Walter A. Brzezinski

Uncontrolled and Apparent Treatment Resistant Hypertension in the United States, 1988 to 2008

Background— Despite progress, many hypertensive patients remain uncontrolled. Defining characteristics of uncontrolled hypertensives may facilitate efforts to improve blood pressure control. Methods and Results— Subjects included 13 375 hypertensive adults from National Health and Nutrition Examination Surveys (NHANESs) subdivided into 1988 to 1994, 1999 to 2004, and 2005 to 2008. Uncontrolled hypertension was defined as blood pressure ≥140/≥90 mm Hg and apparent treatment-resistant hypertension (aTRH) when subjects reported taking ≥3 antihypertensive medications. Framingham 10-year coronary risk was calculated. Multivariable logistic regression was used to identify clinical characteristics associated with untreated, treated uncontrolled on 1 to 2 blood pressure medications, and aTRH across all 3 survey periods. More than half of uncontrolled hypertensives were untreated across surveys, including 52.2% in 2005 to 2008. Clinical factors linked with untreated hypertension included male sex, infrequent healthcare visits (0 to 1 per year), body mass index <25 kg/m2, absence of chronic kidney disease, and Framingham 10-year coronary risk <10% (P<0.01). Most treated uncontrolled patients reported taking 1 to 2 blood pressure medications, a proxy for therapeutic inertia. This group was older, had higher Framingham 10-year coronary risk than patients controlled on 1 to 2 medications (P<0.01), and comprised 34.4% of all uncontrolled and 72.0% of treated uncontrolled patients in 2005 to 2008. We found that aTRH increased from 15.9% (1998–2004) to 28.0% (2005–2008) of treated patients (P<0.001). Clinical characteristics associated with aTRH included ≥4 visits per year, obesity, chronic kidney disease, and Framingham 10-year coronary risk >20% (P<0.01). Conclusion— Untreated, undertreated, and aTRH patients have consistent characteristics that could inform strategies to improve blood pressure control by decreasing untreated hypertension, reducing therapeutic inertia in undertreated patients, and enhancing therapeutic efficiency in aTRH.

Preliminary evaluation of phosphatidylethanol and alcohol consumption in patients with liver disease and hypertension.

AIMS The goal of this preliminary study was to evaluate the relationship between blood phosphatidylethanol (PEth) and recent drinking in patients with liver disease and hypertension. METHODS Twenty-one patients with liver disease and 21 patients with essential hypertension were recruited at an academic medical center. Alcohol consumption was estimated using validated self-report methods, and blood PEth was measured by HPLC-MS/MS at a contracted laboratory. Nonparametric comparisons were made between abstainers/light drinkers, moderate drinkers consuming between 1 and 3 drinks per day, and those drinking above this level. Regression methods were used to estimate the effects of liver disease, gender, and age on the relationship between PEth and alcohol use, and to estimate the strength of the linear relationship between PEth and drinking. RESULTS PEth differed significantly between the three drinking groups (P < 0.001). The relationship between PEth and alcohol did not differ between hypertension and liver disease patients (P = 0.696), nor by gender and age. While there was substantial variability between subjects in the PEth concentration given a similar level of reported drinking, the amount of ethanol consumed was strongly associated with the PEth concentration (P < 0.001). CONCLUSION Results support PEth measurement by HPLC-MS/MS as a promising marker of past 1- to 2-week moderate to heavy alcohol consumption in patients with and without liver disease. PEth appears useful for differentiating abstinence or light drinking from moderate to heavy consumption, but may have limited utility for differentiating moderate from heavy alcohol use.

Thyroid disorders in elderly patients.

Thyroid disorders are common in the elderly and are associated with significant morbidity if left untreated. Typical symptoms may be absent and may be erroneously attributed to normal aging or coexisting disease. Physical examination of the thyroid gland may not be helpful, as the gland is often shrunken and difficult to palpate. Usually only myxedema coma requires levothyroxine parenterally; all other forms of hypothyroidism can be treated with oral levothyroxine. Low-dose levothyroxine should be initiated and increased gradually over several months. In unstable elderly patients with hyperthyroidism, antithyroid medication can quickly produce a euthyroid state. Radioactive iodine therapy is more definitive and is well tolerated, effective, and preferred. Surgical thyroid ablation may be necessary in patients who fail to respond to radioactive iodine therapy and in patients with multinodular goiter. If there is a suspicion of malignant disease, early biopsy or fine needle aspiration for cytology should be considered.

Uncontrolled and Apparent Treatment Resistant Hypertension in the U.S. 1988–2008

Background— Despite progress, many hypertensive patients remain uncontrolled. Defining characteristics of uncontrolled hypertensives may facilitate efforts to improve blood pressure control. Methods and Results— Subjects included 13 375 hypertensive adults from National Health and Nutrition Examination Surveys (NHANESs) subdivided into 1988 to 1994, 1999 to 2004, and 2005 to 2008. Uncontrolled hypertension was defined as blood pressure ≥140/≥90 mm Hg and apparent treatment-resistant hypertension (aTRH) when subjects reported taking ≥3 antihypertensive medications. Framingham 10-year coronary risk was calculated. Multivariable logistic regression was used to identify clinical characteristics associated with untreated, treated uncontrolled on 1 to 2 blood pressure medications, and aTRH across all 3 survey periods. More than half of uncontrolled hypertensives were untreated across surveys, including 52.2% in 2005 to 2008. Clinical factors linked with untreated hypertension included male sex, infrequent healthcare visits (0 to 1 per year), body mass index <25 kg/m2, absence of chronic kidney disease, and Framingham 10-year coronary risk <10% (P<0.01). Most treated uncontrolled patients reported taking 1 to 2 blood pressure medications, a proxy for therapeutic inertia. This group was older, had higher Framingham 10-year coronary risk than patients controlled on 1 to 2 medications (P<0.01), and comprised 34.4% of all uncontrolled and 72.0% of treated uncontrolled patients in 2005 to 2008. We found that aTRH increased from 15.9% (1998–2004) to 28.0% (2005–2008) of treated patients (P<0.001). Clinical characteristics associated with aTRH included ≥4 visits per year, obesity, chronic kidney disease, and Framingham 10-year coronary risk >20% (P<0.01). Conclusion— Untreated, undertreated, and aTRH patients have consistent characteristics that could inform strategies to improve blood pressure control by decreasing untreated hypertension, reducing therapeutic inertia in undertreated patients, and enhancing therapeutic efficiency in aTRH.

Southern Tick-Associated Rash Illness : Erythema Migrans Is Not Always Lyme Disease

Southern tick-associated rash illness (STARI) is a rash occurring after a tick bite. It is a form of erythema migrans, an annular rash with central clearing that is almost identical with the erythema migrans seen in Lyme disease. The etiologic agent is not known but may be a Borrelia species. The tick vector is different in the two diseases. Serious systemic complications are not currently recognized with STARI but treatment with doxycycline is prudent. Differentiating STARI from Lyme disease is discussed.

Pharmaceuticals in drinking water: local analysis of the problem and finding a solution through awareness.

OBJECTIVES To evaluate public awareness of pharmaceuticals in drinking water and to develop educational efforts to promote awareness in our community. METHODS A review of the literature was conducted to gain a full perspective of the current issue. Questionnaires, interviews, and website feedback were used to assess awareness of the problem and the most commonly used medication disposal methods. In addition, educational flyers were created to disseminate information to the public. RESULTS The questionnaires were completed by a total of 96 respondents. Of respondents employed in health care, 72% had previous knowledge of pharmaceutical medications being found in our local (Charleston, SC) water supply, and of respondents not employed in health care, 54% had previous knowledge. For those with previous knowledge, 7% disposed of medications in the toilet or sink, 38% used the trash, and 36% used multiple methods. Of respondents indicating no previous knowledge, 3% disposed of medications in the toilet or sink, 35% used the trash, and 42% used multiple methods. CONCLUSION Public awareness of pharmaceuticals in drinking water and educational efforts focusing on proper disposal of medications are essential in helping to reduce drinking water contamination.

A 22-Year-Old Woman with Abdominal Pain

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion.

Olanzapine and baclofen for the treatment of intractable hiccups.

Intractable hiccups are a relatively uncommon condition characterized by involuntary, spasmodic contractions of the diaphragm. This type of hiccups generally has a duration of more than 1 month. We describe a 59‐year‐old kidney transplant recipient with a complicated medical history (atrial fibrillation, chronic renal failure, type 2 diabetes mellitus, gastroesophageal reflux, gout, hypertension, hyperlipidemia, and obstructive sleep apnea) who developed intractable hiccups that significantly affected his quality of life. Despite an extensive gastrointestinal and pulmonary evaluation, and treatment failures with several different drug regimens—metoclopramide, desipramine, amantadine, cyclobenzaprine, phenytoin, and lorazepam—his hiccups were eventually controlled with a combination of baclofen and low‐dose olanzapine therapy. Baclofen is a γ‐aminobutyric acid (GABA) analog that contains a phenylethylamine moiety. It is hypothesized that having both GABA and phenylethylamine properties activates inhibitory neurotransmitters, most notably GABA, which may in turn block the hiccup stimulus. The exact mechanism through which olanzapine is effective in patients with hiccups is not fully understood. It is thought that the effect is, in part, due to serotonin augmenting phrenic motoneuronal activity on the reflex arcs involved in the generation of hiccups within the spinal cord. In addition, since olanazapine is a dopamine antagonist, particularly a dopamine D2‐receptor antagonist, this could also have played a role in its effectiveness in treating our patient. Strong evidence for a specific treatment regimen for intractable hiccups is lacking in the primary literature. Our case report adds to the available literature, as there are currently no published data on the use of combination therapy for the treatment of intractable hiccups, and the combination of baclofen and olanzapine significantly improved our patients quality of life.

Epidemiology of Hypertension in Diabetes

Given the prevalence and impact of hypertension on vascular disease in diabetic patients, the prevalence, awareness, treatment, and control of hypertension in diabetes has important implications for healthcare policy and professional guidelines. This report examines changes in the clinical epidemiology of hypertension in diabetes from 1988 to 2008 using the National Health and Nutrition Examination Survey database subdivided into 1988–1994, 1999–2004, and 2005–2008. Over time, prevalent hypertension, defined as blood pressure (BP) ≥140/≥90 mmHg or self-reported hypertension treatment, increased from 51 % to 66 %, p < 0.001. BP declined from 145.2/74.7 to 136.5/69.7, p < 0.001, among all patients with diabetes and hypertension. The reduction in BP reflected improvements in hypertension awareness (83–92 %, p < 0.001), treatment (73–87 %, p < 0.001), proportion of treated patients controlled (48–62 %, p < 0.01), and controlled to <140/<90 (35.5–54.6 %, p < 0.001). BP control to the more stringent target of <130/<80 rose (18–36 %, p < 0.01). The proportion of patients with diabetes and hypertension who had normal BP (<120/<80) increased from 10.7 % to 20.8 %, whereas the proportion with Stage 2 hypertension (BP ≥160/≥100) decreased from 23.5 % to 14.5 % (both p < 0.001). Hypertension control improved, although body mass index increased from 31.3 to 33.1 kg/m2, p < 0.001, and likely reflected a decrease in hypertension treated with 0–1 and an increase in treatment with ≥3 antihypertensive medications. Time trends in the clinical epidemiology of hypertension among patients with diabetes are positive, except for prevalence, and parallel findings reported in all patients with hypertension over the same time period.

Lessons Learned from a Middle-Aged Man with Testicular Pain: Exercises in Clinical Reasoning.

Exercises in Clinical Reasoning Lessons Learned from a Middle-Aged Man with Testicular Pain: Exercises in Clinical Reasoning Brittany Payne, MD, MPH, Walter A. Brzezinski, MD, Amanda V. Clark, MD, Carlos A. Estrada, MD, MS, and Ryan R. Kraemer, MD Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham, AL, USA; Medical University of South Carolina, Charleston, SC, USA; Louis Stokes Cleveland VAMedical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA; The University of Alabama at Birmingham, Birmingham, AL, USA.