiovascular events remains debatable. The disadvantage of only using only BP monitored at rest is that it is impossible to obtain high BP measurements during work or outdoor activities involving exercise or stress. As a result of these challenges, HBPM may not be an optimal alternative.Lastly, there are advantages and disadvantages associated with using an automatic BP manometer. Most automatic BP manometers use oscillometric measurements to measure diastolic BP using a constant formula that considers the pressure where oscillations begin and where they have maximum amplitude. Therefore, concerns have been raised regarding accuracy as a single BP formula cannot function accurately for every patient.This statement for HBPM were prepared to provide comprehensive information on HBPM, considering the above benefits and limitations. A survey of 330 physicians on HBPM was conducted in 2016. In the survey, 89.4% of the respondents said that HBPM is necessary or very necessary, but 30% of the respondents said that HBPM is more important than clinic BP monitoring. Meanwhile, 49.7% of the respondents said that they recommend HBPM to patients, thereby showing that it is necessary to improve physicians’ thinking in the role and usefulness of HBPM.The purpose of this statement is to share more professional knowledge about HBPM. In addition, we hope to avoid the white coat effect, and will be able to identify more patients with masked hypertension.Since BP monitoring using a mercury BP manometer has been available, BP levels measured at home are usually lower than those measured in an office setting. However, auscultatory measurement using a mercury-based BP manometer at home is not widely used because it is difficult to perform and requires professional training. In 1981, Donald Nunn invented a completely automatic BP manometer, making ambulatory BP monitoring (ABPM) and HBPM possible. Following this invention, many studies highlighting the importance of ambulatory BP have been conducted in Europe. In Japan, it was reported that HBPM is not less significant compared to ABPM. Active research has led to the emergence of a field called chronologic medicine regarding BP changes, hormonal changes, and differences in occurrence of cardiovascular diseases in a day. The concept of morning hypertension, nocturnal hypertension, and nighttime dipper/nondipper were introduced and their clinical significance was supported by the ABPM study results.Nocturnal hypertension or nighttime nondipper status has been linked to an increased risk of cardiovascular events. Although short-term BP variability throughout the day can be assessed using ABPM, variability assessment is not feasible with HBPM. This is cited as a limitation of HBPM; however, the clinical significance of short-term BP variability is uncertain. Several studies have monitored home BP and observed its relationship to cardiovascular events. These studies have shown that patients with white coat hypertension have higher future hypertension and cardiovascular events than people with normal BP.Japan has had many research achievements related to home BP. In 2003, a guideline on HBPM was published. A comparable guideline was published in Korea by the working group for BP monitoring of the Korean Society of Hypertension (KSH) in 2007, specifically as a chapter of the Guideline of Self-Measuring of BP. However, the 2007 version lacked expertise because the contents were too simple and only covered recommendations on monitoring methods and their effectiveness without any background explanation. Professor Imai's second guideline on HBPM was published in Japan in 2012. The clinical significance of HBPM, selection of a BP monitor, reliability of BP monitors, monitoring method, and recording and archiving of monitoring data is described; however, there were no substantial changes compared to the previously published guideline.In Europe, a guideline on home BP was published in 2000 and revised in 2008. Europe has focused on ABPM and did not take much initiative in recommending HBPM, possibly because the majority of home BP monitors have been produced by companies of Asian countries, including Japan and Taiwan, home BP devices have become widely available and affordable, but ABPM still requires expensive machinery and testing fees. Over time, the importance of home BP has increased in Europe as studies have reported that the association between home BP and cardiovascular events is not weaker than the association between ambulatory BP and cardiovascular events. With these findings, the 2008 guideline recommended HBPM more strongly. However, no further guideline has been published since 2008, and the existing content of the guideline is covered in the Guideline on Hypertension published by the European Society of Hypertension.P < 0.001) , 2322, 2The period when the compression band pressure is higher than the pressure at maximum oscillation is called the escalating phase, and when it is lower, the declining phase. Systolic pressure is the BP at which the amplitude of oscillations observed is 50% of the maximum oscillation during the escalating phase. The diastolic pressure is the BP at which the amplitude of oscillations observed is 75% of the maximum oscillation during the declining phase. The oscillation ratio is an essential algorithm obtained empirically in oscillometric BP monitoring. This empirical ratio is sensitively affected by pulse pressure and aortic stiffness Fig. .Fig. 2A Measuring BP using this fundamental principle has its shortcomings. For example, from a physiological point of view, a comprehensive model should include the concept of dynamic compliance. In addition, the effect of the so-called transluminal pressure applied directly to the artery due to the difference between the pressure of the compression band artery must be considered. A comprehensive simulation that takes all of these factors into account shows a significant difference depending on the dynamic compliance and spasticity of the artery. This means that even in an oscillometric automated device with an optimized algorithm, there can be significant variation in accuracy between individuals. Furthermore, it is difficult to obtain a stable BP value in patients with high BP variability unless BP monitoring is repeated a sufficient number of times.In the early 1990s, auscultatory automatic BP devices had already passed the British Hypertension Society (BHS) validation standards . These dIn conclusion, oscillometric automated devices operate by deriving systolic and diastolic pressure from mean BP using the maximum oscillation amplitude, oscillation ratio, and several standard indicators. However, the specific algorithms used by devices have not been disclosed. Therefore, the accuracy of a device in actual clinical practice should be evaluated according to the international oscillometric automated device validation protocol. In particular, certain groups, such as the elderly, pregnant women, pediatric patients, patients with a very thin or thick upper-arm circumference, and patients with arterial stiffness, who were highly likely not to have been taken into account when the oscillometric BP manometer algorithms were designed, should be cautious of measurement errors. Auscultatory ABPM was partially limited to ABPM, but an auscultatory automated device that can be used in the clinic or home setting will be developed as hardware further improves.Home BP is monitored using oscillometric automated devices. Auscultatory or semi-automatic BP devices are not recommended. There are three types of devices available based on measurement location: finger, wrist, and upper arm.Devices that measure BP using a finger are not recommended because of their inaccuracies due to measurement distortion with peripheral vasoconstriction, BP alteration as the finger is too far away from the heart, and the effect of limb position on BP.Devices that measure BP at the wrist have the same last two problems as the finger devices. Inaccurate measurements may be obtained if the wrist device is not placed at the heart level or if the wrist is flexion or hyperextension during measurement. Also, if the radial artery is not fully compressed, both the radial and ulnar artery oscillation waves influence BP values, making it difficult to produce an accurate algorithm to estimate systolic and diastolic BP and, ultimately, they lead to obtaining inaccurate BP values. However, wrist devices may be considered in special populations, such as obese or elderly individuals, in whom the upper arm is more challenging to perform BP measurement. Because the correct placement of the cuff at heart level is essential for an accurate measurement, some wrist devices have built-in sensors to indicate the correct position. Wrist devices are commonly used among patients despite their limitations because the measurement is readily performed without removing the clothes. Approximately 20 wrist devices that passed validation protocol with established protocols are currently available in the market.Devices that measure BP in the upper arm are the most reliable in both clinical practice and major hypertension trials for HBPM. Most international recommendations for oscillometric automated office BP measurement devices also apply to automated home BP devices. For accurate BP measurement, it is important to use validated home BP devices according to established protocols and to select a cuff to fit the upper-arm circumference. Many new HBPM devices have a built-in memory that automatically stores BP readings. Commonly, home BP devices are inappropriate in patients with arrhythmias. Recently, some devices can detect BP during irregular heart rhythm, such as atrial fibrillation. The majority of HBPM devices assess daytime BP, but some devices become available to measure during sleep thus they can detect sleep BP. Also, some devices are available to transmit BP data to the patients and their healthcare providers via Bluetooth. Approximately 200 devices that passed the validation protocol with established protocols are available on the market.In an auscultatory BP sphygmomanometer, the role of the BP cuff is to compress the artery with the inflatable part of the BP cuff (bladder), whereas, in an oscillometric automated device, the cuff is at the signal sensor of oscillation of the artery. Thus, it is also important to document the cuff's type, shape, and material characteristics under the device validation procedure. The cuff size is selected by upper arm circumferences according to the device’s instructions Table . FurtherA proper device should be selected to measure BP accurately Table .Table 3Phttp://www.dableducational.org, and a list of internationally validated BP devices can be found on the KSH website.For the accurate diagnosis of hypertension, the BP device is validated according to established protocols. However, unfortunately, less than 20% of devices on the market have been validated. Validation of BP devices began in ad hoc protocols in the 1980s, and then reputable organizations published validation procedures. The US Association for the Advancement of Medical Instrumentation (AAMI) and the BHS published more systemized standard protocol for clinical validation of automated BP devices against a mercury sphygmomanometer as a reference value. In 2002, the European Society of Hypertension (ESH) Working group developed the ESH-International Protocol (ESH-IP), and it was stringently revised in 2010. ESH-IP 2002 was widely used and more practical because the sample size and pass criteria were simplified compared to previous protocols. In 2018, the universal protocol (Association for the AAMI/ESH/Organization for Standardization [ISO]), single protocols for global acceptance, was developed. This protocol recommends that reference BP measurements for validation can be obtained using mercury sphygmomanometers or non-mercury sphygmomanometers (aneroid or other) that fulfill the ISO 81060–1 requirement for accuracy  because of concern with mercury toxicity in many countries Table . AAMI, Ehttp://www.dableducational.org/ and the universal protocol for device validation is currently used for the device validation .Fig.Fig50].FMasked hypertension is defined as BP that is less than 140/90 mmHg when measured in the clinic while it is hypertensive when measured with HBPM or ABPM. The frequency of masked hypertension is 15%–30%. It is associated with factors such as male sex, smoking history, and alcohol consumption. It is also common in patients with high occupational stress, and those with a high BP variability are at a higher risk of masked hypertension , 52. SinWhite coat hypertension and masked hypertension are observed in the normal population that have never received antihypertensive treatment and in patients who are already on antihypertensive treatment. According to data from an ABPM registry, the percentage of patients taking antihypertensive medication exhibiting a white coat effect with high clinic BP but normal ambulatory BP  was 13.5% of all treated patients. Also, 13.8% of patients on antihypertensive medication had uncontrolled hypertension misinterpreted due to the masked effect  .P = 0.86) in WUCH patients compared to patients with controlled hypertension [According to a cohort study performed in Spain involving approximately 60,000 patients, there was no significant increase in total mortality  or cardiovascular mortality /ESH Guidelines for the Management of Arterial Hypertension, which includes recommendations on HBPMs , 60 The Based on home BP, the diagnostic criteria for hypertension is a BP ≥ 135/85 mmHg (Table ACC/AHA (American College of Cardiology/American Heart Association) published a new version of the Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults in 2017 and published the “Self-measured blood pressure monitoring at home: a joint policy statement from the American Heart Association and American Medical Association” in 2020 , 63. TheIn 2020, ACC/AHA published their Clinical Practice Guideline for Self-Measured Blood Pressure Monitoring At Home . This inIn Korea, the Guidelines for Blood Pressure Monitoring was published primarily by the working group for BP monitoring of KSH and home BP was covered in the "Self-Measurement of Blood Pressure" section . ThereafThe main recommendations include the following: (1) HBPM is recommended for the diagnosis and assessment of prognosis of hypertension, white coat hypertension, and masked hypertension ; and (2) for accurate home BP measurements, accurate measurement method should be educated to all patients . Home BP is more useful in predicting the incidence of cardio-cerebrovascular disease than clinic BP in patients with hypertension. Since its usefulness is high in terms of the medical economy, the importance of home BP in the diagnosis and the management of hypertension, is emphasized in the hypertension guidelines . And HBPIn the Guidelines for the Management of Hypertension published by the KSH in 2018, hypertension using HBPM is defined as ≥ 135/85 mmHg and “morning hypertension” is defined as cases in which BP measured in the morning is ≥ 135/85 mmHg and is higher than the BP before sleep. However, a home BP level that corresponding to normal BP and a target BP for treatment could not be presented.In 2012, the JSH published "Self-Monitoring of BP at Home (2nd edition)," a guideline for HBPM, with Professor Imai as the lead author . Many seIn this guideline, the diagnostic criteria for hypertension using home BP were defined as ≥ 135/85 mmHg, which was mostly selected based on previous cross-sectional studies and guidelines . AccordiIn 2008, the AHA published a statement with the American Society of Hypertension. Based on previous studies, target home BPs were set at < 135/85 mmHg for the general population, < 130/80 mmHg for high-risk patients and < 125/75 mmHg for diabetic patients. In addition, based on the results of a previous meta-analysis, normal home BP  was reported to be < 120/80 mmHg . Based oThe Guidelines for the Management of Hypertension published by JSH in 2019 also included HBPM as “measurement and clinical evaluation of BP” . In addiThe 2019 JSH Guidelines strongly recommend antihypertensive treatment based on home BP rather than office BP , as home BP is more reproducible and correlates with cardiovascular disease. Furthermore, home BP monitoring is useful for diagnosing white coat hypertension and masked hypertension. It is also actively recommended for patients undergoing antihypertensive treatment as it helps to evaluate hypotension during antihypertensive treatment and improves patient adherence to antihypertenive medication.Intervention studies using home BP have been performed previously, but they did not provide sufficient evidence. Based on the Ohasama and HOMED-BP studies, it was proposed that the target home BP should be set 5 mmHg lower than that for clinic BP for both systolic and diastolic pressures –75. TherHBPM using an automated device enables patients with hypertension to obtain more BP values by monitoring BP at home without limitations on time while avoiding the whitecoat effect. In addition, there are several advantages for hypertension treatment, such as enhanced compliance to antihypertensive drugs, since the patients can directly check the change of BP with medication or lifestyle modification. In particular, the use of home BP is gradually increasing as the number of validated BP manometers has increased in recent years, and the devices have become more popular as the price of manometers has gone down.However, there are still limitations with HBPM. If these limitations are not addressed, it may cause unnecessary concerns to patients and delay appropriate actions. For this reason, health care providers should be fully aware of this and provide education to patients. There are several limitations of HBPM that may become clinically problematic.Measurement of home BP using oscillometric method may be inaccurate in the presence of severe arrhythmia. Accordingly, devices capable of detecting arrhythmia such as atrial fibrillation have been developed, which may help the diagnosis of paroxysmal atrial fibrillation, which is challenging to diagnose. In the case of arrhythmias, errors in the BP measurement using automated devices are inevitable. According to a study by Pagonas et al.  in 2013,Xie et al.  investigGestational BP monitoring is critical to the diagnosis of gestational hypertension. BP during pregnancy directly impacts the mother's health and fetal development, and BP must be accurately monitored using a proper method to determine whether to treat hypertension and maintain proper target BP. In other words, receiving unnecessary treatment due to incorrectly detected high BP resulting from a white coat effect and missing the optimal treatment period by depending on clinic BP and not recognizing masked hypertension may cause problems, including progression of eclampsia. Therefore, BP must be monitored accurately through HBPM or ABPM. However, due to the increase in blood volume and decrease in peripheral vascular resistance, the pulse pressure widens during pregnancy. Thus, oscillometric HBPM may be inaccurate. It should also be considered that there is not much research-validated using conventional BP manometers in pregnant women. Even though a BP manometer is validated, it cannot be considered suitable during pregnancy. According to a meta-analysis done by Bello et al.  in 2018,HBPM may be superior to ABPM in terms of convenience and capability for repeated measurement; however, its limitation is the difficulty in BP monitoring during sleep. Importantly, this limitation lies in that assessment of nocturnal hypertension due to sleep apnea, nighttime dipping, and morning surge is not feasible Fig. .Fig. 8FaThe 2019 International Expert Group of Nocturnal Home Blood Pressure has reported that home nocturnal BP monitoring using automated devices, including the Microlife Watch BPN  and Omron HEM7252G-HP, showed a comparable level of accuracy with ambulatory nocturnal BP monitoring . HoweverAccurate BP monitoring is the most critical aspect of hypertension management. Accurate home BP monitoring better reflects prognosis than clinic BP and can enhance medication compliance and treatment response. Smartwatches and smartphones are essential personal mobile devices. It is estimated that at least 5 billion people possess mobile devices and more than half of these people have smartphones. According to a report by the Korea Information Research and Development Institute in 2018, 37.8% of Koreans ≥ 70 years old had smartphones, tenfold the percentage in 2013, which was 3.6% , from 19Although prior research has reported that the accuracy of BP monitoring using smartphones is 95– 100%, actual measurements are presented as a range rather than specific values as a result may fluctuate depending on the measurement method . Even thBP monitoring using a smartwatch has two challenges. First, the accuracy of photoplethysmographic sensors is not yet validated. If there is a near-infrared light source around the site of BP monitoring, spot monitoring can be less accurate. Second, self-monitoring is prone to error despite proper training. The error can be even more prominent with unstable resting posture.BP obtained through a conventional monitoring device should be entered periodically into the BP monitoring app in the smartphone to monitor BP with a smartwatch. Paradoxically, monitoring BP with a mobile device has collateral benefits. BP should be monitored periodically with a conventional BP manometer and the mobile device and eventually check the BP more accurately. It is recommended to perform the BP measurement three times, 2 min apart for the calibration, and it must be done again if switching the smartwatch to the other wrist.The core problem in the adjustment process is the difference in BPs between the left and right arms. It has been reported in many epidemiological studies that the gap between the systolic/diastolic pressures of the two arms is approximately 3.3/2.0 mmHg, respectively. Also, the BP difference between the two arms widens as BP increases. Therefore, if the calibration is performed using BP values measured in the opposite arm, it can cause an error of at least 3 mmHg, which cannot be addressed by any internal calibration mechanism.Moreover, the clinical studies on smartwatches show that the patient can measure BP on the opposite arm with a general BP manometer while measuring BP with a smartwatch, thus compensating for the difference between the two arms and enabling a simultaneous BP measurement in both arms. However, in real life, BP cannot be measured in both arms without assistance, so the benefit of measuring BP in one arm with a smartwatch while measuring in the other arm with a general BP manometer is not practically obtainable. Therefore, a position paper from the KSH, smartwatch-based cuffless BP measurement recommends calibration by obtaining a BP measurement signal with a smartwatch and then measuring BP in the same arm with a general BP manometer . Also, wDevices certified as medical devices are not recommended for patients with a systolic BP that is considered very high ≥ 160 mmHg or very low ≤ 80 mmHg since their accuracy is not yet validated. They are also not recommended for patients with aortic insufficiency, atrial fibrillation with high heart rate variability, peripheral vascular disease with weak blood flow, glycosuria, cardiomyopathy, end-stage renal failure, hand tremor, or blood coagulation disorder. In addition, they are not recommended for patients taking antiplatelet/anticoagulant drugs or states with hormone fluctuation, such as pregnancy, since their vascular characteristics differ from the normal range.Therefore, accurate self-measured BP monitoring using a smartwatch is achieved only when a standardized procedure is followed. However, it is not recommended for patients with systolic BP considered very high ≥ 160 mmHg or very low ≤ 80 mmHg since it is not well established in these populations.So far, BP monitoring using mobile devices has been primarily effective in raising awareness of the importance of BP management among the general public and the early diagnosis of hypertension rather than monitoring patients with hypertension. Implementation in the geriatric population may be limited as they may find it difficult to adjust the device using a general BP manometer periodically. However, its significance lies in raising awareness of hypertension in tech-savvy adults in their 30 s to 40 s, triggering early hypertension management.On the other hand, periodic BP monitoring  with mobile devices can facilitate routine BP monitoring in patients with hypertension. However, we cannot exclude the risk that patients may self-adjust medication based on a BP result inappropriately measured in an unrelaxed state. In addition, various studies have reported that mobile devices' BP monitoring results indicated significant differences over 24-h periods, between days of the week, and even from season to season . Most imLastly, BP monitoring using a mobile device can open up a new field for assessing the dynamic changes in BP . Only stThis position paper is an official opinion of Korean Society of Hypertension Home Blood Pressure Forum. HBPM has advantages, including effectively diagnoses stress-induced transient BP elevations , insufficient BP control throughout the day , and even BP variability. Additionally, HBPM may increase self-awareness of BP, increasing the compliance of treatment. Cumulative evidence has reported better improved predictive values of HBPM in cardiovascular morbidity and mortality than office BP monitoring.


Sixty‐six PvCO2 samples were obtained, and there was a high correlation between PvCO2 and PaCO2 . Regarding type 2 respiratory failure, there was a high correlation between EtCO2 and PaCO2 (r = 0.81). The Bland–Altman analysis between PaCO2 and EtCO2 revealed a bias of 5.7 mmHg, with limits of agreement ranging from −5.1 mmHg to 16.5 mmHg. In contrast, the analysis between PaCO2 and PvCO2 revealed a bias of −6.8 mmHg, and the limits of agreement ranged from −22.13 mmHg to 8.53 mmHg.A total of 100 samples were included that comprised 67 men (67%). The mean age of the subjects was 77 ± 13 years. Chronic obstructive pulmonary disease (COPD) (43%) was the most common disease. There was a high correlation between EtCO2 measured by CapnoEye® was significantly correlated to PaCO2 levels in patients with respiratory diseases. Moreover, CapnoEye® may be more useful for predicting hypercapnia conditions in which respiratory diseases are compared with measure PvCO2.EtCO 2 measured by CapnoEye® was significantly correlated to PaCO2 levels in patients with respiratory diseases. While type 1 patients displayed a moderate correlation, type 2 patients demonstrated a high correlation between EtCO2 and PaCO2. In contrast, the correlation between PvCO2 and PaCO2 was moderate for both type 1 and type 2. CapnoEye® may be more useful for predicting hypercapnia conditions in which respiratory diseases are compared with measure PvCO2.EtCO ABGarterial blood gasCOPDchronic obstructive pulmonary disease2EtCOend‐tidal carbon dioxideICUintensive care unit2PaCOpartial pressure of arterial carbon dioxide2PaOpartial pressure of arterial oxygen2PvCOpartial pressure of venous carbon dioxide12) is <60 mmHg and/or the partial pressure of arterial carbon dioxide (PaCO2) is >45 mmHg. Respiratory failure is classified according to blood gas abnormalities into types 1 and 2. Type 1 (hypoxemic) respiratory failure is a disorder of the respiratory system in which the PaO2 and PaCO2 are ≤60 mmHg and <45 mmHg, respectively, due to respiratory dysfunction. A PaCO2 > 45 mmHg is defined as type 2 (hypercapnic) respiratory failure. Hypoxemia is a common condition and can be attributed to ventilation failure.Respiratory failure is a clinical condition characterized by the failure of the respiratory system to maintain its major function, that is, gas exchange, in which the partial pressure of arterial oxygen  assessment is essential to confirm the diagnosis of respiratory failure, and frequent measurements are necessary to confirm the respiratory status during the course of treatment. An American Thoracic Society/European Respiratory Society position paper reported on ABG analysis as the preferred method for determining the need for oxygen, as it includes acid–base information.The monitoring of respiratory condition necessitates the most non‐invasive technique in the perioperative period and the intensive care unit (ICU).2) is another non‐invasive method for estimating PaCO2. EtCO2 is generally measured as biological information in patients in the operating room or in the ICU with controlled ventilation. However, it is not usually measured in general wards or laboratories.2.The measurement of end‐tidal carbon dioxide  can non‐invasively measure EtCO2 levels. CapnoEye® was used to measure EtCO2 and PaCO2 in patients with type 1 and 2 respiratory failure. We aimed to calculate and evaluate the correlation coefficients and their measurement accuracies. We also intended to compare differences between venous and arterial carbon dioxide levels only in patients who simultaneously underwent venous blood gas measurements. Furthermore, we also aimed to compare the efficacy of EtCO2 and PvCO2 in predicting PaCO2 levels.We aimed to evaluate the accuracy and efficacy of the novel portable capnometer for predicting PaCO22 was measured from February 2017 to December 2019. Simultaneously, we collected arterial blood gas sampling to measure the PaCO2. Moreover, we only compared the venous carbon dioxide (PvCO2) and PaCO2 values in patients who had underwent the sampling concurrently. These samples were collected under similar conditions at a particular time. EtCO2 was measured using the CapnoEye® . The measured data were compared overall and between the two groups. We collected 66 samples of PvCO2 (34 patients with type 1 and 32 patients with type 2 respiratory failure). The PvCO2 and EtCO2 data were also compared overall and between the groups.We collected a total of 100 samples of EtCO2 and PaCO2 and between PvCO2 and PaCO2 using Pearson's moment correlation coefficient in patients with type 1 and type 2 respiratory failure and both groups overall. We also analyzed the agreement between EtCO2 and PaCO2 and between PvCO2 and PaCO2 using Bland–Altman analysis. Moreover, we calculated the estimated bias  and precision  in subjects with type 1 and type 2 respiratory failure and both groups overall. Data are presented as the mean (standard deviation). Descriptive data are presented as the median, frequency, and percentage. Statistical analyses were performed using JMP 14 .We analyzed the correlation between EtCO2.2This study was conducted in accordance with the tenets of the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Clinical Investigation for the National Center for Global Health and Medicine . All subjects provided informed consent for their inclusion in this study.32, EtCO2, and PvCO2 were 74 ± 13 years, 22.0 ± 4.6, 47.2 ± 11.8 mmHg, 41.5 ± 10.1 mmHg, and 53.4 ± 13.2 mmHg, respectively. Table Table 2 and PaCO2 in all patients . The correlation coefficient was 0.883, and we observed a high positive correlation. . Figure 2 and PaCO2 in all patients , with a correlation coefficient of 0.814, which demonstrated a high positive correlation . Next, we separated the data into two categories, Type 1 and Type 2, and illustrated the correlations between them in the figures  displayed a moderate correlation (r = 0.47), type 2 patients (n = 49) demonstrated a high correlation (r = 0.81) between EtCO2 and PaCO2. In contrast, the correlation between PvCO2 and PaCO2 was moderate for both type 1 (n = 34) and type 2 (n = 32) .No specific technical problems were encountered in these measurements. Figure s Figure . While t2 and EtCO2 and between PaCO2 and PvCO2. The Bland–Altman analysis between PaCO2 and EtCO2 revealed a bias of 5.7 mmHg, with limits of agreement (bias ± 1.96 SD) ranging from −5.1 mmHg to 16.5 mmHg. However, it also revealed a bias of −6.8 mmHg between PaCO2 and PvCO2, with limits of agreement (bias ± 1.96 SD) ranging from −22.13 mmHg to 8.53 mmHg.Figure 42 measured using the novel portable capnometer was significantly correlated with PaCO2 levels in patients with respiratory diseases. The correlation coefficient between EtCO2 and PaCO2 was 0.883, thus indicating a positive correlation . Moreover, the correlation coefficient between PvCO2 and PaCO2 was 0.814 and also indicated a positive correlation . The Bland–Altman analysis demonstrated good agreement and tolerance between the two variables. Furthermore, EtCO2 measured using the novel tool may be more useful for predicting hypercapnia conditions in which respiratory diseases are compared with measure PvCO2. However, the limits of agreement against both groups were wide. Therefore, care providers must pay attention to the characteristics and errors of these devices.In our study, EtCO2 has been measured for the non‐invasive estimation of PaCO2. EtCO2 is commonly measured in the closed circuit in patients undergoing mechanical ventilation. Therefore, it has been most often used as a non‐invasive substitute for PaCO2 in anesthesia, anesthetic recovery, and intensive care.2 would more accurately predict PaCO2. Without significant changes in cardiac output or in the ventilation/perfusion ratio, PaCO2 can be estimated with clinically acceptable sensitivity and specificity than EtCO2.2 is challenging in patients who are not intubated. This can be attributed to the difficulty to collect pure respiratory gas.Conventionally, EtCO2) for determining hypoxemia, measuring SpO2 alone is not sufficient to detect hyperventilation or hypoventilation. Particularly with the administration of supplemental oxygen, patients can display adequate arterial saturation during hypoventilation.2 retention in patients with respiratory failure. Nonetheless, no devices have been identified to easily monitor CO2 retention in general wards and outpatient clinics. Recently developed transportable capnometers can measure EtCO2 easily and non‐invasively in patients who are not intubated. Moreover, a recent study demonstrated that they could provide reliable EtCO2 values compared to PaCO2 in patients undergoing general anesthesia.Despite the usefulness of monitoring oxygen saturation  lower than PaCO2. We also confirmed a high correlation between EtCO2 and PaCO2 in patients with type 1 and 2 respiratory failure. In other words, the non‐invasive estimation of PaCO2 by measuring EtCO2 using CapnoEye® is clinically useful. The measurement of EtCO2 was not associated with any complications. In addition, the patient burden was extremely small. It is necessary to wait for few minutes for a 0‐point correction before the measurement. However, the measurement process is easy. The measurement only required disposable mouthpieces, and CapnoEye® was able to measure EtCO2 at a low price. However, its disadvantage was the inability to continuously monitor and record the parameter. While this measurement device is simple, based on a proprietary algorithm, and is easily measured and carried around, it does not enable offline storage of measurement data; therefore, it requires the user to take notes or pictures of the displayed data on the screen. It could not be used for patients with impaired consciousness or cognitive decline who were unable to respond to our instructions.CapnoEye® can measure EtCO2 was correlated with PaCO2 higher than PvCO2, particularly in type 2 respiratory failure. The measurement of PvCO2 instead of PaCO2 would result in data discrepancies in patients with chronic respiratory failure, as in our patient cohort. The effects of cardiac output and tissue oxygen consumption may have caused differences in the venous and arterial CO2 levels in patients with chronic respiratory failure, compared with known reports. Therefore, our findings suggest that the predicate of arterial blood gas analysis likely preferred EtCO2 to PvCO2 in patients with chronic respiratory failure, predominantly type 2 respiratory failure. Type 2 monitoring is more important in actual clinical practice. This highlights the significance of performing non‐invasive monitoring in patients with a tendency for chronic CO2 retention.A previous study reported that arterial blood gas analysis during the acute exacerbation of chronic obstructive pulmonary disease could be substituted by venous blood gas analysis.52 in patients who were alert and breathed spontaneously. Thus, it was unsuitable for patients who did not spontaneously breathe, were unable to respond to our instructions, or demonstrated poor spontaneous breathing, such as those with neuromuscular diseases. Fourth, some patients with type 2 respiratory failure underwent repeated measurements, which may be a source of bias. However, it is unknown whether EtCO2 measurements using this novel device in patients with refractory failure and spontaneous breathing can be considered an alternative to PaCO2 measurements that use arterial blood gas analysis in clinical settings.Our study had several limitations. First, the Bland–Altman analysis demonstrated that the limits of agreement against both groups were wide. Therefore, care providers must pay attention to the characteristics and errors of these devices. Second, this was a single‐center retrospective study comprising a small sample size. Third, the CapnoEye® measurement changes depending on the patient's breathing pattern. Therefore, it could only evaluate EtCO62 measuring instruments have displayed a high correlation with PaCO2 and are clinically applied as a substitute for PaCO2. The novel portable capnometer can measure EtCO2 in a simple and non‐invasive way. EtCO2 measured using CapnoEye® demonstrated a positive, strong, and statistically significant correlation with PaCO2 levels in patients with respiratory diseases. Furthermore, EtCO2 measured using the novel tool may be more useful for predicting hypercapnia conditions in which respiratory diseases are compared to measure PvCO2.Considering the improved accuracy of measuring instruments, EtCOWe intend to conduct future studies to confirm the usefulness of these measurements, particularly for type 2 patients in primary care.None.This study was conducted in accordance with the tenets of the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Clinical Investigation for the National Center for Global Health and Medicine . Written informed consent was obtained from all patients.MS conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. MS, SF, KS, and KT entered and collected data into the database. MS and SF contributed significantly to managing the data and MS to the statistical analysis. All authors revised the article critically for important intellectual content, gave their final approval of the version to be published, and agreed to be accountable for all aspects of the work.


The purpose of this study was to investigate vaccine effectiveness in relieving symptoms in patients with the SARS-CoV-2 delta (B.1.617.2) variant.In this retrospective study, 31 patients did not receive any vaccine , 21 patients received 1-dose of inactivated vaccine , and 60 patients received at least 2-dose inactivated vaccine . The baseline data, clinical outcomes and vaccination information were collected and analyzed.p = 0.001), but there was no significant difference in any of the other baseline data among the three groups. The TV group showed higher IgG antibody levels and cycle threshold values of SARS-CoV-2 than the NV and OV groups (p < 0.01), and time to peak viral load was shorter in the TV group (3.5 ± 2.3 d) than in the NV (4.8 ± 2.8 d) and OV groups . The patients in the TV group (18%) showed a higher recovery rate without drug therapy (p < 0.001). Viral clearance time and hospital stay were significantly shorter in the TV group than in the NV and OV groups (p < 0.01), and there were no significant differences in these parameters between the OV and NV groups, but IgG values were higher in the OV group (p = 0.025). No severe complications occurred in this study.Patients in the OV group were younger than those in the other two groups (in vivo.In this study, our results shows that two-dose vaccination can reduce viral loads and accelerate viral clearance, and two-dose vaccination enhance the protection of IgG antibodies in vivo; however, one-dose vaccination did not confer protective effectiveness.Our results suggest that 2-dose vaccination can reduce viral load and accelerate viral clearance in patients with the delta variant and enhance the protection afforded by IgG antibodies  Coronavirus disease 2019 (COVID-19) is oneof the most serious global public health crisis in this century, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have caused millions of deaths and placed heavy burdens on individuals and societies . In addiPrevious reports have shown that vaccination is effective in reducing household transmission of the alpha variant by 40–50%, with viral load in the upper respiratory tract significantly lower in vaccinated patients ,15. OtheEvaluating the vaccines against SARS cov-2 variants is the focus of the current pandemic, and it is equally important to take preventive measures to prevent infection . In the via SARS-CoV-2 nucleic acid amplification tests, and the results were confirmed by the Xi’an Center for Disease Control and Prevention. This study was approved by the Ethics Committee of the First Affiliated Hospital of Xi’an Jiaotong University, and all patients provided written informed consent. All research methods were carried out in compliance with the relevant declarations of medical ethics and the Declaration of Helsinki.All patients were treated by the medical team of the First Affiliated Hospital of Xi’an Jiaotong University between 20 December 2021, and 20 January 2022. The eligible discharged patients were screened in this retrospective study , and patThe collected data included demographic characteristics, epidemiological data , clinical data, chest computed tomography (CT), SARS-CoV-2 detection information, antiviral antibody information, complications and outcomes. All data were obtained from the electronic medical record system, and no follow-up data were included in this study. Vaccination information was collected from the patients, including vaccine name, dose, and date of administration. Two-dose vaccination was defined as having received a second or third dose of vaccine at least 14 days prior; one-dose vaccination was defined as having received the first dose of the vaccine at least 21 days ago but not the second dose. Unvaccinated patients did not receive any SARS-CoV-2 vaccine. Antibodies against SARS-CoV-2 (anti-Spike IgG and IgM) were detected by laboratory tests. All data were extracted by two independent physicians, and any disputed data were resolved in consultation with a third independent physician.via quantitative reverse transcription polymerase chain reaction  according to the national guideline and the manufacturer’s instructions, and all patients were examined daily during hospitalization. The conditions for SARS-CoV-2 nucleic acid amplification were 50 °C for 15 min, 95 °C for 15 min, followed by 45 cycles of 94 °C for 15 s and 55 °C for 45 s. Positive detection was defined as a cycle threshold  less than 40(500 copies/ml), and the test procedure was carried out in strict accordance with the protocol. A patient’s viral load was defined as the patient’s lowest Ct value during hospitalization, and the time to peak viral load was defined as the time from the first positive SARS-CoV-2 test to the lowest Ct value during hospitalization. The incubation period was defined as the number of days from contact exposure to the onset of a positive nucleic acid result.SARS-CoV-2 nucleic acid expression was detected with SARS-CoV-2 virus kits via a commercial ELISA kit  according to the manufacturer’s instructions, and the antibodies were detected at admission, day 7, day 10, day 14 and at discharge. Briefly, 96-well plates were coated with purified SARS-CoV-2 antigen in phosphate buffer overnight at 4 °C in physiological saline (PBS). We added 10 µl of each serum sample to a reaction plate, mixed it with 50 µl magnetic beads and 50 µl buffer, incubated it in the reaction plate for 10 min and then washed it. Then, we added 100 µl acridine ester-labeled recombinant magnetic beads and incubated them in the reaction plate for 10 min. After washing, we added the substrate solution and mixed it well to detect the luminescence signal value. The assay detects antibodies to the spike protein of SARS-CoV-2 with a cut-off (CO) value of <1.0 for negative results and the value ≥1.0 were defined as positive, the final value of the test was calculated with the optical density value of the sample/CO value.Serum antibodies (anti-Spike IgG and IgM) against SARS-CoV-2 were detected All patients were treated in an isolation hospital according to the national guidelines. Briefly, therapeutic strategies were selected according to the severity of the symptoms and comorbidities of the patients. Patients with mild symptoms and no pulmonary imaging changes were given prone position ventilation and drug therapy for underlying diseases, and patients with obvious symptoms (with pulmonary imaging changes) were selectively given thymalfasin  and lopinavir/ritonavir (250 mg twice daily). Neutralizing antibodies or convalescent plasma were selectively used for severe patients.SARS-CoV-2 patients were classified into four types: mild, common, severe and critical, the clinical classification of SARS-CoV-2 was defined previously by the National Health Commission of China ,22. A pat tests and analysis of variance (ANOVA). Categorical variables were presented as frequency and percentages and were analyzed using chi-square tests or the Kruskal–Wallis test, Mann–Whitney U test or Fisher exact test. p values <0.05 were considered statistically significant.All data were collected with Excel file  and analyzed by using SPSS v. 22.0  software. Quantitative variables were presented as mean and standard deviation and were tested for normality first, and then hypothesis testing was performed with paired p = 0.001), and no significant differences were confirmed for the other baseline characteristics. Except for the incidence of intestinal symptoms, which was higher in the NV group than in the other two groups (p = 0.02), there were no significant differences in the other symptoms and comorbidities, and the most common symptoms included cough, sputum production, sore throat, anosmia and dysgeusia (p > 0.05); however, the incidence of any symptoms in TV group was significantly lower than NV and OV groups (p < 0.05).There were 112 patients with the SARS-CoV-2 delta variant included in this retrospective cross-sectional study , and thep > 0.05). The TV group showed a similar incubation period of SARS-CoV-2 as the NV and OV groups. However, the cycle threshold value of SARS-CoV-2 was higher in the TV group (32.4 ± 5.1) than in the NV (28.4 ± 5.7) and OV groups , and time to peak viral load were shorter in the TV group (3.5 ± 2.3 d) than in the NV (4.8 ± 2.8 d) and OV groups  and higher in the OV group than in the NV group (p = 0.025). Most patients underwent the therapeutic strategies described in the Methods section, and the patients in the TV group (18%) showed a higher recovery rate without drug therapy .All clinical and epidemiological data are listed in p > 0.05). During therapy, SARS-CoV-2 viral clearance time was significantly shorter in the TV group (11.2 ± 1.9 d) than in the NV (14.3 ± 3.6 d) and OV groups . Moreover, the hospital stays of patients in the TV group (14.4 ± 2.2 d) were shorter than those of patients in the NV (17.6 ± 4.4 d) and OV groups . There were no significant differences in these parameters between the NV and OV groups (p > 0.05). No severe adverse events  occurred in the three groups.The outcome parameters after isolation therapy are shown in The spike protein of the delta variant shows a higher binding affinity with the human angiotensin-converting enzyme 2 receptors than that of the spike proteins of earlier variants, suggesting that the delta variant has a high transmission and rapid cell infectivity ,24. ThusA previous study revealed that vaccination shows a low protective effect against the delta variant except for a satisfactory protective effect against severe infections . There wOur results confirmed that only two-dose vaccinated patients had lower viral load and higher IgG antibody levels, and the IgG value may be one of the indicators reflecting the protective effect of vaccination. These data indicate that the vaccines remain effective against the delta variant. Previous studies have demonstrated that serum IgG in patients with SARS-CoV-2 infection was closely related to its protective effect, and if the IgG antibody value was less than 50 BAU/mL, the protective effect of the vaccine was very limited . In our Despite vaccine neutralization of the delta variant, the symptom with the slowest recovery is anosmia/dysgeusia; indeed, anosmia/dysgeusia may be a good predictor of SARS-CoV-2 infection . One stuThis study has the following limitations. First, due to the vaccination policy, there are increasingly fewer subjects who are not vaccinated; therefore, the numbers of unvaccinated and one-dose vaccinated patients were low in this study, which could cause selection bias and affect the conclusions. Second, this study had a small sample size; we only analyzed the hospitalization data of patients in three specific groups and did not include the data from each patient’s entire disease process, which could also affect the accuracy of the conclusions. Third, we only analyzed the effectiveness of inactivated vaccines and did not include live attenuated vaccines or mRNA vaccines, which may have affected the results. Finally, this study did not analyze the protective effects of vaccines in different populations, which may affect the generalizability of the conclusions.In this retrospective study, our results suggest that two-dose vaccination could alleviate symptoms of the SARS-CoV-2 delta variant, reduce viral load and accelerate viral clearance in patients. The two-dose vaccinated patients showed higher IgG antibody levels than the unvaccinated and one-dose vaccinated patients, and the two-dose vaccinated group exhibited a higher recovery rate without the need for medications than the other two groups.


This is followed by immobilization of streptavidin. Streptavidin serves as a universal anchor for biotinylated antibodies, enabling simple preparation of tailor-made affinity samplers. The functionality of the device was tested using a model protein  and biotinylated anti-hCG antibodies for affinity capture. In a laboratory setting, the performance was demonstrated, and a 14-fold increase of target binding compared to binding without bmAb was achieved. The recovery of hCG captured with bmAb-treated samplers was determined to be 33% and comparable to previously described affinity capture approaches. Application of the smart affinity samplers to human serum containing hCG showed an R2 of 0.98 (200–1000 pg mL−1), precision of ≤ 9.1% RSD, and estimated limit of detection of 65 pg mL−1. Although further optimization and validation are necessary prior to application to real samples in clinical settings, the potential of the device for use in determination of low abundant biomarkers in complex samples has been demonstrated.The modification of an easily available resource like paper to circumvent expensive or intensive sample pretreatment could be the answer to sample analysis in resource-poor regions. Therefore, a novel on-paper device combining sample collection with affinity sample pretreatment is introduced here. Universal smart affinity samplers are produced by a simple KIOThe online version contains supplementary material available at 10.1007/s00216-022-04161-w. That is why recently, sampling cards for blood and other matrices have been facilitated as smart samplers in several ways. These smart samplers allow the pretreatment to start already upon blood collection, thus saving valuable time and material in the preparation of the sample later on. Integration of sample pretreatment steps as, for example, tryptic digestion for bottom-up protein analysis ) was used as internal standard (IS) and purchased from Sigma-Aldrich. The AQUA™ peptide was reduced and alkylated in-house according to the protocol from Lund et al. ). For the βT5 peptide, the following two transitions were monitored: m/z 964.2 → 1036.3 and m/z 964.2 → 1317.8. Similarly, for the internal standard peptide, the transitions m/z 969.2 → 1046.3 and m/z 969.2 → 1327.8 were monitored. Data acquisition and processing were carried out using Thermo Fisher Scientific Xcalibur™ software.Chromatographic separation was carried out with a Dionex  Ultimate 3000 RSCL Nano system equipped with an Acclaim PepMap™ 100 C18  on the fluorescence was investigated , paper which was oxidized and immobilized with streptavidin, and paper that was oxidized and treated with BSA. For the latter two, a volume of only 0.5 µL of protein (SA or BSA) was applied in order to leave a distinct spot on the discs. Figure −1 bmAb. The modified paper was then incubated with 5 µL hCG  was applied and incubation with the target analyte performed using 5 µL of 100 ng mL−1 hCG in 50 mM ABC. Firstly, it was tested if hCG could be captured with oxidized paper discs immobilized with BSA (5 µL of 2% (w/v) in 1 mM HCl) instead of SA . These conditions were compared to the proof-of-principle procedure  SA and subsequently treated with 250 µL of 2.3 mg L−1 in 50 mM ABC with 5% (w/v) BSA). Theoretically, all three volumes of bmAb contained sufficient amounts of antibody to capture the entire amount of hCG added  BSA  bmAb.In order to evaluate whether the amount of bmAb was limiting the hCG binding and to ensure high recoveries of the target analyte, paper discs were treated with varying volumes of bmAb  while the hCG concentration remained constant  BSA, respectively; Fig. −1 in 50 mM ABC, 5% (w/v) BSA) on SA paper discs not treated with bmAb, but otherwise following the standard procedure . Figure −1) of hCG. The correlation value (R2) for the polynomial regression equals 0.98. The relative standard deviation (RSD) of each concentration was 7.0%, 7.0%, 9.1%, and 8.7% for 200 pg mL−1, 500 pg mL−1, 750 pg mL−1, and 1000 pg mL−1, respectively. The calibration curve in Fig. −1) for the used amount of bmAb . This could be a possible explanation for the modest correlation value. However, it is shown that different hCG concentrations can be extracted from human serum when using the tailor-made affinity smart samplers. The average signal to noise ratio (S/N) for the 200 pg mL−1 samples (n = 3) is 6.1. Assuming a S/N = 3 as definition of the limit of detection (LOD), then an estimate of 65 pg mL−1 can be determined for SA-bmAb paper discs Below is the link to the electronic supplementary material.


Malnutrition among adolescents is a persistent problem with a profound impact on different dimensions of health. The objective of this analysis is to assess the burden of malnutrition  and their associated socio-demographic factors among Indian adolescents (10–19 years) from the Comprehensive National Nutritional Survey (CNNS 2016-18) data.We used Individual-level data of 35,831 adolescents from the CNNS conducted in 2016–18 for this analysis. CNNS collected data on the nutritional status of adolescents along with socio-demographic variables from all states of India. Burden of stunting , thinness , overweight (BAZ > 1 SD) and obesity (BAZ > 2 SD) were estimated for the entire country and individual states. A multivariable logistic regression analysis was used to assess the socio-demographic factors associated with stunting, thinness, and overweight.CNNS collected data from 35,831 adolescents, of which 31,941 with BAZ scores, and 32,045 with HAZ scores were included in the final analysis. The burden of stunting and thinness among Indian adolescents was 27.4%  and 24.4% , respectively. The burden of overweight and obesity was 4.8%  and 1.1% , respectively. Adolescents in the age group of 15–19 years  compared to 10–14 years, females  compared to males, were at increased odds of getting stunted. Adolescents from lowest wealth index families  were at increased odds of thinness compared to peers of higher wealth index families. Adolescents of 10–14 years  compared to 15–19 years, urban residents  compared to rural residents, were at increased odds of overweight.Indian adolescents face the double burden of malnutrition that is undernutrition (stunting and thinness) alongside overnutrition (overweight and obesity) that are linked with socio-demographic factors. The National Nutritional Programs (POSHAN Abhiyan) should prioritize high-risk groups specifically older age group (15–19 years), females, and low wealth Index quintile families identified in this analysis. Adolescence (aged 10–19 years) is an essential phase in a child's growth with rapid physical, psychological, and cognitive development . The 1.22) among adolescent boys and girls of 15–19 years age was 45 and 42%, respectively (2) among adolescent girls of age 10–14 as 77% and that of 15–18 years age group as 45% , the National Nutrition Monitoring Bureau (NNMB), the District Level Health Surveys (DLHS), the Annual Health Surveys (AHS), and the Rapid Survey of Children (RSoC). National Family Health Survey-4 reported the nutritional status of the 15–19 years age group using body mass index (BMI) as an indicator but not BMI-for-age z-scores (BAZ) . As per ectively . The RapIn India, there are no nationally representative data on nutritional status of adolescents (10–19 years of age) that use comprehensive and appropriate anthropometric indicators. For adolescents, using the standard BMI-for age (BAZ) scores by World Health Organization (WHO) . The ComThe CNNS was conducted from February 2016 to October 2018 by the Ministry of Health and Family Welfare, Government of India, collaborating with United Nations Children's Fund (UNICEF) and the Population Council. The methodological details of the survey are available in detail in the CNNS report . BrieflyThe CNNS used a household and an individual questionnaire for all participants using the Computer-Assisted Personal Interviewing (CAPI) method in the principal languages of the state and/or English after obtaining informed consent from the caregiver and assent from the adolescent . For eveIndividual-level data for 10–19 years collected from the CNNS was accessed for this secondary analysis. The age group 10–19 years included children who had completed 120 months till 228 months. The age group was classified as early adolescents (120–179 months) and late adolescents (180–228 months). World Health Organization (WHO) Anthro Plus software was used to derive the BMI-for-age z-score (BAZ) and Height-for-age z-score (HAZ) . WHO stap-value < 0.25 on univariate analysis, variables of contextual and clinical importance were included in the final model  was seen in 8,877 Indian adolescents with a burden of 27.4% . The burden of thinness was 24.4%  as seen in 7,896 adolescents. The double burden of stunting and thinness in the same individual was seen in 8.6%  adolescents, while the prevalence of co-existing stunting and overweight was seen in 0.8% . The burden of overweight and obesity among Indian adolescents was 4.8%  and 1.1% , respectively .A higher prevalence of stunting was seen in north-eastern states—Assam , Meghalaya , Nagaland  and Jharkhand  compared to the national average . Seven states have thinness more than the national average , two of which are from the Southern region—Telangana , and Karnataka . Overweight  was seen to be more prevalent in Tamil Nadu , Delhi , Goa , Kerala , Sikkim , Arunachal Pradesh , and Tripura . States with a prevalence of overweight lower than the national average include Madhya Pradesh , Uttar Pradesh , Bihar , and Jharkhand . Obesity was found to be higher than the national average  in states like Goa , Delhi , Tamilnadu , Punjab , and Manipur  .Adolescents in the age group of 15–19 years , female gender , Muslim religion , scheduled caste  and scheduled tribes  were at increased odds of stunted growth compared to their counterparts . SimilarAdolescents from other backward classes , lowest wealth index families , western India  were at increased odds of thinness compared to their counterparts at a statistically significant level. The age group of 15–19 years  compared to 10–14 years age group, Female gender  compared to males were at decreased odds of thinness. Adolescents from eastern India  and north-eastern India  were at decreased odds of thinness compared to adolescents from northern India .Adolescents in the age group of 10–14 years , residence in urban areas , others  category of social class , mothers' education more than 12 years  highest wealth index families  were at increased odds of overweight compared to their counterparts. Similarly, adolescents residing in north-eastern India , eastern India , and southern India  were at increased odds of overweight compared to adolescents residing in north India .Our analysis has shown that among Indian adolescents, 27.4% were stunted, 24.4% were thin, 4.8 and 1.1% were overweight and obese, respectively. While stunting was higher in girls and the late adolescent age group (15–19 years), thinness was higher in boys and early adolescence (10–14 years). Overweight was marginally higher in boys than girls and early adolescence compared to late adolescence. The socio-demographic factors of adolescent malnutrition  in India from our analysis include gender, wealth index, social class, religion, and maternal education.In the present study, the prevalence of stunting was higher in late adolescence (30% in late adolescence vs. 25.6% in early adolescence). According to the Global School-Based survey conducted in 57 Low-Middle-Income countries (LMICs) on children aged 12–15 years, 14.6% of adolescents in India were stunted . Our estThe burden of stunting among girls was higher than boys, corroborating with previous estimates by Bhargava et al. on NFHS data . Indian In the current study, thinness was higher in boys (29.9%) than girls (18.9%). In NFHS-3, the reported prevalence of thinness was 22.3% (boys) and 9.9% (girls), which subsequently decreased to 16.5 and 9% in NFHS-4 in boys and girls, respectively. In many neighboring countries, thinness among boys is higher than girls, viz Indonesia (11 vs. 5%), Bangladesh 19.6 vs. 15.4%), and Nepal (37.8 vs. 26.2%) –25. This.4%, and In the present study, the prevalence of thinness was 27.6% in early adolescence and 20.9% in late adolescence, which was similar to findings by Kumar P et al. observed in adolescents of Bihar and Uttar Pradesh . This coOur analysis has shown a marginally higher prevalence of overweight (BAZ > 1SD) among boys (4.9%) compared to girls (4.7%), with no statistically significant difference. The prevalence rates of overweight reported in NFHS-4 were slightly higher than CNNS data, and there was a marginal increase between NFHS-3 (3.0% in boys and 4.3% in girls) and NFHS-4 (6.2% in boys and 4.9% in girls) . The burThe literature about coexisting stunting with thinness or obesity is sparsely available amongst adolescents in India. The UDAYA study conducted in Uttar Pradesh and Bihar states reports that the co-existence of stunting with thinness was seen in 11 percent of boys and 8 percent of early adolescent girls .The strength of the present analysis is the use of CNNS data, a large, quality-controlled, recent, and representative national sample. We have used BAZ scores, an appropriate indicator for reporting nutritional status among adolescents unlike BMI which is appropriate for adults and used in NFHS surveys. We have not analyzed and triangulated other forms of malnutrition, including the micronutrient deficiencies and co-existence of different forms of malnutrition which is a limitation of this analysis. Another limitation of this analysis is that the socio-demographic predictors of malnutrition among adolescents needs to be triangulated with clinical characteristics and dietary intakes. Since adolescent malnutrition especially stunting and thinness, are high, correcting these in this age group could be the game-changer in breaking the intergenerational cycle of malnutrition. With the identified burden of overweight and obesity, interventions focusing on the early lifestyle changes in this age group must be taken up through already existing national health programs. Identification of state-specific determinants of malnutrition coupled with effective interventional strategies can benefit in a targeted reduction in the burden of malnutrition. Growth monitoring and nutritional surveillance like quarterly anthropometric assessment can contribute to the real-time correction of malnutrition among adolescents. School health programs and POSHAN Abhiyan (Prime Minister's Overarching Scheme for Holistic Nourishment) must be linked with the periodic anthropometric assessment of this age group.Among Indian adolescents, there is the burden of thinness, stunting, and overweight, indicating the double burden of malnutrition. Socio-demographic factors of malnutrition identified in this analysis include gender , religion , social class (Scheduled castes and scheduled tribes), not attending school, no/less maternal education, poor wealth index families. These factors can prioritize interventional strategies at the district and state levels to eliminate malnutrition. Adolescence presents a final opportunity for correction of malnutrition before the child enters adulthood. Nutritional surveillance in this age group coupled with targeted nutritional programs for undernutrition and lifestyle changes for overweight and obesity will correct malnutrition in this crucial age group.The original contributions presented in the study are included in the article/Ethical approvals for the CNNS were obtained from the Population Council's Institutional Review Board, New York, and the Institutional Ethical Committee of Post Graduate Institute of Medical Education and Research, Chandigarh, India (PGI/IEC/2015/1508).RPa, MM, and SC conceptualized the article, interpreted the results, and contributed to manuscript preparation. UT and VK was involved in manuscript writing. NR was involved in conceptualizing the article, performing statistical analysis, interpreting the results, and writing the manuscript. CK performed the statistical analysis. JG, RPu, and RH critically reviewed the manuscript and had the final decision in processing the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Correction to: Virchows Archiv10.1007/s00428-022-03444-yIn the original published version of the above article contained incorrect Table legend. The Table The original article has been corrected.


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