Journal of general internal medicine
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Giant cell arteritis can present with atypical manifestations that delay treatment and risk severe complications. ⋯ Eighteen percent of biopsy-proven giant cell arteritis cases with at least one atypical feature have only atypical features and are more likely to experience delays in treatment. Clinicians should be aware of atypical signs/symptoms of giant cell arteritis and order inflammatory markers early to prevent giant cell arteritis-associated morbidity.
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While obesity and its associated complications, mainly diabetes and hypertension, have been the largest public health problems of modern world, the emerging data suggests an increasing prevalence of primary hyperaldosteronism (PA) as one of the most common undiagnosed causes of hypertension. We believe that rising prevalence of PA in the era of high rates of obesity is likely not a chance finding but is deeply intersected with the rising rates of obesity. Higher serum aldosterone concentrations and urinary aldosterone excretion have been observed in patients with increased body mass index or larger waist circumference. ⋯ The aldosterone excess in these cases can be labelled as acquired hyperaldosteronism to differentiate it from the non-obesity related classical cases of PA. Because of serious consequences, recognizing aldosterone excess in obesity is important, as it gives a more compelling reason for weight loss and guidance to choosing pharmacotherapy wisely. Dietary sodium restriction and mineralocorticoid receptor antagonists play important roles in the management of PA associated with obesity.
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A 52-year-old male comes to the internal medicine clinic for a follow-up for the management of hypertension. He was initially diagnosed with hypertension 5 years ago. His other past medical history includes obesity and hyperlipidemia. ⋯ Multiple comorbidities, including obesity, sleep apnea, chronic kidney disease, heart failure, and diabetes mellitus, are associated with resistant hypertension. Our understanding of the potential etiologies for this condition continues to evolve rapidly. We used a narrative review to explore four research areas in the pathophysiology of resistant hypertension (the sympathetic nervous system, aldosterone excess, endothelial dysfunction, and inflammation) and explore the novel therapies currently in development.
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Non-inferiority (NI) trials require unique trial design and methods, which pose challenges in their interpretation and applicability, risking introduction of inferior therapies in clinical practice. With the abundance of novel therapies, NI trials are increasing in publication. Prior studies found inadequate quality of reporting of NI studies, but were limited to certain specialties/journals, lacked NI margin evaluation, and did not examine temporal changes in quality. We conducted a systematic review without restriction to journal type, journal impact factor, disease state or intervention to evaluate the quality of NI trials, including a comprehensive risk of bias assessment and comparison of quality over time. ⋯ The methodological quality and reporting of NI trials remains inadequate although improving in some areas. Improved methods for NI margin justification, blinding, and analysis method are warranted to facilitate clinical decision-making.
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Professional society guidelines are evidence-based recommendations intended to promote standardized care and improve health outcomes. Amid increased recognition of the role racism plays in shaping inequitable healthcare delivery, many researchers and practitioners have critiqued existing guidelines, particularly those that include race-based recommendations. Critiques highlight how racism influences the evidence that guidelines are based on and its interpretation. However, few have used a systematic methodology to examine race-based recommendations. This review examines hypertension guidelines, a condition affecting nearly half of all adults in the United States (US), to understand how guidelines reference and develop recommendations related to race. ⋯ Hypertension guidelines largely refer to race as a distinct and natural category rather than confront the longstanding history of racism within and beyond the medical system. Normalizing race as a biological rather than social construct fails to address racism as a key determinant driving inequities in cardiovascular health. These changes are necessary to produce meaningful structural solutions that advance equity in hypertension education, research, and care delivery.