By Paul Goldfinger, MD . Blogfinger Off-Shore School of Medicine in Ocean Grove, NJ. (Our motto: “Healthcare are us”)
In May, the NY Times published an article called “Computer Vision Syndrome Affects Millions.” (Link below)
This fascinating condition causes eye symptoms in people who spend a great deal of time in front of computers—more than 3 hours per day. The population at risk is “huge” worldwide. The symptoms include burning in the eyes, double vision, blurry vision, itching, dryness and redness, “all of which can interfere with work performance. ” Then you have the millions of kids playing computer games.
When you sit in front of a computer, your blinks/minute decrease, promoting dry eyes.
Other symptoms include back and neck pain and tension headaches.
The situation is complicated and involves paying attention to your distance to the screen, the height of the screen, taking breaks from the computer, humidity levels in the room, lighting of the screen, positioning the monitor, and getting special computer glasses for that mid-range distance.
A study from Iran of 642 pre-university students revealed that 71% sat too close to the monitor for comfort, and two thirds were improperly positioned in relation to the monitor above or below.
I use computer glasses that take into account the distance to the monitor and also the need for bifocals to provide for looking down at papers to read when working at a computer. Eye doctors can prescribe computer glasses.
Good Morning Dr. Paul Goldfinger. Here are today’s top stories. Friday, September 23, 2016.
The CBS News (9/22) website reports that “falls are the number one cause of fatal and nonfatal injuries among adults over 65,” researchers concluded in a report published in the CDC’s Morbidity and Mortality Weekly Report.
The report found that “in 2014, older Americans fell 29 million times, leading to seven million injuries” that sometimes landed people in the emergency department. Unfortunately, “more than 27,000 falls led to death.”
In a press statement, CDC Director Tom Frieden, MD, MPH, said, “Older adult falls are increasing and, sadly, often herald the end of independence.” Dr. Frieden went on to emphasize that falls can be prevented.
Below is the link to the excellent CBS News article on this subject.
Blogfinger medical commentary by Paul Goldfinger, MD, FACC:
These stats are impressive, and the article describes certain elements that we might not ordinarily think of. Once someone falls, there are a variety of variables that need to be evaluated in order to prevent more falls. For example, is the patient keeping his falls secret for fear of losing independence? Family members must think of this if, for example, bruises are seen or balance problems noticed.
Falls can be minor or terrifyingly dangerous. Falling down even a few steps can result in horrible injuries. And that damage can be made worse by coexisting factors such as chronic therapy with blood thinners, causing traumatic bleeding to be worse than expected.
Don’t forget the need to have an “I fell down and can’t get up” button around the patients neck. I had a patient who fell and got wedged between the toilet and the bathtub, and she could not reach a phone; luckily a friend came by to pick her up for her regular card game. And how about a cell phone to be worn in a holster all the time? There are exercises to improve balance, and make sure to check the lighting in the house.
Head injuries can be deceptive, and, if one occurs, an ER visit and then subsequent observation are essential.
Some of the prevention factors include safe footwear, regular eye exams, and getting rid of throw rugs.
If a senior gets in a car accident, don’t allow him/her to just go home and rest. Always take them to the hospital to be checked. And if they do go home make sure that someone provides oversight to look for emerging signs of trouble.
As we have pointed out in our BF articles, seniors are often on multiple medications, and those may be overdosed, mixed up,causing side effects, or interacting with each other. The end result might be a fall, due to dizziness or a drop in blood pressure. There are other medical issues, such as cardiac rhythm disturbances, that could cause falling, so if someone falls, have them checked even if there is no obvious injury and be sure to have his medication list reviewed—-bring all the meds with you.
We have also reported on drug dependency in seniors, and that might be a factor.
For some seniors, they tend to rush around, and that can cause quick turns and loss of balance. My mother was like that, so I stuck a big sign on her fridge: “Slow Down.” Of course, she gave it back to me by saying, “You talk too fast and not loud enough.” She used to say, “Stop mumbling.” At least she didn’t put any signs on our fridge.
The psycho-social issues resulting from falling are very important as well. Patients sometimes lie about what happened in order to avoid unpleasant consequences such as neurologic findings which could result in loss of a driving license and thus loss of freedom. A neurologist might pick up a problem with peripheral vision which could result in a car accident.
Permanent pacemaker configuration. The generator is under the skin. A wire is passed into a vein beneath the clavicle and into the right side of the heart (the tip is positioned in the right ventricle). In this example there is a second wire in the right atrium.
By Paul Goldfinger, MD, FACC, Dean at the Blogfinger Off-shore School of Medicine . Re-posted from Feb. 2016 on Blogfinger.net
My career spanned the remarkable history of permanent cardiac pacemakers. In the early 1970’s, those devices were as a big as a can of tuna fish. They had limited functions and a variety of technical problems. Today they are miniature electronic marvels.
The story began around 1930 when an Australian researcher found that the heart could be stimulated with a localized electrical shock delivered from a wire.
1949: The Medtronic Company, pioneers in pacemakers, was begun in a garage in Buffalo by an engineer and a physician.
1952: At the Boston Beth Israel Hospital, a patient was admitted with fainting spells due to drastic slowing of the heart. These are called Stokes-Adams attacks. This was the first case to be treated with a temporary pacemaker. A wire was attached to the external wall of his heart, while the pacemaker generator was outside his body.
1957: The first battery powered unit was developed, and, in 1958, the first permanent pacemaker was implanted in a dog, consisting of a generator under the skin and a wire attached to the outside wall of the heart.
1960: The first permanent pacemaker was implanted in a human. In 1961, the first in New Jersey was performed by heart surgeon Victor Parsonnet at Newark Beth Israel. Dr. Parsonnet is one of a core group of doctors world-wide to get credit for pioneering work in permanent pacemakers.
1973- 1980: The era when my own career began, the technology of permanent pacemakers evolved strikingly, with smaller and more complicated “generators,” longer lasting batteries, and better electrode (wire) systems. Medical electronics had been evolving thanks to the invention of the microprocessor.
When a patient only needed a temporary pacemaker, a cardiologist such as myself would pass a wire into the right ventricle through a vein in the arm or neck and attach it to an external pacemaker which hung from an IV pole at the bedside. Eileen sometimes kids me by saying, “If you can put a wire into somebody’s heart, how come you can’t…….(fill in the blank)”
The permanent units could just only control slow heart rates at first, but later, more functions were developed and could be programmed (changing the settings) from without.
At first, pacemakers had to be routinely changed every two years because of battery life, but later the batteries were improved.
In the early 1970’s research with a nuclear powered pacemaker was performed by Dr. Parsonnet and his team at Newark’s Beth Israel Hospital . They were trying to increase the battery life. That technology did not work out.
During this phase, techniques for monitoring the battery life and functions of a permanent pacemaker were developed. Eventually a patient could be followed by the use of a telephone, so hospitals throughout NJ had a setup where they could check their patients by phoning into NBIH for monitoring allowing doctors to predict when a pacemaker had to be changed and how well it was working. In-person visits to a pacemaker clinic were also required to check a variety of other functions .
In late 1970’s, at Dover (NJ) General Hospital and Medical Center, Jean Wiarda, RN ( a cardiac nurse) and myself, with the cooperation of Medtronic, set up the first free-standing pacemaker clinic in north Jersey. After that, many other hospitals followed suit and broke away from the NBIH connection. Later patients were able to phone in their pacemaker signals from home to the clinics. They also had to come for in-person evaluations intermittently depending on what we wanted to measure or program.
A major development, evolving in the 1970’s, was the transvenous lead for permanent pacemakers which eliminated the need to open the chest and sew an electrode into the heart muscle. Instead, an electrode could be passed through a vein under the collar bone and into the right ventricular chamber, eliminating the need for heart surgery.
Now that continues to be standard, although the pacemaker generators are much smaller, and the electrodes have been refined, and sometimes more than one wire is used. Even though the generators are now tiny (you can’t even tell that someone has a unit,) they can perform all sorts of miraculous functions and are totally adjustable from without using a device called a programmer.
Surgeons used to install permanent transvenous pacemakers, but now these complex devices are placed by electrophysiologists, cardiologists who specialize in electrical diagnostics and therapeutics including implantable cardio-defibrillators.
The future of electrophysiology is huge, and progress is made every day in this field.
The latest development, currently being perfected is that of wireless pacemakers, meaning no wires into the heart. This will revolutionize the field since about 250,000 permanent pacemakers are placed yearly in the US, and about 750,000 around the world.
Around here, Jersey Shore Medical Center and Morristown Medical Center have first rate electrophysiology departments.
Editor’s note 10/30/20: Thanks to Dr. Eran Zacks, FACC, FHRS (Fellow Heart Rhythm Society) of Monmouth Cardiology for updating us on new rhythm monitoring techniques and wireless pacemakers.
Blogfinger Medical Report. Paul Goldfinger, MD, FACC.
This headline* is from Reuters Health covering the opinions of some Canadian professors in an article in the Annals of Internal Medicine. They said, ” While there is no direct evidence yet that cloth masks can reduce SARS-CoV-2 transmission, the collective evidence indicating that mask wearing by infected people reduces contamination is convincing and should inform policy.”
They say that “there is ample evidence that the masks can prevent infected droplets from getting into the air or onto surfaces.”
The article said, “There was also evidence, though not as strong, that cloth masks might protect wearers as well.”
A professor in the trial, Dr. Catherine Clase, from the McMaster University in Ontario, said, “While the evidence shows that masks can help, they are no substitute for social distancing and handwashing but should be used along with those measures.”
Dr. Supratik Guha, Professor at the Pritzker School of Molecular Engineering from the University of Chicago said, “I have been stressing that simple reasoning and evidence indicates that the use of a decent cloth mask in indoor or use public places will reduce infection transmission. If most of the population practices this, the multiplicative benefits can be enormous in reduction overall infection rates within a community.”
CDC says: “A cloth face covering should be worn whenever people are in a community setting, especially in situations where you may be near people. These settings include grocery stores and pharmacies. These face coverings are not a substitute for social distancing. Cloth face coverings are especially important to wear in public in areas of widespread COVID-19 illness.
Blogfinger commentary: By Paul Goldfinger, MD. I have observed a significant lack of compliance outdoors in Ocean Grove; probably because people are not sure that the invisible terror will be eliminated by mask practices, and there is some confusion regarding when and how to make use of masks.
Official guidelines by the Camp Meeting Association of Ocean Grove are evasive and unconvincing. They say on their web site: “Wearing masks is strongly encouraged.”
So, to practice masking, one needs some faith in the scientific guidelines, such as they are. I have always tried to practice evidence-based medicine, but the science here isn’t so clear, and maybe we need to believe somewhat in good judgement and even in magic.
I am not convinced that we should wear masks if we are outdoors in open spaces where we can stay away from others or when alone in our cars. But keep in mind that this virus spreads by human to human contact, so you can use some common sense in this regard and judge your situation by that principle and analyze your own environment.
We know that the virus can, under certain circumstances, infect the air we breathe originating in coughing, sneezing and even talking.
So don’t take unnecessary chances. If there is any possibility that human to human contact might occur in any situation, then put on a mask.
The two ladies walking side by side wore masks, but they could have been somewhat more apart. If I were walking alone there, I would be tempted to wear no mask, as many were not doing, but I would surely weave my way around any humans walking or biking towards me.
If you don’t wear a mask outside, at least carry one, just in case.
Best choice: wear the mask on the boards. The beach will be a more difficult decision.
Interestingly, the latest recommendations for in-office readings suggest electronic devices for more accuracy rather than this type or mercury machines.
From the Blogfinger Off-Shore School of Medicine. Paul Goldfinger MD, FACC Dean. Ocean Grove, NJ.
Blogfinger has reported on diagnostic and treatment guidelines for systemic hypertension. (“High blood pressure”).
In 2017, the American Heart Association and the American College of Cardiology came out with new parameters. They reported that the diagnostic cutoff had been reduced from the long-time standard of 140/90 down to 130/80. That means that the diagnosis of hypertension would be made if one’s blood pressure stabilized at over 130/80.
There remains controversy over these guidelines, plus there are many variations on the theme, such as when to start drug therapy, factoring in age, and how to judge success.
The stakes are high, because so many have this diagnosis, and hypertension poses an increased risk of a variety of complications including coronary heart disease, congestive heart failure, stroke, peripheral vascular disease, kidney failure, and mortality.
Most of the time if the top number (systolic) is high, then the bottom number (diastolic) is often elevated as well. Doctors have usually focused their attention on the systolic readings, but now, because the normal diastolic cutoff is above 80 instead of 90, physicians are more likely to be concerned about the diastolic as well because more people will carry the diagnosis of diastolic hypertension.
A small percent of patients have “isolated diastolic hypertension” (high diastolic—over 80 mmHg; normal systolic–less than 130 mm Hg,) but there is some controversy as to the risk of those diastolic elevations. Using the new criteria, it is estimated that 6.5% of the population have this issue.
In general, it has been felt that isolated diastolic hypertension is harmless. But there are few long term clinical trials looking at this.
William McEvoy is professor of preventive cardiology at the National University of Ireland and he said in an interview with Medscape, “Our data suggest that there is no harm of having a diastolic pressure above 80 mm Hg if the systolic is below 130 mmHg and that the new 80 mmHg diastolic threshold means that 12 million adults in the US will be labeled as hypertensive but will not benefit from the diagnosis and may be given unnecessary treatment.”
In another quote he said, “If an individual has normal systolic blood pressure (less than 130 according to new guidelines,) our data suggest that it doesn’t really matter what the diastolic blood pressure is.”
But Paul Whelton, MD, chair of the 2017 AA/AHA guideline committee said he agreed that systolic pressure is the more important measure for predicting cardiovascular risk and for making drug treatment decisions. But he felt that a diastolic of over 90 should be treated, especially in high risk patients such as those with prior cardiovascular disease.
I saw my own eminent cardiologist recently. I brought my record of home readings for his review, and he noticed that my systolic was fine at 110-120 but he raised his eyebrows above the top edge of his computer screen when he saw that my diastolic readings were 80-85. He was reacting to the new guidelines for diastolic pressure, but he could not bring himself to raise my anti-hypertensive drug dosing.
His decision was totally correct, independent of my opinion, since trying to lower that number could produce some unpleasant side effects, and, as noted above, the evidence for his changing my treatment for this is simply not compelling enough. And the best doctors react to more than just numbers.
Here is a link to our 2019 review of new guidelines and related topics:
Dysfunction of the lower esophageal sphincter can cause GERD. Internet graphic.
By Paul Goldfinger, MD, FACC
Most people get “heartburn” at least once in while. Some get it often and have significant problems with it. The term refers to a form of indigestion where acid stomach contents regurgitate (reflux) back from the stomach into the esophagus and/or throat.
GERD means “gastroesophageal reflux disease,” and regardless of the cause, it usually results in chest and/or throat burning (“heartburn.”)
The term “heartburn” is an oxymoron, because this complaint has nothing to do with the heart. The Italians call it “agita.” And both words can have broader meanings such as the way Nora Ephron named her novel about a broken marriage, “Heartburn,” and “agita” can mean a broad sense of upset.
“Heartburn” is a general term for that burning, but there are a variety of specific causes and/or triggers which have the same end result. On the other hand, reflux can occur with symptoms other than heartburn.
Ordinarily, swallowed food (solid or liquid) heads south to enter the esophagus from the throat. It passes a muscular sphincter at the top of the esophagus (the upper esophageal sphincter) then moves through the esophageal tube to the open lower esophageal sphincter to enter the stomach. Then the sphincter closes to prevent regurgitation back into the esophagus from the stomach.
If the lower esophageal sphincter re-opens (relaxes) when it shouldn’t, acid fluid and partially digested food can go back into the esophagus—a process called gastroesophageal reflux, or GERD. Acid in the esophagus can be propelled all the way north to enter the throat area.
That acid, which is manufactured by the stomach, can irritate and damage the lining of the esophagus, can irritate the throat, and can upset the delicate balances which control swallowing in the throat.
If the stomach pushes its upper portion past the diaphragm into the chest, it is called a hiatus hernia which can cause GERD.
The result of GERD may be heartburn, but it may not cause that classic complaint while instead causing throat symptoms such as sore throat, chronic throat irritation (causing recurrent clearing of the throat,) recurrent cough and/or asthma, and other throat complaints including the sense of something “stuck” there, a “lump” in the throat, mucus in the throat, and swallowing problems.
These throat problems might warrant a sub-diagnosis of GERD called”laryngopharyngeal reflux.” There is debate about the exact nature of this diagnosis. Ask your doctor about it—ENT or GI.
Many people are walking around with such varied throat symptoms who never get the proper diagnosis and curative therapy.
GERD may occur only at night, and that is very worrisome if it is frequent. Nighttime acid damage to the esophagus lining can lead to permanent tissue injury and even cancer, and infected acid can be sucked into the lungs—aspiration. Also, nighttime symptoms can result in serious sleep disorders.
There are many factors which can cause or trigger GERD and all its symptoms and complications: Throat disorders such as thickening of throat muscles, dysfunction of upper and/or lower esophageal sphincters, esophageal disorders such as out-pouches called diverticuli, over-weight, pregnancy, lying flat in bed, overeating, going to bed too soon after dinner (allow 3-4 hours,) straining with constipation, pressure on the abdomen as with tight clothing, eating the wrong foods (eg fried, fatty, onions, coffee, tea, spices, citrus, mint, tomato based, and chocolate among others). Caffeine, alcohol, smoking and stress may also be factors.
In any given patient, one or more of these factors may be important. Patients should pay attention to their individual symptom profile and write them down for review with a doctor.
For many, GERD is infrequent and easily treated even without medication. Certain life style changes may be all that’s needed. If needed, there are medications and there are even some invasive/surgical approaches.
GERD/heartburn is a complicated subject, and if you go to a doctor because of recurrent symptoms, he should consider it as a potentially complex situation. If he does not, see a gastroenterologist to be sure that nothing is being missed. Specialized tests may be needed.
Sometimes heart problems can be confused with GERD, so a cardiologist may be involved. Also there is sometimes overlap with ENT and pulmonology.
GERD is becoming a sub-specialty of its own–let’s call them esophagologists.
Treatment: In Part II we will discuss diagnosis and treatment. Suffice it to say that new therapeutic approaches are now available, so most patients don’t need to suffer with GERD.
DIONNE WARWICK. “Alfie”. by Burt Bacharach for the movie.
Paul Goldfinger, MD, FACC. Editor@Blogfinger.net. Re-post from 2019. Ocean Grove, NJ
In the 2011 edition of our book* on preventing heart disease, we have a section on particular foods such as nuts, chocolate, red wine, tea, coffee, salt, and eggs. Regarding the latter, this what we said then:
“The egg industry says that eating eggs is healthy, because eggs contain no fat and do not raise cholesterol blood levels. The American Heart Association disagrees, pointing out that each egg yolk contains 185 mg of cholesterol, and research trials have shown that eating cholesterol promotes heart disease, even if the cholesterol levels do not rise (Nutrition Action Healthletter, July 1997.)
“According to Jeremiah Stamler, a world expert on prevention, eggs do raise total and bad (LDL) cholesterol levels.”
“The AHA recommends that individuals eat no more than four egg yolks per week. They also say that we should eat no more than 300 mg. of cholesterol from all sources each day. Other experts advocate reducing egg intake to only one or two eggs per week (JAMA 4/21/99)”
In the 1990’s, at Dover General Medical Center (NJ) where I worked, one of our gastroenterologists, who was a gentleman egg farmer, loudly asserted that eggs posed no risks despite their cholesterol content. He stressed that eggs have no fats in them, so he brought eggs to the hospital frequently, peddling them in the coronary care unit.
Then in 2013, the British Medical Journal came up with a study that found no risk with one egg per day. So the pendulum was swinging.
Now, in the Journal of the American Medical Association, an impressive study appears looking at 30,000 individuals over 17 years. They found that there was an increased risk of death, stroke and cardiovascular diseases associated with eating eggs. They suggested that eating even 3-4 eggs per week is bad. But the study is subject to criticism of its methodology.
I can conclude that our egg intake should be limited to some extent, perhaps no more than 4 per week, but the verdict is still not in despite this JAMA article which looked at a large number of people and their dietary habits and heart disease risks.
Here is a link to a prior (2016) related post on Blogfinger, and in that post is another link.
Reuters reports that a study suggests “more babies could be born with heart defects in the future as global warming puts pregnant women at greater risk of exposure to dangerously high temperatures.” Currently, “congenital heart defects affect about 40,000 births per year.” The research was published in the Journal of the American Heart Association.
From the authors of the study: “The burden of congenital heart defects (CHD) across the United States may increase as a result of climate change.”
“As global temperatures continue to rise, more intense, frequent, and longer‐lasting heat events are expected.12 Significant gaps remain in understanding the potential impact of climate change on maternal heat exposures and the associated CHD burden.”
“In conclusion, our findings reveal a potential nationwide increase in future maternal heat exposure in the United States.”
Dr. Dianne Atkins, Professor of Pediatrics at the University of Iowa in Iowa City, cautions that “the data from the study is preliminary and is based only on estimates.”
“We cannot be certain that heat exposure will increase the risk of congenital heart disease, but it would be prudent for women to avoid becoming overheated during the early weeks of pregnancy,” Atkins, who was not involved in the study, told Reuters Health by email.
The author of this paper, not an MD, is a Professor of Public Health at the University of Albany, and he concluded by saying, “Although this study is preliminary, it would be prudent for women in the early weeks of pregnancy to avoid heat extremes similar to the advice given to persons with cardiovascular and pulmonary disease during heat spells.”
Blogfinger medical commentary: Paul Goldfinger, MD, FACC
This “research” is mostly speculation, not science. The American Heart Association published this study in their Journal of the American Heart Association. Nothing here is certain including the projections due to global warming. I’m surprised they accepted this paper without an editorial explaining their decision.
A medical journal like this one should be a holy temple of medical science and not a place to camouflage speculation and political correctness as health science. This paper belongs in a journal of public health or environmental science where torturing statistics and speculation might be more at home.
There is no doubt that excessively high temperatures should be avoided by pregnant women, but the same is true for patients with heart disease, lung disease, and any elderly person. As for global warming, that topic should have been barely mentioned and not emphasized.
The AHA should keep its focus on clinical medicine and what can be done to help physicians keep our people safe through evidence based research.
Allowing political correctness to creep into their work is a mistake and will erode the confidence of physicians and patients.
This topic is currently caught up in a tangle of controversies and guideline wars.
British Medical Journal. 2012.
By Paul Goldfinger, M.D., F.A.C.C. Board Certified cardiologist/internist, Editor of Blogfinger.net, and Dean of the Blogfinger Offshore School of Medicine in Ocean Grove, NJ. Closed on Sunday mornings until noon.
PART I: WHAT ARE THE ISSUES?
We wrote a series of this type before, but there are some important issues to discuss now based on changes of guidelines for the diagnosis and treatment of high blood pressure, i.e. hypertension.
Hypertension is a condition which threatens huge numbers of people around the world. The prevalence among adults in the U.S. used to be quoted as 32%, but since the new guidelines came out with new definitions, the number is now estimated to be 46%. And that number goes up with age, so that 76% is the prevalence in adults ages 65-74; and rises to 82% in ages 75 and older.
The measurement of BP is obtained using an electronic or mechanical device—a sphygmomanometer. 120/80 is the classic normal, but even that is controversial. The top number is called the systolic, while the bottom is diastolic. If either number or both is consistently elevated, then a diagnosis of hypertension is obtained. But there are different degrees of severity, and the risks of the disease go up as the numbers go up.
What is clear is that bringing the blood pressure to normal will reduce the risk of devastating vascular problems such as heart attack, heart failure and stroke.
Where the guidelines differ is in the cutoffs for making the diagnosis of hypertension, cutoffs for choosing various therapeutic approaches, and cutoffs having to with target readings when therapy is established.
But the world-wide healthcare establishment has yet to agree about how to correctly diagnose and treat hypertension. And the matter has other ramifications:
a. Many people with the disease have no idea that they have a problem
b. Of those who have been diagnosed and treated, a large percent have failed to reach desirable BP goals. And many who know that they have a problem are in a state of denial and do not go for evaluation or they receive inadequate followup, or they do not reliably and correctly take their medication.
In addition, physicians often fail to deal with hypertension properly, as defined by guidelines. In fact, some doctors ignore guidelines altogether, deciding their approach based on instinct and ignorance.
I have always thought that guidelines were a great idea since most doctors don’t have time to read all the research, so why not take the advice of experts? But there is a caveat: The doctor-patient relationship must be preserved, and the physician must be allowed flexibility in his decisions. However, if guidelines become inviolable laws, then doctors will rebel, and quality care will decline. In medicine, one size does not fit all.
c. There currently is a war of sorts, between the Americans and the Europeans regarding guidelines which determine how to diagnose and treat this important disease. No, it’s not like the D-Day invasion, but it is bad enough that both sides have published their own guidelines: the Americans in 2017 and the Europeans (let’s include Australia in this group) in 2018.
For years, the National Institutes of Health took on the task of issuing hypertension guidelines in the form of the Joint National Commission reports. The last time they did so (JNC8) was in 2014, but then, probably for political reasons, they retreated to their Bethesda headquarters, turning the job over to a combined committee from the American Heart Association and the American College of Cardiology (disclosure: I am a “Fellow” of both organizations. That title is gender neutral.)
And the Europeans have the European Society of Cardiology and the European Society of Hypertension.
To tell the truth, I not only prefer their croissants, their wine, and their beachwear, but I also prefer their hypertension guidelines. However we will get into that later.
d . And why can’t they totally agree? It’s because there have been hundreds of credible research trials on the subject done around the world, many recently, and because there are some philosophical differences between the two sides. And because medicine is a mixture of art and science, and no matter how much doctors try to practice “evidence based” medicine, there always is room for good judgement, style, and experience.
And don’t forget the incursions into medical practice by the bottom-line oriented health corporations, government, “Big Pharm,” and insurance companies; and by many physicians themselves who have been coerced into leaving private practice to become puppets of their employers—large hospital “health” systems.
Along the way, some of these doctors have compromised their standards in exchange for less stress, less administrative duties, more time off, and more cookbook medicine that can torture and break the traditional doctor- patient relationship. And the growing use of physician extenders to replace doctors introduces perhaps more efficiency and more money, but, in my opinion, greater chances for mistakes in patient care. As the hypertension guidelines become more complex, the involvement of physicians gets less.
I’m going to try to penetrate the layers of complexity of all this for you . You would be surprised if you knew how deep those layers go.
Feel free to comment by looking down and finding the comments button.
See you soon for Part II (I hope I can remember my Roman numerals.)
THE MARVELOUS WONDERETTES. And if you think that medicine and music don’t mix, just walk into an OR sometime during major surgery.
The AP (1/17, Choi) says a new report from nutrition, agriculture and environmental experts “recommends a plant-based diet, based on previously published studies that have linked red meat to increased risk of health problems.” The recommendation also “comes amid recent studies of how eating habits affect the environment,” as the production of red meat “takes up land and feed to raise cattle, which also emit the greenhouse gas methane.” The diet, organized by Stockholm-based nonprofit EAT, “says red meat consumption on average needs to be slashed by half globally” and “encourages whole grains, beans, fruits and most vegetables.”
Reuters (1/16, Kelland) reports that if the world followed the recommended diet, researchers said “more than 11 million premature deaths could be prevented each year, while greenhouse gas emissions would be cut and more land, water and biodiversity would be preserved.” Tim Lang, a professor at Britain’s University of London who co-led the research, said, “The food we eat and how we produce it determines the health of people and the planet, and we are currently getting this seriously wrong.”
Blogfinger medical report by Paul Goldfinger, MD, FACC, Dean of the Blogfinger Off-shore Medical School based in Ocean Grove, New Jersey.
Overall, this recommended diet encourages whole grains, beans, fruits and most vegetables, and says to limit added sugars, refined grains such as white rice and starches like potatoes and cassava. Click on links above for more details.
This article is just another in a long series of medical dietary news going back over 60 years advocating reducing red meats in our diets and increasing fruits and veggies. A more recent, but also not very new, component is to reduce carbs and lose weight.
And, as for the food-fashion vocabulary, the following words are not found in these articles: “fiber, kale, gluten-free, or quinoa.”
Now we find “plant-based,” “food systems,” “whole grain,” “greenhouse gas methane,” “production of red meat,” and “legumes.”
Overall, the American public has already reduced its intake of saturated fats.
Eileen and I wrote about nutrition/prevention in our book which is actually still available on Amazon: Prevention Does Work.
This book, like its authors, has aged a bit, but most of it still applies. The science of prevention evolves slowly. Eileen’s 36 recipes are still delicious, evidence-based, easy to prepare, and healthy. Just go to Amazon and type “Paul Goldfinger, MD.’
This current AMA report basically says the same things, quoting from the Lancet, except it is much stricter with its dietary recommendations. But the science behind this latest “news” is rather mushy. The best bet is not to become a vegan, because then your diet becomes impossible to maintain as well as very boring. Instead, the Mediterranean diet still seems the best choice.
The other “hook” in the current pronouncement is to link healthy diets to concerns about the environment. It reminds me of the NY Times which, these days, finds it necessary to politicize everything including sports, sex, health, and food.
Hollywood, Ca. Resistant gonorrhea antibiotic bacteria represent the biggest current threat. There is now only one antibiotic left which is toxic to gonorrhea (“GC”) bacteria.
The United States “continues to have the highest STD rates in the industrialized world,” said David Harvey, executive director of the National Coalition of STD Directors.
Bloomberg News (8/28, Edney) reports there was “a record number of cases of sexually transmitted diseases in 2017, marking the fourth straight year of sharp increases in gonorrhea, syphilis and chlamydia, according to preliminary data from the Centers for Disease Control and Prevention.” The CDC also warned that the growing prevalence of antibiotic-resistant gonorrhea is a contributing factor to the increase.
NBC News (8/28, Carroll) reports on its website that according to the CDC, there were “nearly 2.3 million cases of chlamydia, gonorrhea and syphilis were diagnosed in the U.S. in 2017, surpassing the record set in 2016 by more than 200,000.” The article adds that “less frequent condom use” may be the greatest contributing factor.
The New York Times (8/28, Zraick) reports that there is no “single reason for the increase in sexually transmitted diseases.” Public health officials point to “deteriorating public health services, like S.T.D. testing clinics,” in addition to the opioid epidemic, “as users engage in unsafe practices.”
Blogfinger Medical Opinion. Paul Goldfinger, MD, FACC
One important factor in this issue is that condoms are being used less often. That is partially because of the advent of HIV prevention drugs.
Another problem is that the infrastructure for preventing STD’s is declining across the country. These three articles lay out all the facts. Note that most of these infections are in men, but the numbers are on the rise in women as well. Dating services have also been blamed, but there is no data on this.
Gonorrhea used to be the scourge of soldiers and sailors. They called it “the clap,” but one shot of penicillin would cure it but not so now. There now is an urgent need to develop new antibiotics for that STD.
From the NYT: “Many cases go undiagnosed, and the diseases can cause serious problems down the line, including infertility and increased H.I.V. risk.
“Most people with these S.T.D.s do not know they are infected,” said Dr. Gail Bolan, director of the C.D.C.’s division of sexually transmitted disease prevention. “They don’t realize that these diseases are spreading silently through the country.”
Syphilis could kill people, but after penicillin was developed in the 1940’s, doctors became unfamiliar with the condition. I saw some cases in the 1960’s. Primary syphilis caused a lesion on the genitalia or the lips, but secondary and tertiary forms could cause sterility, abortion, blindness, rash, brain damage and mother to child transmission. And the advanced form may be difficult to diagnose.
All of these conditions can be present without any symptoms, so prevention methods and testing can help with diagnosis. There are tests available to make the diagnosis of STD’s using blood, urine and some other methods.
If you have young people in your family who may be sexually active, have a talk about this or give them our link.
By Paul Goldfinger, MD, FACC, Editor @Blogfinger.net
Four years ago I wrote a piece about the increasing successes of urgent care centers, and, specifically, the Central Jersey Urgent Care at the Asbury Circle (731 Rt. 35, Ocean Twp). I was impressed with their focus on convenience and quality care and their determination to improve the possibilities for patients who are acutely ill. No one likes to go to an ER, and this is an excellent option for many kinds of situations.
Here two links to articles we have posted on this subject
In 2014, I spoke enthusiastically about the urgicenter concept and about the CJUC. Now, the CJUC doctors are operating a total of six centers in this area. Recently the Ocean unit expanded by 1,700 square feet and they have modernized that spacious location and have updated their procedures. Their main goals remain convenience and quality, and I continue to be impressed by the success of their operation. As for convenience, they are about 10-15 minutes from Ocean Grove, and their records indicate that many Grovers go there. You just walk-in; no appointment is needed. All members of my immediate family including myself have received fine care at the CJUC.
Today I interviewed their Practice Manager Anthony Orzo and two of their physicians and I learned of the progress they have made in the last 4 years.
The main theme for the physician directors of the CJUC is to address many of the problems that patients now face in accessing healthcare, particularly urgent care, and then finding solutions to make the experience as excellent as possible. Here is a summary of what I learned:
a. All their doctors are board certified ER physicians who work part time in hospital ER’s to maintain their acute care skills. Today I met Chiraq Patel, MD and Vikram Varma MD. We spoke doctor to doctor, and I was impressed with their desire to operate the finest urgicenter in the area and with their intense emphasis on quality. I found that they have examined their operation top to bottom to insure the best results.
b. The doctors now work with physician extenders, ie nurse practitioners and/or physician assistants. When a patient enters their facility, a triage decision based on the complaint determines whether he will be initially evaluated by an “advanced practitioner” or by an MD. This team of two is always present and often collaborate on patient care. Generally the most worrisome cases go right to the doctor, but their advanced practitioners are instructed to consult with the physician if there is any concern. If you wish, you can request an MD regardless of your complaint.
c. The facility is open from 8-8 every day of the year. Parking is easy. Leaving can be a bit of a challenge on the circle. The staff is welcoming. The waiting area is divided so that potentially infectious patients are placed in one location. They will offer a mask if it is desired. If someone looks worrisome in the waiting area, they will bring them inside immediately. They try to expedite waiting times.
The recent renovation has produced 5 new examining rooms including one where they can offer treatments such as IV’s. There is a welcoming pediatrics area with a colorful hand painted seashore scene on the wall and a very efficient central operations station for personnel to interact and monitor care. It looks like one that you might find in a hospital.
d. The doctor enters a patient’s room with a “scribe” which enables him to focus totally on the patient instead of on a computer. The scribe deals with the computer and the written documentation of the visit.
e. The staff is able to perform a variety of blood tests and other diagnostics such as a Strep throat and HIV testing. They give vaccinations such as flu shots and they do Xrays and ECG’s. The Xrays are over-read within 2 hours by outside radiologists. You can get a physical exam, travel medical counseling, and pediatric care for 6 months and up.
f. Although the CJUC doctors will not function as your primary physician, you can go there for followup of issues that they initially saw you for.
g. The experience is much better than going to an ER, but if necessary, they will arrange to have a patient transported to the hospital. If you need a referral to a specialist, they will help you make that contact.
h. The CJUC offers a phone app which lets you check on waiting times. They also have a brilliant “membership plan” which offers a number of guaranteed visits outside of your insurance. As for the latter, they accept most insurance plans including Medicaid. Their goal is to turn no one away.
On Sunday July 15, they will have an open house from noon to 4 pm, and the public is invited. There will be tours, food, face painting and giveaways. You can see the facility and meet the staff. You will be impressed.
Note the increased number of cases of hypertension if the 2017 cut-offs are used.
Paul Goldfinger, MD, FACC. Editor @Blogfinger
Here is a link to our post last year about the new 2017 guidelines. This is the most recent information available in terms of guidelines for diagnosis and treatment.
For those of you with an active interest in the topic of hypertension, you would do well reviewing the BF posts linked above to appreciate that doctors may disagree about guidelines.
All these guidelines come together now in 2018 as doctors try to figure out what method is best and how to resolve discrepant results.
Currently physicians are trying to come up with a lucid and uniform approach to diagnosing and treating hypertension. Below are some of our conclusions at the Blogfinger Off-Shore Medical School in Ocean Grove, NJ.
a. The 2017 guidelines found that following that cutoff (130/80) reduces risk of stroke and cardiovascular complications if the target readings are achieved, but that can be difficult. We think that the 2017 guidelines, applied carefully to patient care, would be best.
But some major physician groups (eg the American Association of Family Practice) say that for those over age 60, this cutoff is too dangerous and for that group, the cutoff should be 150 mm Hg systolic. But if the patient is high risk (eg someone who has had a heart attack) a cutoff of 140 would be best. They are using the 2013 JNC 8 recommendations.
b. Most medical groups have embraced the new 2017 guidelines.
c. This is not a trivial issue because with the 2017 guidelines for diagnosis, 45% of the US population would be considered to be hypertensive. But the more people who are placed on drug therapy, the more people will show up with complications such as hypotension (excessively low BP) which can result in falling (with injuries,) dizzy spells, fainting, and kidney problems.
d. It seems to me that the 2017 guidelines make sense and will produce better outcomes than the less aggressive cutoffs that existed for many years. Unless all the doctors get it together and agree, there will be a sort of free for-all with individual physicians deciding on their own. Hopefully the smoke will clear and most physicians will be on board.
But what is clear, and I suspect most doctors will agree, we do need to lower BP readings more than in the past, and we do need to diagnose hypertension at lower cutoffs than the past.
e. Finally, patients should follow medical advice which should include preventive measures (diet, weight, exercise, etc.) and usually medication. Regarding the latter, oftentimes combination therapy of 2-4 different drugs may be required to achieve the desired cutoff. Such combinations allow individual drugs to be used at safer lower doses.
Hypertension is the “silent killer,” so follow good medical advice and participate in your care with home BP monitoring and adherence to medical regimens even if you feel fine. That is the essence of prevention.
f. Ask your doctor about his targeted plan for you. Make sure that you are not a therapeutic failure. Know your target reading and keep a written record.
And, to cheer you up, here is Jerry Seinfeld in the drugstore:
