The American journal of medicine
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Review Case Reports
Pulmonary embolism as a result of Hickman catheter-related thrombosis.
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Review Comparative Study Clinical Trial
Role of disease-modifying antirheumatic drugs versus cytotoxic agents in the therapy of rheumatoid arthritis.
Disease-modifying antirheumatic drugs are used to modify or alter the rheumatoid arthritis disease process. Disease-modifying antirheumatic drugs do not demonstrate the characteristic analgesic, antipyretic, and anti-inflammatory actions of the nonsteroidal anti-inflammatory drugs, since weeks or months of treatment are required before clinical benefit is observed. Although they have not been proved to delay, prevent, or reverse articular damage, therapy with disease-modifying antirheumatic drugs, when successful, is associated with decreased pain and joint swelling and improved function. ⋯ Two cytotoxic drugs that are not FDA approved are methotrexate and cyclophosphamide. Methotrexate can be very effective, but its side effects, particularly pulmonary and hepatic, must be carefully monitored. Cyclophosphamide is generally considered too toxic for use in patients with rheumatoid arthritis, although it may be helpful in patients with systemic rheumatoid vasculitis or patients who have failed all other therapies.(ABSTRACT TRUNCATED AT 400 WORDS)
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In the pathogenesis of rheumatoid arthritis, locally produced antibodies complex with an inciting antigen, yet to be identified, within the joint and activate the complement system, resulting in articular inflammation mediated primarily by polymorphonuclear leukocytes and their products. Chronic inflammatory cells then produce soluble factors that induce both tissue destruction and inflammation. A major issue is how and why apparently normal immune responses in the acute stage progress to chronic inflammation in subsequent months to years. ⋯ It is possible that once the inciting agent is cleared from the joint through a normal immune response, the presence of activated cells rich in surface class II histocompatibility (Ia) antigens could, under the influence of multiple genetic or environmental factors, become the target of autoimmune attack. Alternatively, the process might result from the interactions of synovial lining cells and their products with T cells assuming a secondary role. Further research into the relative contributions of soluble products, T helper and suppressor subsets, synoviocytes, and antigen determine which model is correct.
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Hypertension is a major health problem for patients over 65 years of age. Control of elevated blood pressure reduces cardiovascular morbidity and mortality rates among older hypertensive patients. Increased total peripheral vascular resistance is the primary hemodynamic abnormality in these patients. ⋯ The latter condition might be thought to favor blood pressure control with diuretics and impair the response to angiotensin-converting enzyme inhibitor therapy. However, recent studies with lisinopril, a new long-acting, nonsulfhydryl angiotensin-converting enzyme inhibitor, indicate that reductions in systolic and diastolic blood pressure in older hypertensive patients receiving either angiotensin-converting enzyme inhibitor or hydrochlorothiazide monotherapy were not significantly different. These data demonstrate that angiotensin-converting enzyme inhibitor monotherapy can effectively lower blood pressure in older hypertensive patients.
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There are few studies devoted specifically to the epidemiology of older hypertensive patients, although some information has been obtained from broader trials in which either the study populations have become older or an older subgroup has been identified. Three areas have been addressed: the changes of blood pressure with age; the prevalence of hypertension in older persons; and the risks of elevated blood pressure in elderly patients. It has been found that blood pressure, especially systolic pressure, increases with age. ⋯ Older hypertensive patients' risks of cardiovascular complications and death are from two to five times that of normotensive persons. Treatment of diastolic hypertension in older patients can be expected to delay the onset of cardiovascular disease and improve the quality of life. Hopefully, this will prove to be true for isolated systolic hypertension as well.