Critical pharmacologic management in the emergency department

PURPOSE: Starting from a status hypercoagulability previous to substitutive hip and knee surgery, the aim of this work was to investigate the influence of different osteoarthropatic pictures for which arthroplasty is indicated in the activation of the clotting cascade, rheumatoid arthritis (RA) being one of such pictures. PATIENTS AND METHODS: Of 79 patients suitable for prosthetic surgery of hip (53) and knee (26), the preoperative values of several markers, namely, D dimers (D-D), thrombin-antithrombin (TAT) complex, and F1 + 2 prothrombin fragment (F1 + F2) were assessed by enzymoimmunoasay. The mean age of the patients was 65.5 years, and their sex distribution was 50 women and 29 men. The indications for arthroplasty were as follows: osteoarthrosis (62), aseptic necrosis (11), RA (9), articular gout (2), previous fracture (2), more than one diagnosis overlapped in some cases. The results attained were compared with a control group comprised of 33 subjects (16 women and 17 men) with mean age similar to the patient's group (68.06 years). RESULTS: The D-D values in the patients suitable for hip arthroplasty and the TAT values in patients suitable for both types of surgery were significantly higher than those found in the control group (p = 0.012 and 0.01, respectively). The preoperative TAT levels of the RA patients were significantly higher (p = 0.025) than those found in the patients with the other surgical indications. CONCLUSIONS: Previously to the performance of arthroplasty, the patients show hypercoagulative marker values higher than those of age-matched controls. The significant rising of TAT found in RA patients is concordant with the literature, and this fact makes it advisable to include RA among the pathologic situations associated with hypercoagulability, as this is a common indication for substitutive hip and knee surgery with high risk of venous thromboembolic disease.     

Surgical management of portal hypertension

The surgical management of portal hypertension depends on the location of the obstruction. Suprahepatic obstruction is usually optimally treated by a surgical portacaval shunt. In extrahepatic obstruction the treatment should be sclerotherapy. For intrahepatic obstruction in emergency situations, sclerotherapy is the first choice, with portacaval systemic shunts or transjugular intrahepatic portal systemic stent shunt the second option. Liver transplantation in other situations should, if possible, be considered ahead of a portal diversion.     

Safety issues in the pharmacologic management of chronic pain in the elderly

In two experiments, we found that readers are sensitive to manipulations of syntactically marked focus and that focus is an effective message level contextual priming mechanism. Changes in focus resulted in changes in sentence context effects on subsequent target word processing. This was demonstrated in latency to name the target word (Experiment 1) and in initial looking time on the target in silent reading (Experiment 2). Experiment 2 also revealed direct effects on the focused items, as readers made fewer regressions and spent less total time on a word that was focused than when it was not focused. However, no initial processing time effects were found on the focused word.     

Systemic hypertension and its management

The pathophysiology of hypertension in dogs and cats, the methods available to monitor blood pressure, and the signs and treatment of hypertension are reviewed. Clinical signs of hypertension are usually referable to target organ damage, most notably in ophthalmic, renal, and cardiovascular tissues, which have a rich arteriolar supply. Blood pressure should be measured in any animal with renal disease, hyperthyroidism, hyperadrenocorticism, retinal detachment or hemorrhage, hyphema, or echocardiographically determined cardiac hypertrophy. All cats with acquired cardiac murmur should also be evaluated for hypertension. Antihypertensive medication should be administered if the indirect blood pressure in cats is consistently over 170/100 mmHg, or if the indirect blood pressure in dogs is greater than 180/100 mmHg.     

Current management of hypertension in hospital

A study of the notes of 1784 patients new to two London hospitals found a blood-pressure recording in 1027 (58%). Only 423 (32%) of all outpatients had had a blood-pressure recording on their first visit. Of 144 patients with hypertension (systolic greater than or equal to 160 mm Hg or diastolic greater than or equal 100 mm Hg or both) a check recording was made in 89 (62%) and 18 (12%) were put on treatment. We conclude that the opportunity that a hospital visit provides for blood-pressure screening is being incompletely used, and that the discovery of hypertension often does not lead to further action.     

Recognition and management of pulmonary hypertension

Pulmonary hypertension (mean pulmonary arterial pressure > 20mm Hg at rest or > 30mm Hg during exercise) occurs (i) as primary pulmonary hypertension (no known underlying cause), (ii) as persistent pulmonary hypertension of the newborn or (iii) secondary to a variety of lung and cardiovascular diseases. In the last 10 to 15 years there have been significant advances in the medical management of this debilitating and life-threatening disorder. The main drugs in current use are anticoagulants (warfarin, heparin) and vasodilators, especially oral calcium antagonists, intravenous prostacyclin (prostaglandin I2; epoprostenol) and inhaled nitric oxide. Calcium antagonists, (e.g. nifedipine, diltiazem) are used chiefly in primary pulmonary hypertension. They are effective in patients who give a pulmonary vasodilator response to an acute challenge with a short acting vasodilator (e.g. prostacyclin, nitric oxide or adenosine), and are used in doses greater than are usual in the treatment of other cardiovascular disorders. Prostacyclin, given by continuous intravenous infusion, is effective in patients even if they do not respond to an acute vasodilator challenge. The long term benefit in these patients is thought to reflect the antiproliferative effects of the drug and/or its ability to inhibit platelet aggregation. It is used either as long term therapy or as a bridge to transplantation. Inhaled nitric oxide, which is used mainly in persistent pulmonary hypertension of the newborn, has the particular benefit of being pulmonary selective, due to its route of administration and rapid inactivation. Anticoagulants have a specific role in the treatment of pulmonary thromboembolic pulmonary hypertension and are also used routinely in patients with primary pulmonary hypertension. Nondrug treatments for pulmonary hypertension include (i) supplemental oxygen (> or = 15 h/day), which is the primary therapy in patients with pulmonary hypertension secondary to chronic obstructive pulmonary disease and (ii) heart-lung or lung transplantation, which nowadays is regarded as a last resort. Different types of pulmonary hypertension require different treatment strategies. Future advances in the treatment of pulmonary hypertension may come from the use of drug combinations, the development of new drugs, such as endothelin antagonists, nitric oxide donors and potassium channel openers, or the application of gene therapy.     

Behavioral and pharmacologic approaches to smoking cessation

Cigarette smoking continues to be the single, most preventable cause of death and disability in the United States. For individuals who have cancer, continuing to smoke negatively impacts their treatment, survival, and risk for second primary tumors. This review of behavioral and pharmacological approaches to smoking cessation focuses on the recent comprehensive review of cessation interventions by the Agency for Health Care Policy and Research (AHCPR), as well as on new developments in the field. An intervention model is outlined that provides oncologists with a brief and easily implemented method of systematically treating patients who smoke. By assessing patient smoking status, advising smoking patients to quit, and proactively assisting their patients in quitting, oncologists can significantly influence patient health and fulfill their professional and ethical responsibility to address this life-threatening behavior.     

Adherence to highly active antiretroviral therapy

Advances in scientific understanding of and pharmacologic therapies for HIV infection have significantly increased the potential benefits of medical regimens. Patients adherence to these regimens is an essential antecedent to therapeutic effectiveness. Nursing interventions to improve adherence target the patient, the clinician, and the regimen.     

Adherence to Instructions to Practice Relaxation Exercises.

To determine the adherence to relaxation practice, 23 hypertensive patients receiving relaxation training were given tape recorders designed to measure when a relaxation tape was used and were told to listen to the tape five or more times a week. The mean frequency of practice per week as measured by computers was 4.6; 39% of subjects adhered to instructions. Mean frequency of practice by self-report was 5.9; 71% of subjects adhered to instructions. Microprocessor-monitored and self-reported practice were significantly correlated. There was no significant correlation between either microprocessor or self-reported practice and systolic or diastolic blood pressure reductions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multi-modal behavioral approach to the treatment and management of essential hypertension.

Explored the efficacy of a multimodal behavioral approach for the treatment and long-term management of essential hypertension in a 24-yr-old male. Generalization techniques and community measurements were integral components of treatment as well as data collection procedures. Blood pressure was brought within the normotensive range and stabilized without the use of anti-hypertensive medications. Normal readings were maintained throughout a 6-mo follow-up period. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Outcome of hypertension management in Asian Americans

BACKGROUND: Ethnic and/or racial differences in drug response to antihypertensive agents have been recognized, yet the prescribing practices and the information on efficacy of various agents rely mainly on the response of whites to drugs. OBJECTIVES: To assess the management of hypertension in Asian Americans and to compare it with an age- and sex-matched group of white patients with hypertension. METHODS: The patients' medical records were used as the primary source of information for the data collection. The observational period was a 12-month window and included 200 patients of Asian origin with hypertension and 196 white patients with hypertension whose medical records were randomly selected. RESULTS: The study describes the pattern of use of antihypertensive agents and the differences in response to antihypertensive agents between Asian Americans and whites. The preferred antihypertensive agents in both Asian and white patients included monotherapy with either calcium channel blockers or angiotensin-converting enzyme inhibitors. However, medication changes, dose reduction, and the experience of side effects were all significantly more frequently recorded in Asian patients than in white patients (P < .001, P < .008, and P < .002, respectively). CONCLUSIONS: These findings are supportive of some previous reports on ethnic differences in drug response to antihypertensive agents. The findings also point to the need for further prospective studies on the outcome of hypertension management in Asian American patients.     

Problems in practical management of essential hypertension

A study of 100 men with arterial hypertension showed that: 1) hypertension was predominantly moderate with 14% index of placebo reactivity; 2) only 3 patients had a surgically curable etiologic factor; 3) frequent associated findings were hereditary factors (60%), overweight and metabolic disorders (30 to 40%). Such results suggest that: a) hypertension could be treated, in the majority of patients, without preliminary etiologic investigations and, b) non invasive hemodynamics techniques are required to evaluate arterial and cardiac lesions which are the dominant factors in the prognosis.     

Adherence to management of high blood pressure: recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control

Adherence or compliance, in the context of medical treatment, refers to how well a patient follows and sticks to the management plan developed with her/his health care provider, which may include pharmacologic agents as well as changes in lifestyle. Adherence is of great concern in asymptomatic conditions such as hypertension, where lack of control may have serious ramifications including end organ damage and premature mortality. To address this issue, the Canadian Coalition for High Blood Pressure Prevention and Control established a national Advisory Committee on Adherence to the Management of High Blood Pressure. The Advisory Committee consisted of 11 members from different disciplines of health care providers. The Committee reviewed all evidences to date and drew up four practical recommendations with respect to patient, provider and environment. Based on Canadian Task Force on Periodic Health Examination's guidelines, all four recommendations can be classified as 'level C' with a quality of evidence of II.     

A computerized data-handling system in hypertension management

An inexpensive, easy to use, computerized data-handling system is described for managing patients with hypertension. It has been in operation for 2 1/2 years in a clinic that functions with nurse specialists and physicians working as a team. Data entry and retrieval are performed by nurse specialists. Computer entries have been made for over 1,030 new patients who had 5,873 clinic revisits and 1,800 laboratory visits. Several kinds of outputs are generated that assist physicians in patient management. Most useful are those on the laboratory flow sheet, which itemizes all or selected laboratory results by date, and the blood pressure and selected laboratory data flow sheets, which chronologically list pertinent patient data necessary for management.     

Intracranial hypertension in the infant: from its physiopathology to its therapeutic management

Histidine decarboxylase catalyses the formation of histamine, an important biological messenger. In spite of the essential biological functions exerted by histamine the knowledge about the mechanisms involved in the regulation of histidine decarboxylase is rather limited. This is most likely due to the limited supply of suitable tools, including highly specific antibodies. In the present study we describe the production and characterisation of specific antisera against rat histidine decarboxylase using recombinant protein synthesised in a bacterial expression system. The antisera were shown to effectively immunoprecipitate histidine decarboxylase activity in extracts of fetal rat liver as well as to detect the histidine decarboxylase protein by Western blot analysis of COS-7 cells expressing recombinant rat histidine decarboxylase. The results demonstrate the successful production of highly specific antisera to histidine decarboxylase which may become valuable tools in future studies of the structure and function of this enzyme.