MATHEMATICS IN

MEDICINE AND
MEDICAL SCIENCE

Ambulatory blood
pressure
Ambulatory blood pressure
monitoring

Ambulatory blood pressure monitoring (ABPM) measures blood pressure at regular

intervals. It is believed to be able to reduce the white coat hypertension effect in which a
patient's blood pressure is elevated during the examination process due to nervousness and
anxiety caused by being in a clinical setting. ABPM can also detect the reverse condition,
masked hypertension, where the patient have normal blood pressure during the examination

but uncontrolled blood pressure at home.[1] Out-of-office measurements are highly

recommended as an adjunct to office measurements by almost all hypertension

organizations.

Contents
 1. Blood pressure variability

2. Nocturnal hypertension

3. Target organ damage

4. Overnight reduction or surge in blood pressure

5. References

Blood pressure variability

24-hour, non-invasive ambulatory blood pressure (BP) monitoring allows estimates of
cardiac risk factors including excessive BP variability or patterns of circadian variability
known to increase risks of a cardiovascular event.

Nocturnal hypertension

Ambulatory blood pressure monitoring allows blood pressure to

be intermittently monitored during sleep and is useful to
determine whether the patient is a "dipper" or
"non-dipper"—that is to say, whether or not blood pressure falls
at night compared to daytime values. A night time fall is normal
and desirable. It correlates with relationship depth but other
factors such as sleep quality, age, hypertensive status, marital
status, and social network support.[2] Absence of a night time
dip is associated with poorer health outcomes, including
increased mortality in one recent study.[3] In addition, nocturnal
hypertension is associated with end organ damage[4] and is a
much better indicator than the daytime blood pressure reading.

Target organ damage

Readings revealing possible hypertension-related and organ damage, such as left

ventricular hypertrophy or narrowing of the retinal arteries, are more likely to be gained
through ambulatory blood pressure monitoring than through clinical blood pressure
measurement. Clinical BP measurements are fewer in number, and so more subject to the
general marked variability of BP measurements. Additionally, clinical measurements are
affected by the "white coat effect" - the rise in blood pressure many patients experience due
to the stress of being in the medical situation.

Overnight reduction or surge in blood pressure

Optimal blood pressure fluctuates over a 24-hour sleep-wake cycle, with values rising in the
daytime and falling after midnight. The reduction in early morning blood pressure compared
with average daytime pressure is referred to as the night-time dip. Ambulatory blood
pressure monitoring may reveal a blunted or abolished overnight dip in blood pressure. This
is clinically useful information because non-dipping blood pressure is associated with a
higher risk of left ventricle hypertrophy and cardiovascular mortality. By comparing the early
morning pressures with average daytime pressures, a ratio can be calculated which is of
value in assessing relative risk. Dipping patterns are classified by the percent of drop in
pressure, and based on the resulting ratios a person may be clinically classified for treatment
as a "non-dipper" (with a blood pressure drop of less than 10%), a "dipper", an "extreme
dipper", or a "reverse dipper", as detailed in the chart below. Additionally, ambulatory
monitoring may reveal an excessive morning blood pressure surge; which is associated with
increased risk of stroke in elderly people with high blood pressure.

Classification of dipping in blood pressure is based on the American Heart Association's

calculation, using systolic blood pressure (SBP) as follows:

{\displaystyle Dip=(1-{\frac {SBP_{Sleeping}}{SBP_{Waking}}})\times 100\%}

Range Class

<0% Reverse Dipper

0% - 10% Non-Dipper

10% - 20% Dipper

>20% Extreme Dipper

Dippers have significantly lower all-cause mortality than non-dippers or reverse dippers. As a
result, "... ambulatory blood pressure predicts mortality significantly better than clinic blood
pressure."

References
● Banegas, JR (2014). "High prevalence of masked uncontrolled hypertension in people with
treated hypertension". Eur Heart J.
● Holt-Lunstad J, Jones BQ, Birmingham W (March 2009). "The influence of close
relationships on nocturnal blood pressure dipping". International Journal of
Psychophysiology..
● Minutolo R, Agarwal R, Borrelli's, Chiodini P, Bellizzi V, Nappi F, Cianciaruso B, Zamboli P,
Conte G, Gabbai FB, De Nicola L (June 2011). "Prognostic role of ambulatory blood
pressure measurement in patients with nondialysis chronic kidney disease". Archives of
Internal Medicine..
● Use and interpretation of ambulatory blood pressure monitoring: recommendations of the
British Hypertension Society
● Verdecchia P, Angeli F, Gattobigio R (2004). "Clinical usefulness of ambulatory blood
pressure monitoring". J. Am. Soc. Nephrol..
● Morning surge in blood pressure linked to strokes in elderly
● Stroke Prognosis and Abnormal Nocturnal Blood Pressure Falls in Older Hypertensives
● Ben-Dov, Iddo Z.; Jeremy D. Kark; Drori Ben-Ishay; Judith Mekler; Liora Ben-Arie; Michael
Bursztyn (March 26, 2007). "Blood Pressure Measurement and Cardiovascular Risk
Predictors of All-Cause Mortality in Clinical Ambulatory Monitoring Unique Aspects of Blood
Pressure During Sleep". Hypertension

COLOR VISION

Color vision, a feature of visual perception, is an ability to perceive differences

between light composed of different wavelengths (i.e., different spectral power
distributions) independently of light intensity. Color perception is a part of the
larger visual system and is mediated by a complex process between neurons that
begins with differential stimulation of different types of photoreceptors by light
entering the eye. Those photoreceptors then emit outputs that are propagated
through many layers of neurons and then ultimately to the brain. Color vision is
found in many animals and is mediated by similar underlying mechanisms with
common types of biological molecules and a complex history of evolution in
different animal taxa. In primates, color vision may have evolved under selective
pressure for a variety of visual tasks including the foraging for nutritious young
leaves, ripe fruit, and flowers, as well as detecting predator camouflage and
emotional states in other primates.

Wavelength
Isaac Newton discovered that white light after being split into its component colors when
passed through a dispersive prism could be recombined to make white light by passing
them through a different prism.

Photopic relative brightness sensitivity of the human visual system as a function of wavelength
(luminosity function)

The visible light spectrum ranges from about 380 to 740 nanometers. Spectral colors
(colors that are produced by a narrow band of wavelengths) such as red, orange, yellow,
green, cyan, blue, and violet can be found in this range. These spectral colors do not refer
to a single wavelength, but rather to a set of wavelengths: red, 625–740 nm; orange,
590–625 nm; yellow, 565–590 nm; green, 500–565 nm; cyan, 485–500 nm; blue, 450–485
nm; violet, 380–450 nm.

Wavelengths longer or shorter than this range are called infrared or ultraviolet,
respectively. Humans cannot generally see these wavelengths, but other animals may.

Hue detection
Sufficient differences in wavelength cause a difference in the perceived hue; the
just-noticeable difference in wavelength varies from about 1 nm in the blue-green and
yellow wavelengths to 10 nm and more in the longer red and shorter blue wavelengths.
Although the human eye can distinguish up to a few hundred hues, when those pure
spectral colors are mixed together or diluted with white light, the number of
distinguishable chromaticities can be quite high.

In very low light levels, vision is scotopic: light is detected by rod cells of the retina. Rods
are maximally sensitive to wavelengths near 500 nm and play little, if any, role in color
vision. In brighter light, such as daylight, vision is photopic: light is detected by cone
cells which are responsible for color vision. Cones are sensitive to a range of
wavelengths, but are most sensitive to wavelengths near 555 nm. Between these regions,
mesopic vision comes into play and both rods and cones provide signals to the retinal
ganglion cells. The shift in color perception from dim light to daylight gives rise to
differences known as the Purkinje effect.

The perception of "white" is formed by the entire spectrum of visible light, or by mixing
colors of just a few wavelengths in animals with few types of color receptors. In humans,
white light can be perceived by combining wavelengths such as red, green, and blue, or
just a pair of complementary colors such as blue and yellow.

Non-spectral colors
There are a variety of colors in addition to spectral colors and their hues. These include

grayscale colors, shades of colors obtained by mixing grayscale colors with spectral colors,

violet-red colors, impossible colors, and metallic colors.

Grayscale colors include white, gray, and black. Rods contain rhodopsin, which reacts to light

intensity, providing grayscale coloring.

Shades include colors such as pink or brown. Pink is obtained from mixing red and white.

Brown may be obtain from mixing orange with gray or black. Navy is obtained from mixing blue

and black.

Violet-red colors include hues and shades of magenta. The light spectrum is a line on which

violet is one end and the other is red, and yet we see hues of purple that connect those two

colors.

Impossible colors are a combination of cone responses that cannot be naturally produced. For

example, medium cones cannot be activated completely on their own; if they were, we would

see a 'hyper-green' color.

Physiology of color perception

 Normalized response spectra of human cones, to monochromatic spectral stimuli, with
wavelength given in nanometers.

The same figures as above represented here as a single curve in three (normalized cone
response) dimensions

Perception of color begins with specialized retinal cells known as cone cells. Cone cells
contain different forms of opsin – a pigment protein – that have different spectral
sensitivities. Humans contain three types, resulting in trichromatic color vision.

Each individual cone contains pigments composed of opsin apoprotein covalently linked
to a light-absorbing prosthetic group: either 11-cis-hydroretinal or, more rarely,
[5]
11-cis-dehydroretinal.

The cones are conventionally labeled according to the ordering of the wavelengths of the
peaks of their spectral sensitivities: short (S), medium (M), and long (L) cone types. These
three types do not correspond well to particular colors as we know them. Rather, the
perception of color is achieved by a complex process that starts with the differential
output of these cells in the retina and which is finalized in the visual cortex and
associative areas of the brain.

For example, while the L cones have been referred to simply as red receptors,
microspectrophotometry has shown that their peak sensitivity is in the greenish-yellow
region of the spectrum. Similarly, the S cones and M cones do not directly correspond to
blue and green, although they are often described as such. The RGB color model,
therefore, is a convenient means for representing color but is not directly based on the
types of cones in the human eye.

The peak response of human cone cells varies, even among individuals with so-called
]
normal color vision; in some non-human species this polymorphic variation is even

greater, and it may well be adaptive.

Theories

Opponent process theory.

Two complementary theories of color vision are the trichromatic theory and the opponent
process theory. The trichromatic theory, or Young–Helmholtz theory, proposed in the 19th
century by Thomas Young and Hermann von Helmholtz, posits three types of cones
preferentially sensitive to blue, green, and red, respectively. Ewald Hering proposed the
[8]
opponent process theory in 1872. It states that the visual system interprets color in an

antagonistic way: red vs. green, blue vs. yellow, black vs. white. Both theories are
generally accepted as valid, describing different stages in visual physiology, visualized in
[9]: 168 
the adjacent diagram.

Green–magenta and blue—yellow are scales with mutually exclusive boundaries. In the
same way that there cannot exist a "slightly negative" positive number, a single eye
cannot perceive a bluish-yellow or a reddish-green. Although these two theories are both
currently widely accepted theories, past and more recent work has led to criticism of the
opponent process theory, stemming from a number of what are presented as
discrepancies in the standard opponent process theory. For example, the phenomenon of
an after-image of complementary color can be induced by fatiguing the cells responsible
for color perception, by staring at a vibrant color for a length of time, and then looking at a
white surface. This phenomenon of complementary colors demonstrates cyan, rather than
green, to be the complement of red and magenta, rather than red, to be the complement of
green, as well as demonstrating, as a consequence, that the reddish-green color
proposed to be impossible by opponent process theory is, in fact, the color yellow.
Although this phenomenon is more readily explained by the trichromatic theory,
explanations for the discrepancy may include alterations to the opponent process theory,
such as redefining the opponent colors as red vs. cyan, to reflect this effect. Despite such
criticisms, both theories remain in use.

A recent demonstration, using the Color Mondrian, has shown that, just as the color of a
surface that is part of a complex 'natural' scene is independent of the wavelength-energy
composition of the light reflected from it alone but depends upon the composition of the
light reflected from its surrounds as well, so the after image produced by looking at a
given part of a complex scene is also independent of the wavelength energy-composition
of the light reflected from it alone. Thus, while the color of the after-image produced by
looking at a green surface that is reflecting more "green" (middle-wave) than "red"
(long-wave) light is magenta, so is the after image of the same surface when it reflects
more "red" than "green" light (when it is still perceived as green). This would seem to rule
out an explanation of color opponency based on retinal cone adaptation.