My Site - Chapter 25: Treatment Of Hypertension
People with diabetes should be treated to achieve a blood pressure (BP) <130/80 mm Hg. The revisions of these recommendations were completed through collaboration with the Canadian Hypertension Education Program (CHEP). It is recommended that people with diabetes be treated to achieve and maintain a blood pressure (BP) <130/80 mm Hg. Recommendations regarding combination therapy have been expanded since 2008. Strong recommendation added for the use of angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) therapy as first-line in patients with cardiovascular disease, kidney disease (including microalbuminuria) or any cardiovascular risk factors. Recommendation to use dihydropyridine calcium channel blocker (CCB) as the add-on therapy to ACE inhibitor instead of hydrochlorothiazide. Persons with diabetes mellitus should be treated to attain SBP <130 mm Hg [Grade C, Level 3 (1,2) ] and DBP <80 mm Hg [Grade B, Level 1 (3) ]. (These target BP levels are the same as the BP treatment thresholds). Combination therapy using 2 first-line agents may also be considered as initial treatment of hypertension [Grade C, Level 3 (4,5) ] if SBP is 20 mm Hg above target or if DBP is 10 mm Hg above target. However, caution should be exercised in patients in whom a substantial fall in BP is more likely or poorly tolerated (e.g. elderly patients, patients with autonomic neuropathy). For persons with cardiovascular or kidney disease, including microalbuminuria, or with cardiovascular risk factors in addition to diabetes and hypertension, an ACE inhibitor or an ARB is recommended as initial therapy [Grade A, Level 1A (69) ]. For persons with diabetes and hypertension not included in the above recommendation, appropriate choices include (in alphabetical order): Continue reading >>
2017 Guideline For High Blood Pressure In Adults
The following are key points to remember from the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Part 1: General Approach, Screening, and Follow-up The 2017 guideline is an update of the “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7), published in 2003. The 2017 guideline is a comprehensive guideline incorporating new information from studies regarding blood pressure (BP)-related risk of cardiovascular disease (CVD), ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), BP thresholds to initiate antihypertensive drug treatment, BP goals of treatment, strategies to improve hypertension treatment and control, and various other important issues. It is critical that health care providers follow the standards for accurate BP measurement. BP should be categorized as normal, elevated, or stages 1 or 2 hypertension to prevent and treat high BP. Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥140 or ≥90 mm Hg. Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP. Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with clinical interventions and telehealth counseling. Corresponding BPs based on site/methods are: office/clinic 140/90, HBPM 135/85, daytime ABPM 135/85, night-time ABPM 120/70, and 24-hour ABPM 130/80 mm Hg. In adults with an untreated systolic BP (SBP) >130 but <160 mm Hg or dia Continue reading >>
Diabetes With Hypertension
Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Home and Ambulatory Blood Pressure Recording article more useful, or one of our other health articles. This article aims to provide a simple management plan for the management of people with diabetes mellitus who also have raised blood pressure (BP). It is based mainly on the current National Institute for Health and Care Excellence (NICE) recommendations. Patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality and are disproportionately affected by cardiovascular disease. Most of this excess risk is associated with high prevalence of well-established risk factors such as hypertension, dyslipidaemia and obesity in these patients.[1, 2]Hypertension plays a major role in the development and progression of microvascular and macrovascular disease in people with diabetes.[3] Early intervention and targeting multiple risk factors with both lifestyle and pharmacological strategies give the best chance of reducing macrovascular complications in the long term.[4] Antihypertensive therapies may promote the development of type 2 diabetes mellitus. Studies indicate that the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II receptor antagonists (AIIRAs) leads to less new-onset diabetes compared to beta-blockers, diuretics and placebo.[5] Epidemiology Hypertension is more prevalent in patients with type 2 diabetes than in those who don't have diabetes.[4] It is estimated that the prevalence of arterial hypertension (BP greater than 160/95 mm Hg) in patients with type 2 diabetes is in the Continue reading >>
Type 2 Diabetes In Adults: Management
Recommendations from NICE clinical guideline 87 (2009) that have been amended May 2017: Text on sodiumglucose cotransporter 2 (SGLT-2) inhibitors was added to the section on initial drug treatment. The algorithm for blood glucose lowering therapy in adults with type 2 diabetes was also updated to revise footnote b with links to relevant NICE guidance on SGLT-2 inhibitors, and new information on SGLT-2 inhibitors was also added to the box on action to take if metformin is contraindicated or not tolerated. December 2016: The text following recommendation 1.6.31 and the algorithm for blood glucose lowering therapy in adults with type 2 diabetes were updated to include reference to NICE TA418 on dapagliflozin in triple therapy for treating type 2 diabetes. July 2016: Recommendation 1.7.17 has been reworded to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen. December 2015: This guidance updates and replaces NICE guideline CG87 (published May 2009). It also updates and replaces NICE technology appraisal guidance 203 and NICE technology appraisal guidance 248. It has not been possible to update all recommendations in this update of the guideline. Areas for review and update were identified and prioritised through the scoping process and stakeholder feedback. Areas that have not been reviewed in this update may be addressed in 2years' time when NICE next considers updating this guideline. NICE is currently considering setting up a standing update committee for diabetes, which would enable more rapid update of discrete areas of the diabetes guidelines, as and when new and relevant evidence is published. Recommendations are marked as [new 2015], [2015], [2009] or [2009, amended 2015]: [new 2015] indicates that Continue reading >>
Guidelines Management Of Hypertension: Summary Of Nice Guidance
Management of hypertension: summary of NICE Taryn Krause senior project manager, research fellow 1, Kate Lovibond senior health economist 1, Mark Caulfield professor of clinical pharmacology 2, Terry McCormack general practitioner 3, Bryan Williams professor of medicine 4 5, on behalf of the Guideline Development Group 1National Clinical Guideline Centre Acute and Chronic Conditions, Royal College of Physicians, London NW1 4LE, UK; 2William Harvey Research Institute, Barts and the London School of Medicine, and NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London EC1M 6BQ; 3Whitby Group Practice, Spring Vale Medical Centre, Whitby YO21 1SD, UK;4Department of Cardiovascular Sciences, University of Leicester, Leicester LE3 9QP, UK ; 5Leicester NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester LE3 9QP This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists. Hypertension is one of the most important preventable causes of death worldwide and one of the commonest conditions treated in primary care in the United Kingdom, where it affects more than a quarter of all adults and over half of those over the age of 65 years.1This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of hypertension,2 which updates the 2004 and 2006 clinical guidelines.3-5 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Groups experien Continue reading >>
Nice Guidance On Type 2 Diabetes In Adults Whats New?
NICE guidance on type 2 diabetes in adults whats new? Written by: David Morris | Published: 15 February 2016 Patient education is crucial to good management The eagerly awaited NICE guidance on type 2 diabetes in adults (NG 28) was finally published in December 20151 after two substantial revisions and not a small amount of controversy.2 NG28 emphasises the importance of an individualised approach to diabetic care according to the needs, circumstances and preferences of the patient. Co-morbidities, the risks of polypharmacy and reduced life-expectancy should all be factored into decision making. As discussed in the previous NICE guideline of 20093 structured education should be offered to the patient, family members or carers at the time of diagnosis (and the need for further education reviewed annually). Group education is the preferred option with programmes meeting the cultural, linguistic and literary needs within the local group. Dietary advice sensitive to culture and beliefs from an appropriate health care professional, physical exercise and weight loss are central lifestyle issues to be addressed. While a 5-10% weight loss is suggested as a target it is accepted that any weight loss will be beneficial. The holistic approach to patient care advocated in the NICE guideline is to be welcomed. Patient education (utlising programmes such as DESMOND and X-PERT) and lifestyle change remain the cornerstone of treatment for type 2 diabetes. NG 28 advice on management of hypertension largely follows the 2009 guideline2 supplemented by more recent hypertension guidance.4, 5 Target blood pressure is set at 140/80, lowered to 130/80 for those with renal or eye damage or previous cerebrovascular disease (TIA/CVA). An algorithm derived from the NICE guideline advice is shown Continue reading >>
Hypertension In Adults: Diagnosis And Management
Hypertension in adults: diagnosis and management 1.7 Patient education and adherence to treatment The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance. In this guideline the following definitions are used. Stage 1 hypertension Clinic blood pressure is 140/90mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85mmHg or higher. Stage 2 hypertension Clinic blood pressure is 160/100mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95mmHg or higher. Severe hypertension Clinic systolic blood pressure is 180mmHg or higher or clinic diastolic blood pressure is 110mmHg or higher. 1.1.1 Healthcare professionals taking blood pressure measurements need adequate initial training and periodic review of their performance. [2004] 1.1.2 Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. [2011] 1.1.3 Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturers' instructions. [2004] 1.1.4 When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. [2011] 1.1.5 If using an automated blood pressure monitoring device, ensure Continue reading >>
- Conjoint Associations of Gestational Diabetes and Hypertension With Diabetes, Hypertension, and Cardiovascular Disease in Parents: A Retrospective Cohort Study
- Type 1 diabetes as common in adults as children, but many adults misdiagnosed
- At 40, a Surprising Diagnosis: Latent Autoimmune Diabetes in Adults
Nice To Look At Lowering Blood Pressure Targets In Guidance Overhaul
NICE to look at lowering blood pressure targets in guidance overhaul NICE has given the green light for a full update of its guidance on hypertension including the potential introduction of lower blood pressure targets that could see GPs treating many more people with antihypertensive drugs. Pulse previously revealed that NICE experts were considering new evidence on lowering blood pressure to a target of 120mmHg in high-risk patients , as part of a review of the current guidance published in 2011. Having concluded the review, NICE has now announced that it will carry out a full update of the guidelines and confirmed to Pulse that this will consider new evidence on blood pressure targets as part of revisions to the guidelines section on initiating and monitoring antihypertensive drug treatment, including blood pressure targets. The update will also take in new evidence on management of blood pressure in people with type 2 diabetes, previously covered in the condition-specific NICE guidelines on diabetes. Dr Terry McCormack, secretary of the British Hypertension Society and a GP in Whitby, North Yorkshire, was involved in the reappraisal of the guidelines in his role as NICE topic expert advisor. He told Pulse that the full update will include targets, fourth line therapy, lifestyle and diabetes andthat the review of blood pressure targets will specifically evaluate SPRINT. But he noted it was unlikely to reduce the target to as low as 120mmHg and would likely included recommendations on more intensive drug treatment, and adherence. Dr McCormack said: The actual achieved target was closer to 130mmHg. The average number of drugs in each arm were 2.8 and 1.8 which is more significant in my mind. He added: They also stopped drugs in the standard treatment arm, mostly diure Continue reading >>
Nice Guidance - Hypertension Management In Type Ii Diabetes - General Practice Notebook
NICE guidance - hypertension management in type II diabetes the UKPDS study has provided evidence that, in Type II diabetics, antihypertensive therapy was more effective than tight glycaemic control in protecting against macrovascular and microvascular disease, and was the only intervention that improved survival of patients with Type II diabetes (1) measure blood pressure at least annually in a person without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice for a person on antihypertensive therapy at diagnosis of diabetes, review control of blood pressure and medications used, and make changes only where there is poor control or where current medications are not appropriate because of microvascular complications or metabolic problems repeat blood pressure (BP) measurements within: 2 months if BP is higher than 140/80 mmHg 2 months if BP is higher than 130/80 mmHg and there is kidney, eye or cerebrovascular damage. Offer lifestyle advice (diet and exercise) at the same time add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage) monitor blood pressure 1-2-monthly, and intensify therapy if on medications until blood pressure is consistently below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular disease) first-line therapy in hypertension in a diabetic first-line blood-pressure-lowering therapy should be a once-daily, generic angiotensin-converting enzyme (ACE) inhibitor. Exceptions to this are people of African-Caribbean descent or women for whom there is a possibility of becoming pregnant first-line blood-pressure-lowering therapy for a person of African-Caribbean descent should be an ACE inhib Continue reading >>
Treatment Of Hypertension In Diabetes
Tonje A Aksnes; Sigrid N Skrn; Sverre E Kjeldsen Expert Rev Cardiovasc Ther.2012;10(6):727-734. Hypertension Treatment Targets in Diabetic Patients According to major hypertension guidelines, such as the European Society of Hypertension (ESH)[ 9 ] and the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure,[ 10 ] hypertension is defined as a blood pressure (BP) above 140/90 mmHg. However, the real threshold for hypertension and potential organ damage for the individual patient must be based on the total cardiovascular risk for each patient.[ 9 ] Many current antihypertensive guidelines recommend treatment goals lower in diabetic patients (aiming to achieve <130/80 mmHg) due to the higher risk of cardiovascular end points in diabetic patients.[ 10 , 11 ] However, the evidence in favor of initiating BP-lowering therapy in diabetic patients with high normal BP and a target of systolic BP (SBP) below 130 mmHg is scarce, and the recent reappraisal of the ESH guidelines on hypertension management reset the BP goal for diabetic patients to BP <140/90 mmHg and close to 130/80 mmHg, but not below the value.[ 11 ] The Hypertension Optimal Treatment (HOT) trial found that, in the subgroup of diabetic patients, the risk of major cardiovascular events was halved in the group randomized to a diastolic BP (DBP) 80 mmHg compared with the target group with DBP <90 mmHg.[ 12 ] The UKPDS showed in the 1997 follow-up results that more tight (mean 144/82 mmHg; BP goal <150/85 mmHg) versus less tight (mean 154/87 mmHg, BP goal <180/106 mmHg) BP resulted in significant reductions in microvascular disease, stroke- and diabetes-related end points, but no significant benefits were found in terms of myocardial infarction and all-cause mortality.[ 13 Continue reading >>
Management Of Hypertension In Adults In Primary Care: Nice Guideline
Management of hypertension in adults in primary care: NICE guideline Whitby Group Practice, Whitby, North Yorkshire Taryn Krause , BSc, senior project manager/research fellow and Norma O'Flynn , PhD, MRCGP, clinical director National Clinical Guideline Centre Acute and Chronic Conditions, Royal College of Physicians, London Address for correspondence Norma O'Flynn, Royal College of Physicians, National Clinical Guideline Centre for Acute and Chronic Conditions, 11 St Andrews Place, London, NW1 4LE. E-mail: [email protected] Received 2011 Aug 26; Accepted 2011 Aug 30. Copyright British Journal of General Practice 2012 This article has been cited by other articles in PMC. Hypertension is common and is one of the leading causes of cardiovascular events such as stroke and ischaemic heart disease. It is responsible for approximately 12% of consultations in primary care. This is a summary of the key points in the 2011 National Institute for Health and Clinical Excellence (NICE) hypertension guideline. 1 This is an update of NICE clinical guideline 18, which was first published in 2004 and was partially updated in 2006 (clinical guideline 34). The 2006 and 2011 updates were developed in collaboration with the British Hypertension Society (BHS). The areas included for updating were selected because of new evidence that might change existing recommendations. These included the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) in diagnosis; the place of new thresholds and targets for treatment; and a re-examination of the position of angiotensin-converting inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium-channel blockers (CCBs), and diuretics in the treatment algorithm. Consideration of differences in mana Continue reading >>
- Conjoint Associations of Gestational Diabetes and Hypertension With Diabetes, Hypertension, and Cardiovascular Disease in Parents: A Retrospective Cohort Study
- Type 1 diabetes as common in adults as children, but many adults misdiagnosed
- The cost-effectiveness of primary care for Indigenous Australians with diabetes living in remote Northern Territory communities
Nice Ckd Guideline | Nice Guideline | Guidelines
cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or cerebral vascular disease) structural renal tract disease, recurrent renal calculi or prostatic hypertrophy multisystem diseases with potential kidney involvement for example, systemic lupus erythematosus family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease Do not use age, gender or ethnicity as risk markers to test people for CKD. In the absence of metabolic syndrome, diabetes or hypertension, do not use obesity alone as a risk marker to test people for CKD Classify CKD using a combination of GFR and ACR categories. Be aware that: increased ACR is associated with increased risk of adverse outcomes decreased GFR is associated with increased risk of adverse outcomes increased ACR and decreased GFR in combination multiply the risk of adverse outcomes Do not determine management of CKD solely by age Table 1 Classification of chronic kidney disease using GFR and ACR categories Offer a renal ultrasound scan to all people with CKD who: have visible or persistent invisible haematuria have symptoms of urinary tract obstruction have a family history of polycystic kidney disease and are aged over 20years have a GFR of less than 30ml/min/1.73m2 (GFR category G4 or G5) are considered by a nephrologist to require a renal biopsy Advise people with a family history of inherited kidney disease about the implications of an abnormal result before a renal ultrasound scan is arranged for them Agree the frequency of monitoring (eGFRcreatinine and ACR) with the person with, or at risk of, CKD; bear in mind that CKD is not progressive in many people See table below to guide the frequency of GFR monitoring for people with, or at risk of, CKD, but tailor i Continue reading >>
Management Of Hypertension: Summary Of Nice Guidance
Management of hypertension: summary of NICE guidance Management of hypertension: summary of NICE guidance BMJ 2011; 343 doi: (Published 25 August 2011) Cite this as: BMJ 2011;343:d4891 Taryn Krause, senior project manager, research fellow1, Mark Caulfield, professor of clinical pharmacology2, on behalf of the Guideline Development Group 1National Clinical Guideline Centre Acute and Chronic Conditions, Royal College of Physicians, London NW1 4LE, UK 2William Harvey Research Institute, Barts and the London School of Medicine, and NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London EC1M 6BQ 3Whitby Group Practice, Spring Vale Medical Centre, Whitby YO21 1SD, UK 4Department of Cardiovascular Sciences, University of Leicester, Leicester LE3 9QP, UK 5Leicester NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester LE3 9QP Correspondence to: B Williams, Department of Cardiovascular Sciences, University of Leicester and Leicester NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester LE2 7LX bw17{at}le.ac.uk Hypertension is one of the most important preventable causes of death worldwide and one of the commonest conditions treated in primary care in the United Kingdom, where it affects more than a quarter of all adults and over half of those over the age of 65 years.1 This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of hypertension,2 which updates the 2004 and 2006 clinical guidelines.3 4 5 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Gr Continue reading >>
Clinical Management Of Primary Hypertension In Adults (nice Guideline)
Clinical Management of Primary Hypertension in Adults (NICE Guideline) Summary of NICE guidance on high blood pressure. If BP 140/90mmHg, take a second reading; if considerably different, take a third. Record the lower of the last two measurements as clinic BP. Take a supine or seated reading in patients with symptoms of postural hypotension, followed by a reading after 1 min standing. If clinic BP is 140/90mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm diagnosis. If patient is unable to tolerate ABPM, offer home blood pressure monitoring (HBPM). If severe hypertension, consider starting treatment immediately without waiting for results of ABPM or HBPM. Measure BP on both of patients arms, if difference is >20mmHg repeat the measurement and if it remains >20mmHg use the arm with the higher reading for future measurements. While waiting for ABPM or HBPM results, test for proteinuria. Measure plasma glucose, electrolytes, creatinine, eGFR, serum total cholesterol and HDL-cholesterol. Arrange a 12-lead ECG. Assess for hypertensive retinopathy. Estimate 10-year cardiovascular disease (CVD) risk in accordance with the NICE guideline on lipid modification . If hypertension is not diagnosed, assess in 5 years or consider more frequently if clinic BP is close to 140/90mmHg. Take 2 measurements per hour during patients usual waking hours. Use average value of 14 measurements to confirm diagnosis. For each BP recording, take two measurements 1 min apart whilst patient is seated. Record BP twice daily, ideally in the morning and evening. Discard measurements on day 1 and use the average value of remaining measurements to confirm diagnosis. To reduce clinic BP to <140/90mmHg or average ABPM/HBPM to <135/85mmHg in patients <80 years="" li=""> To reduce clinic BP Continue reading >>
- Conjoint Associations of Gestational Diabetes and Hypertension With Diabetes, Hypertension, and Cardiovascular Disease in Parents: A Retrospective Cohort Study
- Type 1 diabetes as common in adults as children, but many adults misdiagnosed
- The Pathophysiology of Hyperglycemia in Older Adults: Clinical Considerations
Guidance Update: Latest Nice Guidelines On Hypertension
Guidance update: latest NICE guidelines on hypertension This course is available for purchase as part of a subscription: Dr Raj Thakkar describes how to implement the latest NICE guidance relating to hypertension in primary care. The module outlines the latest evidence and what to do differently in your practice. NICE guidance CG127. Hypertension in adults: diagnosis and management. August 2011 and updated 2016. New guidelines are in progress given the 2016 surveillance report. NICE quality standard: Hypertension. QS28. Updated September 2015. NICE quality standard. Cardiovascular risk assessment and lipid modification. QS100. September 2015. NICE guidance NG28. Type 2 diabetes in adults: management. December 2015. NICE guideline NG56. Multimorbidity: clinical assessment and management. September 2016. After taking this module, GPs and nurses will be better able to: Recall whats new and whats relevant to them in the latest NICE guidance relevant to hypertension Know what to do differently in practice in the light of the NICE guidance List the causes of secondary hypertension Describe the outcomes of the PATHWAY-2 study, the SYMPLICITY HTN-3 trial and the SPRINT study Outline the different treatment options for hypertension GP and primary care lead for cardiology, Oxford AHSN This is a learning activity provided by MIMS Learning, featuring learning material and a test. Completing the test enables you to claim 1 learning credit (1 hour learning). This credit award is recommended by MIMS Learning based on completing the activity and reflecting on what you have learned. If you spend less time on the activity we recommend claiming fewer credits. Please proceed with the activity until you have successfully answered all the test questions and completed your evaluation. You wi Continue reading >>
