Less than half of at-risk older adults regularly check their blood pressure (BP) at home or in other places outside the health care system, according to an

 released by the University of Michigan National Poll on Healthy Aging.

The online survey of 2023 adults aged 50 to 80 years was conducted in January 2021 and the current report focused on the 60% of respondents who reported either having ≥1 BP-related health conditions, including stroke, coronary heart disease, congestive 

, or said they were taking an antihypertensive medication.

The survey found that 62% of this high-risk group had been instructed by a health care provider to periodically check their BP outside of a health care setting but less than half (48%) report regularly monitoring their BP.

Nearly three-quarters (74%) of the respondents reported having a home blood pressure monitor but less than half said they checked their BP at least once a week; nearly 1 in 5 reported never using the monitor.

Older respondents (aged 65-80 yrs) were more likely than younger ones (50-64 yrs) to do home monitoring of BP—52% vs 45%.

Of respondents who did report regular home monitoring of BP (HMBP) only half shared the readings with a health care provider. The majority (88%) of those who did share readings with a clinician said they received feedback on their report.

"This poll shows that we have more work to do to encourage older adults with certain chronic health conditions to monitor their blood pressure," said Alison Bryant, PhD, of the American Association of Retired Persons, in a statement. "We know that the risk of high blood pressure increases with age, so this is an important topic for older adults to discuss with a health provider."

Articles

A survey of adults aged 50-80 years with hypertension and/ or related comorbidities found even among those with a BP monitor at home, less than 50% checked BP at least once a week.  

Less than Half of Vulnerable Older Adults Monitor BP at Home

How widespread is the Delta variant (B.1.617.2) in the US?

Centers for Disease Control and Prevention (CDC)

, as of September 25, 2021, the SARS-CoV-2 Delta variant made up 

The CDC estimates for the week ending on September 25, 2021, the 5 states with the highest unweighted proportion of new cases attributed to the SARS-CoV-2 Delta variant are:

How many people in the US have been vaccinated against COVID-19?

 as of today, October 14, 2021, at 6:01 PM, EDT:

The 5 states/territories with the highest percentage of population fully vaccinated are:

How many cases of COVID-19 have been confirmed in the US?

, as of today, October 14, 2021 at 6:21 PM, EDT, there have been:

The 5 states with the highest total confirmed cases are:

 California has the highest number of deaths due to COVID-19

 with 70 445 reported fatalities, followed by 

How many cases of COVID-19 have been confirmed globally?

Data from the CDC on the Delta variant and US vaccination rates and from the Johns Hopkins COVID-19 interactive map on cases and deaths in the US and worldwide.

COVID-19 Updates: Delta Variant, US Vaccinations, & Global Data as of October 14, 2021

 among youth, according to new research from the US Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC), published in 

The report was based on data from the 2021 National Youth Tobacco Survey (NYTS), a cross-sectional, self-administered survey of middle (grades 6-8) and high school (grades 9-12) students from January 18, 2021 to May 21, 2021. More than 20 000 students from 279 schools completed the first NYTS that was fully conducted online to allow participation of eligible students in remote learning settings. For that reason, the CDC and FDA noted that the results from the 2021 NYTS, "should not be compared with previous NYTS survey waves that were primarily conducted on school campuses."

Nevertheless, this year's survey provides important insights into youth use of e-cigarettes, which are highlighted in the 7-question quiz below. 

Slideshows

Findings from the 2021 National Youth Tobacco Survey have public health advocates concerned. Find out why in this 7-question quiz. 

Teen E-cigarette Use during COVID-19: A 7-question Quiz

In a secondary analysis of the phase 3 NAVIGATOR clinical trial, the novel thymic stromal lymphopoietin inhibitor tezepelumab was shown to rapidly improve morning and evening peak expiratory flow (PEF) in patients with severe, uncontrolled asthma.

The findings will be presented at the upcoming annual meeting of the American College of Chest Physicians (CHEST 2021), held virtually between October 17-20, 2021.

The phase 3 NAVIGATOR trial randomized 1059 patients aged 12 to 80 years in a 1:1 fashion to receive treatment with tezepelumab 210 mg (n=528) or placebo (n=531) subcutaneously every 4 weeks for 52 weeks. Participants had severe, uncontrolled 

 and were receiving medium- or high-dose inhaled corticosteroids and at least 1 additional controller medication with or without oral corticosteroids.

The results—published in the May 2021 issue of 

showed tezepelumab significantly reduced exacerbations in adults and adolescents, including those with baseline blood eosinophil counts below 300 cells/µL.

A secondary objective of NAVIGATOR was the examine the effect of 

 on morning and evening PEF, which was reported in the current study. A repeated measures model was used to estimate least-squares (LS) mean changes from baseline in weekly mean morning and evening PEF, as well as the difference between treatment groups, according to the study abstract.

At baseline, the weekly mean morning PEF was 261.7 L/min and 262.5 L/min for the tezepelumab and placebo arms, respectively, and the weekly mean evening PEF was 276.9 L/min and 278.2 L/min, respectively. Greater improvements from baseline in weekly mean morning and evening PEF were found with tezepelumab than with placebo over 52 weeks, according to the abstract.

For weekly mean morning PEF, the LS mean difference for the tezepelumab group versus placebo was 7.4 L/min (95% confidence interval [CI]: 3.4-11.4) at week 1, 13.9 L/min (95% CI: 9.2-18.7) at week 2, 16.6 L/min (95% CI: 8.9-24.3) at week 26, and 16.6 L/min (95% CI: 8.1-25.1) at week 52.

For weekly mean evening PEF, the LS mean difference versus placebo was 5.4 L/min (95% CI: 1.7-9.2) at week 1, 12.5 L/min (95% CI: 7.7-17.2) at week 2, 16.4 L/min (95% CI: 8.7-24.2) at week 26, and 14.9 L/min (95% CI: 6.3-23.4) at week 52.

“Treatment with tezepelumab resulted in rapid improvement in both morning and evening PEF versus placebo, with effects observed as early as week 1 and continued improvements seen throughout the 52-week treatment period,” concluded researchers. “This analysis demonstrates that tezepelumab rapidly and sustainedly improves lung function in a broad range of patients with severe, uncontrolled asthma.”

 in response to a May 2021 submission of a Biological License Application for the treatment of severe asthma. 

Reference: Israel E, Ambrose C, Hunter G, et al. 

Rapid improvement in morning and evening peak expiratory flow in patients with severe, uncontrolled asthma treated with tezepelumab. 

CHEST 2021: Patients with severe asthma who received tezepelumab compared with placebo demonstrated rapid improvement in morning and evening peak expiratory flow.

Tezepelumab May Improve Peak Expiratory Flow in Patients with Severe Asthma, Suggests Analysis of NAVIGATOR Trial

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have proven effective in disease modification and symptom improvement across heart failure (HF) phenotypes and severity with results of recent landmark clinical trials laying groundwork for FDA approval and updates to clinical practice guidelines. 

Other findings released in 2021 shed light on factors that both worsen and improve HF-associated morbidity and mortality. Highlights of 9 notable studies follow in the slide show below. 

SGLT-2 inhibitors have proven effective in disease modification as well as symptom improvement across HF phenotypes and severity. Get a quick summary of the research. 

Heart Failure Milestones in Management: 9 Studies Making a Difference in 2021

 as of today, October 13, 2021, at 4:22 PM, EDT:

, as of today, October 13, 2021 at 4:21 PM, EDT, there have been:

 with 70 289 reported fatalities, followed by 

COVID-19 Updates: Delta Variant, US Vaccinations, & Global Data as of October 13, 2021

The US Food and Drug Administration (FDA) issued new guidance urging the food industry to voluntarily decrease the amount of sodium in packaged, processed, and prepared foods by 12% over the next 2.5 years, according to the agency’s October 13, 2021 

“As a nation, we are facing a growing epidemic of preventable, diet-related conditions like cardiovascular disease, diabetes and obesity, and the agency’s work in this area has become even more urgent,” said acting FDA Commissioner Janet Woodcock, MD, and Susan Mayne, PhD, director, Center for Food Safety and Applied Nutrition, in the statement. “For these reasons, we’re taking a critical step to further address preventable diet-related chronic diseases and advance health equity that we hope will become one of the most significant public health nutrition interventions in a generation.”

The new guidance seeks to reduce average 

 intake from approximately 3400 mg to 3000 mg daily during the next 2.5 years. This reduction target is aimed at food manufacturers, chain restaurants, and food service operators for items such as canned vegetables, cheeses, breads, and poultry, according to 

 the FDA issued along with the guidelines.

“Limiting certain nutrients, such as sodium, in our diets plays a crucial role in preventing diseases like hypertension and cardiovascular disease that disproportionately impact racial and ethnic minority groups,” continued Woodcock and Mayne. “The ongoing COVID-19 pandemic has only amplified these health disparities and the need for improved nutrition, as people with cardiovascular disease and other underlying conditions are at increased risk for severe outcomes from COVID-19.”

While the average sodium intake of 3000 mg per day would still be higher than the currently recommended daily limit of 2300 mg for persons aged ≥14 years, “even these modest reductions made slowly over the next few years will substantially decrease diet-related diseases,” stated Woodcock and Mayne.

According to the FDA, Americans consume 50% more sodium than recommended, and over 95% of children aged 2 to 13 years surpass the recommended limits of sodium for their age groups.

Although consumers may want to reduce their sodium intake, approximately 70% of the sodium Americans eat comes from packaged, processed, and restaurant foods, according to the press release. “Changes across the overall food supply will make it easier to access lower-sodium options and reduce intake even in the absence of behavior change,” stated Woodcock and Mayne.

Additional voluntary reductions to sodium are likely forthcoming, according to the press release. In the interim, the FDA intends to monitor how the impacted manufacturers are complying with the new guidance.

“This iterative approach will help support gradual reductions in sodium levels broadly across the food supply so that consumers’ tastes adjust, health outcomes improve and no one company or category of food is singled out or scrutinized,” stated Woodcock and Mayne.

The FDA issued new guidance today providing short-term sodium reduction targets for food manufactures, chain restaurants, and food service operators. 

FDA to Food Industry: Cut Sodium in Processed and Packaged Foods

"Would you refill my Xanax prescription?" "Can you order an MRI to see what's causing these headaches?" "I think my mother needs a wheelchair once she's home."

For some patients each one of these requests may be entirely appropriate but for others, in your clinical judgement, they may be unnecessary or entirely inappropriate. How a clinician manages the conversation around those requests and reaches the answer, "No," can affect the relationship with the patient as well as the physician's own sense of professionalism. 

A 5-step approach endorsed by the American Academy of Family Physicians abbreviated as FAVER, can help clinicians build awareness of their own discomfort in these situations, minimize conflict with patients, and maximize quality of care:

eestablish Rapport. The following slides provide a topline tutorial. 

Getting to no: how to respond to inappropriate patient requests.

Fielding inappropriate patient requests and getting to "No" while preserving rapport with a patient is an essential clinical skill. AAFP has a 5-step approach.   

Inappropriate Patient Requests: How do you Get to No?

People aged ≥60 years should not begin daily aspirin regimen for primary prevention of cardiovascular disease (CVD) or stroke and those aged 40 to 59 years who are at increased risk for CVD should make a decision with their healthcare provider about whether the benefits of aspirin for CVD prevention outweigh the risks, notably internal bleeding.

 statement issued today by the US Preventive Services Task Force (USPSTF).

“Daily aspirin use may help prevent heart attacks and strokes in some people, but it can also cause potentially serious harms, such as internal bleeding,” said Task Force member John Wong, MD, in a USPSTF 

“It’s important that people who are 40 to 59 years old and don’t have a history of heart disease have a conversation with their clinician to decide together if starting to take aspirin is right for them.”

The draft recommendation is a shift in USPSTF guidance from its 2016 statement in which task force members advised daily low-dose aspirin for adults 50 to 59 years with a ≥10% 10-year CVD risk, without increased risk for bleeding and recommended that a decision to begin prophylactic aspirin be individualized for adults aged 60 to 69 years with similar risk.

At the time the evidence was insufficient to assess the harms/benefits of initiating aspirin in adults aged <50 years or ≥70 years.

To update the 2016 recommendation USPSTF commissioned a systematic review to evaluate new evidence for the effectiveness of aspirin to reduce CVD event risk (MI, stroke) and CV- and all-cause mortality in persons without a history of CVD. The analysis also evaluated the risk of aspirin-associated bleeding in primary prevention populations.

The 13 randomized controlled trials (RCTs) identified that provided results on the efficacy of aspirin to prevent CVD morbidity and mortality included a total of 161 680 individuals; men and women were evenly distributed across RCTs and mean age ranged from 53 to 74 years. The majority of trials used low-dose aspirin (≤100 mg/day).

Adults ages 40 to 59 years with a 10% or greater 10-year cardiovascular disease (CVD) risk.

The decision to initiate low-dose aspirin use for the primary prevention of CVD in adults ages 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. Grade C Recommendation

he USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults aged 60 years or older. Grade D Recommendation

The Task Force found that aspirin use for primary prevention of CVD is associated with decreased risk of MI and stroke but has no effect on CV mortality or all-cause mortality.

Pooled analysis of 11 trials using low-dose aspirin, the dose most relevant to current clinical practice, found a statistically significant decreased risk of nonfatal MI; similarly, pooled analysis of 5 trials showed low-dose aspirin linked with statistically significant decrease in risk of nonfatal ischemic stroke.

Fatal CV events were less common, researchers reported, with pooled analysis showing no statistically significant effect of low-dose aspirin on fatal MI, stroke, CV- or all-cause mortality (follow-up, 3.6-10 years). The authors note that they see no suggestion that aspirin’s relative effect on CVD outcomes is modified by baseline CVD risk, however, the absolute magnitude of the benefit is higher in those at higher CVD risk. 

Evidence for the relative benefit of aspirin on CVD outcomes, the USPSTF found, was not impacted by age. Total enrollment in the CVD prevention trials included 22 000 aged <50 years and >37 000 aged ≥70 years, leading the task force to conclude the evidence on the benefit of aspirin was adequate for all age groups, including those aged 40 to 49 years and those aged ≥70 years.

The USPSTF reviewed 14 RCTs in CVD primary prevention populations that reported on the bleeding harms of aspirin. Looking at a pooled analysis of 10 trials (n=119,130) reporting on low-dose aspirin use, the practice was associated with a 58% increase in major GI bleeding and a similar analysis of 11 trials (n=134 470) showed an increase in intracranial bleeds in the aspirin vs placebo group.

The data, according to the draft recommendation, suggest the increased risk of bleeding seen with aspirin occurs “relatively quickly” after treatment initiation and that is no differential effect relative to characteristics including age, sex, diabetes, CVD risk, race, or ethnicity. The absolute risk of bleeding, however, and thus the magnitude of harm, does increase with age and more so in adults aged ≥60 years.

A microsimulation model study commissioned by the USPSTF to assess net benefit of aspirin use in primary prevention found a modest net benefit in both quality-adjusted life-years (QALY) and life-years gained in both men and women ages 40 to 59 with a ≥10% 10-year CVD risk. Aspirin initiation in adults aged 60 to 69 years yielded a gain in QALY that ranged from slightly negative to slightly positive depending on CVD risk level and a general loss of benefit in life-years. Starting aspirin in adults aged 70 to 79 had negative net benefit on both QALY and life-years overall, even in those with up to a 20% 10-year CVD risk.

The USPSTF concludes in this draft statement:

In primary prevention populations, low-dose aspirin reduces major CVD events, MI, and ischemic stroke, but also increases major GI bleeding, extracranial bleeding, and intracranial bleeding. More precise real-world US-based estimates for bleeding events in the general population and specific populations with elevated CVD risk are necessary to accurately estimate the net benefit.

Reference: Guirguis-Blake JM, Evans CV, Perdue LA, Bean SI, Senger CA. 

Aspirin use to prevent cardiovascular disease and colorectal cancer: an evidence update for the US Preventive Services Task Force.

 Evidence synthesis No 211. Agency for Health Care Research and Quality publication No 21-05283-EF-1; September 2021.

The USPSTF shift to a more conservative recommendation on use of aspirin compared to its 2016 stance is based on new RCT data and net benefit modeling. 

USPSTF Shift: Aspirin Use for Primary CVD Prevention Carries Greater Risk, Less Benefit 

 We’d like to start with a patient case presentation. We have a 24-year-old woman who presents with 6 months of abdominal pain, a 20-pound weight loss, and an increase in bowel movements. She’s having 7 nonbloody bowel movements during the day, and she often wakes up at night with urgency in having to run to the bathroom again. She has occasional nausea and vomiting. Fasting seems to improve her symptoms.

We’d like to poll the audience with some questions about this case. What is this patient suffering from? A) cancer; B) irritable bowel syndrome; C) anorexia nervosa; D) celiac disease; E) Crohn’s disease; or F) ulcerative colitis?

What would be your test of choice? A) CT scan; B) MRI; C) colonoscopy; or D) sigmoidoscopy? Dr Hanauer, with this interesting presentation of this patient who’s having increased bowel movements, abdominal pain, and some systemic symptoms, how would you initially work this patient up?

 As I mentioned earlier, we’re looking for red-flag symptoms or aspects that would be associated with inflammation, and she certainly has these. She has progressive symptoms associated with weight loss and nocturnal bowel movements, which would be very uncommon in patients who have irritable bowel syndrome. Likewise, the abdominal pain is less likely going to be present in patients who have celiac disease, who are more commonly going to present with diarrhea. The fact that she’s not having bloody bowel movements despite these pretty severe symptoms makes me think against ulcerative colitis and more likely the setting of Crohn’s disease. That would lead to additional diagnostic testing.

 Thank you. Dr Ungaro, when thinking about this patient, what initial tests would you consider doing? What would be your final test of choice in working this patient up?

 As we alluded to before, in all these cases, you want to rule out infection. Although in this case, she’s beyond just a regular enteric infection. But it’s always important to have that initial set of stool studies. Because we’re highly suspicious that there’s some inflammatory condition of the bowel, possibly IBD [inflammatory bowel disease], whether it’s Crohn’s or ulcerative colitis, I’d go for a colonoscopy and cross-sectional imaging. I’d probably do MR [magnetic resonance] enterography or CT enterography plus a colonoscopy to get a diagnosis of the tissue biopsy and also get a full evaluation of the true extent of the disease and evaluate for any potential complications.

When patients are having lots of weight loss and other systemic symptoms, you want to make sure there are no strictures, fistulas, or potential abscesses if they’re having fevers in addition to their other symptoms. A full evaluation would require both the colonoscopy and the MRI. Although for the purposes of the multiple-choice question here, I’d probably want to go for colonoscopy, where you’re also going to get tissue to cinch that diagnosis.

 That’s great. Thank you. Dr Sands, when thinking about this patient, what factors would be most important to consider when choosing a therapeutic agent?

 This patient is fairly sick. Assuming that the diagnosis is indeed Crohn’s disease, you have a number of options. The things you’ll end up considering are of course the efficacy and safety, the convenience to the patient, and access to the treatment. Hopefully most patients will be insured, because many of the treatments we use are of considerable cost. All those factors play a role.

Fortunately, we have many agents—many more than we had even 20 years ago—that are effective, work quickly, and can work in more severe disease, such as this patient has based on her weight loss and remarkable symptoms. These include broad categories of biologic agents such as anti–TNF [tumor necrosis factor] antibodies; other newer biologic agents, such as vedolizumab and ustekinumab; and also older agents such as methotrexate, which has a steroid-sparing role, and mercaptopurine and azathioprine, which are immune modulators in the class of thiopurines. Although we’ve tended to move away from those because they don’t have wonderful safety profiles, they’re adequate safety profiles, and we used them for many years. But the biologic agents prove to be probably safer.

Videos

GI specialists review the case of a 24-year-old woman who presents with symptoms that suggest inflammatory bowel disease and suggest how they would appropriately test and diagnose the patient before initiating therapy.