The American journal of medicine
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Comparative Study
Stepped care and profiled care in the treatment of hypertension: considerations for black Americans.
The stepped-care approach to the treatment of hypertension has proved to be effective in helping control hypertension and in reducing morbidity and mortality associated with hypertension and related cardiovascular disease. Nevertheless, modifications to the stepped-care approach can provide more effective care for certain patient subgroups. ⋯ Profiled care may prove particularly valuable in treating hypertensive patients in black urban communities where all forms of hypertension are disproportionally represented because of various physical, psychosocial, and socioeconomic factors. Along with efforts by the government and private sectors to eliminate barriers to effective hypertension control in poor black communities, profiled care can help achieve control equal to that achieved in more affluent communities.
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Comparative Study
Effect of glycemic control on microvascular complications in patients with type I diabetes mellitus.
The relation between the control of blood glucose levels and the progression of early diabetic retinopathy and the width of skeletal muscle capillary basement membrane was studied in 54 insulin-dependent diabetic patients. After initial ophthalmologic evaluation including seven-field fundus photography and fluorescein angiography and measurement of levels of glycosylated hemoglobin and width of skeletal muscle capillary basement membrane, the patients were divided into two groups: an experimental group of 30 patients who were treated with continuous subcutaneous insulin infusion and a control group of 24 patients who continued to receive conventional treatment--usually two injections of insulin daily. After a mean follow-up period of 31.4 months, the experimental group had a significant decrease in glycosylated hemoglobin levels as compared with baseline values (mean +/- SEM, 7.2 +/- 0.3 percent versus 10.1 +/- 0.4 percent), reflecting improved control of blood glucose levels. ⋯ There was a tendency for skeletal muscle capillary basement membrane width to increase in thickness over time in those patients whose retinopathy worsened irrespective of treatment. It is concluded that meticulous diabetic control may slow the progression of early diabetic retinopathy. Changes in skeletal muscle capillary basement membrane width may reflect the course of diabetic retinopathy.
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The relation between the serum anion gap and the serum total carbon dioxide concentration was studied in 100 admissions of patients with diabetic ketoacidosis and 43 normal control subjects. In 20 admissions of patients with diabetic ketoacidosis (Group 1), the patients had no other conditions or medications known to alter acid-base or electrolyte homeostasis, whereas in 80 admissions of patients with diabetic ketoacidosis (Group 2), the patients had at least one of these factors. Analysis of the change in total carbon dioxide compared with the change in anion gap in Group 1 and control subjects revealed the following relation: change in total carbon dioxide = 0.74 + 1.00 X change in anion gap, in meq/liter (r = 0.886, p less than 10(-7]. ⋯ Analysis of all admissions of patients with diabetic ketoacidosis and control subjects combined showed that the anion gap increased 0.24 meq/liter per mg/dl increase in blood urea nitrogen (with total carbon dioxide constant). Because the highest blood urea nitrogen level in Group 1 and control subjects was 22 mg/dl, the change in total carbon dioxide-change in anion gap regression is generally not valid for blood urea nitrogen levels higher than 22 mg/dl. Thus, both the wide prediction interval and volume depletion (as reflected by blood urea nitrogen level) impair the usefulness of the anion gap as a screen for mixed acid-base disorders in patients with diabetic ketoacidosis.
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Historical Article
What should patients be told prior to a medical procedure? Ethical and legal perspectives on medical informed consent.
Ethicists and the medicolegal system agree that patients have rights to information prior to an elective medical procedure. Yet, it is far from clear whether there is at the present time an adequate framework for informing patients. ⋯ Medical ethicists also have offered general principles for consideration by physicians: the importance of patient autonomy and preferences in decisions related to their own health care. This report examines the historical development of informed consent in the United States, legal and ethical perspectives in medical informed consent, and the pragmatic issues yet to be considered by physicians in keeping their duty to inform patients prior to a medical procedure.