The Medical clinics of North America
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Med. Clin. North Am. · Sep 1988
Review Randomized Controlled Trial Clinical TrialDiagnosis of pulmonary infections in immunocompromised patients.
In an immunocompromised patient with fever and pulmonary infiltrates, it frequently is difficult to decide which invasive procedure, if any, to use to obtain a definitive diagnosis. Because most lung infiltrates in immunosuppressed patients are caused by bacteria and sputum usually is readily available for examination, empiric therapy with potent, safe, broad spectrum, antibacterial drugs often is successful. Invasive procedures that prove a diagnosis may result in substantive changes in therapy in perhaps as few as 10 to 20 per cent of patients, and the procedure itself may harm the patient. ⋯ New diagnostic and therapeutic developments may change decision analysis in the near future. At present, cultures for viruses and fungi and serologic techniques have little application at most medical centers, and decisions on data from invasive procedures pivot on interpretation of histology and smears. Development of assays for antigen (for example, Aspergillus) and rapid culture techniques (for example, cytomegalovirus and the shell vial method), coupled with new, effective antimicrobials, may demand maximum effort for a definitive diagnosis in every patient.
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Before any more progress is made in reducing the incidence of sudden cardiac death, our ability to identify those at risk must be refined further. The close association with coronary artery disease necessitates that the first step must be the identification of those with underlying coronary artery disease. This is underscored by the disturbing fact that, in many, sudden death is the first sign of coronary disease. ⋯ At the present time, we can identify certain subsets that warrant aggressive therapy: survivors of sudden death events or sustained ventricular tachycardia, obstructive cardiomyopathies, aortic stenosis, left main coronary artery disease, and congenital QT prolongation. Less aggressive but also less specific therapies, such as beta-blockers in myocardial infarction survivors, can be given more indiscriminately. Ultimately, of course, the greatest impact will come from prevention of coronary artery disease.
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Med. Clin. North Am. · Jul 1988
ReviewSuicide: a guide to risk factors, assessment, and treatment of suicidal patients.
This article summarizes what is known about risk factors for suicide in both adolescent and adult populations. It also translates this knowledge base into practical considerations for the physician on the assessment and treatment of suicidal patients. Since most patients who commit suicide have seen a physician in the weeks to month prior to their deaths, and many kill themselves with medications prescribed by their doctors, the physician's early detection and treatment of suicidal behaviors and associated psychiatric disorders in his or her patients becomes a major suicide prevention strategy.
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Potent effective antiviral drugs recently have been licensed for several viral diseases, ushering in a new era in the treatment of viral diseases. Several unique features in the process of a viral infection have been identified as target points for inhibition. The unique steps and the interfering compounds are the subject of this review.
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Hypertension represents a problem of special importance in the black patient primarily because of frequency and increased severity. Differences between hypertension in blacks and whites in the United States seem to be mostly epidemiological, pathophysiological, and in responsiveness to drug therapy. ⋯ Agents that seem to depend more on a stimulated renin-angiotensin-aldosterone system are generally less effective as monotherapy in this group of patients. However, proper combinations of low dose diuretics, with almost any other therapeutic agent, seems to produce a responsiveness in the black hypertensive that is equal to comparable white patients.