The American journal of medicine
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In order to determine prognostic factors in noncardiac medical patients treated by mechanical ventilation in a Veterans Administration hospital, 78 patient records were reviewed. Disease severity was scored by the Acute Physiology and Chronic Health Evaluation (APACHE) II system. Physicians' prior impressions of prognostic factors were compared with the actual results of this study. ⋯ At the San Francisco Veterans Administration Medical Center, a low serum albumin level may aid in the decision whether to begin mechanical ventilation, and a high fractional inspired oxygen concentration at 24 hours may aid in the decision regarding further aggressive care. These findings need to be validated in other patients before being applied. Conversely, certain older patients, and those undergoing emergency intubation or intubation for a prolonged time, may have as good a prognosis as patients without these factors.
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Clinical Trial
Conversion from low-dose insulin therapy to glipizide in patients with non-insulin-dependent diabetes mellitus.
This study examines the effect of glipizide therapy in patients with non-insulin-dependent diabetes mellitus (NIDDM) previously treated with a low-dose insulin regimen. To determine the comparative safety and efficacy of these two treatment regimens, 135 patients with NIDDM who received low-dose insulin (40 units per day or less) were enrolled in a prospective, multicenter trial. After a four-week period of continued insulin therapy, therapy was converted to the second-generation oral sulfonylurea, glipizide. ⋯ As this study showed, many patients with NIDDM currently receiving treatment with low-dose insulin can have maintained and some even improved glucose and lipid parameters when therapy is converted to glipizide. The rate of hypoglycemic adverse reactions corrected for duration of treatment in all 135 patients was 0.32 event per patient-month of therapy with insulin as compared with 0.12 event per patient-month of therapy with glipizide. When issues of efficacy, safety, and convenience are considered, it might be more appropriate to administer an oral sulfonylurea to patients with NIDDM rather than proceeding to therapy with insulin.
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The current study examines the impact of glipizide, a second-generation sulfonylurea, on diabetes control in patients in whom adequate control was not achieved while receiving treatment with first-generation agents. The interim results of this multicenter study are presented in which patients in whom euglycemia was not achieved based on fasting and two-hour postprandial plasma glucose criteria with first-generation sulfonylureas were given glipizide therapy for 24 weeks. Twenty-three percent of the patients who had only fair results with first-generation sulfonylureas (fasting plasma glucose level of more than 140 mg/dl, postprandial plasma glucose level of more than 175 mg/dl) had good to excellent results with glipizide therapy alone (fasting plasma glucose level of less than 140 mg/dl or less than 115 mg/dl, respectively). ⋯ At least a 25-mg/dl decrease in fasting plasma glucose and postprandial plasma glucose levels was also seen in 47 and 46 percent of patients given treatment with glipizide who had poor control (fasting plasma glucose level of more than 200 mg/dl, postprandial plasma glucose level of more than 235 mg/dl) with first-generation agents. Glipizide was extremely well tolerated, with no significant side effects. Preliminary data indicate that glipizide may provide a significant advantage in terms of safety and efficacy over first-generation agents.
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The effect of glipizide alone and glipizide preceded by a short course of insulin therapy (10 weeks) was studied in 69 patients with non-insulin-dependent diabetes mellitus (NIDDM) in a 10-month study. The patients were obese, had poor glycemic control, and, in all patients, first-generation sulfonylurea therapy had failed. The majority were Mexican-Americans, an ethnic population with a high incidence of NIDDM and insulin resistance. ⋯ Some patients in whom first-generation oral agents fail may not have to be given permanent insulin therapy, especially those with fasting plasma glucose levels of less than 200 mg/dl. There was no overall difference between these treatments with respect to glycemic control or lipoprotein profiles. In the interests of simplifying both therapy and monitoring, enhancing patient compliance, and achieving cost reductions, therapy with glipizide alone ultimately may be sufficient for cases in which immediate control is unnecessary (for example, patients with asymptomatic hyperglycemia, and in the absence of hyperlipidemia and vascular disease).
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Described in this study are 38 patients who received treatment for thrombotic thrombocytopenic purpura in 15 hospitals in Israel and the New York City area since 1977, when plasma therapy was introduced. Thirty-seven patients received plasma therapy and 30 survived. In 12 patients (37 percent of survivors), relapsing thrombotic thrombocytopenic purpura developed, manifested by thrombocytopenia and microangiopathic hemolytic anemia, and less frequently by neurological or renal abnormalities. ⋯ Two relapses, however, were fatal, demonstrating that relapsing thrombotic thrombocytopenic purpura is not a benign disorder. Infections, pregnancy and surgery were frequently associated with the initial episodes and the relapses. Hence, patients who recover from thrombotic thrombocytopenic purpura should be alerted to the possibility of relapse in association with these conditions.