White coat hypertension and other stories . . .

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5243 (Published 07 October 2015) Cite this as: BMJ 2015;351:h5243

Blood pressure that is raised in a medical setting but normal at home is still known as “white coat hypertension,” despite the general phasing out of white clothing. Its opposite, in which home readings are higher, is called “masked hypertension.” The extensive literature on these anomalies has recently been reviewed (American Journal of Hypertension (2015, doi:10.1093/ajh/hpv157). Oddly, male sex was associated with masked hypertension (odds ratio 1.47, 95% CI 1.18 to 1.75), whereas white coat hypertension (3.38, 1.64 to 6.96) was strongly associated with female sex.

To investigate the pattern of cognitive decline in Parkinson’s disease, investigators at the University of Pennsylvania set up a cohort of 141 patients of average age 69 years who had been diagnosed an average of five years previously (Neurology 2015, doi:10.1212/WNL.0000000000002001). At the start, 8.5% had mild cognitive impairment, and of these all had progressed to dementia by year 5. In the total cohort, the cumulative incidence of cognitive impairment was 47.4% at year 6.

Occupational noise exposure seems to be a risk factor for coronary heart disease (CHD). The American National Health and Nutrition Examination Survey first reported this association, and it has now been confirmed in the 1999-2004 cohort of 5223 participants aged 20-69 years (Occupational and Environmental Medicine 2015, doi:10.1136/oemed-2014-102778). Those with bilateral high frequency hearing loss were more likely to have CHD (odds ratio 1.91, 95% CI 1.28 to 2.85) after adjustment for covariates. This association was particularly strong for workers who were currently exposed to loud occupational noise (4.23, 1.32 to 13.55).

With an average age approaching 80 years, most heart failure patients are unlikely to regularly use smartphone apps. However, this may change, and there is now an app that measures six minute walking distance (Circulation Heart Failure 2015, doi:10.1161/CIRCHEARTFAILURE.115.002062), which is strongly associated with prognosis in heart failure. Investigators who tested it on patients of mean age about 47 say it is easy to use and yields accurate repeatable measurements in the clinic and at home.

A year after it was first marketed in 2006 as a drug to help smoking cessation varenicline came under suspicion of causing suicidal thoughts or behaviours, leading the US Food and Drug Administration to issue a warning. But this has not been validated by further observational studies. The latest uses the QResearch database, which holds data from 753 NHS general practices across England (Lancet Respiratory Medicine 2015, doi:10.1016/S2213-2600(15)00320-3). Varenicline was not associated with an increased risk of documented cardiovascular events, depression, or self harm compared with nicotine replacement therapy.

ISCHEMIA is the name of a trial currently randomising high risk patients with stable coronary artery disease (SCAD) to receive optimal medical therapy or revascularisation. Cardiologists in a large Polish centre looked at how well the trial’s entry criteria matched SCAD patients who had undergone revascularisation in their unit (Trials 2015, doi:10.1186/s13063-015-0934-4)—61.3 % met at least one of the exclusion criteria, and these patients tended to be at highest risk.

It is often stated that spiritual care is an essential element of end of life provision. Minerva agrees, but was given pause for thought by the results of a cluster randomised trial of taking a spiritual history from patients with an incurable, life threatening disease (Palliative Medicine 2015, doi:10.1177/0269216315601953). The “ars moriendi” method of recording spiritual concerns had no effect on patient scores for spiritual wellbeing, quality of life, patient-provider trust, or pain.

People around the world still die from lack of access to surgery for abdominal emergencies. A survey carried out in India (Lancet Global Health 2015, doi:10.1016/S2214-109X(15)00079-0) found that the risk of death from such emergencies was four times higher in areas more than 50 km from a fully equipped hospital, and 16 times higher if the distance was more than 100 km.

What does “getting beaned” mean? Is it a reference to a surfeit of jelly beans, or to the broad bean poisoning sometimes seen in glucose-6-phosphate dehydrogenase deficiency, or perhaps an arcane ritual required by Oxford dining clubs? In the US at least it means being hit in the face by a baseball ball or, less commonly, the bat. In a survey of baseball related facial injuries from New Jersey (Otolaryngology Head and Neck Surgery 2014, doi:10.1177/0194599815602668), 80% occurred under the age of 18 years, and 98.8% of patients did not require admission, although 26.9% had fractures, usually of the nose. Beaning is getting less common, and baseball (played in Red Sox or other colours) is one of the safest team sports.


Cite this as: BMJ 2015;351:h5243

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