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New information concerning the risk of mild unrecognized increased in blood pressure on mortality and a new definition of normal blood pressure levels necessitate reevaluation of the relationships between oral contraceptives (OCs) or estrogens and blood pressure changes. Several aspects of the relationship of OCs to blood pressure and to cardiovascular diseases can be summarized. A rise in blood pressure occurs in virtually all women who use OCs for 6 months or longer. These prospective studies involved 60,000 women, 35,000 of them using birth control pills. After 5 years of OC use, a mean increase in systolic pressure of 12.3 mm Hg and of diastolic, 8.8 mm Hg was seen in these normotensive females. The current evidence indicates that a high risk group likely to develop contraceptive hypertension cannot be identified, but there are characteristics which are known to increase the risk of cardiovascular disease such as heart attacks and strokes in all OC users. These include cigarette smoking, diabetes, and hyperlipidemia. In such susceptible persons, extreme caution is advised in prescribing estrogens in order to reduce the likelihood of premature cardiovascular disease. The increase in blood pressure associated with OC administration is generally mild, yet it may be progressive. Discernible increases in blood pressure normally occur as early as 6 months after OC use begins, and the greatest increase in blood pressure is usually seen during the 1st 2 years of OC use. It is prudent to monitor blood pressure at least every 6 months in women receiving estrogens and OCs. Developing the most effective therapeutic approach to estrogen induced hypertension, when withdrawal of the estrogen source is not feasible, would be enhanced by a clear understanding of the mechanisms by which the hypertension occurs. In general, any of these mechanisms can increase blood pressure independently or in combination: fluid volume expansion, vasoconstriction, and the sympathetic nervous system. The influence of estrogens on these factors is reviewed. When hypertension is encountered in a woman receiving estrogens, the ideal 1st step is discontinuation of the estrogen source. In some patients the severity of the hypertension or the presence of complications necessitates emergency treatment. The use of diuretics, antisympathetic agents, vasodilators, and parenteral agents for malignant hypertension represents an appropriate sequence to follow in such cases.
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PMID:Estrogens and hypertension. 710 45

One hundred cases of hypertensive complications due to irregular drug-therapy were studied in medicine units of Dhaka Medical College Hospital for the period of one year from February 7, 1989 to February 6, 1990. Among those stroke had headed the list (48%) manifesting in various ways e.g. cerebral haemorrhage with focal neurological signs--hemiplegia, hemiperesis, aphasia etc. Hypertension associated with varying degrees of cardiac ischaemias and heart failure was seen in 14% and 10% cases respectively. Highest incidence of complications was seen in 1-5 years after detection of hypertension with mean age of 55 +/- 18.70 years. Out of 48 cases of strokes, smoker were 41 (75.92%). Regarding reasons of noncompliance of drugs, personal carelessness was the prominent one (47%). Among the risk-factors for atherosclerosis family history tops the list (66%). Diabetes coexists with hypertension in 13% cases. Ocular complications were seen in 06% cases of malignant hypertension with variable retinal changes.
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PMID:Study of complications in hypertensive patients having irregular treatment. 803 Dec 88

Besides defining the appropriate doses of frusemide in uraemic patients, A. Heidland's contribution to the treatment of hypertension in chronic renal failure consisted in the following demonstrations: (1) In patients on chronic haemodialysis, calcium antagonists have a beneficial effect on their glucose intolerance and decreased plasma levels of 25OH vitamin D while their effect on blood lipids is neutral. (2) In 5/6 nephrectomized rats, captopril, verapamil, and metoprolol have the same protective effect on their GFR and tubular secretion of protons, at equal blood-pressure-lowering effect. (3) In rats with streptozotocin-induced diabetes, atrial natriuretic peptide does not play a role in their hyperfiltration. (4) Severe retinopathy is observed in patients with uraemic nephropathies at a much smaller elevation of their blood pressure than in patients with essential hypertension. This article reviews the following points: (1) The role of hypertension in the loss of renal function is convincingly demonstrated only in a few experimental models, and in man only in malignant hypertension and diabetic nephropathy but not in essential hypertension nor in non-diabetic nephropathy. However, preliminary results suggests that antihypertensive treatment may retard the progression of renal disease in normotensive patients (DBP <90 mmHg) with either microalbuminuric diabetes and normal renal function or non-diabetic uraemic nephropathy. (2) Only the ACE inhibitors have been proved to have a specific renal protective effect, independent of their diurnal blood-pressure-lowering effect, both in diabetic nephropathy and in non-diabetic uraemic nephropathy.
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PMID:Hypertension and progression of renal insufficiency. 807 21

Treatment of hypertension reduced markedly (by more than 40%) the prevalence of cerebrovascular attacks, the prevalence of cardiac failure, malignant hypertension and ophthalmological complications of hypertension. The impact of antihypertensive treatment on the incidence of ischaemic heart disease is less marked. The wide use of diuretics and beta-blockers is supported by the fact that large studies of antihypertensive treatment revealed that they reduced the cardiovascular mortality and morbidity in a marked way. On the other hand, diuretics exert a negative effect on insulin resistance, glucose tolerance, cholesterol and may lead to hypokalaemia and hyperuricaemia. Non-selective beta-blockers are not optimal from the aspect of the risk profile of hypertensive patients. Therefore there is justified hope that wider use of calcium antagonists, beta-blockers of the third generation, ACE inhibitors and selective alpha 1 blockers will have a greater impact on IHD, as these drugs do not exert a negative effect on metabolic risk factors. At present an individual approach to treatment which takes into account other diseases present or complications of hypertension, in particular diabetes and hyperlipoproteinaemia, is the basic approach so far and the basis of therapeutic tactics.
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PMID:[Current trends in antihypertensive therapy: pro and con]. 837 69

Feedback control is an important mechanism for reaching a targeted goal. Biologic examples range from achieving the appropriate blood pressure level to glycemia control. Computer-based feedback control systems have many potential applications in medicine. Closed-loop systems directly sense the state of the patient and then deliver an intervention without human action. Closed-loop systems have been used to control postoperative fluid infusion, reduce malignant hypertension to a reasonable range through nitroprusside infusions, and control continuous insulin infusions-in effect, an artificial pancreas. Sensory problems have limited the direct application of closed-loop systems to date; most current medical uses of computer-based feedback control are open loop, where a human is interposed between the suggested intervention and the delivered treatment. Because many variables important to the management of diabetes are objective, many opportunities exist for open-loop control in diabetes management. Open-loop systems have already been used to suggest insulin dosage adjustments and treatment for hypercholesterolemia and to remind physicians of various mellitus. However, existing applications have only scratched the surface. Many more facets of diabetes management could be standardized and assisted by open-loop control systems if the management rules could be more exactly specified, a task requiring substantial time commitments by diabetologists. Efforts to translate existing knowledge bases into precise guidelines will be helpful, but new primary studies and decision analyses are needed to define the optimal use of some interventions.
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PMID:The promise of computerized feedback systems for diabetes care. 855 13

New South African guidelines are proposed by the Hypertension Society of Southern Africa for the management of hypertension by primary health care services in South Africa. Specific South African guidelines are appropriate for hypertension, which is now recognised as one of the five major diseases that must be given priority by the new Government. Furthermore, patient participation and empowerment in blood pressure (BP) control become feasible through the new concept of lifestyle modification. This article gives the rationale underpinning these guidelines. The correct methods to measure blood pressure (BP), with patients sitting for 5 minutes, correct cuff-size and repeated readings, are emphasised to eliminate the 'white coat' effect and ensure accurate BP readings. The rationale for the overall management of all atherosclerosis-related risk factors is given, as are the principles of non-drug hypertension treatment and patient education. We emphasise that patients must understand hypertension to be a risk factor and not a disease. Patients should also be empowered to contribute to effective BP control. The justification for the chosen BP levels at which specific action is required by the primary health care team is given. The BP levels span the range from mild hypertension, requiring conservative treatment schedules, to possible malignant hypertension, which requires urgent management and referral to the appropriate level of care. The motivation for cost-effective antihypertensive drug therapy is provided. The recommended initiation of drug therapy is with effective, safe low-cost drugs. Suggested first-line therapy comprises lifestyle management and low-dose diuretics. The second-line drugs, in order of increasing price, are low-dose reserpine, or a beta-blocker, or a calcium blocker, or an ACE inhibitor. For third-line therapy hydralazine is chosen, or other second-line drugs could be added. Where possible, the examples of specific drugs given are those for which a generic is available, to ensure cost-containment. The motivation for drug choices for hypertension in special cases such as pregnancy, the elderly, blacks and patients with diabetes and renal disease is given. The management of malignant hypertension receives special attention.
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PMID:Rationale for the hypertension guidelines for primary care in South Africa. 860 Jun 5

Continuous or intermittent use of unfractioned heparin is the anticoagulant of choice to prevent the extracorporeal circulation clotting during the hemodialysis session. However, low molecular weight heparin (LMVH) could be an alternative treatment especially in case of high risk bleeding or during some clinical conditions such as diabetes mellitus, cerebrovascular bleeding, malignant hypertension. LMVH may be given as a single initial bolus injection generally adequate. Heparinization must be lowered or stopped when an effective anticoagulation is previously used.
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PMID:[Anticoagulation of the extracorporeal circuit in chronic hemodialysis]. 967 63

The appearance of diabetes in advanced age may be considered as a part of the involutive processes of aging, and as such, it might have a pathogenesis completely different from that of type 2 diabetes of medium age. As a matter of fact, it has been observed that the pancreas undergoes numerous structural and functional alterations with advancing age, both in exocrine and endocrine parts. The present studies have been performed to reveal the quantity and quality of the pancreatic lesions, which may be attributed to atherosclerosis. We have already studied elderly subjects, therefore, we were now looking for further supports in a population of middle age people, died in complications of malignant hypertension. We investigated the pancreas, kidney and heart of 36 subjects (20 males and 16 females) with mean age of 48.6+/-8.9 years. Of this group, eight subjects (22.2%) became diabetic after the appearance of malignant hypertension. Arteriolar atherosclerosis damage (hyalinosis, thickening and stenosis) of the pancreatic arterioles were found in 92.8% of the non-diabetic, and in 87.5% of the diabetic subjects. Lesions of the pancreatic islets were observed in 32% of the non-diabetics, and in 50% of the diabetic subjects. The pancreas is an organ, which tends particularly to develop atherosclerotic damage. The vascular lesion of atherosclerotic origin, independently from the mechanism of its appearance, causes first only a decrease of the blood flux and hypoxia in the pancreatic islets with a consecutive functional decline of the beta-cells. This is then followed by structural modifications of the islets accompanied by the appearance of hyalinosis, loss of beta-cells, and a further decrease of insulin production.
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PMID:Atherosclerosis and pancreatic damage. 1131

For various ethnic and socioeconomic reasons the pattern of renal disease in the inner city displays distinctive features. Hypertension is frequent, often intractable, and generally conditioned by salt sensitivity and a high sodium intake. Chronic hypertensive nephrosclerosis, found predominantly in African Americans, comprises marked cardiomegaly, renal shrinkage, and hypertensive retinopathy. It has been overdiagnosed in the past, but actually accounts for less than 20% of end-stage renal disease (ESRD) in African Americans. Malignant hypertension, less frequent nowadays, may cause renal shutdown, which is reversible in a few cases; the heart and kidneys are often of normal size. Idiopathic focal segmental glomerulosclerosis is the most common cause of the primary nephrotic syndrome in blacks, but its incidence has also been rising in whites and Hispanics; it does not respond well to treatment, and almost one half of the patients develop ESRD within 10 years. Systemic lupus erythematosus is also more common in African Americans, in whom the severe proliferative forms of lupus nephritis pursue a more virulent course: one half of such patients develop ESRD in 5 years. Cocaine, the use of which has assumed epidemic proportions, may cause accelerated hypertension, acute renal failure from rhabdomyolysis, and progression of preexisting renal disease. Heroin nephropathy has all but disappeared and has been replaced by human immunodeficiency virus (HIV) nephropathy. The prognosis of HIV-infected patients maintained by dialysis has greatly improved. Sickle glomerulopathy, consisting of mesangial expansion, basement membrane duplication, and the absence of immune deposits, may cause the nephrotic syndrome in 4% of patients with severe sickle cell anemia, heralding death within 2 years in one half of patients and ESRD in two thirds; survival has not improved with dialysis. Diabetes is now the most common cause of ESRD. Familial aggregation of ESRD is frequently encountered. Interventions useful in the general population, such as vascular bypass procedures, should be undertaken with great caution and restraint in dialysis patients.
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PMID:Renal disease in the inner city. 1145 21

A 53-year-old woman was admitted because of hypertension and diabetes mellitus. Elevated diastolic blood pressure, hypertensive retinopathy and renal dysfunction indicated malignant hypertension. Adrenocorticotropic hormone (ACTH) and cortisol levels were high although there were no Cushingoid features. One mg dexamethasone administration decreased neither ACTH nor cortisol levels. Brain magnetic resonance imaging revealed a left pituitary tumor (7 mm x 6 mm). Upon removal, the tumor showed positive ACTH staining by immnohistochemistry, and was diagnosed as pituitary ACTH-secreting adenoma (Cushing's disease). Her blood pressure, renal function, blood glucose and hormone levels subsequently improved. Malignant hypertension and deteriorated diabetes mellitus may have been due to subclinical Cushing's disease.
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PMID:Subclinical Cushing's disease accompanied by malignant hypertension and diabetes mellitus. 1213 26


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