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About White-Coat Hypertension

“But doc, my blood pressure is always normal at home.” I wish I had a dollar for every time I have heard that line and I know it is true. When some patients come to see me, their blood pressure is abnormally high (above 130/90). This is known as “white-coat hypertension.” Although it has been thought to be from anxiety about seeing the doctor, even long-established patients who have no conscious anxiety can exhibit elevated blood pressure in the office.

Because blood pressure naturally fluctuates and the office visit is not a “normal” setting, it is important for patients who have high blood pressure (hypertension) to have their own blood pressure cuff at home. Now that devices are automated and easy to use, everyone with hypertension should be monitoring their blood pressure in the comfort of their own home. I advise multiple readings over a week at different times of day. Get a reading when resting and when rushing around. Take your blood pressure after you exercise and after a meal. It is important to keep a log and write it down. Only then can we see patterns and know if the blood pressure is controlled or not.

Blood pressure readings in the doctors office are not necessarily the most accurate. Patients are often rushed trying to get parked and in on time. Medical assistants can use the wrong size cuff or not position the arm correctly. Listening (auscultation) is not very accurate due to human error. It is the multiple readings over time that give a more accurate picture of blood pressure control.

High blood pressure in the office can be true hypertension or it can be white-coat hypertension that is usually controlled at home. If a patient is on blood pressure medication and has controlled blood pressure at home, I will not add more medication just because they are elevated in the office. If a patient has not been diagnosed with hypertension and his or her blood pressure is elevated in the office, he or she is advised to get their own blood pressure cuff for at home and return with readings for us to review. This way we can minimize unnecessary and expensive medication and make sure we are protecting the patient as well.

*This blog post was originally published at EverythingHealth*

Adult Vaccines: Most Doctors Don’t Stock All Of Them

Less than one in three primary care practices offer all 10 recommended adult vaccines, citing a variety of financial and logistical reasons.

Researchers sponsored by the Centers for Disease Control and Prevention sampled 993 family physicians and 997 general internists. Of the respondents, 27 percent (31 percent of family practitioners and 20 percent of internists) stocked all 10. Results appear in the Feb. 17 issue of the journal Vaccine.

The 10 vaccines were hepatitis A; hepatitis B; human papillomavirus vaccine (HPV); combined measles, mumps, and rubella (MMR); meningococcal conjugate vaccine (MCV4); pneumococcal polysaccharide (PPSV23); tetanus diphtheria (Td); combined tetanus, diphtheria, and pertussis (Tdap); varicella; and zoster.

Of the responding practices, two percent plan to stop vaccine purchases, 12 percent plan to increase them and the rest had no plans to change their vaccination stocking habits. But physicians who identified themselves as their respective practices’ decision makers for stocking vaccines were more likely to decrease the number of different vaccines stocked for adults (11 percent vs. three percent; P=.0001).

The National Vaccine Advisory Committee, a group that advises the various federal agencies involved in vaccines and immunizations, arrived at even bleaker figures in 2009, reported the April 2009 issue of ACP Internist. For example, 62 percent of decision makers in practices said they had delayed purchase of a vaccine at some time in the prior three years due to financial concerns. And in the prior year, 16 percent of practice decision makers had seriously considered stopping vaccinations for privately-insured patients due to the cost and reimbursement issues. Read more »

*This blog post was originally published at ACP Internist*

The Nursing Shortage: A Big Disconnect

With the aging of America, it’s well known that there will be a shortage of registered nurses and nursing assistants to take care of the population. It’s predicted that the shortage of nurses in California will climb to 80,000 by 2015. California has just 653 registered nurses employed per 100,000 people.

One of the problems is a lack of qualified faculty to teach at nursing schools. California was forced to turn away 23,000 qualified applicants from nursing programs during 2008-2009. And this week Humboldt State University announced plans to discontinue the school’s nursing program because of financial concerns and inability to retain nursing faculty. Shortage of nurses and closing nursing programs — now there’s a big disconnect.

*This blog post was originally published at EverythingHealth*

Consumer Health Information: The New Third Party In The Exam Room

It was sometime in the mid-nineties that parents started showing up in my office with reams of paper. Inkjet printouts of independently unearthed information pulled from AltaVista and Excite. Google didn’t exist. In the earliest days of the Web, information was occasionally leveraged by families as a type of newfound control.

A young father and his inkjet printer

One case sticks clearly in my mind. It was that of a toddler with medically unresponsive acid reflux and chronic lung disease. After following the child for some time, the discussion with the family finally moved to the option of a fundoplication (anti-reflux surgery). On a follow-up visit the father had done his diligence and appeared in the office with a banker box brimming with printed information. He had done his homework and his volume of paper was a credible show of force.

At the time in Houston, the Nissen and Thal fundoplication were the accepted fundoplication procedures in children. Deep from the bottom of one of the boxes, the father produced a freshly-reported method of fundoplication from Germany. He had compared the potential complications with other types of fundoplication and this was the procedure he wanted.

What he didn’t understand was that an experimental technique used on a limited numbers of adults didn’t necessarily represent the best option for his toddler. I gave it everything I had but didn’t get very far. The tenor of his argument was slightly antagonistic. Ultimately there was nothing more I could do. I deferred the remainder of the discussion to one of our best “talking” surgeons, but knew the father wouldn’t get the time and consideration that I had offered.

I never saw the child again. As they say, the father voted with his feet. Read more »

*This blog post was originally published at 33 Charts*

Three R’s Of Health And Wellness

I’d like to talk about how rodents, relationships, and riding relate to overall health and wellness.

This idea comes from a nicely-written New York Times piece entitled, “Does Loneliness Reduce the Benefits of Exercise?” Here, Gretchen Reynolds reviews a few intriguing studies about how relationships may affect exercise, stress hormone levels, and intelligence. The combo caught my eye.

Anyone who pays attention to wellness knows that exercise produces more flexible arteries, more durable hearts, and leaner body shapes. These benefits are obvious, and honestly, sometimes a bit tiresome to write about.

To me, a far more interesting — and lesser known — benefit of regular exercise is that it might make us smarter. Here’s where the rodents come into the story.

As was summarized in the New York Times piece, when researchers allowed rats and mice access to running wheels they observed (a) that they all ran, and (b) those rats that did run scored better on rodent IQ tests, and actually grew more brain cells. This is a striking finding because nerve cells — unlike blood, GI and skin cells, which turnover rapidly — grow very slowly, if at all.

But that’s not the entire story. The Princeton researchers wanted to know whether the rat’s social relationships could have measurable biologic effects.

It turns out that rodents — like humans — are quite social. So social, in fact, that in these trials the brain-growing effect of exercise was blunted when rodents lived alone. Compared to rats and mice that lived in groups, those that were kept in isolation failed to grow new nerve cells in response to exercise. And importantly, isolated rats produced higher levels of stress hormones than those who lived in groups, even though both groups ran the same distance. Read more »

*This blog post was originally published at Dr John M*

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