The American journal of medicine
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Even though a well-functioning primary care system is widely acknowledged as critical to population health, the number of primary care physicians (PCPs) practicing in the United States has steadily declined, and PCPs are in short supply. The reasons are multiple and include inadequate income relative to other specialties, excessive administrative demands on PCPs and the lack of respect given to primary care specialties during medical school and residency. Advanced practice nurses can augment the services of primary care physicians but cannot substitute for them. ⋯ The income gap between primary care and other specialties should be narrowed. The administrative load placed on PCPs, including cumbersome electronic medical records, must be lessened. Insurers, including Medicare and Medicaid, must provide the resources to allow primary care physicians to act as leaders of multidisciplinary teams.
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Hypertension is a primary contributor to cardiovascular disease, and the leading risk factor for loss of quality adjusted life years. Up to 50% of the cases of hypertension in the United States remain uncontrolled. Additionally, 8%-18% of the hypertensive population have resistant hypertension; uncontrolled pressure despite 3 different antihypertensive agents. ⋯ Initial randomized (non-sham) trials and registry analyses showed impressive benefit, but the first sham-controlled randomized controlled trial using monopolar radiofrequency ablation showed limited benefit. With refinement of techniques to include multipolar radiofrequency, ultrasound denervation, and direct ethanol injection, randomized controlled trials demonstrated significant blood pressure improvement, leading to US Food and Drug Administration approval of radiofrequency- and ultrasound-based denervation technologies. In this review article, we summarize the major randomized sham-controlled trials and societal guidelines regarding the efficacy and safety of renal artery denervation for the treatment of uncontrolled hypertension.
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Serial blood pressure and heart rate measurements, particularly obtained by the patients at home, are currently recommended for the management of patients. ⋯ Patient-generated serial home blood pressure and heart rate logs provide essential data for the patients' management and could potentially be useful in research; circadian variation of blood pressure and heart rate calls for implementation of chronotherapeutic principles for the time of drug administration.
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Venous thromboembolism risk increases in hospitals due to reduced patient mobility. However, initial mobility evaluations for thromboembolism risk are often subjective and lack standardization, potentially leading to inaccurate risk assessments and insufficient prevention. ⋯ Initial mobility evaluations by admitting health care professionals during venous thromboembolism risk assessment may not reflect patient mobility over their hospital stay. This highlights the need for objective measures like JH-HLM in risk assessments to improve accuracy and potentially reduce thromboembolism incidents.