Treating Resistant Hypertension: Cut Out the Salt

Treating Resistant Hypertension: Cut Out the Salt

Treating Resistant Hypertension: Cut Out the Salt

In a small randomized crossover study, a low-salt diet had dramatic effects on blood pressure.

Patients with resistant hypertension — elevated blood pressure that persists despite the use of three or more antihypertensive agents — are frequently encountered in clinical practice. To examine the role of salt sensitivity in resistant hypertension, investigators conducted a randomized crossover evaluation of two 7-day diets, one low-sodium (50 mmol/day) and one high-sodium (250 mmol/day), separated by a 2-week washout period. Twelve adults (mean age, 56; 8 women; 6 black patients) completed the study. At baseline, participants were taking an average of 3.4 antihypertensive medications, and the mean office blood pressure was 145.8/83.9 mm Hg. All participants continued taking their medications during the study.

Mean urinary sodium excretion during the low-salt diet was significantly lower than during the high-salt diet, indicating adherence to the dietary salt intake regimen. Compared with the high-salt diet, mean office systolic and diastolic blood pressures were lower by 22.7 mm Hg and 9.1 mm Hg, respectively, during the low-salt diet. After adjustment for multiple testing, the between-diet differences in office systolic blood pressure and in all 24-hour ambulatory blood pressure measurements remained significant.

Comment: According to this small study, excessive dietary sodium intake is an important contributor to resistant hypertension. We are well reminded that ensuring a reduction in sodium ingestion is a crucial component in the care of hypertensive patients.

— Joel M. Gore, MD

Published in Journal Watch Cardiology September 23, 2009

Citation:
Pimenta E et al. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: Results from a randomized trial. Hypertension 2009 Sep; 54:475. [Medline® Abstract] [Free full-text article pdf]

Copyright © 2009. Massachusetts Medical Society. All rights reserved.

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Mario Santoro

National EMS Memorial Service Honoree
Mario Santoro New York Presbyterian Hospital New York, New York
When the first aircraft hit the north tower of the World Trade Center, Mario Santoro and his partner were the first emergency medical team assigned to the scene. They were stationed at Church and Fulton Streets. On site the team immediately started treating the numerous patients that were exiting the tower. When the second aircraft hit the south tower they entered it to reach patients and began treatment. When the tower came crashing to the ground all communication with the team was lost.
"They treated the injured and directed other ambulance crews to the place they were needed most. This is the first time in the history of our department where a crew has not come home�It has been a very difficult time," stated co-worker Brian Washburn. Santoro is one of the team dubbed the "elite eight".
Mario Santoro was employed with New York Presbyterian Hospital in New York City, New York as an advanced emergency medical worker. He lost his life when the World Trade Center fell to the ground caused by the terrorist attacks of September 11, 2001. Prior to working with Presbyterian Mario was employed with MetroCare Ambulance.
Honored 2002

Keith Fairben

National EMS Memorial Service Honoree
Keith Fairben New York Presbyterian Hospital New York, New York
As a father looks diligently through the rubble of the fallen World Trade Center, tears fall from the eyes of those around him. They can only grieve as they feel a small part of the pain he must feel within. The father, a volunteer firefighter for 32 years, is searching though the giant heap of twisted metal and sacred dust for a reason. He is looking for a victim lost in the fallen Twin Towers; however, not just any victim, he is looking for his only child, his son.
Keith G. Fairben, 24, lost his life while trying to save others injured in the worst terrorist attack in America on September 11, 2001. He responded to the call minutes after the first plane hit. The elder Fairben called his son on his cell phone: "Dad, I'm really busy. I am at the World Trade Center. I can't talk now." "Be careful", his father said, "Call us later." That was the last he heard from young Keith.
Keith Fairben worked for New York Presbyterian Hospital of New York City, New York. He had worked there as a medic going on four years. Keith had completed an 11-month EMT program at North Shore University Hospital in May 2001. He seemed to have a penchant for saving people. "I know when they find him, he will be with someone. He wouldn't abandon anyone," stated Keith's father.
No truer statement was ever made, that we are to bury our parents, not our children. Many parents have buried their children that were lost in the World Trade Center. However, what a beautiful legacy to quote, "He wouldn't abandon anyone."
Honored 2002

FW: Requested DocAlert: Smokeless Tobacco and Risk of Myocardial Infarction or Stroke: Systematic Review With Meta-Analysis

Smokeless Tobacco and Risk of Myocardial Infarction or Stroke: Systematic Review With Meta-Analysis

Dear Clinician,

Here is the information you requested (sourced from BMJ).

Published 18 August 2009, doi:10.1136/bmj.b3060
Cite this as: BMJ 2009;339:b3060
[Free full-text BMJ article (pdf)] [PubMed abstract]

Research

Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis

Paolo Boffetta, epidemiologist, Kurt Straif, epidemiologist
1 International Agency for Research on Cancer, Lyon, France
Correspondence to: P Boffetta, Genetics and Epidemiology Cluster, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69008 Lyon, France boffetta@iarc.fr

Objective To assess whether people who use smokeless tobacco products are at increased risk of myocardial infarction and stroke.

Design Meta-analysis of observational studies from Sweden and the United States.

Data sources Electronic databases and reference lists.

Data extraction Quantitative estimates of the association between use of smokeless tobacco products and risk of myocardial infarction and stroke among never smokers.

Review methods Both authors independently abstracted risk estimates and study characteristics. Summary relative risks were estimated on the basis of random effects models.

Results 11 studies, mainly in men, were included. Eight risk estimates were available for fatal myocardial infarction: the relative risk for ever use of smokeless tobacco products was 1.13 (95% confidence 1.06 to 1.21) and the excess risk was restricted to current users. The relative risk of fatal stroke, on the basis of five risk estimates, was 1.40 (1.28 to 1.54). The studies from both the United States and Sweden showed an increased risk of death from myocardial infarction and stroke. The inclusion of non-fatal myocardial infarction and non-fatal stroke lowered the summary risk estimates. Data on dose-response were limited but did not suggest a strong relation between risk of dying from either disease and frequency or duration of use of smokeless tobacco products.

Conclusion An association was detected between use of smokeless tobacco products and risk of fatal myocardial infarction and stroke, which does not seem to be explained by chance.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://imageb.epocrates.com/mailbot/links?EdID=42356822&LinkID=36943 and http://imageb.epocrates.com/mailbot/links?EdID=42356822&LinkID=48281.

© 2009 BMJ Publishing Group Ltd.

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QOD

Which of the following is not a common complication
of an influenza infection?
a. Otitis media
b. Guillain-Barre syndrome
c. Bacterial pneumonia
d. Acute bronchitis

Numerous potential complications can stem from a primary influenza infection and contribute to the
initial presentation. An example might be the patient who presents with chest pain in the setting of a viral
respiratory illness and is found to have myocarditis as a complication of an influenza infection. Some of the
more common complications include acute bronchitis, bacterial pneumonia, and, in children, otitis media.

Answer: b

QOD

Which of the following findings on transvaginal ultrasound is the first non-controversial and definitive sign in the initial diagnosis of an intrauterine pregnancy?
A. double decidual sign
B. intradecidual sign
C. pseudogestational sac
D. ring signE. yolk sac in the uterus


A double decidual sign is one of the first signs that is seen in an IUP and should be visualized 5 weeks after the last menstrual period. The double decidual sign is described as two echogenic rings surrounded by intrauterine fluid collection. (See Figure 1.) Caution should be taken, however, to differentiate this from a pseudogestational sac, which can be seen in ectopic pregnancy. This pseudogestational sac (see Figure 2) is due to a small amount of fluid being trapped within the endometrial canal, mimicking the appearance of the double decidual sign. Because of the risk of potential misinterpretation, there is controversy about using the double decidual sign to rule in an IUP.
The intradecidual sign is a linear echo in the uterine cavity in a pregnancy < 9 weeks in conjunction with a gestational sac or an echogenic area of early implantation located within a markedly thickened uterine cavity. (See Figure 3.) These findings may be mistaken for a decidual cyst or an endometrial cyst, which may coexist with ectopic pregnancy and makes the intradecidual sign controversial as a reliable finding for an IUP.
By 5.5 weeks from the last menstrual period, a yolk sac should be visualized within the gestational sac. (See Figure 4.) This is the earliest definitive sign of an intrauterine pregnancy. Gestations longer than 5.5 weeks have a visible IUP seen nearly 100% of the time. Operator expertise, however, decreases the sensitivity of TVU to 73-93%. If a definite IUP is seen and the patient is not at risk for heterotopic pregnancy (ectopic pregnancy and IUP), the patient does not have an ectopic pregnancy.
Diagnostic criteria for a tubal ectopic pregnancy on TVU include an empty endometrial cavity with either a heterogeneous adnexal mass (seen in approximately 60% of cases), an extra-uterine gestation sac with a yolk sac that may have a fetal pole +/- cardiac activity (seen in 13% of cases), or a ring sign. A ring sign is a mass in the adnexa with a hyperechoic ring around the gestational sac seen on TVU in approximately 20% of cases. (See Figure 5.) Diagnostic criteria for interstitial/cornual ectopic pregnancy include an empty endometrial cavity with a pregnancy visualized outside of the endometrial echo and surrounded by myometrium within the interstitial region.
Studies have shown that the overall sensitivity of TVU (TransVaginalUltrasound) for diagnosing ectopic pregnancy ranges between 74% and 98% and has a specificity of 99.9%. Patients with PUL on an initial TVU may in fact have an ectopic and should be followed closely.
In the event of rupture of the ectopic pregnancy, free fluid may be seen on TVU as an anechoic area around the uterus, in the pelvis or Morrison's pouch. (See Figure 6.)
Answer: E

CME

New York Presbyterian Hospital
Emergency Medical Services

Continuing Medical Education

NYP/Weill Cornell/Room M-107
Thursday November 5, 2009 4:00-8:00pm

Medical / Legal Considerations
With John Morrone, JD, MBA, NREMT-P
Andrew Leftt, JD
HIPPA/HITECH, EMTALA, Paramedic/EMT Liability, Ambulance Operations/MVTL, Federal Laws regarding healthcare, medical devices and FDA Law

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Please E-mail it to me.
STEVE SAMUELS EMT-P
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