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Apr 27, 2018

What to wear

The story

You put on a white coat to hide the fact that yesterday’s scrubs are underneath, but patients see it and their pressure goes through the roof. New registry data links white-coat hypertension to long-term outcomes.

The basics

If you’re worried that the patient who huffed into clinic an hour late may be stressed out rather than hypertensive, then you’re onto something. Ambulatory blood pressure (ABP) monitoring replaces intermittent reads in clinic with wearable devices that report on blood pressure during the day and night to give a fuller picture. Governing bodies in the UK and Canada recommend ABP monitoring to confirm a diagnosis of hypertension, while the USPSTF recommends measuring blood pressure outside of the clinic (ABP or home monitoring) before beginning treatment.

The box

ABP readings place patients into 4 categories (see this 2x2 matrix): sustained hypertension (elevated clinic and elevated 24-hour ABP), white-coat hypertension (elevated clinic and normal 24-hour ABP), masked hypertension (normal clinic and elevated 24-hour ABP), and normotension (normal clinic and normal 24-hour ABP). Experts have argued for years about whether white-coat hypertension is benign or harmful.

The registry

The Spanish Ambulatory Blood Pressure Registry enrolled 64,000 patients from primary care practices across Spain. White-coat hypertension was found in 25% of patients and was linked to double the risk of mortality as normotension when untreated. ABP was a better predictor of mortality than clinic blood pressure, and systolic trumped diastolic pressures in predicting outcomes. Masked hypertension affected almost 4% of patients and was the most dangerous risk factor in the study, with an almost 3-fold higher risk of mortality compared to normotension.
NEJM

The takeaway

Hypertension remains the most significant and treatable cause of worldwide premature death. ABP registries provide key data on how the disease works and what's driving outcomes.

Say it on rounds

When your checking account looks great before monthly rent

Your used to a free falling cash flow, but spills in elderly patients are a bit more jarring. In 2015 there were 29 million falls in adults over age 65 and 33,000 fall-related deaths. Citing data from over 20 studies, the USPSTF maintained it's Grade B recommendation that physicians offer exercise to elderly adults at risk for falls to decrease fall burden. Most exercise interventions examined were year-long programs with 3 sessions a week, and on the whole regular exercise led to an estimated reduction in relative fall risk of 10%. 
JAMA

When you can't find a working printer for a transfusion consent

You would think science would have solved this problem already, but more elegant solutions are in the works. Patients with severe beta-thalassemia (BT) need lifelong transfusions and iron chelation therapy. An early phase study of 22 patients with transfusion-dependent BT found that autologous stem cell transplant with a genetically modified adult hemoglobin A decreased the need for transfusions at 2 year follow-up in all patients. Fifteen of 22 patients stopped receiving transfusions entirely. A 2-minute video explains this latest advance in gene therapy.
NEJM

When a tiny bit of spring has you thinking full-on summer

It can’t come soon enough. For years we’ve been told that there’s no value in SPF sunscreen > 50, but a real life (and highly practical) study of 200 adults found that SPF 100 beat SPF 50 in day-after sunburn scores. Participants were given two tubes of unmarked sunscreen to apply to the right and left side of the face, and the results were judged by blinded investigators. The authors argue that while SPF 50 shines in the lab, in real life people don’t ever apply the recommended amount of sunscreen and therefore benefit from higher SPFs.
J Am Acad Dermatol

Brush up

Alcohol withdrawl

At this point in the year you could lecture us on alcohol withdrawal, but here are some basics: chronic GABA agonism from too much of the sauce leads to unopposed NMDA excitotoxicity during withdrawal. Delirium usually peaks at 3 days, but it can last up to a week. Use the CIWA-Ar scale for symptom-based treatment. Benzos are the cornerstone of therapy, but propofol, phenobarbital, and dexmedetomidine are used in refractory cases.

What's the evidence

For giving thiamine before glucose to prevent Wernicke's encephalopathy? Med school taught you to always give thiamine first, but a 2012 case review found that while prolonged feeding in patients at-risk for Wernicke's (think: alcoholism and profound nutritional deficits) was associated with worse neurologic outcomes, there is no data to suggest harm from a single dose of glucose before thiamine. For patients in danger of hypoglycemia, give both without delay.

What your tech friends are talking about

We're only a week into Westworld, but Amazon is already giving Alexa a better memory and the ability to have more natural conversations. When she'll be able to run your list for you remains unclear.

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