Fenoldopam: a new dopamine agonist for the treatment of hypertensive urgencies and emergencies

Vascular nephropathies are a steadily increasing cause of end-stage renal failure. Arterionephrosclerosis and arteriolonephrosclerosis are common features in the hypertensive patient. This is especially true for blacks of African descent, in whom hypertension and nephrovasculopathies are a major cause of renal insufficiency. That primary hypertension leads to renal vascular lesions, glomerular obsolescence and interstitial fibrosis has long been established. It should not, however, obscure the fact that renal vascular lesions can be observed in animal models as well as in some humans, especially young blacks, in the absence of, or anticipating the onset of hypertension. This leads to considering the hypothesis that nephroangiosclerosis might stem from a genetic defect in the renal vascular bed and that this defect is strongly associated with the hypertensive trait. Atherosclerotic renal disease is a major, potentially treatable cause of chronic renal disease is a major, potentially treatable cause of chronic renal failure, especially in whites. It leads to renal atrophy, but the ischemic kidney retains a vigorous potential for tubular cell regeneration, which pleads for early recognition and treatment. Recent data suggest that renal ischemia, be it due to renal artery stenosis or to cholesterol crystal embolism, ranks among the multiple causes of secondary focal segmental glomerulosclerosis. Irrespective of its initial mechanism, ischemia induces renal fibrosis, the pathophysiology of which is centered on increased generation of angiotensin II. Finally, renal vascular lesions are commonly observed in the course of various nephropathies, even in the absence of hypertension, and the relationship between these lesions and the unfavorable prognosis of glomerulopathies, especially primary focal-segmental glomerulosclerosis, membranous glomerulopathy and IgA glomerulonephritis, remains to be elucidated. Expanding knowledge of the spectrum of nephrovasculopathies opens perspectives for investigating, understanding and treating a major mechanism of progressive renal insufficiency.     

The hypertensive elder: a review for the primary care provider

Hypertension, the most prevalent cardiovascular disorder in America, affects over 50% of the older adult population. Management of hypertension in the elder is influenced by numerous age-related factors, including physiological changes, co-morbid conditions, functional or cognitive impairments, and polypharmacy issues. As data on the damaging effects of untreated hypertension increase, practice guidelines are increasingly focused on early detection and successful management of blood pressure in the primary care setting. The primary health care provider, having an advanced knowledge base and excellent communication skills, can make effective management of hypertension a reality. This article presents a comprehensive review of assessment, diagnosis, and treatment of hypertension in the older adult. Lifestyle modification and pharmacologic therapy are discussed. Elements of patient education are described, with special emphasis on promoting adherence to a long-term treatment regimen.     

Managing suicide risk in primary care: Practice recommendations for behavioral health consultants.

Psychologists working in primary care clinics can have a significant positive impact on preventing suicide. For psychologists working within the behavioral health consultant (BHC) model in primary care, however, the issue of how to appropriately manage suicide risk within this model has yet to be adequately addressed. Given the time-limited and focused nature of the BHC model, it is important to establish a framework for psychologists to provide adequate care that is practical within this model of health care. This article offers 26 empirically supported recommendations for suicide screening, accurate and time-efficient risk assessment, and effective risk management strategies, as well as suggestions for consultation with primary care physicians, all of which are consistent with the BHC model. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managing the elderly hypertensive patient beyond blood pressure reduction

ANTIHYPERTENSIVE TREATMENT OF THE ELDERLY: Several prospective, randomized, long-term trials on antihypertensive drug treatment have shown that elderly patients with systolic and diastolic or isolated systolic hypertension benefit from a reduction in blood pressure. Antihypertensive treatment reduces the overall mortality by 20%, cardiovascular mortality by 33%, the incidence of fatal and non-fatal cerebrovascular events by 40% and the complications of coronary heart disease by 15%. In addition, elderly patients have a high risk of overt or latent and asymptomatic cardiovascular diseases. For this reason, not only antihypertensive treatment, but also risk factor modification (such as cholesterol reduction therapy) is, in absolute terms, more beneficial in elderly patients than in middle-aged patients, particularly in patients with concomitant cardiovascular diseases and other risk factors. QUALITY OF LIFE: Although the randomized trials have focused on mortality and morbidity as main endpoints, it is questionable whether longevity is a worthwhile social objective in itself. Quality of life is an important aspect of antihypertensive treatment, since hypertension is generally symptomless while drug therapy may have adverse effects on the quality of life. The frequency of adverse effects is similar in both middle-aged and elderly hypertensive patients, with about 2% of patients per year in both age groups withdrawing from randomized treatment due to objectively assessed adverse effects. The rate of subjectively assessed adverse effects during treatment is also similar in younger and elderly patients. In general, clinical studies have suggested that a blood pressure reduction does not influence the well-being of elderly patients, whether measured in physical, emotional or social terms. Both calcium antagonists and diuretics have shown an age-dependent effect in comparative trials, with a higher blood pressure reduction in elderly than in younger patients. CONCLUSION: Antihypertensive therapy in elderly hypertensives adds longevity and need not compromise quality of life. Although the reduction and normalization of blood pressure is the primary goal, the increased availability of antihypertensive preparations and drugs for treating concomitant diseases and risk factors allows the physician to tailor treatment of the elderly to the needs of the individual patient.     

Managing risk in a changing health care system

This article examines the information requirements and other strategies needed to manage business and financial risk in health care organizations. The business and financial risk of providers in the changing health care market is defined. The major factors that are increasing risk are outlined, and strategies for measuring and managing risk are discussed. The interaction of business and financial risk is described, and strategic goals that will minimize the effect of this interaction are presented.     

Managing the occupational environment of managed care

The emergence of managed care has resulted in a practice environment buffeted by rapid and sweeping changes. Shifts in philosophy and approach to payment for health care affect the nature of the service and the method of its delivery. The occupational adaptation frame of reference is used to illustrate the challenges imposed by the physical, social, and cultural components of the changing occupational environment. Perceptions, observations, and concerns of middle level occupational therapy, physical therapy, social work, and nursing managers illustrate the impact of this new environment. Therapists are challenged to understand their own changing work setting and to apply the same effort to mastering its challenges as they would to examining the context of their patient's occupational performance and to designing and implementing an appropriate clinical intervention.     

Anthroposophic perspectives in primary care

Anthroposophically Extended Medicine (AEM) is a truly integrative healing system. AEM represents an expansion, not an alternative to conventional medicine. Its unique understanding of the interplay among physiological, soul and spiritual processes in healing and illness serves to bridge allopathy with naturopathy, homeopathy, functional/nutritional medicine and other healing systems.     

Antihypertensive drugs in primary care

Although it is recommended that drugs be avoided as much as possible during pregnancy, attitudes towards setting, time and method of the performed studies, and characteristics of the investigated population have been shown to vary. A collaborative and permanent network of different observational points is essential in monitoring and assessing the rational use of drugs, especially during pregnancy. In a context where knowledge is often scant and contradictory, the importance and the need for information on drug use during pregnancy remain unquestioned. If health (drug) information is the interface between those who produce and have knowledge and those who are beneficiaries of such knowledge, information for pregnant women (as well as for all lay people) is mandatory. Initiatives, people and instruments whose job it is to produce and diffuse informations have to be assessed and qualitatively harmonized to adequately answer to questions and needs. Women need information (concerning both pregnancy and drugs) on which to base choices on their own health care (and pregnancy). Clearly, this interaction depends on the kind of information and on the spirit with which it is provided. Thus it is essential that information (especially during pregnancy) be based on transparency and accountability, and it be directed by the principles of equity, effectiveness and affordability.