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A Delphi technique was used to ask general practitioners for their opinions as to which clinical problems and types of measure they thought most appropriate for the development of outcome measures for use in primary health care. The study comprised two rounds of postal questionnaires, targeted at general practitioners in academic departments throughout the United Kingdom and at trainers in the northern region, with the second questionnaire feeding back opinions from the first. Ninety eight participants suggested one or more areas in which outcome measures could be developed, giving a total of 451 suggestions. Consensus produced in the second round indicated that three clinical conditions were preferred for the development of outcome measures: asthma, diabetes and hypertension. Six categories of outcome measures were developed from the responses given in the first round--level of function, level of clinical control, incidence of complications, iatrogenic problems, patient understanding of a condition, and quality of life. Participants gave these measures different levels of importance according to the clinical problem in question. This Delphi study of doctors' opinions is a first step in the development process of appropriate, practicable measures of outcome for use in primary care and has achieved a degree of consensus among general practitioners.
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PMID:Outcome measures for primary health care: what are the research priorities? 141 43

Dentists are aware of contraindications to the use of vasoconstrictors in patients with cardiovascular diseases. However, there are some other noncardiac conditions we should know. This article discusses the absolute contraindications to the use of vasoconstrictors in patients with a history of hyperthyroidism, diabetes, allergy to sulfites, asthma, and pheochromocytoma.
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PMID:Contraindications to vasoconstrictors in dentistry: Part II. Hyperthyroidism, diabetes, sulfite sensitivity, cortico-dependent asthma, and pheochromocytoma. 835 Nov 15

Over the past decade we have seen a shift in the strategy for the treatment of hypertension, from stepped therapy--involving a highly structured, unvarying series of steps--to recommendations for more individualized treatment. How shall we accomplish that goal? Severe hypertension provides a clear indication to bypass earlier recommendations. Demographic data such as age, gender, and race, often cited, have proved less helpful. Concomitant medical problems, which are found in greater than 50% of hypertensive patients, are most often the crucial determinants in the selection of antihypertensive therapy. Concurrent coronary artery disease, diabetes mellitus, heart failure, azotemia, asthma, chronic obstructive pulmonary disease, borderline cognitive dysfunction, anxiety, and depression are all common. Each has implications for antihypertensive therapy. Moreover, blood pressure reduction is a surrogate for our real goal, which is reduction of cardiovascular risk. Thus, consideration of concomitant medical problems has extended to left ventricular hypertrophy, obesity, hyperlipidemia, and insulin resistance as additional risk factors in hypertension. Consideration of all of these factors makes it possible to individualize antihypertensive therapy in most patients.
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PMID:Evolution of the treatment of hypertension: what really matters in the 1990s? 151 35

The risk for cardiovascular complications is already substantially increased in persons with borderline elevation of arterial pressure (141-159/90-94 mmHg and transiently below). It increases progressively with higher grades of hypertension. The main aim of treatment is thus a significant improvement in survival for the patient. Persons with raised blood pressure (BP) have often additional cardiovascular risk factors such as deranged carbohydrate metabolism, dyslipidemia, left ventricular hypertrophy, smoking and others. Treatment of hypertensive patients should thus not only normalize BP but should at the same time reduce associated risk factors or at least not increase them. Conventional antihypertensive treatment based on thiazides in high doses or beta-blocking agents led to marked reduction of strokes and heart failure, but did not satisfactorily reduce coronary heart disease or sudden cardiac death. It has been suspected that other cardiac risk factors are insufficiently influenced or eventually even deteriorated by conventional therapy, thus counteracting partly a beneficial effect of lowered BP. Beta-blockers however have at least a secondary preventive effect after myocardial infarction. Newer antihypertensive drugs such as ACE-inhibitors, calcium antagonists and alpha 1-blockers reduce left ventricular hypertrophy and are at least neutral with regard to metabolism of lipids and carbohydrates. The non-thiazide diuretic indapamide and the serotonin (S2-) blocker ketanserin likewise are neutral with regard to glucose and lipid metabolism. The efficacy of these new drugs regarding long term survival is as yet undetermined. Persisting borderline or established hypertension should as a rule always be approached with basic non-pharmacologic measures: loss of overweight, reduction of alcohol intake, exercise, avoidance of high salt foods, abstention from smoking and withdrawal of BP-raising drugs. If antihypertensive medication is indicated, potential first line drugs are ACE-inhibitors, calcium antagonists, beta-blockers, thiazides at low dose, indapamide, ketanserin, the alpha 1-blocker prazosin and others; initially as monotherapy, if needed in combinations of 2 or 3. Older patients or those will with additional disturbances such as diabetes, hypercholesterolemia, nephropathy, heart failure, ischemic heart disease, arrhythmias, claudication, asthma and others need problem-adjusted modifications of treatment.
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PMID:[Antihypertensive therapy in the nineties]. 153 54

Twenty pancreata of non-diabetic patients and 17 pancreata of diabetic patients, including two patients with insulin-dependent diabetes mellitus, were immunohistochemically studied using antiserum against human islet amyloid polypeptide (IAPP). The islet beta cells in non-diabetic patients were immunoreactive for both IAPP and insulin. Amyloid deposition immunoreactive for IAPP was detected in six of 20 pancreata of non-diabetic patients. The plasma glucose level of three of these six patients was elevated to more than 200 mg/dl, and that of the other three ranged from 143 to 162 mg/dl; all six were receiving intravenous hyper-alimentation and had no history of diabetes prior to treatment. Amyloid deposition was present in all patients with non-insulin-dependent diabetes mellitus (NIDDM). The deposition was absent in the pancreata of two secondary diabetic patients, one of whom had received steroid hormone for bronchial asthma and the other of whom had liver cirrhosis with hepatocellular carcinoma; deposition was also absent in the pancreas of a patient with impaired glucose tolerance diagnosed on a 75-g oral glucose load. Heterogeneous expression of immunoreactivities of beta cells for insulin and for IAPP was present, suggesting independently regulated production and secretion of the peptides. Immunoreactivity of beta cells was more sensitively decreased for IAPP than for insulin in the islets of NIDDM patients. The decreased immunoreactivity for IAPP suggested an initial stage of disturbed beta-cell function, even if the immunoreactivity for insulin was apparently intact or the amyloid deposition in the islets was insignificant. The degree of amyloid deposition immunoreactivity for IAPP did not necessarily reflect the severity of diabetes mellitus. Amyloid deposits were seen at the narrow spaces beneath the insular capsule of connective tissues and the perivascular region or, in some cases, occupying the whole of the islet. The diabetogenic role of IAPP is unclear, but the deposition might be an accelerating factor which disturbs beta-cell function.
Diabetes Res Clin Pract 1992 Jan
PMID:Islet amyloid polypeptide (IAPP) and pancreatic islet amyloid deposition in diabetic and non-diabetic patients. 154 Dec 32

Investigated the impact of childhood chronic illness within a family context. We interviewed 30 mothers of 6- to 14-year-old children with asthma or diabetes and 30 mothers of healthy children of the same age and sex. Family functioning, extrafamilial social support available to mothers, and child life stress events were examined in relation to the children's psychological adjustment and illness events. The mothers of asthmatic children reported a greater number of internalizing behavior problems in their children, perceived their own social support as less adequate, and reported a greater number of stressful events. Regression analyses demonstrated that family functioning, maternal social support, and chronic illness were significantly related to the psychological adjustment of the child. The importance of family functioning and resources available to the family, such as social support, are discussed as protective influences in coping with childhood chronic illness.
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PMID:Childhood chronic illness as a family stressor. 154 20

To determine the cost-effectiveness of selective use of nonionic low-osmolality contrast material, the authors randomly assigned 955 patients to receive high-osmolality and 1,158 to receive low-osmolality intravenous contrast material. All patients had one or more of the following perceived risk factors for adverse reactions: prior reaction to contrast material, allergies, asthma, diabetes, cardiac or renal disease, anxiety, severe illness, and age greater than 50 years. The occurrence of any adverse event, need for therapy, or subjective symptoms was assessed in a double-blind fashion. An adverse reaction necessitating the attention of a physician occurred in 3.9% (n = 37) of patients in the high-osmolality and 0.9% (n = 10) of patients in the low-osmolality groups (P less than .000005). Therapy was administered to 1.4% (n = 13) and 0.5% (n = 6), respectively (P = .035). The difference was due to a reduction in urticaria and other mild anaphylactoid reactions. In a multivariate analysis, only prior reactions and allergy were independent risk factors. Selective use of intravenous nonionic contrast material is best justified in those with prior reactions, allergy, or asthma; at least 67% of reactions would be prevented.
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PMID:Nonionic low-osmolality versus ionic high-osmolality contrast material for intravenous use in patients perceived to be at high risk: randomized trial. 154 74

This study measured the prevalence of chronic medical conditions in 4,549 middle aged persons attending three large general practices in Dublin over the course of a calender year. The prevalence of the following conditions were measured: coronary heart disease, hypertension, stroke, diabetes, asthma, chronic bronchitis, rheumatic disorders, dyspepsia, depression, anxiety disorders, psychoses, and cancer. In order to obtain a valid denominator for the study a second community based study was carried out in the same areas to determine what proportion of persons visit their general practitioner over the course of a year. Overall 40.5% of males and 44% of females suffered from a least one of the twelve conditions, with rheumatic disorders having the highest prevalence (14.5%) and psychotic disorders the lowest (0.75%).
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PMID:General practice estimates of the prevalence of common chronic conditions. 147 57

The relationship of stature with the prevalence of 18 chronic diseases or groups of diseases was analysed using data from the 1983 Italian National Health Survey, based on a sample of 63,859 individuals aged 20 or over randomly selected within strata of geographical area, size of the place of residence and of the household in order to be representative of the Italian population. Rate ratios (RR) were computed using multiple logistic regression, including terms for sex, age, geographical area, education and smoking. For 15 out of 18 diseases or groups of diseases the RR was below unity in the highest quartiles of height, and the inverse trends with stature were significant for 11 (diabetes, RR 0.90 for highest vs lowest quartile; heart disease, RR 0.92; chronic bronchitis and emphysema, RR 0.84; bronchial asthma, RR 0.70; anaemias, RR 0.70; liver cirrhosis, RR 0.62; urolithiasis, RR 0.76; renal insufficiency, RR 0.71; arthritis, RR 0.89; psychiatric and neurological disorders, RR 0.82). None of the diseases considered showed significant direct trends with height, but hypertension (RR 1.09 for the highest vs lowest quartile), haemorrhoids or varices (RR 1.09) and cancers (RR 1.22) tended to be elevated in the highest quartile of height. The generalised inverse relationship between height and prevalence of chronic disease suggests that poorer nutrition in childhood and adolescence is an unfavourable indicator for the subsequent occurrence of several diseases. Major exceptions were hypertension and varices, two conditions highly dependent on the pattern of health care utilization, and cancer.
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PMID:Height and the prevalence of chronic disease. 160 29

A sample of 1377 physicians were surveyed by mailed questionnaire to study to what extent primary care physicians are involved in the long-term care of children with chronic disorders. The sample included all pediatricians practicing in the province of Quebec and a stratified random sample of general practitioners (10% sample in urban areas and 25% sample in rural areas). A response rate of 81% was achieved. Referral patterns were studied for asthma, congenital heart disease, and diabetes. Although pediatricians referred their patients less frequently than general practitioners, referral patterns depended mainly on the clinical condition. "No routine referral" was the most popular management strategy for asthma, whereas for congenital heart disease and diabetes more than 20% of physicians referred their patients for all aspects of care. Rural physicians tended to assume patient care to a greater extent than did urban physicians. Most pediatricians referred patients directly to subspecialists practicing in tertiary care centers, whereas general practitioners often sent patients to pediatricians practicing elsewhere, or to other specialists. These data suggest that the availability of medical resources in the community and accessibility to tertiary care centers also influence physicians' involvement in the long-term care of these children.
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PMID:Referral patterns for children with chronic diseases. 161 83


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