More articles from Review
- Management of variceal bleeding in the 1990s
Therapeutic options now include pharmacologic reduction of portal hypertension, endoscopic obliteration of varices, placement of decompressive shunts, and liver transplantation.
- Recurrence, remission, and relapse of seizures
Drug treatment after a first seizure reduces the risk of recurrence by about half, but many patients find the adverse effects intolerable.
- The role of blood viscosity in the development and progression of coronary artery disease
Accumulating evidence suggests that increased blood viscosity is an independent risk factor for atherosclerotic heart disease and its complications.
- Parathyroid carcinoma: 50-year experience at The Cleveland Clinic Foundation
BACKGROUND Parathyroid carcinoma is rare, with a reported prevalence of 0.6% to 4.0% in patients presumed to have primary hyperparathyroidism. This study examines the long-term results of surgical therapy and combination chemotherapy.
PATIENTS From 1938 to 1988, 1260 operations for primary hyperparathyroidism were performed; only six patients (0.47%) were subsequently found to have parathyroid carcinoma. A seventh patient was referred to our institution after the diagnosis of parathyroid carcinoma had been made.
RESULTS All patients had excessive hypercalcemia (serum calcium concentration > 12.0 mg/dL) with a range of 12.3 to 18.3 mg/dL. Locally recurrent tumors causing recurrent hypercalcemia were managed by repeated neck exploration and tumor resection. Six of the seven patients (85%) survived 5 years, while four patients (57%) survived 10 years.
CONCLUSIONS Diagnosis of parathyroid carcinoma rests upon postoperative surveillance of patients who have undergone previous neck exploration and resection of apparently benign adenomas. Long-term survival is possible with repeated resection of locally recurrent tumors.
- The pulmonary effects of free-base cocaine: a review
Respiratory symptoms, pulmonary hemorrhage, pulmonary edema, asthma, pulmonary barotrauma, and other pulmonary effects of free-base cocaine are reviewed.
- Noninfectious respiratory disease in pregnancy
BACKGROUND Pregnancy increases the risk of many noninfectious respiratory conditions.
OBJECTIVE To review the clinical presentation and management of a variety of noninfectious respiratory conditions in pregnant women.
SUMMARY Asthma, aspiration pneumonia, venous air embolism, adult respiratory distress syndrome, pulmonary embolism, and deep venous thrombosis may have unique features in pregnant women.
CONCLUSIONS Evaluation and treatment of these diseases and conditions requires an understanding of the normal physiologic alterations that accompany pregnancy and an awareness of the risks of medication use during pregnancy and in the postpartum period.
- Noninvasive risk assessment after myocardial infarction
BACKGROUND Mortality from acute myocardial infarction is substantially less than it was two and even one decade ago. This improvement in both short-term and postdischarge outcome results both from early interventions to restore myocardial perfusion and mitigate expansion and remodeling, and from later assessment and management of functional status at the time of hospital discharge.
OBJECTIVE Recent studies suggest that invasive evaluation of the patient who has had a myocardial infarction (MI) should not be recommended on a routine basis. This review provides an approach to the noninvasive assessment of the patient.
DISCUSSION Stress testing to ascertain post-MI ischemia, ejection fraction determination to evaluate ventricular volumes and function, and ambulatory electrocardiographic monitoring, electrophysiologic study, and signal-averaged electrocardiography to assess presence and type of ventricular ectopy are discussed.
CONCLUSION The approach to the post-MI patient offered herein is felt to be medically sound and cost-effective. Refinement and alterations in this approach will be necessary as outcomes in specific patient groups, such as thrombolysis patients, women, and the elderly, become clearer.
- The changing profile of anesthetic practice: an update for internists
BACKGROUND Internists are commonly consulted to "clear" patients for anesthesia and surgery. Newer anesthetic agents and techniques now extend limits and possibilities beyond what many internists were taught.
OBJECTIVE To update internists on recent changes in anesthetic management and how they affect the preoperative evaluation.
SUMMARY Recent advances in anesthetic management include new monitoring standards, balanced anesthetic technique, new agents, equipment changes, better understanding of human factors, and expanded pain management techniques.
CONCLUSIONS Postoperative care will likely assume increasing importance in determining anesthesia-related morbidity and mortality. For this reason, increased interaction and cooperation between surgeons, internists, and anesthesiologists are needed.
- The role of multiple risk factors in cardiovascular morbidity and mortality
BACKGROUND Cardiovascular disease remains the leading cause of death in the United States.
OBJECTIVE To identify important modifiable cardiovascular risk factors and appropriate interventions.
DISCUSSION The three most important modifiable risk factors are hypertension, cigarette smoking, and dyslipidemia. Systolic hypertension poses a greater risk than diastolic, but the prognostic significance of diastolic blood pressure may have been underestimated. When a smoker quits, the cardiovascular risk soon approaches that of the nonsmoker. Cardiovascular risk increases progressively with elevations of the serum total cholesterol level above 200 mg/dL. Recently identified risk factors include hyperinsulinemia and left ventricular hypertrophy.
CONCLUSION Each patient deserves an evaluation of cardiovascular risk followed by education about and therapy for those risk factors that can be changed. When more than one risk factor is present, as is often the case, the increase in risk may be synergistic rather than additive.
- Cardiopulmonary exercise testing in patients with chronic obstructive pulmonary disease
Defining the etiology of dyspnea, evaluating impairment, and assessing the response to therapy are among the current indications.