Treatment of hypertension at the university medical clinic

The treatment of high blood pressure at the general medical clinic of a traditionally oriented university hospital was found to be unsatisfactory for most patients. Charts of all hypertensive patients (diastolic blood pressure, greater than or equal to 105 mm Hg) who made their first clinic visit in 1964 or 1971 were reviewed. Half of all patients were lost to follow-up within the first year, and blood pressure control was achieved by only one third of the patients. New information contained in the Veterans Administration study reports (1967 and 1970) had no effect on workup, compliance, or blood pressure decline. Furthermore, no significant relationship was found between blood pressure reduction and medical process, therapeutic regimens, or patient compliance. These data suggest that, in contrast to experience obtained in programs specifically designed for long-term management of this chronic disease, the present-day general medical clinic cannot satisfy the needs of most hypertensive patients.     

Management of specific medical conditions in the perioperative period

BACKGROUND: Reversal of ischemia after myocardial infarction by revascularization is worthwhile only if viability exists in a sufficiently large portion of the left ventricle. METHODS AND RESULTS: To determine myocardial hypoperfusion reversibility and its influence on segmental and global function, we studied 50 patients after myocardial infarction. Three technetium 99m-tetrofosmin scintigraphies were performed: 1 at rest, 1 after 0.6 mg sublingual nitroglycerin (NTG), and 1 after injection at peak stress. First-pass multigated radionuclide angiography was obtained at rest and after NTG. Each patient also underwent a stress redistribution-reinjection thallium-201 scintigraphy. During stress 99mTc-tetrofosmin, 104 segments had normal uptake, 51 showed moderately reduced uptake, and 186 had severely reduced uptake. Of these 186 segments, 33 (18%) improved at rest, and 41 (22%) improved only after NTG. Fifty-nine (79%) of these segments with improved uptake were also found to have reversible defects on 201TI imaging. In the 26 patients with ventricular dysfunction, a 73% agreement was found between the functional and 99mTc-tetrofosmin uptake post-NTG improvement, whereas a 69% agreement was found with thallium reinjection. No significant differences were seen between 99mTc-tetrofosmin and 201T1 imaging. CONCLUSION: Nitroglycerin administration during 99mTc-tetrofosmin scintigraphy improves the detection of myocardium with reversible hypoperfusion in patients with a previous myocardial infarction.     

Treatment of portal hypertension

Abnormalities of carbohydrate metabolism in hyperthyroid patients have been long noted. Elevated proinsulin level is considered as an early marker of B-cell impairment. Proinsulin levels in hyperthyroid patients decreased after antithyroid drug therapy. However, proinsulin in hypothyroid patients was only rarely reported, and the difference was only demonstrated after glucose stimulation-there was a greater response of proinsulin secretion after thyroxine therapy-and the basal fasting proinsulin level was not different after therapy. One of the reasons might be that the assay was not sensitive enough to detect the change of basal proinsulin levels in patients with hypothyroidism after therapy. A newly developed immunochemiluminometric assay of proinsulin was used to demonstrate that the suppressed proinsulin level increased after thyroxine therapy in hypothyroid patients (4.2 +/- 2.4 vs. 10.0 +/- 5.6 pmol/L, p < 0.05; n = 7). On the other hand, our study also confirmed that the proinsulin levels decreased in hyperthyroid patients after antithyroid therapy by methimazole (27.8 +/- 26.0 vs. 15.8 +/- 15.7 pmol/L, p < 0.05; n = 12). In conclusion, proinsulin increased in hypothyroid patients after thyroxine therapy and decreased in hyperthyroid patients after methimazole therapy. The results demonstrated there is a high correlation between thyroid function and B-cell function in hypothyroid as well as hyperthyroid patients.     

Adverse environmental conditions in the respiratory and medical ICU settings

Sleep deprivation and fragmentation occurring in the hospital setting may have a negative impact on the respiratory system by decreasing respiratory muscle function and ventilatory response to CO2. Sleep deprivation in a patient with respiratory failure may, therefore, impair recovery and weaning from mechanical ventilation. We postulate that light, sound, and interruption levels in a weaning unit are major factors resulting in sleep disorders and possibly circadian rhythm disruption. As an initial test of this hypothesis, we sampled interruption levels and continuously monitored light and sound levels for a minimum of seven consecutive days in a medical ICU, a multiple bed respiratory care unit (RCU) room, a single-bed RCU room, and a private room. Light levels in all areas maintained a day-night rhythm, with peak levels dependent on window orientation and shading. Peak sound levels were extremely high in all areas representing values significantly higher than those recommended by the Environmental Protection Agency as acceptable for a hospital environment. The number of sound peaks greater than 80 decibels, which may result in sleep arousals, was especially high in the intensive and respiratory care areas, but did show a day-night rhythm in all settings. Patient interruptions tended to be erratic, leaving little time for condensed sleep. We conclude that the potential for environmentally induced sleep disruption is high in all areas, but especially high in the intensive and respiratory care areas where the negative consequences may be the most severe.     

Treatment concepts in therapy refractory hypertension

Although inadequate lowering of elevated blood pressure is not unusual in the doctor's office, both physician and patient accept such a situation. One reason for this therapeutic failure may be either a true or an apparent therapy-resistance, with the latter being far the more common of the two, and often associated with a multiplicity of causes. Since cerebral complications in particular correlate directly with the level of blood pressure, a search for the underlying cause is always worthwhile for the patient.     

Treatment of hypertension in nondiabetic renal disease

To clarify whether long-term impaired glucose tolerance (IGT) is associated with dysfunction of peripheral and autonomic nerves, age-matched men with IGT and diabetes mellitus were followed prospectively for 12-15 years, when peripheral and autonomic nerve function was assessed. The patients comprised four subgroups: (1) 51 IGT subjects (duration of IGT at least 12-15 years); (2) 35 diabetic patients, with IGT 12-15 years ago, who later developed diabetes; (3) 34 diabetic patients, duration of diabetes at least 12-15 years; and (4) 62 age-matched non-diabetic control subjects. Mean age of the whole study population was 61 +/- 2 years (mean +/- SD), not different in the four groups. Peripheral nerve function tests included nerve conduction velocities, amplitudes, distal latencies, F-reflexes, and sensory perception thresholds for heat, cold, and vibration. Autonomic nerve function tests included the heart rate reaction during deep breathing (expiration to inspiration ratio) and to tilt (acceleration and brake indices). Despite 12-15 years of IGT, peripheral nerve function did not differ between IGT and control subjects, whereas autonomic nerve function deviated; an abnormal expiration to inspiration ratio (a sign of vagal nerve dysfunction) was significantly more common (15/51 versus 5/62; p < 0.01) in IGT than in control subjects. Diabetic patients (groups 2 and 3) showed lower conduction velocities (in general 2-4 m s-1 lower) than IGT and control subjects in all tested nerves. In conclusion, diabetes but not IGT, is associated with peripheral nerve dysfunction.     

Alveolar epithelial fluid clearance persists in the presence of moderate left atrial hypertension in sheep

Shaker channel mutants, in which the first (R362), second (R365), and fourth (R371) basic residues in the S4 segment have been neutralized, are found to pass potassium currents with voltage-insensitive kinetics when expressed in Xenopus oocytes. Single channel recordings clarify that these channels continue to open and close from -160 to +80 mV with a constant opening probability (Po). Although Po is low ( approximately 0.15) in these mutants, mean open time is voltage independent and similar to that of control Shaker channels. Additionally, these mutant channels retain characteristic Shaker channel selectivity, sensitivity to block by 4-aminopyridine, and are partially blocked by external Ca2+ ions at very negative potentials. Furthermore, mean open time is approximately doubled, in both mutant channels and control Shaker channels, when Rb+ is substituted for K+ as the permeant ion species. Such strong similarities between mutant channels and control Shaker channels suggests that the pore region has not been substantially altered by the S4 charge neutralizations. We conclude that single channel kinetics in these mutants may indicate how Shaker channels would behave in the absence of voltage sensor input. Thus, mean open times appear primarily determined by voltage-insensitive transitions close to the open state rather than by voltage sensor movement, even in control, voltage-sensitive Shaker channels. By contrast, the low and voltage-insensitive Po seen in these mutant channels suggests that important determinants of normal channel opening derive from electrostatic coupling between S4 charges and the pore domain.     

Driving patterns and medical conditions in older women

OBJECTIVES: To describe driving patterns (e.g., driving frequency) in older women drivers and to evaluate the impact of medical conditions and comorbidity on driving patterns. DESIGN: Cross-sectional examination of the association between medical conditions and driving patterns. SETTING: Population-based cohort from the Pittsburgh Center of the Study of Osteoporotic Fractures (SOF). PARTICIPANTS: A total of 1768 women aged 71 years or older. MAIN MEASUREMENTS: Driving information was obtained through a driving questionnaire, including driving status, weekly mileage, longest trip in the past year, etc. Data for demographics, lifestyle behavior, and medical conditions were collected through the SOF study. RESULTS: Among the participants, 1103 (62.3%) were current drivers, 337 (19.1%) had stopped driving, and 329 (18.6%) had never driven in their lifetime. The proportion reporting driving cessation and decline in driving amount increased with age. The prevalence of most medical conditions was higher among former drivers than in current or never drivers. Even after controlling for age and other demographic variables, fractures, heart disease, diabetes, self-reported poor vision or hearing, as well as comorbidity were found to be associated independently with decreased driving amount, including driving cessation, decline in mileage, and avoiding long trips. CONCLUSION: Both individual medical conditions and comorbidity influence driving patterns in older drivers. Because it is common for older people to have several medical conditions simultaneously, comorbidity might be a more comprehensive measure of medical impact on driving.     

Management of chronic medical conditions in children and adolescents

The care of children and adolescents with chronic medical conditions is an area of great interest for primary care physicians. With longer lives and more "mainstreaming" of care, the primary care physician often finds an increased role in the management of children and adolescents with chronic conditions such as mental retardation, Down syndrome, and diabetes mellitus. This article discusses familiarity with the most common chronic conditions and common pitfalls of management.     

Evaluation of the quality of filling out medical records in a hypertension consultation

The aim of the study was to evaluate the completion of medical records of a hypertension clinic and to compare standardized computerized records versus standard medical records. The medical records of 163 consecutive hypertensive patients attending at the Broussais hospital hypertension clinic between December 1995, 6th and January 1996, 21st were checked. At the last visit, the patients were attended by 16 physicians working in 4 different teams. The medical data were recorded by physicians in the computerized system called ARTEMIS in 120 patients and in standard structured forms in 43 patients. The patients notes were checked to see if 9 clinical items were recorded at the first visit (V1), at the visit before last (V2) and at the last visit (V3). The overall completion rate was high at V1 (92.2%) and significantly decreased at follow-up visits (82.6% at V2 and 83.2% at V3). The completion rate was significantly higher in the computerized records than in the standard notes: 95.8% vs 82.2% at V1, 91.9% vs 56.3% at V2 and 91.6% vs 59.7% at V3. During follow-up (V2 vs V1), a significant decrease in the completion rate of 6 items was observed in the standard notes (tobacco use, alcohol consumption, physical activity, compliance to treatment, body weight, manual blood pressure measurement). In the computerized records, only physical activity completion rate decreased. In conclusion, the computer may help to increase the quality of the medical records as reflected by the completion rate of items related to hypertension care.     

Treatment of hypertension during the course of kidney diseases

The aim of this paper was to discuss: pathomechanism of arterial hypertension in patients with renal diseases and the choice of antihypertensive therapy and optimal target blood pressure in these patients.     

Do medical conditions affect cognition in older adults?

Women with breast cancer today have many more therapeutic options available to them for their surgical therapy. Almost all patients with breast cancer have some options for breast conservation. Active patient involvement in analyzing and understanding the pros and cons of each of these options seems extremely important to the long-term emotional and psychological outcome of their breast cancer therapy. Several reports this year have reintroduced the issue of adequate local control. The common philosophy a decade ago was that because systematic therapy (adjuvant chemotherapy) was improving, local therapy would become of lesser importance. Several studies this year have indicated the extreme importance of local control in maximizing survival advantage because of the relationship of increasing local failure and deteriorating survival from systemic disease. Despite significant improvements in treatment, our screening and diagnostic approaches have still failed to identify the majority of lesions prior to the patient's own palpation of the tumor. Using new diagnostic modalities that do not involve surgery, the biopsy of lower probability lesions with great accuracy is expected to improve the efficacy of the current screening measures. Despite all the improvements, the most important therapeutic step in the management of breast cancer remains earlier diagnosis and earlier extirpation of the initial invasive focus of malignancy.