Tag Archives: Pharmacy

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4 reasons why every spa should have its own protocols

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With so many spas and medical spas in business these days, it’s hard to keep up with all the amazing menu offerings that are available on the market, including rejuvenating facials; chemical peels; dermalinfusion therapies; and treatments for the hands, neck and scalp. It’s almost endless.

But as spa practitioners and owners, it’s not only a good idea to offer incredible services at competitive prices, it’s crucial to have the protocols for these services written down and recorded at your spa. A written protocol is the step-by-step procedure that includes information like the name of the service, price, the amount of time needed, the products used, supplies required, specific techniques or equipment incorporated, and the step-by-step breakdown of instructions to perform it.

Like a chef writes and follows carefully crafted recipes, spa owners and their staff must create and adhere to protocols.

1. Make your mark on the industry.

For starters, protocols are what bring your unique spa industry vision to the marketplace. The details of how and why you choose to generate a specific menu item is what makes you stand out.

You are creating a proprietary experience for your guests. This doesn’t happen by chance, it happens with a well-thought-out plan for each service on offer. Yes, vendors and product lines have their own protocols but keep in mind that they are generic, dispensed to your competitors and biased towards their product line or equipment.

It’s your job to use those as a road map but also to supplement them with professional touches like aromatherapy, arm and hand massage, a special mask and the ambiance of the room. Furthermore, you will want to type your protocols out, print them on your letterhead and have them in a notebook. You will need them on hand if reception has to answer questions about a service or you are training new staff members.

2. Consistency of client experience.

Another major reason that you must have written, standard spa protocols is that you want to ensure that your client has the same experience no matter which employee that they see for a treatment or which location they visit (if you have more than one).

Just like any major restaurant franchise or cafe wants you to have the same dish or latte every time you visit one of their locations, your estheticians should be providing services with precision and consistency as well. Creating a standard experience for your clients is what separates the mediocre spa facilities from the extraordinary ones. Clients are loyal when they know that their hard-earned money will guarantee them a great experience.

Clients also refer their friends and family members to your spa when they know that you will give their loved ones an exemplary treatment. If clients get the sense that services are constantly changing, products are different every visit and they regularly experience an “off day” at your spa, then it’s time to get serious about your protocols before you lose business.

3. Uniformity of staff performance.

As a spa owner, the last thing you want is clients favoring one esthetician over another because they get a better service or result from one and not the other. Yes, skin care technicians and estheticians come from different educational backgrounds and have different personalities and idiosyncrasies that make them suited for some clients and not others.

However, one thing that cannot happen at your spa is that some estheticians are following protocols and some are not. This can cause some unique problems in terms of cost of service and quality of service.

As we know, protocols are designed in a certain way to maximize product and supply usage and standardize cost. If an esthetician is not aware or not following protocols, then you could be losing money on services instead of making a profit.

Moreover, if estheticians are performing protocols improperly then they run the risk of misusing product, mishandling equipment and possibly creating and undesirable outcome for your client.

4. A valuable tool when liability is in question.

Just like state regulations require spas to have their Material Safety Data Sheets readily available in case a client has a reaction to a product or product ingredient, it’s equally important to have your written protocols at arm’s reach. Unfortunately, clients can have less than ideal outcomes from a service or an allergic reaction or injury.

In these times of conflict, it is crucial that you have a written record of your treatment protocols. Not only does it show that you are upholding professional standards, it is a valuable tool in the case of medical malpractice or some other legal proceeding.

Follow my expert advice and make sure that your spa has a written protocol on file for every item on your menu. The importance of these documents is clear. From sharing your unique methodologies and vision in the industry; standardizing the client experience, regulating employee performance and protecting yourself in legal proceedings. The protocol is a powerful document and one that should not be forgotten.

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When the healthcare C-suite embraces the digital age

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In the healthcare ecosystem, digital technologies have been gaining prevalence, market share, and clinical applicability for years. In the 21st century, the ubiquity of these innovative advancements is increasing.

On the leadership front, many health systems have been lagging behind in terms of bringing the digital age into the C-suite, but that calculus now seems to be irrevocably changing.

The (Digital) Times Are A-Changin’

In early January, the Cleveland Clinic announced that it was promoting one of its own physicians to the position of Chief Research Innovation Officer (CRIO). Dr. Lara Jehi, M.D., has now been installed in this new position, and one can only hope that other influential healthcare organizations will take a page from the Cleveland Clinic’s newly enhanced executive playbook, including the appointing of women to such crucial and timely roles. Their press release reads thus:

“In this newly created position, Dr. Jehi will establish and oversee a robust research informatics environment to advance biomedical research throughout Cleveland Clinic. She will work closely with information technology, research, finance and other key departments to optimize the enterprise’s digital infrastructure to support research activities and accelerate new treatments for patients.

“‘As healthcare has become vastly more data-intensive, the Chief Research Information Officer role will bridge research and patient data with clinical care,’ said James Young, M.D., Cleveland Clinic’s Chief Academic Officer. ‘Dr. Jehi’s expertise as both a data-based researcher and physician will provide strategic vision to leverage large clinical informatics systems to drive innovation.’”

For those closely observing the development of healthcare technology and innovation, this announcement by the highly respected Cleveland Clinic should bring with it a sense that healthcare is beginning to catch up with the exponential change occurring within and without this particular milieu. And with Cleveland’s plan for Dr. Jehi to “work closely with information technology, research, finance and other key departments,” we have hints of how the tech aspects of healthcare must be fully integrated into every aspect of research, care delivery, and management.

According to some reports, artificial intelligence (AI), machine learning, and other innovations are already robustly infiltrating the healthcare landscape, and as the century progresses there will be no turning back from this inexorable technological acceleration.

The (Tech) Writing on the Wall

Several decades ago, Laurie Anderson, a highly innovative and tech-savvy musician, futurist, inventor, and performance artist, stated unequivocally that the future of global society was digital. Even in the 1980s, Anderson was reading the technological writing on the wall, likely well before most civilians were aware of these shifts in the cultural wind.

The advent of the consumerized version of the internet in the 1990s seems to have truly ushered in the pace of technological change that we are now experiencing, even though the military, cutting-edge private sector companies, and some universities (e.g., MIT, among others) were already laying the groundwork.

Healthcare has indeed already embraced robotic surgery and the electronic medical record (EMR), but other technologies are also coming to the fore, not the least of which are machine learning and AI. As such innovations develop further and are accessible to more corners of the healthcare system, many organizations will need to follow Cleveland Clinic’s lead and appoint executive officers who can skillfully carry them into the future.

A Seat at the Tech Table

As mentioned above, Cleveland has already made its mark by appointing a female doctor to lead them into the tech-heavy future. Clearly subverting a male-centric tech leadership paradigm long propagated in Silicon Valley, women holding such high-ranking positions sends the message that the healthcare C-suite is open to women with the knowledge and expertise to lead. In this deepening digital age in healthcare and medicine, all parties must be brought to the table as positions such as Chief Information Officer (CIO) become more commonplace.

And when addressing concerns about diversity at the tech table, nurses with facility in the digital realms must also be offered a seat from which they can champion and advocate for their colleagues at the bedside who themselves closely interact with new technologies that directly impact patient care and nursing practice.

Master’s, Ph.D., and DNP (Doctor of Nursing Practice) programs focused on informatics and tech leadership are increasingly prevalent in the nursing educational system, and it must be widely accepted that nurses must be an integral part of this ongoing conversation, as well as physical and occupational therapists, speech language pathologists, and other providers with a stake in how these changes are introduced and integrated.

Unstoppable Innovation

The pace of innovation and change is — and will continue to be — exponential, and as machine learning, AI, and other developments ripen and mature into the next iterations of advancement, the healthcare C-suite must rise to the occasion.

From Ohio State University’s Innovation Studio to the Cleveland Clinic’s appointment of Dr. Jehi as Chief Research Innovation Officer, we can clearly see that healthcare leadership and technological innovation must be fully integrated and aligned as we collectively move forward.

The future of global healthcare is being written as we speak. Organizations that can embrace and crusade for appropriate leadership and stewardship in the digital age will be the ones to carry us all into an unknown and innovative future ripe with potential, hazard, challenge, and as yet unforeseen advancement and success.

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New drug testing rule targets applicants for unemployment benefits

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On Oct. 4, 2019, the U.S. Department of Labor published a final rule giving states more freedom to expand the number of people who must pass drug tests in order to qualify for unemployment benefits. Those who fail the test would be disqualified from receiving unemployment assistance.

Note that unemployment benefits are paid for by employer — and, in some states, employee — payroll taxes and are generally granted to employees who lose their job through no fault of their own.

Before we explore the new rule, let’s take a trip down memory lane.

In 2016, the Obama-era DOL issued a final rule imposing strict limitations on drug testing of unemployment benefits applicants. States were allowed to drug-test only if:

  • the applicant was fired due to illegal use of a controlled substance; or
  • the only suitable work available to the applicant is in an occupation that regularly performs drug testing. These occupations are determined by the Secretary of Labor.

States could deny unemployment assistance to anyone who tested positive for drugs in either of those two scenarios. However, in 2017, Congress passed a resolution of disapproval — which was then signed into law by President Donald Trump — rescinding the 2016 regulation.

Fast forward to the 2019 final rule. States can still drug-test unemployment applicants “for whom suitable work (as defined under the State law) is available only in an occupation that regularly conducts drug testing.”

But because the list of occupations is no longer restricted to those identified in the 2016 rule, states now have the power to determine and add such occupations. Most notably, states can demand that unemployment applicants undergo drug testing if their most recent occupation required pre- or post-hire drug testing in order to obtain or maintain employment. If implemented by the state, such legislation would inflate the number of people who can be drug-tested when seeking unemployment compensation.

Supporters of the new rule agree that states should have more say in the drug testing of unemployment applicants, especially since unemployment is a joint (federal-state) program. Further, even though federal law contains extensive requirements for unemployment benefits, much of the details regarding eligibility are established under state law.

Proponents assert that the new rule promotes job readiness, as drug testing is a crucial criterion for employment in many industries and is usually an indicator of whether an applicant or employee is fit to work.

The new rule, however, has garnered heavy criticisms from employee rights advocates, who argue that it could cause a much bigger group of workers to not receive unemployment assistance, which goes against the fundamental goal of the program. Moreover, in the preamble to the rule, the DOL did not specifically address commenters’ concern that some drug tests come back positive for legally prescribed drugs and over-the-counter medications.

Policy analysts caution that workers are increasingly choosing to not apply for unemployment benefits because they believe they won’t qualify or fear their privacy will be invaded.

Opponents contend that the new rule will motivate employers who did not require pre- or post-hire drug testing for certain occupations, to start doing so — since the fewer employees who draw unemployment benefits on the employer’s account, the lower the employer’s unemployment tax rate. According to critics, the rule will make it easier for corporations to downsize and outsource.

Some dissenters claim that states already lack sufficient funding to run their unemployment program and ordering more drug testing will increase administrative costs and burdens.

Currently, Mississippi, Texas, and Wisconsin are the only states that have passed legislation to drug-test unemployment applicants; these laws were enacted prior to the 2019 final rule. At least 20 states deny unemployment compensation to applicants who were fired for unlawful drug use.

The new rule took effect Nov. 4, 2019. But the regulation might be challenged in court, as legal scholars have questioned its legality, asserting that it inappropriately grants states the authority to determine the occupations that regularly perform drug testing. Further, employee rights advocates have deemed the rule a violation of people’s right to privacy under the Fourth Amendment of the U.S. Constitution.

No matter which side of the aisle you’re on, this is a topic to watch.

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2020 is the Year of the Nurse: Is your organization preparing?

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On Jan. 30, 2019, the Executive Board of the World Health Organization (WHO) declared 2020 “The Year of the Nurse and Midwife (YONM)” in commemoration of the 200th birth anniversary of Florence Nightingale. The WHO has shared the following in anticipation:

“Nurses and midwives play a vital role in providing health services. These are the people who devote their lives to caring for mothers and children; giving lifesaving immunizations and health advice; looking after older people and generally meeting everyday essential health needs. They are often, the first and only point of care in their communities. Quite simply, the world will only achieve universal health coverage by recognizing the critical role they play and by investing more in the nursing and midwifery workforce.”

“The year-long global focus on nurses and midwives is a unique opportunity to get involved! Campaign assets will be made available.”

In terms of healthcare organizations employing nurses, the opportunity exists for nurses to be rightfully honored for their place in the global health delivery system, and for their employers to create a new vision of what nurses can accomplish in the 21st century.

More than Cannon Fodder

If healthcare leaders were to question nurses regarding their working conditions, recognition, and how valued they feel, they would doubtless hear that nurses feel like so much cannon fodder crushed beneath undue stress, poor staffing, high injury rates, and the threat of aberrant behavior by both patients and staff.

In a study published in late 2018 by the Bureau of Labor Statistics (BLS), nurses were shown to experience high rates of work-related injuries. To wit:

“Many of the approximately 3 million RNs working across all industries face workplace hazards in performing their routine duties. RNs spend time walking, bending, stretching, and standing (exposing themselves to possible fatigue, as well as slips, trips, and falls); often lift and move patients (becoming vulnerable to back injuries); and come into contact with potentially harmful and hazardous substances, including drugs, diseases, radiation, accidental needlesticks, and chemicals used for cleaning (which can cause exposure-related injuries and illnesses). In 2016, workplace hazards for RNs resulted in 19,790 nonfatal injuries and illnesses that required at least 1 day away from work, at an incidence rate of 104.2 cases per 10,000 full-time workers (private industry).”

“Since the workplace injuries and illnesses of RNs bear monetary and societal costs, understanding those injuries and illnesses can help combat future hazards through improvements in policy and technology. RNs are the keystone of the healthcare system, and injury and illness prevention strengthens the system at its core and improves patient care.”

Regarding workplace violence, the BLS concluded:

“While violent events accounted for only 12.2 percent of all injuries to RNs in 2016, the incidence rate — 12.7 cases per 10,000 full-time workers — was approximately 3 times greater than the rate of violent events for all occupations (3.8 cases per 10,000 workers).”

These and other statistics help us recognize nurses being on the edge. According to the National Institutes of Health, “some nurses graduate and start working and then determine the profession is not what they thought it would be. Others may work a while and experience burnout and leave the profession. Turnover in nursing seems to be leveling off, but only after years of steady climbing in rates. Currently, the national average for turnover rates is 8.8% to 37.0%, depending on geographic location and nursing specialty.”

Recognize, Reward, and Improve Nurses’ Experience

If nurses are more than just cannon fodder who we throw to the wolves each day, how can leaders utilize YOTN in order to improve nurses’ experiences and decrease attrition from the profession? In the face of an increasingly older population, nurses must be valued and retained, not just worked to the bone and replaced by the next group also destined to burn out.

There are any number of strategies to employ, including but not limited to:

  • Improving staffing, especially in relation to nurse-patient ratios
  • Instituting anti-bullying initiatives to weed out nurse bullies who prey on colleagues
  • Improving nurse compensation and benefits
  • Increasing educational opportunities, including humane loan forgiveness programs
  • Succession planning funneling high-performing nurses into leadership
  • Leveraging available technologies to decrease nurses’ injuries that far outstrip injury rates of construction workers
  • Moving beyond Nurses’ Week platitudes like tote bags and monogrammed coffee mugs
  • Training nurses robustly in assertive communication, conflict resolution, leadership, and delegation
  • Increasing salaries for nursing professors in order to create nursing schools’ capacity; too many qualified candidates are turned away every year due to lack of instructors and space

An Opportunity Not to be Squandered

The Year of the Nurse could be a watershed moment for nurses around the world, or the opportunity could be squandered by legislators and healthcare leaders who fail to do what must be done. Nurse attrition is real, and if bullying, staffing, injury, violence, and unsafe practices remain the norm, we will continue to see massive attrition and worldwide nursing shortages.

As the largest segment of the healthcare workforce, nurses are the backbone and lifeblood of care delivery. Woe to us and the public we serve if we fail to improve the lot of nurses and provide for them the recognition, opportunities, compensation, education, and safety they deserve.

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Study: Robotic transplants safe for obese patients with kidney disease

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University of Illinois at Chicago research finds that robotic kidney transplants for obese patients result in survival outcomes comparable to those in nonobese patients.

Published in the American Journal of Transplantation, the study highlights 10 years’ worth of data from some 230 robotic-assisted kidney transplants in patients with obesity conducted at University of Illinois Health hospitals.

The study reports one- and three-year patient survival rates of 98% and 95%, respectively, among kidney transplant patients with obesity. Only 17 of 239 patients developed graft failures and returned to dialysis, resulting in a 93% three-year kidney graft survival rate.

Patients had a median age of 48 and a median body mass index of 41.

Wound complications occurred in nine patients and a surgical site infection occurred in only one patient. The study reports that 88 patients were readmitted to the hospital within 30 days, but only 10 readmissions were related to surgical complications.

When compared to nonobese patients, the results are strikingly similar. Nonobese patient results were gleaned from the United Network for Organ Sharing for the same time period, January 2009 to December 2018.

Patients who are obese aren’t good candidates for surgery, so they have traditionally been deemed ineligible for kidney transplants, says Dr. Mario Spaggiari, assistant professor of surgery at the University of Illinois at Chicago’s College of Medicine.

“Advances in surgical care, including increasing proficiency and acceptance of robotic surgery, are making kidney transplants a safe option for more people,” Spaggiari said.

Robotic surgery helps to lessen adverse surgical events associated with obesity in open transplants, Spaggiari said. Specifically, the number of post-surgical wound infections dramatically reduces when robotic surgery is used to perform the transplant. This is an important factor in the long-term viability of the transplanted organ.

Surgeons at University of Illinois Health were among the first to offer robotic kidney transplants to obese patients. Transplants using the technology have been performed at UI Health since 2009.

“Our surgical program is focused on advancing care for everyone, including members of vulnerable communities who experience increased rates of various comorbidities, including obesity,” said Dr. Enrico Benedetti, professor and Warren H. Cole Chair of Surgery.

“Ten years of transplant experience shows us that obesity does not have to be a disqualifying factor in kidney transplants. To our knowledge, this is the largest cohort to date of robotic kidney transplants and these findings tell us that kidney transplantation is a viable option for many people with obesity,” Benedetti said.

“The patients who received transplants spent more than three-and-a-half years on dialysis before undergoing surgery, and that is just the median number,” Spaggiari said. “Without surgery, these people would have had no choice but to remain on dialysis — which can itself be a barrier to achieving an ‘ideal’ weight for transplant — and accept the limitations it places on their quality of life. With surgery, they can get back to normal life, which is most important. They can also have increased chances of achieving other health-promoting behaviors, like exercise or weight loss.”

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Investigational hyperbaric oxygen therapy indications: Preconditioning for cardiac surgery

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This article originally appeared on WoundReference.


Welcome to another post on plausible, off-label uses for hyperbaric oxygen therapy (HBOT). We have previously discussed the rationale for using hyperbaric oxygen therapy (HBOT) in an “off-label” indication. We suggested that there must be a scientific rationale, physiology that made sense for use of HBOT, and some sort of verified outcome (case report, case series, controlled clinical trial, etc.).

Today, we are going to discuss the use of HBOT for patients who have an ischemia/reperfusion injury (IRI) to the myocardium. While HBOT has been studied after acute myocardial infarction (AMI) in conjunction with stenting/angioplasty and/or alteplase (tPA) administration, our primary focus will primarily be on patients who have a planned instrumentation of the coronary arteries or coronary artery bypass grafting (CABG) surgery.

Unfortunately for you, the reader, this discussion needs to spend some time in the world of cellular and molecular biology. We will briefly discuss the effects of HBOT at the cellular and gene level within the body (primarily vascular endothelial cells).

Of necessity, the brevity of this discussion will leave a number of gaps for you to fill in. However, I will provide you with a list of reference papers to read.

Some of you took a course in cellular/molecular biology in college. I certainly did, because that was a required upper-level course for biology majors. I kept the textbook for a number of years. Whenever I would read from that textbook, I would fall soundly asleep. Now, I’m looking at a stack of cellular/molecular biology articles dealing with the heart and HBOT. After all these years, and many gray hairs … wait for it … wait for it … I still fall soundly asleep.

So, I’m going to cut to the chase and give you my opinion first!

If I were scheduled to have an angioplasty/stenting or a CABG procedure, I would DEFINITELY approach the hyperbaric physician and cardiologist about having a standard wound healing HBOT table (2.4 ATA for 90 minutes of O2 breathing with standard air breaks) one time immediately (within 4 hours) before the procedure.

There are several randomized controlled studies and multiple animal models that suggest this simple, one-time, treatment reduces risk of death, preserves more myocardial tissue, reduces intensive care unit (ICU) stay, reduces overall blood loss, preserves ejection fraction, and reduces restenosis rates. While we will not discuss it, there are also hints that this one-time treatment reduces the post-cardiopulmonary bypass confusion (“pump brain”) that is thought to be caused by lipid peroxidation.

Now for the details. Hold onto your hats, because we are going to move through several areas of research. I will hit only the high points and try not to overwhelm you with minutiae or too many acronyms. Fortunately, or unfortunately, you are going to see how my mind works in devious ways in order to make sense of this literature.

What does scientific literature say regarding HBOT for cardiac surgery preconditioning?

I performed a PUBMED search using the terms “hyperbaric oxygen” cardiac preconditioning. The results netted 17 papers, of which 11 were pertinent to this topic. As a result of searching the references within these papers, two more papers were found of pertinent interest: the HOT-PI and the HOT MI trials.

The Rubicon Foundation repository of hyperbaric oxygen studies was also queried. There were two papers that were duplicated in the PUBMED search and one abstract presented at the UHMS Annual Scientific Meeting in 2007. Of interest, this abstract was written by the same research group who published several studies found in the PUBMED collection and provides more detail.

How does HBOT work in the endothelial cells? Why should we even consider this? What is the HBOT mechanism of action here?

Great questions! We will discuss the papers in chronological order. Some of the early HBOT work in this area began in 1997…

1. Hyperbaric oxygen and thrombolysis in myocardial infarction: the “HOT MI” pilot study (1997)

The first pilot study (HOT MI) was a randomized clinical trial composed of 82 patients and 16 were excluded for hemodynamic instability. Sixty-six were analyzed with 34 in the tissue plasminogen activator (rTPA) only group and 32 in the HBOT plus rTPA group. These patients had an acute myocardial infarction (AMI) and all were recipients of rTPA. There was no sham treatment with HBOT in this trial.

The end result of the study was that the HBOT group had lower creatine kinase (CK) levels at 12 and 24 hours. There were two deaths in the control group and none in the HBOT group (not significantly different). There was a trend to higher ejection fraction in the HBOT group (not significant). It would take nearly five years for other research groups to see this trial and begin to look at mechanisms that support HBOT in the presence of IRI of the heart. But, they did.

2. Inhibition of restenosis by hyperbaric oxygen: a novel indication for an old modality (2002)

A 2002 randomized controlled clinical trial of patients with either unstable angina or AMI undergoing percutaneous coronary intervention (PCI) would be the next stepping stone for HBOT and cardiac preconditioning. The primary endpoints of this study were death, repeat MI, emergent CABG, and target lesion restenosis at 8 months.

To qualify for this study, the patients must either have unstable angina or an AMI. Fifty-one patients were enrolled with 24 in the HBOT arm and 27 in the control arm. There was no sham treatment to the control arm. The HBOT arm patients received two HBOT treatments consisting of 2.0 ATA for 90 minutes of oxygen breathing and no recorded air breaks. The first treatment was either 2 hours before or immediately after PCI with a second treatment within 18 hours after the first treatment.

Results were positive for HBOT preconditioning. In follow-up, 8 months from the cardiac incident and intervention, there was one repeat MI in the HBOT group and four in the control group (not statistically significant). There were five restenosis lesions in the control group and none in the HBOT group (p= 0.026). No emergent CABG in either group.

Two deaths in the control group during the 8-month follow-up period (not statistically significant). Finally, recurrence of chronic angina developed in six control patients and no HBOT patients (p=0.014). While there could be some bias caused by no sham HBOT control, this is unlikely to be a problem because the final review was 8 months following the intervention.

These authors did not measure any biochemical or other cellular markers. However, they do theorize that heat shock protein (HSP) may ameliorate oxidative stress and that lipid peroxidation was decreased. Much of the bench science of HBOT and IRI has yet to be discovered and fully tested, but this RCT again shows the positive effect of preconditioning the heart for interventional procedures. Another positive clinical study.

3. Hyperbaric oxygen: a new drug in myocardial revascularization and protection? (2006)

New technologies for mapping gene responses at cellular levels, cellular chaperones, and biochemical markers have emerged by 2006. These could only be imagined and hinted at previously. Yogaratnam (an important researcher in this sub-specialty interest) and colleagues first attempt to explain the biochemical and cellular response mechanisms for HBOT and myocardial function. In addition, they hint that there are protective oxidative functions for HBOT, reactive oxygen species (ROS), and other oxidative mechanisms.

The core mechanism for HBOT function is amelioration of the IRI. The primary fact is that an ischemic injury with resultant reperfusion sets off an inflammatory cascade at which white blood cells are called to the area of injury (the function of cellular chaperones), clog the arterioles/capillaries, degranulate, and set off a self-propagating inflammatory reaction, thus resulting in significant programmed cell death (apoptosis).

HBOT can reduce the injury and preserve tissue through reducing the ability of the WBC to attach and degranulate in the vascular endothelium. (I’m going to leave this reference to the reader, but perform a PUBMED search on the terms “Thom S” and white blood cell binding nylon columns.)

Hint: Think about Velcro. The vascular walls are the “loops” and the WBCs are the “hooks” in Velcro. When the hooks attach to the loops, then degranulation and injury occurs. Obviously, HBOT applied before or at the exact time of injury would give the best outcome (by reducing/preventing the loops to become active). But, there is a small time window (an hour or so) after injury whereby HBOT reduces the amount of myocardial injury.

Still awake? Read on …

There are also hints that myocardial ischemia and stress activate several heat shock proteins (HSP). These are thought to have protective roles for myocardial tissues. The research question (as of 2006) is, “Does HBOT induce HSP activation?” And, the answer is a distinct “Maybe.” Technology in 2006 still limits finding a definitive answer. But, technology will catch up … you’ll see.

Still with the Yogaratnam (2006) paper, we find that a number of tissues (skeletal muscle, heart muscle, small bowel, and liver) also respond positively to HBOT prior to occlusion and reperfusion injury. The tissue exposed to HBOT prior to the insult maintained homeostasis and ATP levels vs. control. In addition, this paper discusses HBOT and ROS. While we have thought about ROS after HBOT as a negative, this is not shown in the literature. In fact, the opposite has been noted.

HBOT-generated ROS are thought to decrease neutrophil adhesion by one (or more) of the following mechanisms:

  1. HBOT inhibits some of the internal pathways, such as inhibiting cGMP that leads to altering CD11a/18 neutrophils and then inhibits intercellular adhesion molecule-1 (ICAM-1)
  2. A specific ROS, superoxide, may inhibit neutrophil adhesion through a Nitric Oxide (NO) pathway
  3. ROS, superoxide, and hydrogen peroxide may directly act on ICAM-1and modulate endothelial Nitrix Oxide Synthase (eNOS)

The Yogaratnam (2006) paper demonstrates multiple pathways of activity for HBOT and preservation of myocardial function through a thorough evaluation of the extant literature of the day.

Their conclusion is that there are many examples of research that support HBOT in revascularization use, however those theories could not be demonstrated in the laboratory. I suspect that was simply due to lack of advanced techniques in exposing small proteins and pathways that measure in the kilo-Dalton range (very, very small proteins). The authors conclude that the use of HBOT in organ preconditioning is a fascinating theory in its infancy and bears exploring fully.

4. Pharmacological preconditioning with hyperbaric oxygen: can this therapy attenuate myocardial ischemic reperfusion injury and induce myocardial protection via nitric oxide? (2008)

The second study by this group posits that IRI is inevitable during CABG. In this paper, they focus heavily on the research that shows HBOT to stimulate NO. This NO production may be responsible for a measurable myocardial protective effect. This paper again provides significant background material that prepares the team for human clinical research.

5. Hyperbaric oxygen preconditioning improves myocardial function, reduces length of intensive care stay, and limits complications post coronary artery bypass graft surgery (2010)

In 2010, the same team detailed results from a randomized, controlled, blinded clinical trial of using HBOT exposure prior to CABG. From January 2005 to July 2006, there were 774 consecutive patients presenting for first-time elective CABG. Of those patients, 81 matched the study criteria and were randomized to control (no HBOT prior) or the HBOT group (2.4 ATA for 60 minutes of O2 breathing with one 5-minute air break).

This treatment was completed approximately 4 hours prior to CABG. All other treating physicians were blinded as to study patients vs. control. The control group (unfortunately) were not treated in a sham manner, hence a small tick-off to interpretation bias potential since the researchers did know which patients received preconditioning. Note that the researchers had no input in any part of the patient surgery, postoperative care, or overall management. This is a small detriment to an otherwise excellent study!

The purpose of the RCT was to demonstrate that the effect of HBOT preconditioning was capable of improving left ventricular stroke work (LVSW). There was a clear increase in stroke volume (SV) and LVSW in the HBOT preconditioned patients. And, as icing on the cake, the HBOT preconditioned group had a number of secondary endpoints significantly different from the control group.

The HBOT group had a smaller rise in Troponin T (evidence of lesser myocardial stunning), an 18% drop in ICU length of stay (LOS), nearly 12% less blood loss, lower blood transfusion requirements, lower need for inotrope support, lower pulmonary complications (less intubated time), and lower incidence of wound infections.

From a fiscal standpoint, this group presented an abstract at the 2007 UHMS Annual Scientific Meeting. At that time, the study discussed above had been closed approximately one year and their data analysis was still ongoing. However, they showed a $570/patient savings in ICU costs to the hospital. Over the timeframe of this study (for 40 patients), the savings was nearly $20,000 (2007 USD).

At this point, I’m taking a slight jog in the course of literature review. It’s about this time (2010) where laboratory science catches up and can demonstrate the effects of HBOT on tiny subcellular and biochemical markers. In particular, there are two studies by Godman, et. al. that deserve some attention.

6. Hyperbaric oxygen induces a cytoprotective and angiogenic response in human microvascular endothelial cells (2010)

The first study is a genome-wide microarray analysis of gene expression on human microvascular endothelial cells exposed to HBOT under the same conditions as human patients. The controls received 100% O2 and 1 ATA for the same time that the other cell culture received HBOT (2.4 ATA for 60 minutes O2 exposure).

Just for your information, this paper still puts me to sleep when I read it … however, it is full of undeniable gene stimulation or inhibition, up-regulating six cellular chaperones, and other mind-boggling details. As a result of one HBOT exposure, there were 8,101 genes that were significantly regulated (up or down) in the HBOT group. Nearly 4,000 of these genes were still up/down regulated at measurements 24 hours after HBOT exposure.

The authors were particularly interested in the usefulness of HBOT as a preconditioning stress in order to protect cells and gene expression. Note to reader … the following should sound familiar … The chaperone genes are related to HSP. A number of these genes were still active 24 hours after HBOT exposure. A secondary endpoint of this research was that the microvascular cell culture exposed to HBOT immediately started to form vascular tubules vs. no differentiating growth in the control group.

Interesting, huh? Aren’t you glad to be reading the condensed version?

7. Hyperbaric oxygen treatment induces antioxidant gene expression (2010)

Godman et al. published a second paper in 2010 looking at effects of HBOT and antioxidant gene expression. They found an up-regulation of antioxidant and cytoprotective effects that resisted otherwise lethal oxidative stress. While I disagree with their conclusion that HBOT may become an anti-aging wonder, the basic science in the paper makes it worthwhile reading.

8. Research report: the effects of hyperbaric oxygen preconditioning on myocardial biomarkers of cardioprotection in patients having coronary artery bypass graft surgery (2011)

Yogaratnam returns (2011) with a secondary review of their earlier data, specifically myocardial biomarkers suggesting that HBOT preconditioning induced cardioprotection following IRI. Good stuff. By now, you know this research group’s methods and general results. I will simply report that they analyzed results of eNOS and HSP72 between the HBOT and control populations. In the HBOT group, both eNOS and HSP72 were increased.

Well, where are we in the grand scheme of explaining the research?

I think I’ve covered the bench research down to the gene level in adequate detail. All of the bench research focuses on components that show HBOT to be cytoprotective. I’ve discussed three randomized controlled trials with significant statistical power. These studies demonstrate HBOT effectiveness in myocardial survival and lowering serum markers showing myocardial injury patterns. What more do we need before we have enough evidence to say that this indication is plausible, even if it is off-label?

Hang on tight. More papers and more trials yet to report.

Oh, have I said it? Nope, not one negative trial up to this point. Let’s see how that holds up.

9. Anti-apoptotic effect of hyperbaric oxygen preconditioning on a rat model of myocardial infarction (2011)

A 2011 paper shows a research protocol using rat myocardium and permanent ischemia. They demonstrated that myocardial infarct size was significantly smaller in the HBOT preconditioned rats. They also showed apoptotic pathways were suppressed, resulting in preserved myocardium. They discussed a biphasic tolerance pathway against subsequent insults. The first lasted 2-3 hours after HBOT exposure, then a second, delayed, phase from 24-72 hours.

10. Preconditioning with repeated hyperbaric oxygen induces myocardial and cerebral protection in patients undergoing coronary artery bypass graft surgery: a prospective, randomized, controlled clinical trial (2011)

Another RCT was published in 2011 looking at cerebral and myocardial protection in patients undergoing CABG. This is a randomized, controlled, single-blinded study involving 25 control and 24 HBOT candidates. The preconditioning period was over five days prior to CABG. HBOT treatments were at 2.0 ATA with 70 minutes of oxygen breathing in two periods separated by a 5-minute air break.

The results of the study mirror those of the Yogaratnam study with similar reduction in ICU stay, reduced ventilatory ICU support, and reduced blood loss. The studies differed in hemodynamic values, and this study found no difference with PVR, SW, and LVSW after surgery.

The authors do admit that sample size in this study is small and they may not have the statistical power to notice small differences between groups. They demonstrated a reduced biomarker burden in the HBOT group for neurologic and cardiac injury. They theorize that the HBOT effects had to do with endogenous antioxidant activity being more beneficial for patients in the active HBOT group.

An entire Undersea and Hyperbaric Medicine journal (2015, Volume 2) issue is devoted to preconditioning and HBOT. The editorial for this issue laments the fact that HBOT is not routinely used prior to cardiac insult in the U.S. The treatment is simple, with few negative side effects, and relatively inexpensive.

11. Preconditioning with hyperbaric oxygen and calcium and potassium channel modulators in the rat heart (2019)

We conclude with a Serbian study just published in 2019. This is a bench laboratory study of rat myocardium. There were 4 study groups and all study groups received HBOT. 1) HBOT only, 2) HBOT + Verapamil, 3) HBOT + amlodipine, and 4) HBOT + nicorandil.

The study involved a 20-minute global ischemia of the heart and a 30 minute reperfusion period before the animal was sacrificed. After reporting results, this study shows that all four groups were benefited from preconditioning with HBOT. In addition, the amlodipine group better preserved functional and structural properties of the heart after ischemia.

So, what is the conclusion on HBOT for cardiac surgery preconditioning?

I told you at the beginning of the blog where my sympathies lie for this intervention. Nothing has changed. Every study (animal and human) demonstrated the cardioprotective effect of HBOT preconditioning prior to PCI or to CABG surgery when cardiopulmonary bypass was used. To be fair, there was one paper with several patients in the CABG group who had off-bypass surgical procedures. Cardioprotection from HBOT was less evident in that subset.

I think that there are enough studies with enough positive evidence of effect that cardioprotection with HBOT should be a UHMS-approved indication. That decision has not happened yet, although it will likely be visited in the near future.

Related topics

In case you missed it, see the introduction to this blog series. This blog series focuses on conditions that are off-label and have plausible literature evidence for improvement after HBOT:

  • Selected causes of infertility
  • Preconditioning for cardiac surgery (this article)


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Study: Declining admission, mortality rates due to ED physicians improving outcomes, efficiency

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The results of a new study show a substantial decline in mortality rates among Medicare beneficiaries visiting an emergency department from 2009 to 2016, especially among patients with high-severity conditions.

Healthcare continues to be in the spotlight as policymakers seek to improve care and its costs. Many policymakers who focus on emergency medicine (EM) characterize it as being overutilized by patients, excessive when it comes to performing tests, overly expensive, and prone to diagnostic errors.

Visits to the ED are getting more expensive, with the average price of a visit rising 135% from 2008 to 2017. Despite these rising costs, and ongoing efforts to encourage patients to see their primary care physician or use urgent care, 20% of people in the United States visit an emergency department each year. In fact, ED utilization rates have been increasing steadily since the 1990s, especially among those with Medicaid.

As ED visits have increased, hospital capacity has declined. The effects of these trends remain unclear; many worry that reduced admissions, increased discharges to home, and decreased hospital capacities may increase the risk of patient harm.

To address some of these concerns, a team of researchers looked at Medicare beneficiaries receiving care in U.S. emergency departments. They found that mortality within 30 days of an ED visit declined recently, especially among the highest-severity patients.

Furthermore, ED doctors were admitting fewer patients to the hospital and sending more patients home instead. The findings suggest that the quality of the nation’s ED care, while over utilized and getting more expensive, is improving over time.

Retrospective Study Results Suggest Improvements in ED Outcomes and Efficiency in Care

Laura Burke, MD, MPH, an emergency medicine physician at Beth Israel Deaconess Medical Center (BIDMC), and colleagues performed a retrospective study that looked at more than 15 million U.S. emergency department visits among traditional Medicare beneficiaries from 2009 to 2016.

The team evaluated several aspects of ED outcomes. The researchers compared the number of hospital admissions compared with discharges to home, for example, and looked at whether the admission/discharge ratio was changing over time.

Burke and colleagues examined whether the changes in mortality rates for these patients were similar across different types of hospitals, such as urban and rural hospitals, small community hospitals, and large academic medical centers. The researchers also looked at whether trends in admissions and mortality rates were the same for the sickest ED patients as for the healthiest.

They found that mortality rates within 30 days of an ED visit improved by 23% from 2009 to 2016. Extrapolated to national ED visit rates among Medicare recipients, this would translate to nearly 200,000 fewer deaths in 2016 than if mortality rates had stayed at 2009 levels. The fact that mortality rates improved despite sending more patients home and admitting fewer to the hospital suggests that ED physicians are improving efficiency of care and outcomes.

Furthermore, nonprofit, major teaching hospitals and urban hospitals saw the more significant improvement in mortality over time.

The results of the study suggest declining admission and mortality rates are due to improved outcomes and efficiency of care in U.S. emergency departments.

“When researchers and policymakers studying emergency care look only at trends in patients who are discharged from the ED, as they commonly do, they may miss the fact that this pool of discharged patients is becoming increasingly complex over time as more patients who would’ve been hospitalized in the past are now being managed in the ED and sent home rather than deferring additional testing and treatment to the hospital setting,” said Burke. “Additionally, the fact that these gains were not equally distributed across hospitals means that there should be greater attention paid to those hospitals that have lagged behind and understanding how we can best help all hospitals improve.”

The researchers published their results in JAMA Internal Medicine.

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The benefits of cognitive behavioral therapy in the palliative setting

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Advanced stages of diseases such as cancer, COPD, end-stage renal disease and heart failure can lead to a constellation of physical and psychosocial distress. Symptoms such as fatigue, poor sleep and appetite, dyspnea, nausea and pain impact quality of life and can cause significant suffering.

Often, these symptoms are intertwined with intense feelings of sadness, anxiety or depression. For those involved in the care of these individuals, the goal is to alleviate physical and emotional suffering as much as possible with the purpose of improving quality of life and optimizing well-being.

In recent years, a great deal of attention has been given to the value of cognitive behavioral therapy (CBT) in the palliative setting. Traditional CBT is a very effective form of psychotherapy centered around changing maladaptive thought patterns or perceptions that lead to mood disorders such as anxiety and depression.

Simply stated, changing maladaptive thoughts to more realistic, positive or adaptive ones leads to improvements in mood. But this approach does not always fit perfectly into the palliative or hospice setting wherein patients with serious disease have very real fears about suffering, uncontrolled pain, dyspnea and other noxious symptoms; these thoughts are not maladaptive nor are they unreasonable.

Fortunately, mental health and palliative clinicians have focused on modifying cognitive behavioral therapy to better address the unique needs of those living with life-limiting illness.

With CBT’s emphasis on the present rather than on what lies ahead, clinicians can address a patient’s symptom burden and its resulting psychosocial impact.

For an individual with metastatic pancreatic cancer and concomitant shortness of breath, for instance, incorporating CBT techniques can be very effective in terms of promoting relaxation, shifting the focus away from troubling symptoms and addressing intrusive thoughts that lead to anxiety.

The keys to easing suffering through cognitive behavioral interventions are to:

1. Acknowledge the very real fears, worries and concerns that patients have.

2. Educate them about the cyclical and bidirectional nature of physical symptoms and anxiety (e.g., dyspnea can make one feel anxious and the anxiety, in turn, may manifest itself physiologically as shortness of breath).

3. Create awareness of the automatic thoughts that get triggered when symptoms or side effects arise. Oftentimes patients mistake medication or treatment side effects for progression of disease (i.e., “My nausea must mean that the tumor is growing.”).

4. Utilize a variety of techniques to address intrusive thoughts, calm the acute stress response and manage depression or anxiety.

These techniques include, but are not limited to, cognitive restructuring (questioning and modifying potentially maladaptive thoughts); relaxation techniques, such as autogenic relaxation training and deep breathing exercises; promoting engagement in self-soothing and pleasurable activities; problem-solving around troublesome symptoms; and acceptance of disease progression through mindfulness and meditation.

It can be very beneficial to incorporate existential therapies and spiritual practices, particularly when the illness is deemed terminal and the clinician is called upon to support the individual and his/her family around acceptance.

For patients facing life-limiting disease, suffering can be physiological, emotional and existential. Burdensome symptoms not only impact quality of life, but they have a bidirectional relationship with anxiety and depression. Treating this set of symptoms through cognitive behavioral therapy may ease unnecessary suffering and lead to improved mood, more meaningful interactions with loved ones and overall improved quality of life.

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The successful healthcare career toolbox

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Like any career, forging a way forward in the world of healthcare takes diligence, planning, and nurturing of your goals.

Whether seeking a career in nursing, physical therapy, medicine, or interventional radiology, many tools and strategies for creating a successful career are ubiquitous. For those interested in achieving their career objectives, the contents of your career-building toolbox should not be overlooked.

The Nuts and Bolts

For the healthcare professional, some essential building blocks are the resume or CV, cover letter, business card, and complete LinkedIn profile. There are others, but most everyone will agree that these are absolutely necessary.

Your Resume or CV:

Your resume or CV is essential — even in the 21st-century job marketplace. While some employers no longer require a resume, this document is something that every healthcare professional must have in their toolbox; it also must be regularly updated (at least annually) in order to prevent last-minute editing for a quick turnaround.

If an individual says, “I’m perfectly happy in my job and plan to stay here until I retire,” that’s a nice sentiment, but healthcare is volatile and even the most loyal employee can be suddenly laid off due to reorganization, corporate acquisitions, or mergers. Therefore, an updated resume is essential.

The Cover Letter:

Cover letters can be written on the fly, but having a skeleton letter on hand is helpful, as well as a thank you letter for after interviews. There are plenty of online templates, and for those who find writing such letters difficult, having a template makes the last-minute job easier.

Cover and thank you letters must be well-written, structurally and grammatically flawless, and make a strong case on your behalf. They should not simply regurgitate your resume’s contents; rather, they should call attention to the resume elements that are most salient.

Writing cover letters isn’t rocket science, but a career coach or expert can be employed to help craft the most compelling letter possible, and this also applies to resumes.

LinkedIn’s Robust Platform:

LinkedIn is an essential networking tool, as well as a useful online platform for showcasing your experience, background, and accomplishments.

Building a robust professional network is crucial, and LinkedIn is your playground for such an endeavor. Using this platform, you can connect with current and former colleagues, industry experts, thought leaders, and recruiters. You can also join groups that include other professionals with whom you have something in common (e.g., operating room nurses, healthcare executives, medical entrepreneurs; etc.)

While your LinkedIn profile indeed used to serve as a simple online resume, it’s now more like a resume on steroids since it can include colleagues’ endorsements of your self-selected skills; written recommendations; uploaded documents, including your resume and various certificates; videos of your presentations; slideshows; etc.

LinkedIn also allows you to post updates and curated content to your newsfeed (similar to Facebook), and you can use LinkedIn’s native publishing platform to write articles that demonstrate your expertise and leadership. If a potential employer or colleague Googles you (a common practice) and reads your original articles, this may be key to your being asked for an interview.

Recruiters also spend time on LinkedIn searching for potential job candidates. In fact, for some positions, your LinkedIn profile may serve as the only way by which you can apply, thus not having a complete profile takes you out of the running for those opportunities. LinkedIn also contains a feature by which a job-seeker can flag their profile so that recruiters know they’re in the market for a new position.

There are additional features of LinkedIn, but these are the essentials that easily make the case for logging on and creating a powerful profile that will work for you and your career.

Your Business Card:

The majority of healthcare professionals who are not self-employed business owners have likely never thought of having their own business card. However, a business card is a small and important investment that every professional should make.

If you’re in a restaurant or grocery store and happen to meet the CEO of a healthcare facility where you’ve always dreamed of working, you likely won’t have a copy of your resume in your purse or back pocket.

And if you find yourself at a medical conference meeting valuable colleagues, exchanging contact information is essential. While you can program one another’s details into your phones, one or both of you may not remember who this individual is or why you wanted to get in touch in the first place.

Enter the simple business card, which serves as a mini resume that can jog the memory of a new contact so that they remember you and why they want to follow up.

A business card is a simple affair without frills or logos and contains just the facts. The front of the card will contain:

  • Your name and credentials
  • Phone
  • Email
  • City and state
  • Customized LinkedIn profile URL

The back of the card will display five or six bullet points outlining the essential skills or professional characteristics that make you stand out. For example:

  • Successful nurse executive
  • 20+ years CEO of large health system
  • MSN in Healthcare Administration
  • Expertise in staffing and onboarding

Don’t Skimp on the Toolbox

Your healthcare career toolbox is your passport to more success, satisfaction, and connection. Use these tools and strategies to your advantage and enjoy the fruits of your labors that can powerfully influence how other professionals and colleagues perceive your value and expertise.

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Study reveals the best time to take blood pressure medications

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The number of Americans at risk for heart attacks and strokes keeps increasing. In the United States, an estimated 103 million adults have high blood pressure, nearly half of all adults. Recently published guidelines have redefined hypertension as a reading of 130 systolic or 80 diastolic. The previous standard was 140 over 90.

The percentage of U.S. adults with high blood pressure jumped from 32% under the old definition to nearly 46% under the new definition. Overall, cardiovascular diseases remain the leading cause of death in the world, claiming nearly 18 million lives in 2015, and in the U.S., heart disease is the No. 1 cause of death and stroke.

In 2009, Americans visited their healthcare providers more than 55 million times to treat high blood pressure. About 7 in 10 adults with high blood pressure use medications to treat the condition. However, what time of day should patients take their blood pressure medications?

A new large study, the Hygia Chronotherapy Trial, investigated the effect of time of day when people take their blood pressure medications on their risk of cardiovascular problems.

The study, led by Professor Ramón C. Hermida, Director of the Bioengineering and Chronobiology Labs at the University of Vigo, Spain, found that patients who took their medications at bedtime had nearly half the risk (45% reduction) of dying from or suffering heart attacks, myocardial infarction, stroke, heart failure or requiring coronary revascularization compared to patients who took their medications in the morning.

The Hygia Project is composed of a network of 40 primary care centers within the Galician Social Security Health Service in northern Spain. A total of 292 doctors are involved in the project and have been trained in ambulatory blood pressure monitoring, which involves patients wearing a special cuff that records blood pressure at regular intervals throughout the day and night. The Hygia Chronotherapy Trial monitors blood pressure for 48 hours rather than the usual 24 hours.

In this multicenter, controlled, prospective endpoint trial, 19, 084 hypertensive patients (19,614 men, 8,470 women, average age, 60 years) were assigned to take the entire daily dose of 1 or more than 1 hypertension medications at bedtime (n=9552) or all of them on waking (n=9532).

At inclusion and every clinic visit (at least annually) throughout follow-up, ambulatory blood pressure monitoring was performed for 48 hours. The researchers adjusted their analyses to account for factors that could affect the results, such as age, sex, Type 2 diabetes, kidney disease, and smoking and cholesterol levels.

During the average 6.3 years follow-up, 1,752 patients died from heart or blood vessel problems or experienced myocardial infarction, stroke, heart failure, or coronary revascularization. Individual outcomes showed that the risk of death from heart or blood vessel problems was reduced by 66%, the risk of myocardial infarction was reduced by 44%, coronary revascularization by 40%, heart failure by 42%, and stroke by 49%.

Data from ambulatory blood pressure monitoring showed that patients who took their medications at bedtime had significantly lower average blood pressure both at night and during the day, and their blood pressure dipped more at night compared with those who took their medications on waking.

According to Hermida, the results of this study show that patients who routinely take their anti-hypertensive medication at bedtime, as opposed to when they wake up, have better-controlled blood pressure and a significantly decreased risk of death or illness from heart and blood vessel problems.

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