JAMA

your-doctor’s-office-could-be-reading-your-blood-pressure-all-wrong

Your doctor’s office could be reading your blood pressure all wrong

blood pressure, health, hypertension, JAMA, Science / /

Under pressure

Before participants took readings in any of the positions, the researchers had them simulate walking into a doctor’s appointment. They walked for two minutes and then sat calmly in position for five minutes before taking the three readings. Before moving onto the next position, they got up and walked again and sat for another five minutes. The participants were also randomized into groups that took the first three readings (desk 1, lap, side) in different orders, with all groups ending on desk 2.

The researchers then compared the differences between desk 1 and desk 2 to differences between lap and desk 1 and side and desk 1 for each participant. The desk 1-desk 2 differences captured intrinsic variability of blood pressure reading within each participant. The comparisons to lap-desk 1 and side-desk 1 captured changes based on the improper arm positions.

In all, there was little difference in the desk 1-desk 2 comparison, with participants having a mean difference of -0.21 mm Hg in systolic blood pressure and 0.09 in diastolic. But, the improper arm positions had significant effects on the readings. Lap arm position resulted in a mean increase of 4 mm Hg in both systolic and diastolic readings. Side arm position led to systolic readings that were 6.5 mm Hg higher and diastolic readings that were 4 mm Hg higher. For those with high blood pressure readings—about 36 percent of the participants—the wrong arm position caused yet higher readings, with systolic readings about 9 mm Hg higher than desk readings.

The authors speculate that simple physiological mechanisms likely explain the increase in blood pressure when the arm is lower than the heart—more gravitational pull, compensatory constriction of blood vessels, and muscle contraction may lead to higher pressure. As for why health care providers are known to sometimes use these wrong arm positions, it may be a lack of awareness, training, equipment, and/or resources.

The authors of the study call for more training and education about proper blood pressure measurements, which are essential for appropriate management of hypertension and prevention of cardiovascular disease.

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In abortion ban states, sterilization spiked after Dobbs and kept climbing

Abortion, contraception, health, JAMA, maternity, reproductive health, Science, sterlization, women's health / /

Can’t blame ’em —

Sterilizations spike with abortion bans and declining access to care and contraception.

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A woman holds a placard saying

Enlarge / A woman holds a placard saying “No Forced Births” as abortion rights activists gather at the Monroe County Courthouse for a protest vigil a few hours before Indianas near total abortion ban goes into effect on September 15, 2022.

The more abortion access is jeopardized, the more women turn to sterilization, according to a new report in JAMA that drew on health insurance claims of nearly 4.8 million women in the US.

In states that enacted total or near-total abortion bans following the US Supreme Court’s Dobbs decision in June 2022, the rate of sterilizations among reproductive-age women that July spiked 19 percent. A similar initial spike was seen across the nation, with states that either limited or protected access to abortions seeing a 17 percent increase.

But, after that, states with bans saw a divergent trend. The states that limited or protected abortion access saw sterilization procedures largely level off after July 2022. In contrast, states with bans continued to see increases. From July 2022 to December 2022, use of sterilization procedures increased by 3 percent each month.

The study adds to previous data finding that overturning Roe v. Wade and limiting legal access to abortion spurred reproductive-age people to seek permanent contraception. A study published in JAMA Health Forum in April, for instance, found an abrupt increase in tubal ligation and vasectomies in people aged 18 to 30 shortly after the Dobbs decision. The current study furthers the finding by assessing trends of sterilization procedures in the context of state abortion laws and policies.

The surge in sterilization is just one of the many ways reproductive healthcare in the US has been rocked or upended by the Supreme Court’s 2022 decision. In June, a study in JAMA Network Open found that states with the most restrictive abortion policies saw declines in prescriptions filled for birth control pills and emergency contraception. The finding suggests that the abortion bans and limitations have disrupted and created barriers to contraception access in restrictive states.

On Tuesday, meanwhile, the March of Dimes released a report painting a bleak picture for Americans who become pregnant. The analysis found that over half of US counties do not have a hospital that provides obstetric care. In the last two years, 1 in 25 obstetric units shut down. Further, 35 percent of counties in the US are considered maternity deserts, meaning that 1,104 counties in the US do not have a birthing facility or even a single obstetric clinician. Living in a maternity desert is associated with receiving less prenatal care and higher rates of preterm birth. Those 1,104 counties are home to 2.3 million women of reproductive age who gave birth to over 150,000 babies in 2022.

The US continues to have the highest rate of maternal deaths among any high-income country, with Black women seeing the highest death rates, according to the latest report from the Commonwealth Fund.

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Buying shady weight loss drugs online is a bad idea, in case you were wondering

counterfeit drugs, diabetes, fda, JAMA, obesity, Ozempic, Science, wegovy, weight loss / /

buyer beware —

Risk assessment study of illegal online pharmacies offers some unsurprising data.

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Buying shady weight loss drugs online is a bad idea, in case you were wondering

Buying counterfeit weight loss drugs from illegal online pharmacies that don’t require prescriptions is, in fact, a very bad idea, according to a study published Friday in JAMA Network Open.

The counterfeit drugs are sold as equivalents to the blockbuster semaglutide drugs, Ozempic and Wegovy, which are prescription only. When researchers got their hands on three illegal versions, they found that the counterfeit drugs had low-purity semaglutide, had dosages that exceeded the labeled amount, and one had signs of bacterial contamination.

The three substandard drugs tested came from three different illegal online pharmacies, which sold them as generic semaglutide drugs for weight loss, appetite suppression, diabetes, and cardiovascular health. However, the researchers, led by scientists at the University of California, San Diego, and the University of Pécs in Hungary, had initially tried purchasing counterfeit drugs from six such sellers.

Three of the illegal pharmacies, which specifically sold Ozempic knockoffs, never delivered the drugs after researchers paid for them. Instead, the researchers were hit with “nondelivery” scams, in which the sellers requested additional, hefty payments, supposedly needed to get through customs. These extra fees ranged from $650 to $1,200—much more than what the researchers paid for small dosages of the counterfeit drugs, which ranged from $113 to $360 across the six sellers.

Rogue pharmacies

The Ozempic scams were run out of the rogue online pharmacies: weightcrunchshop.com, puremedsonline.com, and genius-pharmacy.com. The three pharmacies that delivered dubious drugs included semaspace.com, uschemlabs.com, and biotechpeptides.com.

Two of the sellers—semaspace.com and uschemlabs.com—have already received warning letters from the Food and Drug Administration for selling unapproved, misbranded drugs. At the time of publication, the Semaspace website was no longer reachable. The US Chem Labs site was still available, but their semaglutide vials were all listed as out of stock.

The study’s findings, while unsurprising, highlight the risk people may take in efforts to get hold of the popular drugs. Steep prices, lack of insurance coverage, and drug shortages have kept the drugs out of reach for many who could benefit from them. Compounding pharmacies have stepped in to make copycat versions. While these are legal and can come from legitimate pharmacies—ones that are properly registered and require prescriptions—they also carry risks. Compounded drugs are not approved by the FDA and may pose safety and efficacy risks. Last week, the FDA warned of increasing reports of people overdosing on semaglutide products made in compounding pharmacies, leading some patients to be hospitalized.

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Modern lives are messing up menstrual cycles—earlier starts, more irregularity

Apple, health, IPhone, JAMA, menstrual cycles, obesity, period, puberty, Science / /

downward trend —

Earlier and irregular periods are both linked to poor health outcomes.

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Panty liners, hygienic tampons, and sanitary pads.

Enlarge / Panty liners, hygienic tampons, and sanitary pads.

People in the US are starting their menstrual cycles earlier and experiencing more irregularities, both of which raise the risk of a host of health problems later in life, according to an Apple women’s health study looking at data from over 70,000 menstruating iPhone users born between 1950 and 2005.

The mean age of people’s first period fell from 12.5 years in participants born between 1950 and 1969 to 11.9 years in participants born between 2000 and 2005, with a steady decline in between, the study found. There were also notable changes in the extremes—between 1950 and 2005, the percentage of people who started their periods before age 11 rose from 8.6 percent to 15.5 percent. And the percentage of people who started their periods late (at age 16 or above) dropped from 5.5 percent to 1.7 percent.

In addition to periods shifting to earlier starting ages, menstrual cycles also appeared to become more irregular. For this, researchers looked at how quickly people settled into a regular cycle after the start of their period. Between 1950 and 2005, the percentage of people obtaining regularity within two years fell from 76.3 percent to 56 percent.

The study, published by researchers at Apple and Harvard in the journal JAMA Network Open, notes that both of these findings bode poorly for long-term health. Early starting age of menstrual cycles is linked to adverse health outcomes, including cardiovascular diseases, cancers, spontaneous abortion, and premature death, the researchers write. And a longer time to regularity is linked to fertility problems, longer menstrual cycles, and an increased risk of metabolic conditions and all-cause mortality.

Looking across race and ethnicity categories, researchers found that the trends affected all groups. However, Black and Hispanic participants had consistently earlier menstrual starting ages than white and Asian participants. Black participants also saw a larger magnitude shift toward earlier starting ages compared with white participants.

It’s unclear what’s driving the menstrual changes, but the authors speculate that there could be a multitude of factors. The most prominent potential factor is childhood obesity, which has increased in the US over the course of the study period and is known to be linked to earlier puberty. However, the authors note that obesity doesn’t explain the totality of the shifts—an exploratory analysis indicated that obesity only accounted for 46 percent of the trends seen in the study. And other studies have indicated that the shift toward earlier menstrual cycles began before the upward trend of obesity in the US.

The authors of the current study point to various potential environmental factors, including endocrine-disrupting chemicals, metals, air pollutants, dietary patterns, psychosocial stress, and adverse childhood experiences.

The study has limitations, of course, including that it relied on self-reported data and was limited to people who own iPhones, who generally skew toward higher socioeconomic status. Thus, the findings may not be generalizable to the population overall. Still, the data fits with other studies, and the researchers called for more awareness among health care practitioners and more studies to look at trends and health outcomes.

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Hospital prices for the same emergency care vary up to 16X, study finds

emergency department, emergency medical care, hospitals, JAMA, medical bills, Science, trauma, trauma care / /

Activation fees —

Hospitals’ “trauma activation fees” are unregulated and extremely variable.

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Miami Beach, Fire Rescue ambulance at Mt. Sinai Medical Center hospital. ]

Enlarge / Miami Beach, Fire Rescue ambulance at Mt. Sinai Medical Center hospital. ]

Since 2021, federal law has required hospitals to publicly post their prices, allowing Americans to easily anticipate costs and shop around for affordable care—as they would for any other marketed service or product. But hospitals have mostly failed miserably at complying with the law.

A 2023 KFF analysis on compliance found that the pricing information hospitals provided is “messy, inconsistent, and confusing, making it challenging, if not impossible, for patients or researchers to use them for their intended purpose.” A February 2024 report from the nonprofit organization Patient Rights Advocate found that only 35 percent of 2,000 US hospitals surveyed were in full compliance with the 2021 rule.

But even if hospitals dramatically improved their price transparency, it likely wouldn’t help when patients need emergency trauma care. After an unexpected, major injury, people are sent to the closest hospital and aren’t likely to be shopping around for the best price from the back of an ambulance. If they did, though, they might also need to be treated for shock.

According to a study published Wednesday in JAMA Surgery, hospitals around the country charge wildly different prices for trauma care. Prices for the same care can be up to 16-fold different between hospitals, and cash prices are sometimes significantly cheaper than the negotiated prices that insurance companies pay.

“The findings illustrate substantial, and often irrational, variations” in trauma pricing, according to the study authors—a group of researchers at Johns Hopkins and the University of California, San Francisco. They suggest that “price variations cannot be explained by trauma severity alone.”

For the study, they obtained data on “trauma activation fees” (TAFs) from hospitals across the US. TAFS were created in 2002 to be standardized billing codes that would help recuperate readiness costs for trauma care. Those overhead costs are what hospitals pay to maintain readiness to provide emergency trauma care around the clock, including having operating rooms constantly ready, as well as sufficient staffing, equipment, and supplies, like blood products. TAFS are billed with four codes corresponding to trauma response levels (I through IV), which are based on standardized criterion of injury severity. These fees are in addition to billing for a patient’s actual medical care.

Wide variation

The researchers pulled TAF data from a platform that aggregates hospital-disclosed pricing data called Torquise Health. From there, they obtained 3,093 unique TAF observations across 761 unique hospitals in 49 states. They broke out TAF fees by different types of trauma response levels as well as types of prices: list prices, cash prices often paid by the uninsured, and negotiated prices paid to insurers.

The prices varied dramatically for each trauma level and pricing type. For instance, for the most severe trauma response level (level I), the median TAF list price was $6,607, while the median negotiated price was $3,431, and the median cash price was $2,663. For the list prices, the span between the 10th percentile prices and the 90th percentile prices went from a low of $1,650 up to 11 times more than that: $18,500. Looking across the percentiles for the negotiated prices, costs ranged from $900 to 11,661, 13 times more. And the cash prices ranged from $660 to $8,190, 12 times more.

The largest spread was seen in the cash prices for trauma response level II TAFs. There, the median cash price was $2,630, but the span between the 10th and 90th percentiles was $768 to $12,140, which is 16 times more.

In all the data, cash prices were often lower than the negotiated prices. This is good for uninsured patients who may be offered cash prices, but it’s not great for the insured. “One could argue that insured patients who are already paying insurance premiums should not pay more than cash prices,” the authors wrote.

Overall, the pricing and lack of transparency is a problem that requires intervention, the authors conclude. “The unexpected and pressing nature of trauma means patients are sent to the closest appropriate hospital and unable to compare prices as they do with nonemergency and shoppable medical services,” the authors wrote. Moreover, the people who will suffer the most from these wide-swinging prices are the uninsured and most financially vulnerable patients, they add.

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