The American journal of medicine
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Aortoesophageal fistula (AEF) is a relatively rare but life-threatening cause of upper gastro-intestinal bleeding. The clinical characteristics of AEF are so unique that a presumptive bedside diagnosis can be made at the time of presentation. ⋯ We summarize our findings with respect to the etiology and clinical characteristics of AEF. Further, we discuss the diagnostic modalities that may be used to confirm the diagnosis, and the therapeutic modalities available to slow the hemorrhage, so as to allow time to correct the anatomic defect.
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In minorities, as in the general population, hypertension is taken seriously because it is a risk factor for cardiovascular disease. Until recently, our understanding of the role that hypertension plays in the heart disease seen in minorities has been limited by a paucity of prospective data regarding the prevalence, natural history, and pathophysiology of the disease process in minority populations. In the last few years large-scale epidemiologic studies and well-controlled clinical studies alike have confirmed usually high rates of hypertension-related morbidity and mortality in minorities, particularly blacks and Hispanics. ⋯ Inner-city patients are, increasingly, black and Hispanic patients, and these patients are more likely to be underinsured or uninsured, to be functionally illiterate in English, to be disinclined to seek health care, and to be less capable of following a prescribed regimen than the populace as a whole. The nature of the therapeutic regimen itself is probably the most important determinant of compliance, and compliance with drug therapy will be improved if the clinic chooses a simplified drug regimen and avoids drugs that produce intolerable side effects. Once-a-day--or, with transdermal clonidine, one-a-week--single-drug therapy may not be possible in all patients, but multiple drug therapy and multiple daily dosing schedules should be avoided wherever possible.
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Despite the demonstrated efficacy of traditional antihypertensive therapy in reducing blood pressure, hypertension continues to be a major cause of cardiovascular disease morbidity and mortality. Stepped-care therapy is a nonphysiologic approach that, due to potential metabolic derangements and stimulation of undesirable reflex responses, may not substantially reduce the cardiovascular and renal complications associated with hypertension or improve long-term survival in many hypertensive patients. ⋯ Certain classes of drugs are not only more effective but also more appropriate from a physiologic standpoint in specific types of patients. Therapy selection based in part on hemodynamic mechanisms and demographic patterns is a more rational approach to patient management and may contribute to a better overall outcome than has been observed with conventional treatment.
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The Muir-Torre syndrome (MTS) is an autosomal dominant genodermatosis characterized by: (1) at least a single sebaceous gland tumor (either an adenoma, an epithelioma, or a carcinoma) and (2) a minimum of one internal malignancy. To date, 120 patients with MTS have been reported. The most commonly associated neoplasms were colorectal (51%) and genitourinary (25%). ⋯ The cancers appear to have an indolent course in many of the MTS patients; the median survival has not been reached and the median follow-up is 10+ years. Patients with an MTS-associated cutaneous lesion should have a complete evaluation for gastrointestinal or genitourinary cancers. Although the penetrance of this disease is variable, its autosomal dominant inheritance suggests that relatives should be examined for sebaceous gland tumors and internal malignancy.
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Review Case Reports
Tissue-plasminogen activator for pulmonary embolism resulting in shock: two case reports and discussion of the literature.
Two patients with significant relative contraindications to fibrinolysis, and with refractory shock caused by acute pulmonary embolism, who were successfully treated with recombinant tissue-type plasminogen activator (rt-PA) are reported. The role of rt-PA in the management of pulmonary embolism is discussed, and pertinent literature is reviewed.