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Medscape
4 hours ago
- Medscape
New Blood Pressure Guidelines: My Likes and Concerns
The American Heart Association and American College of Cardiology, along with numerous other professional societies, have released new guidance on hypertension. The 105-page document updates guidance from 2017. Here are a few highly selected likes and worries. Things I Like Accurate measurement of blood pressure. The authors place great emphasis on the accurate measurement of blood pressure (BP). This includes a picture of a patient who is sitting, feet on the floor and arm resting on a table. Adjacent to the picture is an 8-point list of how to take a BP. It boggles my mind how badly BP is taken in the healthcare setting. I don't think I've ever witnessed it done properly — not once, in 30 years of practice. I am not sure how the culture evolved not to care about accurate BP measurement. We have time-outs, sepsis protocols, and quality measures for numerous conditions, and yet, something as simple as accurate recording of a vital sign is virtually ignored. Mediocrity has been codified as standard when it comes to measuring BP. A healthcare system could improve its quality overnight if it made accurate BP recording a point of emphasis. Good on the authors. Home-based BP monitoring. A corollary of accurate BP measure is the class 1/evidence level A recommendation to supplement office BP measures with home-based monitoring. While this makes sense, it's actually supported by multiple RCTs which, taken together, show that home monitoring of BP plus lifestyle interventions leads to clinically significant BP reduction that persists for at least 12 months. The authors emphasize that cuffless technology options that are often embedded in wearable devices are not reliable enough for clinical use. One caveat the authors did not mention, but which I find important, is practical guidance on use of home BP devices. I have seen people who spend far too much of their life recording and pondering their BP. Patients need clear education regarding the natural fluctuations of BP, and that the goal is to reduce average BP over days to weeks. We want patients to have good BP and good lives. More often than not, I find myself telling patients to use their home BP cuff less, not more. Single-pill combination drugs. My view of single-pill combination drugs has changed. I used to be against combining agents in a single pill because it can be hard to change course. The guidelines give a class 1 recommendation for using combination pills for patients with stage 2 hypertension (systolic BP ≥ 140 mm Hg and diastolic BP ≥ 90 mm Hg). I like this call on both efficacy (it probably will take multiple drugs) and efficiency grounds; having only one pill and one prescription to fill and refill is important. Renal denervation caution is warranted. Renal denervation (RDN) is on the precipice of becoming cardiology's biggest blemish — even worse than left atrial appendage occlusion. Doctors and hospitals are coiled and ready to deploy this procedure to the millions with high BP. The only thing maintaining sanity is the reluctance of payers — thankfully. Here is a quote from the guideline document: While some trials showed a small but significant reduction in 24-hour ambulatory SBP by 3 to 5 mm Hg over the sham arm, others failed to reach their primary endpoint. Although broader indications are approved for the RDN devices by the FDA, given the relatively short duration of follow-up in clinical trials with modest BP-lowering effects and the absence of CVD outcome trials, RDN should not be considered as a curative therapy for hypertension or full replacement for antihypertensive drugs. I would have been stronger, but this is decent. The problem comes in that RDN makes the colored recommendation box, albeit with the lowest 2b level. I call this a problem because procedure-loving doctors only need it to be recommended. The level of recommendation does not matter in the real world of US medicine. I reiterate: RDN trials found either no significant or clinically small reductions in systolic BP. There are no sham-controlled efficacy data beyond a few months and not even a hint of clinical outcome data. A middle-aged person does not require BP control for 3 months; they need it for 3 decades. RDN was a nice idea, but before a single dollar is paid to a doctor or hospital for this procedure, we should have far more persuasive evidence. I would have left it out of the colored box of recommendations. Two Things I Worry About Summary statements and colored boxes. The document begins with take-home messages. I take from this that the writers think clinicians are not capable of reading the document. These efforts to dumb down medicine, which are not specific to hypertension guidelines, worry me greatly. Hypertension is one of the most common and modifiable risk factors for cardiovascular health. Clinicians should be encouraged and expected to read the details of the document — including the references. Few things could be more important in the prevention of cardiovascular disease than extreme knowledge of hypertension. I feel the same way about the colored boxes of recommendations, which attempt to simplify what is complex. I believe it best to provide the narrative review and references — with a table, perhaps — but jettison the summary boxes, because the vast majority of patients do not fit into such algorithms. Risk-based recommendations use the new PREVENT risk score. A major feature of this guideline is to base treatment not only on BP measures but also on overall cardiovascular risk. For instance, for patients with stage 1 hypertension and a 10-year PREVENT risk score of < 7.5%, the recommendation is for lifestyle interventions only. Risk-based intervention is a decent idea; my worry here is the use of the new PREVENT score. PREVENT is a new AHA initiative; it replaces the pooled cohort equation (PCE). Proponents of the score cite its many advantages. These include broader outcomes, such as heart failure, atrial fibrillation, stroke, as well as atherosclerotic events. PREVENT is also derived from more diverse and contemporary data that include kidney function and social determinants of health. These factors are believed to lead to improved calibration between expected and observed event rates. The provocative feature of PREVENT in the statin decision was that more accurate calibration — with less risk overestimation — led to fewer patients being labeled statin eligible. Similar concerns arise in the hypertension guideline. Will use of PREVENT lead to undertreatment? Another highly provocative feature of PREVENT is that it does not include race as a determinant of risk. While this may satisfy equity concerns, some cite strong associations of race and risk in hypertension — and not considering race may lead to undertreatment of vulnerable people. I am neither a statistician nor an epidemiologist, but decreeing a new risk score that could affect so many patients, and the most important modifiable cardiovascular risk factor, seems like a major risk. The authors give this a class 1/evidence level B rating, but I find no trials comparing PREVENT and PCE as risk modifiers. I am not saying it is wrong to use PREVENT; rather, I am saying that even a little undertreatment of BP could be a public health disaster. Let me know what you think in the comments section.
New York Post
4 hours ago
- New York Post
Piercing your kids' ears puts them at risk for this allergy — the EU even has laws for it
Tiny studs, big trouble? Parents itching to pierce their kids' ears might want to put down the needle — a growing body of research suggests the popular practice could cost more than just a few tears. 'Delay ear piercings in young girls,' Dr. Niha Qamar (@doctor._.q), a board-certified allergist and immunologist, said in a recent TikTok, warning it could increase the risk of a serious, lifelong allergy. Dr. Niha Qamar is a board-certified allergist based in New York. TikTok/@doctor._.q Nationwide, nickel is the leading cause of allergic contact dermatitis — a red, itchy rash that flares up when the skin touches a normally harmless material. Roughly 1.1 million American children are affected by a nickel sensitivity, and studies show that number has quadrupled over the past 30 years. Researchers say early ear piercings are a major factor. In a Swedish study of 960 schoolgirls aged 8 to 15, researchers found that 'the ones who had ear piercings had 13% nickel allergy, versus 1% of the girls who didn't have ear piercings,' Qamar said. Another study out of Finland showed that 31% of pierced kids had a reaction to nickel — compared to just 2% of those without. And in the US, a study found that just 4% of men with no piercings were sensitive to nickel, while 11.1% and 14% of those with one or multiple piercings, respectively, were affected. 'Europe actually passed legislation to decrease the amount of nickel in jewelry (for this reason),' Qamar said. Many Americans get their ears pieced as infants or young children. deltahman – That regulation, the Nickel Directive, was introduced by the European Union in 1994 to limit how much nickel can leach from items like earrings. In the years since, countries like Denmark have reported major drops in sensitization, along with an estimated $2 billion in related health care savings. Nickel allergy isn't deadly, but it can make life miserable. Reactions may include hives, cracked skin, burning, itching and discoloration. More severe symptoms can strike when someone eats nickel-rich foods or has a metal device implanted. Blisters, diarrhea, fatigue, headaches and full-body swelling are all on the table. With no cure, managing symptoms becomes a lifelong battle — and avoiding nickel isn't easy, since it lurks in everything from jewelry and belt buckles to bra hooks and braces. Some people require treatment, which can include medication and even light therapy. With nickel sensitization on the rise in the US, major medical groups are calling for tighter regulations like those already in place in Europe. In 2020, the American Academy of Pediatrics urged the federal government to crack down on nickel in clothing and jewelry. 'The burden of symptoms and cost is high,' the policy statement notes. 'The United States can act on EU data revealing that legislation to limit exposures in childhood, especially with earrings, can impact the prevalence and potentially the severity of disease.' Until then, Qamar says parents should play it safe and hold off on piercing their kids' ears. 'If your child is getting pieced ears, get jewelry that is nickel free,' she recommended. 'That will reduce the risk of nickel sensitization.'
Miami Herald
5 hours ago
- Miami Herald
The Great Shift: How Gen Z is reshaping the future of nursing
It's no longer a "coming trend" - Gen Z nurses have arrived, and they're already changing the dynamics of the U.S. nursing workforce. Born between the mid-1990s and early 2010s, this is the most racially and ethnically diverse generation in American history and the first to grow up entirely in the digital age. They enter the world of registered nurses, a profession with deep traditions and high-pressure demands. Yet they carry with them a distinctly modern set of priorities: flexible scheduling, mental health resources, technology that works for them, and a sustainable work-life balance. Many Gen Z RNs completed their education and clinical training during the COVID-19 pandemic, stepping into hospitals and clinics in a time of crisis. The urgency of that period shaped their perspective. They believe nursing is meaningful work, but it cannot come at the expense of their health, autonomy, and professional growth. That shift is challenging employers to rethink long-standing nursing workforce norms and update their healthcare staffing strategies. The alternative - continuing with business as usual - risks losing this generation to burnout or career changes, worsening an already critical shortage. A 2024 study from the NCSBN (National Council of State Boards of Nursing) reported that more than 138,000 registered nurses had left the workforce since 2022 and 40% (1.6 million nurses) plan to exit the workforce by 2029. In the same period, the median age of RNs increased from 46 to 50 and the number of nurses reporting a change in job setting increased by 4%. Vivian Health shares how healthcare organizations must adapt their retention strategies for registered nurses to meet the expectations of Generation Z and secure the future of patient care. 1. Explore Flexibility in Scheduling To provide round-the-clock coverage, hospitals and clinics often rely on long, fixed shifts and rotating schedules designed more around staffing efficiency than staff choice. Even off the clock, many RNs remain on call for their employers. But for Gen Z, flexibility is a central measure of job satisfaction, ranking alongside - or above - pay. According to Kaylee Parker, BSN, RN, and Senior Customer Success Manager at Vivian Health, this has proven true for younger nurses in her experience. "[Gen Z nurses are] more willing to trade traditional 12-hour shifts for shorter, mixed, or set schedules if it means better work-life balance, says Parker. "They're more likely to request self-scheduling, predictable rotations, or the option to swap shifts digitally. While older generations often accepted overtime as part of the job, many Gen Z nurses draw clearer boundaries and are more vocal about avoiding burnout." Employers are testing flexible nurse scheduling systems that allow more input from the nurses over shift selection and offer shorter or split shifts to reduce fatigue. Allowing nurses to have some control over the shifts they work (including preferences for days off or working consecutive days, flexibility for unit-specific needs, and providing transparency) greatly improves the level of reported job satisfaction. Technology may be able to help too. Some health systems are adopting AI-powered staffing tools to anticipate patient surges and match available nurses accordingly. Flexible scheduling is not just an HR perk - it's becoming a competitive advantage in nurse recruitment. 2. Make Mental Health Support a Core Job Benefit Gallup research shows that 68% of Gen Z reports feeling stressed "a lot of the time." For nurses, that's layered on top of high patient loads, life-and-death decision-making, and exposure to employers are beginning to treat mental health resources as core infrastructure, including: On-site counseling for immediate support networks to create safe spaces for shared sessions after critical incidents. By normalizing these supports in hiring, during onboarding, and in everyday operations, employers signal that their nurses' well-being is a priority and part of the job description - not a personal luxury. 3. Integrate Better Healthcare Technology That Actually Helps Nurses Nurses need tools that work, and those tools must enhance patient care rather than create administrative headaches. Gen Z nurses, as digital natives, are less tolerant of outdated or inefficient systems. Modern nursing is being transformed by new technology designed to improve efficiency, boost patient safety, and reduce nurse workload. Smart IV pumps automate accurate medication delivery through built-in dose error reduction, reducing the need for constant manual monitoring by nurses. Smart beds enhance both comfort and safety by repositioning patients, detecting attempts to exit, and syncing data directly to electronic health records, reducing manual documentation and preventing fall risks. Electronic Health Records (EHRs) centralize clinical documentation, support AI-powered alerts, provide mobile charting options, and streamline team communication, helping nurses focus more on patient care. Across the board, these innovations reduce manual work, accelerate decision-making, and contribute to more efficient, coordinated nursing workflows. Organizations investing in these improvements can market themselves to job seekers as innovation-driven workplaces. 4. Redefine Work-Life Balance in Nursing The leading causes of nurses leaving the workforce are "stress and burnout" and "workload," but for Gen Z, work-life balance for nurses is not just a factor - it's often a deal-breaker. The profession's traditional schedules - with unpredictable shifts and mandatory overtime - are in direct conflict with Gen Z's priorities. Some healthcare systems are taking steps toward structural change, including reducing reliance on mandatory overtime, establishing predictable rotation patterns, and expanding paid leave programs to encourage actual rest. Frontline caregivers have suggested adopting rotating shift schedules, allowing remote charting, and even offering "mental health days" that don't count against vacation or sick leave, as changes that could help staff better manage personal needs without compromising patient care. 5. Offer Meaningful Career Development The cultural dimension of nursing workforce trends is just as important as operational ones. The #1 takeaway from a 2024 Forbes article about Gen Z's impact on the workforce is that Gen Z employees place a premium on feeling that they are doing meaningful work and making a positive impact. However, traditional career ladders in nursing often lead to administrative or management roles. Gen Z is reshaping advancement expectations and wants growth opportunities that align with personal purpose and skill-building, not just hierarchical promotions. "Many younger nurses see nursing as a launchpad," says Parker. "They're open to leadership, advanced practice roles, or even branching into healthcare tech and policy. The new generation is more entrepreneurial. They're interested in roles that allow autonomy, creativity, and cross-disciplinary skills. Rather than staying in one unit for decades, younger nurses anticipate pivoting through multiple specialties and settings during their career. Gen Z also values transparency, collaborative problem-solving, and approachable leadership. Including frontline nurses in policy discussions, creating cross-generational mentorships, and rewarding contributions based on impact can keep engagement high. Institutions that implemented peer-support programs, frequent leadership check-ins ("leadership care rounds"), and town halls to discuss concerns found better morale and improved ability to handle stress during the crisis. Why These Adaptations Matter The arrival of Gen Z nurses coincides with one of the most challenging staffing landscapes in modern healthcare. Retention is not just about filling schedules - it's about sustaining the profession's capacity to deliver safe, high-quality care. The nursing workforce trends shaping today's hospitals and clinics are driven by both demographic shifts and the lived experiences of these new professionals. Healthcare employers who embrace flexible nurse scheduling, invest in mental health in nursing, commit to nursing technology integration, and prioritize work-life balance for nurses aren't just responding to Gen Z demands - they're building resilience into their organizations. This story was produced by Vivian Health and reviewed and distributed by Stacker. © Stacker Media, LLC.
