Dress and deportment of medical residents: formal or informal?

PURPOSE: Health care workers, including physicians, have adopted more casual dress. The appearance of a physician may influence patients' opinion of physician knowledge, competence and trustworthiness. We hypothesized that medical inpatients and outpatients would rate these attributes higher in residents who dressed and acted in a more formal manner. METHODS: Prospective cohort included both inpatients and outpatients. One hundred thirty three patients, aged 62.3 ± 16 years, 49% of whom were female, were surveyed. One of two male resident physicians approached each patient, ostensibly to obtain consent to a brief mini-mental status examination. The physician was dressed, and acted, either "formally" (F) or "informally" (I). Patients then completed a six item questionnaire, using a 5 point Likert scale, to assess their confidence in the resident. Total scores could be 6 to 30. Total scores were compared using one-way ANOVA. RESULTS: Patients' perceptions were high for both F and I: 25.5 ± 3.1 vs. 24.1 ± 3.0, respectively (p=0.013). This difference was driven by the "lab coat" question: patients generally preferred physicians to wear a lab coat (3.9 ± 1.0 vs. 2.8 ± 1.3, p < 0.0001). Responses to four of the other five questions were numerically, but not statistically, higher in F. There was no difference in preference between the two residents: 24.6 ± 2.8 vs. 24.9 ± 3.5, p=0.56. CONCLUSION: More formal dress and demeanor by residents leads to a modest, but significant, increase in patient perception of the resident's value. Wearing a white lab coat, in particular, has a positive effect.

Accuracy of drug store blood pressure monitors: an observational study.

OBJECTIVES: Publically accessible blood pressure monitors are widely used, but little information is available on their accuracy. We compared blood pressure readings of 17 drug store monitors with those obtained using a validated home monitor (Omron BP742CAN) and both with those taken at home using the Canadian Hypertension Education Program protocol. MATERIALS AND METHODS: Duplicate readings were taken using the drug store monitor (VitaStat, n=6, and PharmaSmart, n=11) on the left arm and the Omron on the right in three participants: two normal and one untreated hypertensive patient. We used Bland-Altman methods for comparison. We explored the correlation with average home blood pressure readings. RESULTS: Home average blood pressure for our three participants was 121±6/73±5, 106±6/62±4, and 142±8/81±7 mmHg. The mean systolic blood pressure difference (drug store-Omron) was -1.8±8.2 mmHg. Diastolic pressure difference was 1.7±5.6. Individual paired systolic differences varied from -19 to 14 mmHg. For the participant who required a large cuff, drug store systolic readings tended to be higher (4.1±6.7). In our three participants, drug store monitors as a group read higher than home systolic blood pressure: 7.5 [95% confidence interval (CI) 1.5-13.4], 1.2 (95% CI -4.0 to 6.4), and 1.0 (95% CI -2.5 to 4.4) mmHg. Diastolic blood pressure and heart rate differences were similar in magnitude. CONCLUSION: On average, drug store monitors recorded lower systolic blood pressures and higher diastolic blood pressures than a validated monitor, but the difference was neither statistically nor clinically significant. Single reading comparisons showed a much broader range. In three participants, drug store monitors did reflect the average home blood pressure.

Comparing health behaviours of internal medicine residents and medical students: an observational study.

PURPOSE: During residency, many physicians find it difficult to maintain a healthy lifestyle; however, there is little objective data available. In this study, residents' health behaviours and cardiovascular risk status were compared with those of medical students. METHODS: Medical residents (n=55, postgraduate years 1 to 4) were compared with medical students (n=62, years 1-4). The main dependent variable was the average number of steps per day (assessed using a pedometer) at work and leisure over three days, during which subjects were not on call or post-call. In addition, all subjects completed a three day food log. Frequency of vigorous exercise was assessed by a single question. Body mass index (BMI), waist circumference, blood pressure, total and high-density lipoprotein cholesterol, smoking habits and random blood glucose were measured, and Framingham Risk Score coronary artery disease 10 year probabilities (FRS) were calculated. RESULTS: Residents recorded 8344±3520 steps per day while students recorded 10703±3986 (p < 0.002). 35% of residents and 52% of students averaged more than 10,000 steps per day and senior residents took fewer steps than junior residents. Both groups frequently failed to achieve the recommended daily servings of fruits and vegetables; on average, 3.5±2.0 servings for residents and 5.4±2.2 for students (p < 0.0001). BMI and FRS were higher among the residents in comparison with the students. CONCLUSION: Medical residents at our institution appear less active and consume fewer servings of fruits and vegetables than undergraduate medical students. These differences are associated with higher BMI, waist circumference and cardiovascular risk.

Research of a Holiday kind: elevators or stairs?

BACKGROUND: Staff in hospitals frequently travel between floors and choose between taking the stairs or elevator. We compared the time savings with these two options. METHODS: Four people aged 26-67 years completed 14 trips ranging from one to six floors, both ascending and descending. We compared the amount of time per floor travelled by stairs and by two banks of elevators. Participants reported their fatigue levels using a modified Borg scale. We performed two-way analysis of variance to compare the log-transformed data, with participant and time of day as independent variables. RESULTS: The mean time taken to travel between each floor was 13.1 (standard deviation [SD] 1.7) seconds by stairs and 37.5 (SD 19.0) and 35.6 (SD 23.1) seconds by the two elevators (F=8.61, p<0.001). The difference in time taken to travel by stairs and elevator equaled about 15 minutes a day. Self-reported fatigue was less than 13 (out of 20) on the Borg scale for all participants, and they all stated that they were able to continue their duties without resting. The extra time associated with elevator use was because of waiting for its arrival. There was a difference in the amount of time taken to travel by elevator depending on the time of day and day of the week. INTERPRETATION: Taking the stairs rather than the elevator saved about 15 minutes each workday. This 3% savings per workday could translate into improved productivity as well as increased fitness.

Vitamin D and hypertension in pregnancy.

PURPOSE: Vitamin D Deficiency is common, particularly in northern latitudes. We examined the association between vitamin D status and hypertension in late pregnancy. METHODS: A case-control study was conducted during two time periods: September-October, 2008, and January-March, 2009, in women near term. A case was defined as having two or more documented blood pressure readings above 140/90 (either/or) at any time during pregnancy (n=78). Controls had at least two blood pressure readings, with none above 140/90 during pregnancy (n=109). Serum 25-hydroxyvitamin D (25(OH)D) was measured in all participants. RESULTS: In the summer, 13% of controls and 29% of the cases had 25(OH) D levels < 50 nmol/L. During the winter, these numbers rose to 44% and 49% respectively. Both cases and controls were more likely to be vitamin D deficient in the winter (p=0.002). There was a negative correlation between BMI and 25(OH)D (r=-0.202, p=0.002). In univariate analysis, cases had lower 25(OH)D (p=0.046), but also higher body mass index, so that in multivariate analysis 25(OH)D status was no longer significant. There was no difference in mean oral daily vitamin D intake (dietary intake and supplements, 746 and 785 IU respectively). Controls gained less weight in pregnancy. There was a negative correlation between the highest blood pressure measured in pregnancy and 25(OH)D levels (r= -0.118; p=0.012). CONCLUSION: There is a high prevalence of vitamin D deficiency in pregnant women recruited in Saskatoon, Saskatchewan. Women with low circulating vitamin D concentrations are more likely to have hypertension.

Comparison of two oscillometric blood pressure monitors in subjects with atrial fibrillation.

OBJECTIVE: To compare blood pressure readings obtained with two commonly used oscillometric monitors: Omron HEM 711 AC (OM) and Welch-Allyn 52000 series NIBP/oximeter (WA) with mercury sphygmomanometers (Merc) in subjects with atrial fibrillation. METHODS: We recruited 51 hemodynamically stable subjects with atrial fibrillation. Fifty four subjects in normal sinus rhythm served as controls. Supine blood pressure readings in each arm were recorded simultaneously using one monitor and Merc. The second monitor then replaced the first and readings were repeated. Merc was then switched to the opposite arm, and both monitors retested. Apical heart rates were ascertained with a stethoscope. We used the averaged, same arm Merc readings as "gold standard". RESULTS: Automated blood pressure readings were obtained in all control subjects and in all but three of those with atrial fibrillation. Both monitors, and operators, noted a difference between apical and radial/brachial pulse rates: apical-recorded: Merc 6.1 + or - 15.0; OM 5.5 + or - 13.7; WA 10.0 + or - 21.2 beats per minute. Both monitors were accurate in controls: over 90% of readings were within 10 mmHg of averaged Merc, and both achieved European Hypertension Society standards. In subjects with atrial fibrillation, about one quarter of all oscillometric readings differed from Merc by more than 10 mmHg. Both falsely high and falsely low readings occurred, some up to 30 mmHg. There was no relation between accuracy and heart rate. CONCLUSIONS: Single blood pressure readings, taken with oscillometric monitors in subjects with atrial fibrillation differ, often markedly, from those taken manually. Health care professionals should record multiple readings manually, using validated instruments when making therapeutic decisions.

Prevalence and duration of exercise induced albuminuria in healthy people.

PURPOSE: Vigorous exercise increases urine protein excretion. However, whether exercise increases urine albumin enough to reach the threshold for microalbuminuria (2.8 and 2.0 mg/mmol creatinine in women and men respectively) is uncertain. Furthermore, the duration of such albuminuria is unknown. We aimed to estimate the prevalence and duration of exercise induced microalbuminuria in normal healthy volunteers. METHODS: Thirty normal subjects provided a urine sample, then exercised to maximal heart rate, or exhaustion, using the standard Bruce Treadmill protocol. Further urine samples were collected within 15 min of completing exercise, and 24 and 48 hr later. Urine creatinine was measured by the Jaffé method and albumin via immunoturbidometry. RESULTS: Baseline urine albumin: creatinine ratio (A/C) was 0.5 +/- 0.3 (SD) in women (n=14) and 0.4 +/- 0.1 mg/mmol in men (n=16). Immediately after exercise A/C increased to 5.6 +/- 9.7 (in women) and 7.6 +/- 17.6 (in men). Twelve of 30 subjects reached the threshold for microalbuminuria and 2 that for macroalbuminuria. By 24 hr all had returned to baseline and there was no further change at 48 hours. CONCLUSIONS: A short period, 15-20 min, of maximal exercise leads to A/C ratios above the microalbuminuria threshold in a substantial proportion of normal subjects. Physicians should not measure urine albumin in patients who give a history of such activity in the past 24 hr.

Oscillometric measurement of ankle-brachial index.

INTRODUCTION: Peripheral arterial disease is a coronary risk equivalent; a low ankle-brachial index (ABI) is indicative of systemic vascular disease, and should place a patient in the high-risk category. Few physicians measure ABI because it is technically challenging and time consuming. Oscillometric blood pressure monitors are readily available and easy to use. The use of a simple method of documenting ABI was assessed and compared with the conventional method. METHODS: The oscillometric ABI (OABI) was measured for normal volunteers, patients attending a cardiovascular risk clinic (Cardiovascular Risk Factor Reduction Unit [CRFRU] at the University of Saskatchewan, Saskatoon) and patients referred to a vascular laboratory (vasc lab). The latter group had Doppler ABI (DABI) measurements and served to validate OABI. An Omron HEM 711C oscillometric system (Omron Canada Inc) with appropriate cuff size for arm and leg circumference was used. RESULTS: The mean +/- SEM OABI was 1.13+/-0.08 in normal volunteers (n=26), 1.10+/-0.10 in CRFRU patients (n=11, P not significant) and 1.03+/-0.14 in vasc lab patients (n=57, P<0.05 compared with normal volunteers). No difference was found between sexes, and there was no correlation with age. In the vasc lab group, the correlation with DABI was 0.71 (P<0.05). The sensitivity of OABI to detect DABI of less than 0.9 was 0.71, and the specificity was 0.89. OABI was found to be less sensitive at detecting low values in patients with nonpalpable pulses on physical examination. CONCLUSION: The OABI is feasible and operator-independent, but does not detect low ABI efficiently. If OABI is abnormal, low DABI is likely. The OABI is less likely to detect disease in patients with nonpalpable peripheral pulses. Such patients are better referred directly to a vascular laboratory for DABI testing.

Cardiovascular risk reduction via telehealth: a feasibility study.

BACKGROUND: Successful cardiovascular risk reduction (CVRR) requires ongoing care, which can be difficult for patients living outside urban areas. The authors tested the feasibility of CVRR using telehealth. METHODS: Telehealth care (T group, n=9) was offered at three- to six-month intervals to patients referred from La Ronge, Saskatchewan (385 km northeast of Saskatoon, Saskatchewan). All patients who were referred to the project accepted. For the initial visit, the clinic travelled to La Ronge; all other visits were performed using telehealth (CommunityNet). Body measurements, blood pressure readings, fasting laboratory tests and food and exercise logs were completed in La Ronge. During the telehealth session, patients met with a nurse, a dietician, a fitness consultant and a physician. Changes in medication were faxed or telephoned to the local pharmacy. The T group's outcomes were compared with a control group (C group, n=15), which was offered usual care from La Ronge and had been referred to the clinic previously. Change in Framingham risk score, as well as patient and provider satisfaction, was assessed. RESULTS: The groups were similar in age (T: 44.3+/-12.8 years, C: 48.3+/-14.3 years) and initial Framingham risk score (T: 12.0+/-13.0%, C: 11.1+/-10.0%). All nine T group patients completed two or more visits, while only eight of 15 patients the C group did so. Both groups achieved a small reduction in Framingham risk score (T: -1.9+/-5.0%, C: -2.0+/-6.1%). Those with the highest initial Framingham risk scores tended to show the greatest reduction. The T group's patient and health care provider comments were generally positive. CONCLUSIONS: CVRR via telehealth is feasible and compares favourably with usual care. In particular, more complete follow-up occurs.

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in hypertension due to primary aldosteronism: a case for exclusion.

Aldosterone antagonists are the mainstay of therapy in patients with hypertension due to primary aldosteronism. However, in our experience, these patients are sometimes placed on angiotensin-converting enzyme (ACE) inhibitors in accordance with guidelines applying to the general hypertensive population. We believe this practice is inappropriate because of the inability of ACE inhibitors to lower blood pressure in patients with low renin levels. Furthermore, pleiotropic effects of ACE inhibitors are unlikely to provide significant benefits in the absence of blood pressure reduction. Therefore, ACE inhibitors should be discouraged for the majority of patients with primary aldosteronism, even in the face of renal or cardiac disease.

Accuracy of home blood pressure readings: monitors and operators.

OBJECTIVE: To evaluate the accuracy of automated digital blood pressure monitoring devices and operators in the community. Also, we tested the effects of a simple education program, and looked for arm-arm differences. DESIGN: Subjects who had bought their own automated digital blood pressure monitor were recruited via an advertisement in the local newspaper. On arrival, they were asked to record their blood pressure exactly as they would at home. The investigator noted any technique deficiencies then corrected them. Blood pressures were then recorded by the investigator and the subject, on opposite arms, simultaneously, and repeated with the arms switched. Finally, subjects recorded their blood pressure again. The subjects' readings were compared to the average of monitor and mercury readings using Bland-Altman methods. RESULTS: A total of 80 subjects were tested. Before educating, subjects' systolic blood pressure (SBP) readings were +5.8+/-6.4 (standard deviation) mmHg greater than the mean of all readings, and diastolic blood pressure (DBP) were +1.3+/-4.0 mmHg; after educating they were +1.3+/-4.0 and -1.3+/-2.7 respectively. The monitors, as a group, were accurate, and met British Hypertension Society and AAMI highest standards. We found no differences among monitors that had been validated (n=26) and those that had not. There were differences between the arms: 5.3+/-5.2 mmHg for SBP and 3.4+/-3.3 mmHg for DBP. Most patients had never been informed by anyone of proper blood pressure measuring techniques. CONCLUSIONS: We conclude that home blood pressure measurement, as practiced in our community, is prone to error, mostly due to mistakes by the operator. These can easily be corrected, so that readings become more accurate. Attention should be paid to arm-arm differences.

Are hot tubs safe for people with treated hypertension?

BACKGROUND: People with hypertension are commonly warned to check with a physician before using a hot tub, but there is little literature on which to base this advice. We compared symptoms, heart rate, and systolic and diastolic blood pressure in response to 10 minutes of hot-tub immersion in a group of patients with treated hypertension and in a control group normotensive subjects. METHODS: We recruited 21 patients (18 men and 3 women aged 43-76 years) with stable, treated hypertension and 23 control subjects (14 men and 9 women aged 19-83 years) without hypertension. They were studied, in mid-afternoon, at a public facility. Systolic and diastolic blood pressure and heart rate were measured at baseline, during immersion in a hot tub at 40 degrees C and for 10 minutes after immersion. We asked each subject to report any symptoms. RESULTS: None of the subjects reported dizziness, chest pain or palpitations. During immersion, systolic blood pressure fell in both groups, from a mean (and standard deviation [SD]) of 144 (17) mm Hg to 122 (18) mm Hg in the hypertensive group (p < 0.05) and from 130 (14) mm Hg to 110 (17) mm Hg in the control group (p < 0.05). It returned toward baseline within 10 minutes after the subjects left the hot tub. Diastolic blood pressure also fell, whereas heart rate was increased in both groups. The hypertensive group showed a slightly lower maximal increase in heart rate than the normotensive group (5 [SD 5] v. 13 [SD 10] beats/minute, p < 0.05). INTERPRETATION: Immersion in a hot tub for 10 minutes lowers blood pressure in subjects with treated hypertension, but no more than in normotensive control subjects. Spending 10 minutes in a hot tub should be safe for most treated hypertensive patients.

White coat hypertension in treated hypertensives: a three year follow-up study.

Patients who participated in an initial study in a hypertension outpatient clinic in a tertiary care hospital in Western Canada were approached three years later to participate in a follow-up study. The aim of this study was to describe changes, over three years, in office (OBP) and ambulatory blood pressure and blood pressure load (BPL) in a group of treated hypertensives, with and without white coat hypertension (WCH). In the initial study, 103 consecutive patients with OBP over 140/90 (either/both), despite being prescribed two or more antihypertensive drugs, were divided into groups based on average daytime ambulatory blood pressures (DABP). Sustained hypertension was defined as DABP > 140/90 (both) and WCH as DABP < 135/85 (both). All others were defined as borderline hypertension. In 1998, we repeated office and DABP readings in 79 of the original 103 patients. Daytime BPL decreased significantly over the three years of the study for those originally categorized as sustained hypertension [78 + 21 to 50 + 34 for systolic BPL (p = < 0.001) and 75 + 21 to 41 + 29 for diastolic BPL (p = < 0.001)]. Similarly, BPL fell in borderline hypertensives while BPL remained low, but increased somewhat, for WCH. OBP declined in all groups; thus, from a medical standpoint, this supports the argument that all those diagnosed with hypertension based on the OBP should remain on antihypertensive treatment. For nurses counselling patients with WCH, it provides a cautionary note that these patients, if already on antihypertensive medication, should probably continue treatment as WCH does not appear to be stable over time.