NEJM -- Recent Issues

21 September 2008

Evaluation of Hypertension

Hypertension significantly increases the risk of developing coronary disease, heart failure, renal failure, and stroke. Risk further increases dramatically in the presence of smoking, glucose intolerance, hyperlipidemia, left ventricular hypertrophy (LVH), male gender, African American race, or increasing age. Treatment of hypertension greatly reduces its morbidity and mortality risks
The definition of hypertension is somewhat arbitrary because actuarial data show that morbidity and mortality related to complications of hypertension increase almost linearly with increasing levels of either systolic blood pressure (SBP) or diastolic blood pressure (DBP).

The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC), a national consensus group, has issued several reports that include recommendations of the classification of hypertension. they designate three stages:
• Prehypertension: DBP 80 to 89 mm Hg, SBP 120 to 139 mm Hg
• Stage 1: DBP 90 to 99 mm Hg, SBP 140 to 159 mm Hg
• Stage 2: DBP 100 mm Hg or greater, SBP 160 mm Hg or greater.
Establishing the Diagnosis
1. Measurement of Blood Pressure
Blood pressure is properly measured in both arms while the patient is seated comfortably, with feet on the floor, and after resting for 5 minutes. Coffee intake and smoking should be halted at least 30 minutes before taking the pressure
2. Number of Blood Pressure Determinations and Settings
Use of proper technique for measurement of the blood pressure is essential (see Chapter 14 and later discussion). Except in patients with severely elevated blood pressure, the diagnosis of hypertension should almost always be based on multiple determinations of blood pressure, preferably not only on different visits, but also by different personnel and in different settings. As noted earlier, there is a tendency for blood pressures to be higher when taken by a physician than when taken by a nurse or other medical worker
3. Home and Office Determinations
Teaching the patient to check his or her pressure at home and at work can greatly facilitate diagnosis and management, but home determinations should be viewed as an adjunct, not as a replacement for office-based measurements. Home determinations are diagnostically useful when there is concern the office reading might represent white-coat hypertension caused by patient anxiety. Home determinations are usually lower than those obtained in the office
4. Ambulatory Blood Pressure Monitoring
When there is a marked discrepancy between home and office pressures or a wide variation in pressures obtained throughout the day, 24-hour ambulatory monitoring may be useful, though usually it is unnecessary and quite expensive
• On encountering blood pressure elevation, confirm the diagnosis, but do not test for underlying pathophysiology (except in cases of suspected secondary hypertension) because such testing is not yet sufficiently accurate to aid in clinical decision making.
• Check for and rule out any clinically suggested secondary causes.
• Assess the severity of the blood pressure elevation.
• Identify any target-organ (end-organ) damage.
• Identify any and all concurrent cardiovascular risk factors, including clinically overt cardiovascular disease.
• Combine these risk determinations into an overall estimate of cardiovascular risk

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20 Desember 2007

Treatment strategies in GERD

The goals of treatment of GERD are to :

  1. Relieve symtoms
  2. Heal oesophagitis
  3. Maintain remmision
  4. Improve quality of life
  5. Prevent complications

Medication the have been used to relive GERD include antacids, prokinetic agent, histamine 2 resceptor antagonist (H2RA) and PPIs. PPIs are the most effective treatment for control of symptoms and healing of oesohagitis and erosive GERD.
While antacids are use for treatment of GERD, ther is only one out of three studies that shows evidence of antacid efficacy in relieving GERD symtoms. H2RA are mos effective than placebo for relieving mild to moderate GERD symtoms with a response rate between 60% to 70%.
Short term trials using PPIs have shown faster healing raes and more complete heart burn relief than H2RA of prokinetics in patiens with erosive GERD. Amongst the PPIs, standar doses have resulted in comparable helaing and remission rates in erosive oesophagitis. For NERDthe PPIs are also significantly superior to prokinetic agents in heartburn remission and to H2RA in overall symptom improvement. However they have a lower efficacy (10% - 30% less) in NERD patients than in patients with erosive GERD.

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Pancreatoblastoma is a primary malignant tumor of the pancreas consisting of an epithelial component showing acinar differentiation, nests of squamoid cells (or squamoid corpuscles), and occasional endocrine cells. There may be a mesenchymal component in some tumors. Although the tumor has a predilection for children, it has also been reported in adults. Synonyms for this tumor include pancreaticoblastoma and carcinoma of the pancreas, infantile type

Pancreatoblastoma presents as a solitary mass that can arise in any location in the pancreas. The tumor tends to be relatively large, ranging from 7 to 18 cm, and on cross section it has been described as being tan-yellow with incomplete lobulations. The consistency may vary from soft and fleshy to focally fibrous, and there may be areas of necrosis and hemorrhage. Cystic change may be present, and on rare occasion a gritty texture has been described due to abundant calcification.
Pancreatoblastoma may have a partial fibrous pseudocapsule, but there is often invasion into adjacent pancreas, duodenum, or soft tissues. The first case of pancreatoblastoma was illustrated in 1959 by Frantz , and it was the same case reported by Becker in 1957 as the first pancreatic tumor in a child (a 15-month-old boy) treated by pancreaticoduodenectomy.

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