Elderly Hypertensives: How Are They Different?

J Clin Hypertens (Greenwich). 2012;14:779–786. ©2012 Wiley Periodicals, Inc. Once considered an inconsequential part of the aging process, the development of isolated systolic hypertension represents a late manifestation of increased elastic artery stiffness and is the predominant hypertensive subtype in the middle‐aged and elderly populations. Its inherent increased risk for vascular events, such as coronary heart disease, stroke, heart failure, peripheral artery disease, chronic kidney disease, and dementia, highlights the importance of its control. The purpose of this short review is to summarize how hypertension is different in the elderly when compared with “essential hypertension” in younger adults. The emphasis will be on the multiple ways that increased artery stiffness affects the natural history and clinical manifestations of hypertension in the elderly.     

Senior Health Clinics: Are They Financially Viable?

Are hospital‐based outpatient interdisciplinary clinics a financially viable alternative for caring for our burgeoning population of older adults in America? Although highly popular, with high patient satisfaction rates among older adults and their families, senior health clinics (SHCs) can be expensive to operate, with limited quantifiable health outcomes. This study analyzed three geriatric hospital‐based interdisciplinary clinics in rural Arkansas by examining their patient profiles, revenues, and expenses. It closely examined the effects of the downstream revenue using the multiplier effect and acknowledged other factors that weigh heavily on the success of SHCs and the care of older adults. The findings highlight the similarities and differences in the three clinics' operating and financial structures in addition to the clinics' and providers' productivity. The analysis presents an evidence‐based illustration that SHCs can break even or lose large amounts of money.     

Hold-Over Admissions: Are They Educational for Residents?

PURPOSE

Since implementation of resident duty-hour restrictions, many academic medical centers utilize night-float teams to admit patients during off hours. Patients are transferred to other resident physicians the subsequent morning as “hold-over admissions.” Despite the increase of hold-over admissions, there are limited data on resident perceptions of their educational value. This study investigated resident perceptions of hold-over admissions, and whether they approach hold-over admissions differently than new admissions.

METHOD

Survey of internal medicine residents at an academic medical center.

RESULTS

A total of 111 residents responded with a response rate of 71 %. Residents reported spending 56.2 min (standard deviation [SD] 18.9) compared to 80.0 min (SD 25.8) admitting new patients (p?<?0.01). Residents reported spending significantly (p?<?0.01) less time reviewing the medical record, performing histories, examining patients, devising care plans and writing orders in hold-over admissions compared to new admissions. Residents had neutral views on the educational value of hold-over admissions. Features that significantly (p?<?0.01) increased the educational value of admissions included severe illness, patient complexity, and being able to write the initial patient care orders. Residents estimated 42.5 % (SD 14) of their admissions were hold-over patients.

CONCLUSIONS

Residents spend less time in all aspects of admitting hold-over patients. Despite less time spent admitting hold-over patients, residents had neutral views on the educational value of such admissions.     

Paclitaxel‐Eluting Stents: Are They All Equal?

In Germany, four different drug eluting stents (DES) systems are currently commercially available. Whereas sirolimus has been clinically tested in only a single type of stent with a single type of coating in only a single dose, paclitaxel has been tested on various stent designs, in various dose densities, and in various relase formulations with or without a polymer carrier. Therefore, the question arises: are all paclitaxel stents equally safe and effective? Six clinical randomized trials investigated the safety and efficacy of paclitaxel‐eluting stents in patients with de‐novo lesions: TAXUS‐I (61 pats), TAXUS‐II (536 pats), ASPECT (177 pats), ELUTES (190 pats), DELIVER‐I (1041 pats) and TAXUS‐IV (1314 pats). In the TAXUS‐series, paclitaxel released from the stent was controlled by the Translute? polymer. In the other studies, however, no polymer carrier was used. In TAXUS‐I, II & IV, the dose density of 1 μg/mm² significantly reduced angiographic parameters of restenosis and improved clinical outcomes. In ASPECT and ELUTES there was a dose‐dependent effect on angiographic parameters of restenosis with the best results for a paclitaxel dose density of apprimately 3.0 μg/mm². Clinical outcomes at 6 and 12 months, however, were not improved in these studies without coating. The studies unanimously show that the paclitaxel‐eluting stents are safe, if clopidogrel is added to ASA for 3 to 6 months. The safety of paclitaxel‐eluting stents is independent of the stent design, the dose density and the presence or absence of a polymer carrier system. For paclitaxel‐eluting stents using a polymer carrier, the dose density of 1 μg/mm² is highly effective, whereas for paclitaxel‐eluting stents without a polymer carrier, the minimal effective dose density is much higher (3 μg/mm²). Despite their improvement of angiographic parameters, paclitaxel‐eluting stents without a polymer carrier did not demonstrate a positive effect on clinical outcome. In contrast, polymer‐based paclitaxel elution produced significant clinical benefit. (J Interven Cardiol 2003;16:485–490)     

Food Allergy and Atopic Dermatitis: How Are They Connected?

Food allergy predominantly affects children rather than adults with atopic dermatitis (AD). Early food sensitization has been found to be significantly associated with AD. Three different patterns of clinical reactions to food allergens in AD patients have been identified: 1) immediate-type symptoms, 2) isolated eczematous late-type reactions, and 3) combined reactions. Whereas in children, allergens from cow’s milk, hen’s egg, soy, wheat, fish, peanut, or tree nuts are primarily responsible for allergic reactions, birch pollen–related food allergens seem to play a major role in adolescent and adults with AD in Central and Northern Europe. Defects in the epidermal barrier function seem to facilitate the development of sensitization to allergens following epicutaneous exposure. The relevance of defects in the gut barrier as well as genetic characteristics associated with an increased risk of food allergy remain to be further investigated. Many studies focus on sufficient strategies of prevention, which actually include breastfeeding or feeding with hydrolyzed formula during the first 4 months of life.     

Electrocardiographic Interpretation Skills of Cardiology Residents: Are They Competent?

Achieving competency at electrocardiogram (ECG) interpretation among cardiology subspecialty residents has traditionally focused on interpreting a target number of ECGs during training. However, there is little evidence to support this approach. Further, there are no data documenting the competency of ECG interpretation skills among cardiology residents, who become de facto the gold standard in their practice communities. We tested 29 Cardiology residents from all 3 years in a large training program using a set of 20 ECGs collected from a community cardiology practice over a 1-month period. Residents interpreted half of the ECGs using a standard analytic framework, and half using their own approach. Residents were scored on the number of correct and incorrect diagnoses listed. Overall diagnostic accuracy was 58%. Of 6 potentially life-threatening diagnoses, residents missed 36% (123 of 348) including hyperkalemia (81%), long QT (52%), complete heart block (35%), and ventricular tachycardia (19%). Residents provided additional inappropriate diagnoses on 238 ECGs (41%). Diagnostic accuracy was similar between ECGs interpreted using an analytic framework vs ECGs interpreted without an analytic framework (59% vs 58%; F_1,1333 = 0.26; P = 0.61). Cardiology resident proficiency at ECG interpretation is suboptimal. Despite the use of an analytic framework, there remain significant deficiencies in ECG interpretation among Cardiology residents. A more systematic method of addressing these important learning gaps is urgently needed.     

Alcohol Consumption and HIV Disease Progression: Are They Related?

BACKGROUND: The relationship between alcohol consumption and HIV disease progression has received limited attention in the era of highly active antiretroviral therapy (HAART). METHODS: We assessed CD4 cell count, HIV RNA levels, and alcohol consumption in the past month, defined as none, moderate, and at risk, in 349 HIV-infected people with a history of alcohol problems. We investigated the relationship between alcohol consumption and HIV disease markers CD4 cell count and HIV RNA level, stratified by HAART use, using multivariable regression. RESULTS: No significant differences in CD4 cell count or HIV RNA level were found across the categories of alcohol consumption for patients who were not receiving HAART. However, among patients who were receiving HAART, log HIV RNA levels were significantly higher in those with moderate (2.17 copies/ml) and at-risk (2.73 copies/ml) alcohol use compared with none (1.73 copies/ml; p = 0.006). CD4 cell counts in those with moderate (368 cells/microl) and at-risk (360 cells/microl) alcohol use were lower than for subjects who reported none (426 cells/microl; p = 0.07). CONCLUSION: Among patients who have a history of alcohol problems and are receiving antiretroviral treatment, alcohol consumption was associated with higher HIV RNA levels and lower CD4 counts. No comparable association was found for similar patients who were not receiving HAART. Addressing alcohol use in HIV-infected patients, especially those who are receiving HAART, may have a substantial impact on HIV disease progression.     

Antihistamines in Ocular Allergy: Are They All Created Equal?

Use of topical antihistamines in the treatment of allergic conjunctivitis has evolved over the past several decades as our knowledge of the nature of the underlying disease has progressed. Formulations for the eye typically employ H₁-receptor antagonists with a dual action, both directly as competitors for histamine receptor occupancy and as mast cell–stabilizing agents. Many of these compounds also display activity against late-phase allergic symptoms. Of the newest available drugs, several have a prolonged duration of action allowing once-daily dosing. Future development is likely to focus on long-acting agents such as these and on drugs that can target additional histamine receptor subtypes.     

Red Yeast Rice Preparations: Are They Suitable Substitutions for Statins?

Red yeast rice, a commercially available food supplement known to reduce serum cholesterol, has been repeatedly advocated as alternative therapy for hypercholesterolemic patients that refuse statins, cannot tolerate statin therapy's side effects, or request a “naturopathic” medicine. Red yeast rice contains a fungus (Monascus purpureus), which was utilized in the original production of lovastatin (MEVACOR, Merck & Co, Whitehouse Station, NJ), the first marketed pharmaceutical statin, and is chemically identical to such product. Their identical properties account for the similarity in therapeutic and side effects of red yeast rice and lovastatin. The red yeast rice ingredient that blocks cholesterol production is monacolin K. Because red yeast rice preparations have large variability in monacolin K content, predicting or understanding dose-related efficacy and side-effect risks of red yeast rice is practically impossible. The lipid-regulating potency of red yeast rice in commercial preparations was found to be extensively different according to the number or concentration of monacolin K they possess. Furthermore, more than one type of monacolin was found in different preparations (or batches) of red yeast rice. Other ingredients found in red yeast rice are also known to be potentially toxic. The US Food and Drug Administration issued warnings to consumers in 2007 and in 2013 against taking red yeast rice products due to the lack of assurance about its efficacy, safety, and lack of standardized preparation methods. This article discusses my clinical trial results with red yeast rice, reviews the literature on its therapeutic and side effects, and discusses why red yeast rice is not an acceptable substitution for statins.     

Detecting Deception in Our Research Participants: Are Your Participants Who You Think They Are?

There is increasing awareness of the potential negative impacts of participant deception on research, including possibly undermining reliability and reproducibility of study findings. These deceptive individuals set their personal interests above the rules of study participation, thereby jeopardizing data quality as well as placing themselves and others at risk. The costs of participant deception are numerous. Overall, it reduces statistical power and may even result in false conclusions about efficacy and safety. To date, most studies have not utilized sufficient methods to detect rule‐breaking subjects. The purpose of this article is to bring to the attention of alcohol and other drug researchers issues involving deceptive participants. The review will suggest alcohol‐specific as well as more general strategies to identify and thereby minimize enrollment of these deceptive participants. Specifically, we will identify strategies that are employed in different phases of human alcohol research and advance approaches that may be helpful to the field in reducing these contaminants. As a field, we need to be more proactive in identifying the deceptive participant even at the cost of more burdensome study enrollment. In light of the systemic nature and multipronged damage that this emerging pattern of deception inflicts on clinical research, it is imperative that we each assume greater responsibility for our role in mitigating this source of research contamination.