Friday, 12 April 2019

Why you should keep tabs on your drinking

The need to support injured soldiers dates back to our earliest days as a nation, starting with the pilgrims of Plymouth Colony. But it was not until 1865 that Abraham Lincoln, the 16th President of the United States, gave us this mission:

“To care for [the person] who shall have borne the battle and for his [or her] widow [or widower or partner], and his [or her] orphan.”

The United States Department of Veterans Affairs (VA) was established on March 15, 1989, replacing the previous Veterans Administration. Its charge is to continue to provide benefits and care to veterans and their families.

The mission set out by President Lincoln remains essential today. Veterans, and family or survivors of veterans, who may be eligible for VA benefits and services make up a quarter of the United States’ population. The “compensation and pension examination” is the first step in determining a person’s eligibility for this assistance.

These exams are carried out by expert and dedicated clinical professionals within the VA Healthcare System. Those who act in this role must be perceptive and embrace the concept of respect for the individual who has served and has suffered. The assessment must go beyond completing a check-off list or categorizing a person’s experiences into “yes” or “no.” Rather, the clinician must look beyond those criteria to the person who has been hurt, injured, changed, or compromised. Sometimes this damage is clear to the person’s friends and loved ones, or is obvious in the exam room. Sometimes the damage is hidden and suffered in silence. The only way to provide comprehensive and meaningful care is through respectful engagement and interaction.

Once a person’s claim has been accepted, he or she is given an appointment with the appropriate provider to address any specific injuries or other health problems. This may include another compensation and pension exam for the purpose of evaluating any mental health concerns, such as post-traumatic stress disorder, to make sure the veteran is connected with the appropriate care.

The interaction during these evaluations is designed to be non-adversarial and supportive, but for some, the examination can be stressful and upsetting. Mutual greetings and brief small talk can help engage the veteran, reduce anxiety as much as possible, and convey respect for the individual’s life story. Simple things like taking a break when emotions run high and having a box of tissues handy can help ease distress and avoid any re-traumatizing or increasing the burden on the veteran. Having a spouse, partner, or other family member participate can help support the veteran and often provides additional important information for the clinician. Each provider’s efforts to listen, clarify when needed, and consistently demonstrate care, concern, and respect should be the thread that connects the VA with the veteran.

From my participation in over a thousand compensation and pension exams, I have had the privilege of sharing in the historical reflection on events, tragedy, heroism, and unspoken emotions. I have witnessed the unearthing of hidden fears and buried feelings of guilt, blame, and anger. In these meetings, I have learned the true meaning of resilience. I have joined in the process of not only compensating people for their service, but also connecting them to the care they need. It is a good day when I am able to assist in some fashion, and I’m grateful for the opportunity to do so. That is what it means to truly express “Thank you for your service.”

From those who served in our country’s earliest wars to present-day returning veterans, there is one constant that has kept them going on in life — that of personal determination to survive, the commitment to never lose sight of one’s meaning in life, and the strength of humor. My interactions with these individuals have reminded me to enjoy the gift of smiling, laughing, and caring about others every day. I’m heartened to see more public discourse about the pain of miscarriage. Recently, Mark Zuckerberg, the CEO of Facebook, went public on his Facebook page with the pregnancy losses that he and his partner suffered. Beyonce and Jay-Z wrote a song about their first pregnancy loss. Nicole Kidman, Mariah Carey, Celine Dion, Courteney Cox, and Brooke Shields have all publicly shared their miscarriage experiences. But all too often, I still find women and their partners suffering in silence and alone.

Recently, researchers at Albert Einstein College of Medicine in New York City surveyed over, 1,000 adults in the United States to determine what the general public knows about the causes of miscarriage and its emotional effects. Their results were published earlier this year in a paper called “A National Survey on Public Perceptions of Miscarriage.”

Fifteen percent of those surveyed said that they (or a partner) had experienced a miscarriage. Over half of the respondents believed that miscarriages were uncommon, even though studies show that approximately one in four pregnancies ends in miscarriage. Over three-quarters of respondents thought miscarriage resulted from stress, and over a quarter also thought that the most important causes were lifestyle choices made during pregnancy. But in fact, most miscarriages are the result of chromosomal abnormalities in the developing fetus, structural abnormalities of the uterus, or endocrine or autoimmune disorders in the mother.

To me, the most striking part of the survey was that many of those who had experienced a miscarriage reported feeling that they had done something wrong, and that they felt alone and ashamed. However, when their friends disclosed their own miscarriages to them, they felt less alone. They also felt less isolated when celebrities disclosed their miscarriages.

While it’s great that so many public figures have spoken up about their own miscarriages lately, the study results make clear that we still need to get discussion of miscarriage out of the closet. Here’s the advice I always give my patients who have experienced a miscarriage:

    Nothing you did caused this miscarriage, and nothing you could have done would have prevented it.
    Even if you had been perfectly still in bed, were totally relaxed, and ate nothing but healthy foods, you would still have had a miscarriage.
    You will be surprised at how many of your close friends and family members have experienced miscarriage. Share this experience with them.
In a previous blog, I reported on the preliminary results from SPRINT, a clinical trial that examined whether a systolic blood pressure target of 120 mm Hg or less would be better than a target of 140 mm Hg in patients with hypertension (high blood pressure). The National Heart, Lung, and Blood Institute of the National Institutes of Health issued a press release with the exciting results. Now, the full paper has been published in The New England Journal of Medicine, and the results appear to be as practice-changing at it initially seemed, demonstrating a stricter blood pressure goal can reduce the likelihood of dying. In the world of medicine, this is really big news.

The SPRINT researchers randomly assigned 9,361 patients at increased cardiovascular risk (though without diabetes) with a systolic blood pressure of 130 mm Hg or higher to either standard treatment or to intense treatment. Standard treatment meant a target of less than 140 mm Hg for the systolic blood pressure (the top number) and intense treatment meant a target of less than 120 mm Hg. On average, the patients in the trial were followed for 3.26 years, at which point the trial was stopped earlier than planned because researchers felt the results were too compelling to allow the study to continue. There was a 25% reduction in the rate of cardiovascular complications, including events such as heart attack, heart failure, and stroke. There was a 27% reduction in the risk of death.

It is important to note that very few interventions in medicine actually reduce the risk of death. Among physicians who lead clinical trials, this would be considered a home run.

To achieve the greater degree of blood pressure reduction, on average, three medications were needed instead of two. Not surprisingly (to any physician), this resulted in more side effects such as low blood pressure, fainting, kidney failure, and electrolyte abnormalities on blood tests. Practically speaking, that means to achieve the impressive results seen in this study, patients will need to take more medications and have to be followed carefully by their doctors. Otherwise, the benefits demonstrated in this research setting may not be fully reproducible in real-world practice, and the risk of serious side effects may be even higher.

Also, the results don’t apply to everyone at increased cardiovascular risk who has high blood pressure. For example, patients with diabetes, heart failure, a previous stroke, or younger than 50, were not enrolled in the trial. Those with a very high blood pressure (systolic of 180 mm Hg or greater) were also excluded from the study. There were many patients 75 years of age or older in the trial—which is great, because many studies exclude older people—but none of these elderly study volunteers lived in nursing homes or assisted-living facilities.

What should patients with high blood pressure do now? Making an appointment to see your primary care physician to determine if you need more aggressive blood pressure management makes sense. There is no emergency to do this, as the adverse effects of high blood pressure in the range studied in this trial typically take time to manifest. But I wouldn’t suggest waiting until your annual check-up either — the beneficial results seen in the SPRINT trial started to become apparent at approximately one year. And it may take a few visits to get on a medication regimen that lowers blood pressure without causing too many side effects. The good news is that there are many generic blood pressure medications, so with some trial and error, many patients can achieve the degree of blood pressure control noted in this study.

The reality, though, is that in the United States and worldwide, many patients have blood pressure that is not controlled even to the previously recommended goals. So, the major remaining challenge is how we can make sure that patients similar to those in the trial benefit from this major advance in our understanding of the treatment of high blood pressure. Current estimates in a paper just published in the Journal of the American College of Cardiology suggest that in the U.S., the results of SPRINT would directly apply to roughly 8% of adults and approximately half are not being treated for high blood pressure—that works out to over 8 million people!

Identifying those people, some of whom may even have a blood pressure in the 130s, will not be easy, as they may not regularly seek medical care. Therefore, the SPRINT study also implies that even if you don’t have a diagnosis of high blood pressure, you should know what your blood pressure is and talk with your doctor about how to assess risks and benefits to you of treatment to achieve what is the optimal blood pressure goal for you.

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