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 277,896 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Pulmonary mucormycosis is relatively uncommon but an important opportunistic fungal infection in immunocompromised persons. The literature on the subject is sparse. We describe a recent case and review the literature to delineate the clinical characteristics of this infection. We searched the MEDLINE database for articles published in the English-language literature since 1970 and carefully analyzed 87 cases. The main risk factors were diabetes mellitus, hematologic cancers, renal insufficiency, and organ transplantation. Several patients had no apparent immune compromise. There was a predilection for involvement of the upper lobes. Air crescent signs on chest x-ray films were predictors of pulmonary hemorrhage and death from hemoptysis. Fiberoptic bronchoscopy was a useful diagnostic method, and histopathologic examination was more sensitive than fungal cultures. The overall survival rate was 44%. Patients treated with a combined medical-surgical approach had a better outcome than patients who did not undergo surgery. Thus, this relatively rare but often fatal disease should be suspected in immunocompromised patients who fail to respond to antibacterial therapy. Early recognition and aggressive management are warranted to maximize chances for cure. Optimal therapy requires systemic antifungal therapy, surgical resection, and, when possible, control of the patient's underlying disease.
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PMID:Pulmonary mucormycosis: the last 30 years. 1038 6

Tight glucose control with intensive therapy in patients with type 1 diabetes (formerly known as juvenile-onset or insulin-dependent diabetes) can delay the onset and slow the progression of retinopathy, nephropathy and neuropathy. Optimal blood glucose control is defined by a target glycosylated hemoglobin level of less than 7 percent, a preprandial glucose level of 80 to 120 mg per dL (4.4 to 6.7 mmol per L) and a bedtime glucose level of 100 to 140 mg per dL (5.6 to 7.8 mmol per L). This article provides guidelines to help family physicians teach patients with type 1 diabetes how to achieve tight glucose control to help minimize complications. Guidelines include maintaining blood glucose levels at near normal by taking doses of short-acting insulin throughout the day supplemented by a nighttime dose of intermediate-acting insulin, monitoring blood glucose levels frequently, following a prudent diet, exercising regularly and effectively managing hypoglycemia, as well as empowering patients to lead their control efforts and rigorously controlling other risk factors for cardiovascular disease. Support from physicians, family members and friends is crucial to the success of a regimen of tight glucose control.
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PMID:Educational guidelines for achieving tight control and minimizing complications of type 1 diabetes. 1056 96

Patients with diabetes and/or severe arteriosclerosis are often unable to tolerate volume removal during hemodialysis (HD) and develop hemodialysis-induced symptoms. These problems can be omitted by well-balanced correction of the acid/base status. We compared 20 high-risk patients which were either treated with standard HD (dialysate bicarbonate 33 mmol/l, treatment A) or treated with standard HD and additional administration of NaHCO3 (120-160 ml 8.4% NaHCO3 solution over the venous line during HD) to correct the metabolic acidosis to upper normal values (treatment B). The following parameters were compared: 1. Acid/base status; 2. EEG monitoring and clinical observation of dialysis-induced symptoms; 3. Invasive monitoring of circulation by Swan-Ganz thermodilution; 4. Ventilation, oxygen consumption and lactate production. Optimal correction of acid/base values resulted in symptom-free hemodialysis sessions with stable PaCO2 in the normal range, cardiovascular stability assessed by invasive monitoring, normal ventilation and higher oxygen consumption and decreased lactate production. Optimal correction of acid/base balance further led to the absence of EEG alterations and of dialysis-induced symptoms during treatment B as compared to treatment A. The baroreceptor response in these patients is usually disturbed due to sclerosis of the pressosensible vessels, especially the aortic arch and the pulmonary arteries impairing a compensatory increase of heart rate upon volume removal. However, chemoreceptors are able to increase sympathetic tone with preservation of blood pressure in this situation. In addition a decrease of PaO2 during volume removal can only be answered by an early increase of ventilation response due to stimulation of chemoreceptors provided that PaCO2 is maintained normal. Furthermore, normal cerebral blood flow also depends on a normal PaCO2. Based on these pathophysiological mechanisms the therapeutic strategy of additional bicarbonate administration to correct the acid/base status guarantees a stable normal PaCO2 and facilitates a symptom-free HD in high-risk patients.
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PMID:How can hemodialysis-associated hypotension and dialysis-induced symptoms be explained and controlled--particularly in diabetic and arteriosclerotic patients? 1074 10

This review attempts to highlight the potential of calcium-channel blockers in the prevention of sequelae of diabetes mellitus and hypertension in patients who have both disorders. Evidence-based medicine is driven by the results of randomized, clinical trials. Major contributions were therefore derived from post hoc analyses of the diabetic patients enrolled in placebo-controlled trials, such as Systolic Hypertension in the Elderly Program (SHEP), Systolic Hypertension in Europe (Syst-Eur), and Systolic Hypertension in China (Syst-China), and stepped-care blood-pressure-oriented trials, such as the Hypertension Optimal Treatment (HOT) and United Kingdom Prospective Diabetes Study (UKPDS). Several studies, such as the Fosiniprl; versus Amlodipine Cardiovascular Events Trial (FACET) and Appropriate Blood Pressure Control in Diabetes (ABCD) Trial, have compared the relative merits of angiotensin-converting enzyme and calcium-channel blockers in preserving renal function and metabolic balance in diabetic patients with hypertension, but their publications focused on cardiovascular disorders, which were only secondary end points. On balance, the articles reviewed prove that dihydropyridine calcium-channel blockers score particularly well in the prevention of cardiovascular complications in diabetic patients with hypertension.
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PMID:Treatment of diabetic patients with hypertension. 1098 Oct 70

The recommendations of several authoritative bodies that blood pressure be lowered to lower-than-traditional goals in patients with high-risk hypertension have recently been validated by data from several randomized clinical trials. In the Hypertension Optimal Treatment (HOT) trial, the best prognosis was in diabetic patients treated to a diastolic blood pressure of 80 mm Hg. In the United Kingdom Prospective Diabetes Study 38, a major reduction in nearly every type of cardiovascular event was noted among patients with type II diabetes who were treated to the lower blood pressure goal of less than 150/85 mm Hg. In the quality-of-life substudy of the HOT trial, the greatest improvement was found in patients treated to the lowest diastolic blood pressure goal of less than or equal to 80 mm Hg. Two economic analyses suggest that attainment of the lower blood pressure goal not only is possible and effective in reducing cardiovascular risk but also saves money overall by reducing expenditures for stroke, myocardial infarction, and other cardiovascular events.
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PMID:Intensive antihypertensive treatment to the new lower blood pressure targets. 1098 Oct 83

The Hypertension Optimal Treatment study was a large, randomized, multicenter study to determine the answers to two questions: 1) what is the optimal target blood pressure to be sought in the treatment of patients with moderate hypertension? and 2) does low dose aspirin therapy decrease morbidity and mortality in patients with hypertension? After 3.8 years of follow-up for the almost 19,000 patients, the following conclusions from the study could be ascertained 1) lowering diastolic blood pressure in patients with diabetes to levels below 80 mm Hg decreases the risk of major cardiovascular events and cardiovascular mortality compared with lowering it to "normal" (< 90 mm Hg) levels. It may lower total mortality, but this study was not powered for this end point; 2) aspirin therapy, in patients with hypertension, is safe and decreases major cardiovascular events and acute myocardial infarction; 3) there does not appear to be an additional effect on cardiovascular mortality or overall mortality below that observed with a reduction of diastolic blood pressure to less than 90 mm Hg for the population as a whole; and 4) the lowest cardiovascular event rate for the population as a whole was achieved at a diastolic blood pressure of 83 mm Hg. Several limitations to this study exist, including the low event rate achieved and the generalizability of this study to the average nondiabetic patient with hypertension seen in clinical practice.
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PMID:The Hypertension Optimal Treatment Study: what did it give us? 1098 Oct 87

Diabetes mellitus without previous myocardial infarction carries the same risk of a future myocardial infarction as someone who has had one. Intense glucose, lipid, and blood pressure control in diabetic patients is advocated to reduce cardiovascular events and decrease the incidence of end-stage renal disease, retinal damage, and peripheral vascular disease. Recent studies, including the Systolic Hypertension in the Elderly Program, indicate that low-dose diuretics, compared with placebo, reduce fatal and nonfatal myocardial infarctions but not fatal and nonfatal strokes in diabetic patients. Similarly, captopril (and diuretics) compared with diuretics and beta-blockers decreased fatal and nonfatal myocardial infarctions but not fatal and nonfatal strokes in the Captopril Prevention Project. Intense blood pressure therapy with captopril and intense blood pressure therapy with atenolol equally lowered macrovascular and microvascular events compared with less intense blood pressure treatment in the United Kingdom Prospective Diabetes Study. Fewer myocardial infarctions were seen with enalapril than with nisoldipine in the Appropriate Blood Pressure Control in Diabetes trial. Intense blood pressure control with felodipine, enalapril, and hydrochlorothiazide reduced overall cardiovascular events and mortality but not myocardial infarction and strokes in the Hypertension Optimal Treatment trial. Nitrendipine alone or together with enalapril and hydrochlorothiazide decreased fatal and nonfatal strokes and cardiovascular mortality but not myocardial infarctions in the Systolic Hypertension in Europe trial. These trials, in aggregate, reinforce the importance of intense blood pressure control, which can be achieved only with combination drug therapy rather than a specific monotherapy drug class recommendation.
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PMID:Controversies surrounding the treatment of the hypertensive patient with diabetes. 1098 Nov 15

Irreversible, nonenzymatic glycation of the haemoglobin A beta chain leads to the formation of haemoglobin A1c (HbA1c), a stable minor haemoglobin component with enhanced electrophoretic mobility. The rate of formation of HbA1c is directly proportional to the ambient glucose concentration. HbA1c is commonly used to assess long-term blood glucose control in patients with diabetes mellitus, because the HbA1c value has been shown to predict the risk for the development of many of the chronic complications in diabetes. There are currently four principal glycohaemoglobin assay techniques (ion-exchange chromatography, electrophoresis, affinity chromatography and immunoassays) and over 20 methods that measure different glycated products. The ranges indicating good and poor glycaemic control can vary markedly between different assays. At the moment values differ between methodologies and even between different laboratories using the same methodology. Optimal use of HbA1c testing requires standardisation. There is progress towards international standardisation and improved precision of HbA1c which will lead to all assays reporting results in a standardised way. Clinicians ordering HbA1c testing for their patients should be aware of the type of assay method used, the reference interval, potential assay interferences (e.g. haemoglobinopathies, chronic alcohol ingestion, carbamylation products in uraemia) and assay performance. And they should know that a variety of factors have been shown to directly influence HbA1c values, e.g. iron deficiency anaemia, chronic renal failure and shortened red blood cell life span.
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PMID:[What you always wanted to know about HbA1c]. 1099 66

Results from the United Kingdom Prospective Diabetes Study showed that intensive treatment of type 2 (non-insulin-dependent) diabetes mellitus, with sulphonylureas or insulin, significantly reduced microvascular complications but did not have a significant effect on macrovascular complications after 10 years. Insulin resistance plays a key role in type 2 diabetes mellitus and is linked to a cluster of cardiovascular risk factors. Optimal treatment for type 2 diabetes mellitus should aim to improve insulin resistance and the associated cardiovascular risk factors in addition to achieving glycaemic control. Treatment with sulphonylureas or exogenous insulin improves glycaemic control by increasing insulin supplies rather than reducing insulin resistance. Metformin and the recently introduced thiazolidinediones have beneficial effects on reducing insulin resistance as well as providing glycaemic control. There is evidence that, like metformin, thiazolidinediones also improve cardiovascular risk factors such as dyslipidaemia and fibrinolysis. Whether these differences will translate into clinical benefit remains to be seen. The thiazolidinediones rosiglitazone and pioglitazone have been available in the US since 1999 (with pioglitazone also being available in Japan). Both products are now available to physicians in Europe.
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PMID:Antidiabetic drugs present and future: will improving insulin resistance benefit cardiovascular risk in type 2 diabetes mellitus? 1112 20

The principles of managing type 2 diabetes mellitus in the elderly are no different from those in younger patients, but the priorities and therapeutic strategies need to be cautiously individualised. The objectives of treatment are to improve glycaemic control in a stepwise approach that involves nonpharmacological methods including diet and exercise, and pharmacological therapy including mixtures of oral antihyperglycaemic agents alone or in combination with insulin. Although the goals of treatment may be the same for elderly and younger patients, certain aspects of type 2 diabetes in the elderly require special consideration. Treatment decisions are influenced by age and life expectancy, comorbid conditions and severity of the vascular complications. Adherence to dietary therapy, physical activity, and medication regimens may be compromised by comorbid conditions and psychosocial limitations. Drug-induced hypoglycaemia has been the main consideration and the most serious potential complication. In addition, the long term macrovascular and microvascular complications of type 2 diabetes are a source of significant morbidity and mortality. Indeed, vascular and neuropathic complications are already present at the time of diagnosis in a significant number of patients, and the impact of improved diabetes control depends on the age and life expectancy of the patient. Age-related changes in pharmacokinetics and the potential for adverse effects and drug interactions should also be considered when choosing appropriate pharmacological therapy. In general, a conservative and stepwise approach to the treatment of the elderly patient with type 2 diabetes is suggested; treatment may be initiated with monotherapy, followed by early intervention with a combination of oral agents including a sulphonylurea as a foundation insulin secretagogue in addition to a supplemental insulin sensitiser. Insulin therapy is eventually required if significant hyperglycaemia [glycosylated haemoglobin (HbA1c) >8%] persists despite oral combination therapy. Combination therapy with evening insulin and a long-acting sulphonylurea such as glimepiride is an effective strategy to improve hyperglycaemia in the elderly patient with type 2 diabetes in whom polypharmacy with oral agents is unsuccessful. In addition, such a regimen is simple to follow for the patient who may not be able to adhere to a more complicated insulin regimen. Hyperglycaemia in the elderly can be managed well with practical intervention and a straightforward treatment plan to enhance compliance. Optimal glycaemic control should be possible for every patient if treatment is individualised; however, strict glycaemic control may not be achievable in all patients or even desirable in many elderly patients.
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PMID:Management of type 2 diabetes mellitus in the elderly: special considerations. 1123 37


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