OBJECTIVE:To assess the effect of a physician and pharmacist teamwork approach to uncontrolled hypertension in a medical resident teaching clinic, for patients who failed to meet the recommended goals of the fifth Joint National Commission on Detection, Evaluation and Treatment of High Blood Pressure. HYPOTHESIS:Physician and pharmacist teamwork can improve the rate of meeting national blood pressure goals in patients with previously uncontrolled hypertension. DESIGN:A single-blinded randomized controlled trial lasting 6 months. SETTING:A primary care outpatient teaching clinic. PATIENTS:A sample of 95 adult hypertensive patients who failed to meet national blood pressure goals based on three consecutive visits over a 6-month period. INTERVENTION:Patients were randomly assigned to a control arm of standard medical care or to an intervention arm in which a physician and pharmacist worked together as a team. MAIN RESULTS:At study completion, the percentage of patients achieving national goals due to intervention was more than double the percentage in the control arm (55% vs 20%, p Ͻ .001). Systolic blood pressure declined 23 mm Hg in the intervention arm versus 11 mm Hg in the control arm ( p Ͻ .01). Diastolic blood pressure declined 14 and 3 mm Hg in the intervention and control arms, respectively ( p Ͻ .001). The intervention worked equally as well in men and women and demonstrated noticeable promise in a minority of mixed-ancestry Hawaiians in whom hypertension is of special concern. CONCLUSIONS:Patients who fail to achieve national blood pressure goals under standard outpatient medical care may benefit from a program that includes a physician and pharmacist teamwork approach.KEY WORDS: blood pressure; coronary heart disease; risk factor; pharmacist; ambulatory care. J GEN INTERN MED 1998;13:740-745. G uidelines from the fifth report of the Joint NationalCommittee on Detection, Evaluation and Treatment of High Blood Pressure (JNC-V) recommend prescribing pharmacologic intervention for the treatment of patients with hypertension when 3 months of lifestyle modification fails to lower systolic or diastolic blood pressure below 140 or 90 mm Hg, respectively. 1 Published recommendations also provide for physician discretion to withhold drug therapy from patients with diastolic blood pressure less than 95 mm Hg or systolic blood pressure less than 150 mm Hg in the absence of target organ damage and other cardiovascular risk factors.According to the JNC-V criteria, up to 50 million Americans are estimated to be hypertensive. Among those being medically treated for hypertension, it is further estimated that 71% fail to achieve JNC-V goals. 1,2 A third (36%) are thought to have blood pressures that exceed even higher thresholds of 160 mm Hg for systolic blood pressure and 95 mm Hg for diastolic blood pressure. 2 Because of the widespread failure to reduce the prevalence of hypertension and to reach the goals established by the JNC-V, arguments have been made for the development and implementation of focused programs to ...

Objective To evaluate the efficacy of ginkgo biloba, acetazolamide, and their combination as prophylaxis against acute mountain sickness.

Previous studies suggest that 5 days of prophylactic ginkgo decreases the incidence of acute mountain sickness (AMS) during gradual ascent. This trial was designed to determine if ginkgo is an effective prophylactic agent if begun 1 day prior to rapid ascent. In this double-blind, randomized, placebo-controlled trial, 26 participants residing at sea level received ginkgo (60 mg TID) or placebo starting 24 h before ascending Mauna Kea, Hawaii. Subjects were transported from sea level to the summit (4205 m) over 3 hours, including 1 hour at 2835 m. The Lake Louise Self-report Questionnaire constituted the primary outcome measure at baseline, 2835 m, and after 4 h at 4205 m. AMS was defined as a Lake Louise Self-report Score (LLSR) >/= 3 with headache. Subjects who developed severe AMS were promptly transported to lower altitude for the remainder of the study. The ginkgo (n = 12) and placebo (n = 14) groups were well matched (58% vs. 50% female; median age 28 yr, range 22-53 vs. 33 yr, range 21-53; 58% vs. 57% Caucasian). Two (17%) subjects on ginkgo and nine (64%) on placebo developed severe AMS and required descent for their safety (p = 0.021); all recovered without sequelae. Median LLSR at 4205 m was significantly lower for ginkgo versus placebo (4, range 1-8 vs. 5, range 2-9, p = 0.03). Ginkgo use did not reach statistical significance for lowering incidence of AMS compared with placebo (ginkgo 7/12, 58.3% vs. placebo 13/14, 92.9%, p = 0.07). Twenty-one of 26 (81%) subjects developed AMS overall. This is the first study to demonstrate that 1 day of pretreatment with ginkgo 60 mg TID may significantly reduce the severity of AMS prior to rapid ascent from sea level to 4205 m.