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Overcoming resistant hypertension
Dr. Turin Chowdhury
In the fight against hypertension the controlof high blood pressure has two phases to work. First is to bring the blood pressure down to the optimal desirable range. The second, probably the most challenging, phase is to keep that pressure down in the optimal range. 
People having the problem hypertension are more likely to develop heart disease or have a stroke than people with normal blood pressure levels. Uncontrolled hypertension can also lead to kidney failure and eye damage.
Resistant Hypertension
In the treatment goal of the hypertension situation we want to achieve the treatment goal in terms of controlling the blood pressure always, but sometimes it seems the blood pressure just simply come under control. It is still higher than it should be. Patients are considered to have resistant hypertension when their blood pressure remains elevated despite use of multiple anti-hypertensive medications. Estimated 10% of the hypertensive patients appear resistant to therapy. Various factors can contribute to resistance, so every patient should undergo a thorough, orderly, and carefully directed evaluation.
Pseudo-resistance
Before labeling any patient as having resistant hypertension we must exclude some circumstances which can lead to higher blood pressure reading in a patient falsely. For example, there is a situation called "white coat" hypertension - in thei condition a patient feels stressed when he or she visits a doctor or a hospital. So there patients will have higher blood pressure readings during a hospital visit than the normal time. So if we consider this patient as a resistant hypertension case depending on these reading, we will end up in wrong conclusion. In as many as 30% of patients, there is a disparity between blood pressure readings obtained in the clinic and those measured at home.
Consequence
The dangerous part of resistant hypertension is that this condition does not produce immediate symptoms. There are no warning signs. Therefore, it can remain undiagnosed for a long time in a patient with higher level blood pressure but the patient is thinking that he is taking regular medication thus his blood pressure is taken care off. People having the problem of sustained uncontrolled hypertension are more likely to develop heart disease or have a stroke than people with controlled high blood pressure levels. Uncontrolled hypertension can also lead to kidney failure and eye damage. Hypertension is nicked as silent killer because there are frequently no warning signals that hypertension exists. High blood pressure is truly a silent killer because the condition often goes undetected for many years until the first sign of trouble, usually a stroke or heart attack. Heart failure, stroke, myocardial infarction, and renal failure are related to the degree of the elevation in blood pressure. Other risk factors, such as diabetes and cholesterol abnormality further increase the cardiovascular risk in these patients.
Causes of resistant hypertension
The causes of the resistant hypertension should be considered in different angles.
* Patient-related reasons
* Physician-related reason s
* Drug-related reasons
* Cause of hypertension-related reasons
* Patient-related reasons:
There are a number of patient-related reasons which may play a role in resistant hypertension. These include;
* Noncompliance with treatment schedules,
* Use of drugs that interact with antihypertensive medications,
* Obesity, metabolic syndrome and
* Dietary factor.
Noncompliance with treatment schedules
This is considered as the major stumbling block in many patients who are diagnosed as having resistant hypertension problem. This mainly happens due to the lack of knowledge about the disease and relative issues. Some more the absence of symptoms contribute to noncompliance. Patients think, as they are not feeling the symptom related discomfort so it is not necessary to act in accordance with treatment plan. But in reality the regularity in terms of medication is very necessary for the treatment of high blood pressure. Sometimes the cost or side effects of medications and complex dosing schedules of the anti-hypertensive drugs contributes to the attitude of the patients.
Drug interactions
Often we are not aware of the possible hypertensive effect of the medications we take as the over the counter drug. Some commonly used medications and illicit substances may interfere with blood pressure control. Especially in our country perspective people often takes medication prescribed by non-medical practitioners and sometimes by self.
Obesity
It has been reported that obesity is associated with increased blood pressure and decreased response to therapy. Loss of as little as 10 pounds promotes a reduction in blood pressure. So obese people, despite taking proper medication have more chance to develop resistant hypertension. The obesity situation in our country is now worsening, thus anticipating the increase in the resistant hypertension prevalence is very much logical.
Inappropriate diet
Salt intake is reported to directly contribute in higher blood pressure in some hypertensive patients, but it is also an imperative part of diet. So moderation in salt consumption is very much needed for the control of high blood pressure. But noncompliance with salt restriction is common and often ignored or unrecognized leading to poor control of blood pressure which has risk of resulting in resistant hypertension situation.
Physician-related reasons
Three major areas of concern in terms of physician related reasons should be considered,
* Failure to provide adequate patient education,
* Failure to do accurate clinical diagnosis, and
* Failure to provide appropriate drug therapy.
Inadequate patient education
It is the attending physician's duty to provide the patient a clear idea of overall therapeutic program of the treatment of the hypertension of that particular patient. The physician should teach the patient should about the chronic nature of the disease and hence the need for continuous therapy. The patient should be made aware of the possible roles of salt restriction, weight control, exercise, and over all life style modification in the standpoint of the patient's own health status. Patients are likely to be more compliant to the treatment plan if they are informed about possible long-term complications that relate to the heart, brain, and kidney. They also should be told about the rationale for therapy and its potential side effects.
Inaccurate clinical diagnosis
The attending physician must be careful regarding to establish that the patient's hypertension is truly resistant in nature, rather not pseudo-resistant. Any other possible secondary form of hypertension or preexisting essential hypertension concern should be excluded carefully.
Inappropriate drug therapy
The attending physician should be very much careful for choosing the drugs taking in consideration about the patient's co-morbidities apart from the hypertension problem. The dosages and the types of the medication should be properly fixed. The issue of some commonly used medications may interfere with blood pressure control should be considered actively and the patients should be suggested according to that.
Drug-resistant hypertension
The good news is that the availability of a wide variety of powerful antihypertensive medications has almost eliminated true drug-resistant hypertension, thanks to the continuous research in the hypertensive pharmacology field. However, it must be kept in mind that many mechanisms induced by these very drugs can make hypertension difficult to manage.
Secondary hypertension
If a patient's hypertension problem could not be controlled even after desperate attempt than there might be a secondary cause behind this hypertension. Such as, some sort of tumors or some metabolic problems, etc. It has been estimated that about one tenth of patients with resistant hypertension have an identifiable secondary cause.
Resistant hypertension management
Uncontrolled hypertension can cause significant morbidity and mortality, so it is very important to manage the resistant hypertension problem immediately and systematically. Rational management of resistant hypertension requires a systematic approach based on the cause of an elevated blood pressure in the particular patient. An overall management approach should be based on a careful evaluation and rational medical therapy.
With appropriate evaluation of both patient and physician related reasons, many cases of resistant hypertension can be resolved. Patients often do not understand the implications of their disease and need specific information regarding the importance of compliance with medication schedules and dietary restrictions. Physicians should always the patient education a important tool against the fight against diseases like hypertension. After all a blind man in terms of knowledge cannot become good fighter against the enemy called disease.
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CAMPUS CAPERS
South Asian Awareness Week
Rayyan Kamal
It's currently South Asian Awareness Week at Yale. This formidable fortnight was ushered in last Wednesday night by a performance by a South Asian fusion a cappella group, Raagapella, from Stanford University. It is evident that the South Asian Society has really gone all out to make this a week to remember.
The scheduled events include everything from an hour-long show featuring an Indian comedian to a panel discussion on South Asian regional cooperation with the consuls-general of Bangladesh, India and Pakistan.
I expected the panel discussion to be boring, and would not have attended had it not been for the persistence of my father. Ultimately, I did not regret going because it turned out to be rather interesting. All three consuls-general were intelligent and articulate, but I would have to say that the Indian consul-general stole the show, if you can use that phrase in this setting. Unlike his counterparts, he did not consult notes while delivering his opening speech. He also made countless hilarious comments like "several thousand years ago, Indians discovered the number zero. Many people say that we are still there even today." My personal favorite was what he said in reference to the fact that India's growth rate is less than China's. "I would blame this on democratic drag. If tomorrow, we became a Communist nation, I have no doubt that our growth rate would surpass China's overnight. And, as several of my smarter colleagues like to say, India is the world's fastest growing democracy."
The Pakistan consul-general seemed very friendly. He seemed intent on blaming Afghanistan for all of Pakistan's problems, though. "It's all Afghanistan's fault that the West thinks Pakistanis are harboring terrorists. We are peaceful people. Look at me! My daughter is in the audience. Look at her! Do we look like killers to you?" And our very own consul-general held his own too. He was made to answer many hard questions regarding the political situation in Bangladesh, and he did so with grace and aplomb. I later found out that he currently represents all of West and South Asia in the Society of Foreign Consuls in New York.
As important as politics and world affairs are, I must admit that the most popular event of the week was not the panel discussed above. Rather, it was a concert given by Salman Ahmad, lead guitarist of the Pakistani rock band Junoon, and the renowned tabla player Pundit Sameer Chatterjee. Despite some technical difficulties I think the show was a success. Salman Ahmad made several insightful comments about the universal nature of music and the divide between "Islam and the rest of the world." In fact, he has recently come out with a documentary called "It's my Country Too" that explores the experiences of Muslim-Americans post 9/11. I felt ashamed for having assumed he would be stupid just because he was a rock star.
South Asian Awareness Week, which is actually goes on for over a week, will end this Friday with a gala banquet. Many of the members of the South Asian Society are my friends, and I am proud of them for having worked so diligently to ensure the success of these exceptional events.
Rayyan Kamal is a sophomore at Yale University.
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Pregnant mothers should know
Caesarean section isn't
the best childbirth option
Dr. Joseph Mercola with Rachael Droege
A Caesarean section is a surgical procedure for childbirth in which the baby is delivered through an incision in the woman's abdomen. This practice was developed as an alternative method of childbirth in cases where a vaginal birth would endanger the life of the mother or newborn. This procedure, nicknamed "C-section," can indeed save lives in the event something goes wrong during pregnancy.
However, in reality C-sections are often used when the possibility of a natural, vaginal birth still exists, which is extremely unfortunate since there are many benefits to a natural birth. In fact, one in four babies in the United States is now born through surgery. The United States already has one of the highest rates of caesarean section worldwide (over 24 per cent), and the number is growing. According to the World Health Organization, no country is justified in having a caesarean rate greater than 10 per cent to 15 per cent.
Placenta previa
As I mentioned earlier, there are times when a C-section is necessary, such as in the event of a prolapsed umbilical cord (the umbilical cord slips through the cervix before the baby and may endanger the baby's oxygen supply) or placenta previa, which occurs when the placenta grows in such a way that it blocks the baby's exit through the cervix. Other situations, including when the baby is in a transverse (sideways) position or if the mother is having an outbreak of genital herpes, may also call for a caesarean section.
Unfortunately, the growing fanfare surrounding caesarean sections is another health care "illusion." The rising rate of C-sections is not due to an increase in the complications mentioned above, but rather to an increase in elective caesareans for reasons such as patient or practitioner convenience, pain-free labour or provider liability fears, none of which constitute a valid reason for C-section.
Risky surgery
Caesarean section is major surgery and brings with it many risks to both mother and baby. Babies born by C-section do not receive the natural stimulation that comes from moving down the birth canal, and therefore must often be given oxygen or a rub down to help them breathe. They also miss out on the natural hormones that are released during vaginal birth to help the baby during his first moments of life.
There is also a risk that the surgeon's knife could accidentally cut the baby or that the baby could be born prematurely if the surgery is performed too soon. A recent study in the August 2003 Journal of Allergy and Clinical Immunology also found that caesarean section might increase the infant's risk of developing a food allergy.
Women who undergo caesareans are at an increased risk of many complications compared with a natural birth. These include:
1. Increased risk of mortality; 2. Infection to various organs including the uterus, bladder or kidneys; 3. Increased blood loss; 4. Increased risk of complications in future pregnancies; 5. inecreased bowel function; 6. Respiratory complications; 7. Longer hospital stay and recovery time; 8. Adverse reactions to anaesthesia; 9. Risk of additional surgeries such as hysterectomy or bladder repair
One of the complications of a C-section that is hardly ever addressed is the problem that the resulting surgical scar has on the mother. It frequently blocks the proper flow of energy through the autonomic nervous system and seriously impairs her ability to stay healthy. Fortunately, this block is relatively easy to repair with a simple injection of procaine into the scar, however very few physicians are aware of this issue and do not check for it.
Caesareans also have a psychological effect on women. As written in "Having a Baby, Naturally," which is an excellent resource for all mothers-to-be, "Most women who have caesarean sections reported that the experience was traumatic." Women are also less able to care for the newborn immediately after childbirth and therefore may miss out on bonding opportunities.
While there are times when a C-section cannot be avoided, there are things you can do to make your pregnancy as healthy as possible and minimise your C-section risk:
Take a high-quality fish oil regularly. DHA in fish oil is responsible for preventing the vast majority of premature deliveries, maximising intelligence, and optimising vision in infants.
Midwives have a lower C-section rate than hospitals. Eat a nutritious diet with plenty of whole, raw, unprocessed foods. If you are concerned that you are not meeting your nutritional requirements, consider supplementing your diet with Living Fuel.
Make a Birth Plan. This is a document that states the expectant mother's or couple's interests or desires for their birth experience. It is not a legal document but simply a good way of letting the doctors and hospital staff know of your wishes. Many interventions (such as epidurals, pitocin, etc.) can lead to an increased risk of C-section and can be avoided by making your desires clear.
Talk to Your OB/GYN. Be sure to talk to your doctor early in the pregnancy, or even before hand, about different issues, including C-sections. For example, you can ask how often they perform C-sections (women have a higher chance of having a C-section if their doctor is male rather than female).
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Human Rights HERO, Ansar Burney
visits Bangladesh for fact-finding
on camel jockeys
Ansar Burney, the renowned human rights activist and head of the Ansar Burney Trust International, visited Bangladesh to gather first-hand information about former camel jockeys repatriated from the Middle East, meeting with a number of human rights organizations in Dhaka, says press release of Ansar Burney Trust.
Burney, who was declared an international human rights hero by the United States Department of State, and his wife Shaheen Burney, undertook the visit as the first stage in a fact finding mission regarding underage child camel jockeys from UAE, Qatar and other Middle Eastern countries. They also sought to create awareness against trafficking of young girls and children for slavery and prostitution from or via Bangladesh. They will also visit Sudan, Pakistan and Mauritania in this regard.
During their stay in Dhaka, Mr and Mrs Burney had meetings with Kazi Rafiqul Alam, President of Dhaka Ahsania Mission (DAM) and Mrs Salma Ali, Executive Director of Bangladesh National Women Lawyers Association (BNWLA). Both NGOs worked along with the Bangladeshi Ministry of Interior in the repatriation of former child camel jockeys from UAE and their rehabilitation with their families in Bangladesh.
In their meetings the human rights leaders lauded the United Arab Emirates for banning on the use of underage camel jockeys and for repatriating these children to their respective countries. During meeting Mrs. Salma Ali said that her BNWLA also received dozens of former underage child camel jockeys outside of the system set up by the UAE and Bangladesh in collaboration with UNICEF. After the ban by the UAE government on the use of underage jockeys some families along with children left the country outside the repatriation program. The Dhaka Ahsania Mission also confirmed that dozens of such children arrived outside the government system.
Burney noted that the UAE has committed to an expansion of the existing repatriation program to provide assistance for those former camel jockeys who had returned home on their own.
These NGO's also informed that they have received money from UAE through Ministry of Home Affairs, Government of Bangladesh for the integration and rehabilitation of these children.
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