The American journal of medicine
-
The risk of overwhelming sepsis in asplenic patients has been recognized increasingly over the past several decades, but the underlying mechanisms are not fully understood, and there is controversy over the true magnitude of risk and the value of specific interventions. Review of recent series indicates that postsplenectomy sepsis is more likely after splenectomy in childhood than after splenectomy in adulthood but may occur after splenectomy at any age. ⋯ Predisposition to pneumococcal sepsis and to other infections reflects the role of the spleen in mechanical filtration of particulate material in the bloodstream, generation of opsonins and other soluble mediators of phagocytosis, and anatomic juxtaposition of different elements of the immune system. Whereas pneumococcal vaccine is indicated in asplenic patients, the value of other interventions requires further evaluation.
-
The third-generation cephalosporins are useful for empiric therapy of most of the severe infections in adults as a result of their broad spectrum of antimicrobial activity (particularly against clinically important gram-negative bacteria), good tissue penetration, and lack of serious adverse effects. This review examines their use in respiratory tract infections, bacterial meningitis, skin-structure infections, and urinary tract infections in adult patients. Penicillin G remains the optimal therapy for severe community-acquired pneumonia, since Streptococcus pneumoniae still accounts for the majority of cases. ⋯ However, in meningitis in which gram-negative bacilli are suspected and where specific problems include antibiotic resistance among these organisms and the inadequate penetration of many antibiotics into the cerebrospinal fluid, third-generation cephalosporins are the drugs of choice, and they have markedly improved the clinical outcome. Most skin-structure infections are due to S. aureus and are best treated by an anti-staphylococcal penicillin or an older cephalosporin. Nevertheless, the third-generation cephalosporins have proved to be highly effective agents for infections of skin and soft-tissue infections associated with both gram-positive and gram-negative pathogens in patients at risk from these organisms or in the elderly.
-
The limited data available from the long-term clinical trials on the treatment of hypertension, as well as several short-term studies, indicate that the lowering of blood pressure in minority patients is feasible over the long term with a marked decrease in morbidity and mortality. The presence of left ventricular hypertrophy and diabetes in a higher number of black compared with white patients does not appear to be a major determining factor in the choice of initial monotherapy. ⋯ When these latter agents are added to a diuretic, however, a good blood pressure response is achieved. There are few data available on the results of long-term treatment in Asian or Hispanic persons.
-
Despite recent advances in both prevention and treatment, cardiovascular disease remains the leading cause of mortality in the United States. One of the major modifiable risk factors for cardiovascular disease, hypertension, is a leading cause of stroke, kidney disease, and diseases of the heart and coronary circulation. Essential hypertension is the most common cause of systemic blood pressure elevation and it responds readily to both pharmacologic and non-pharmacologic treatment. ⋯ For both blacks and Hispanics, however, the decreases in cardiovascular mortality have been less striking. Many factors could account for this disparity, among them the availability of health care facilities in minority neighborhoods, and the health-care-seeking behavior of the patients themselves. Understanding epidemiologic and pathophysiologic data regarding differences between blacks, Hispanics, and non-Hispanic whites will help reduce hypertension-related morbidity and mortality.