Lippincott's primary care practice最新文献

Despite many recent advances, heart failure continues to be a major cause of morbidity and mortality in the United States. Once a patient is identified and evaluated as having heart failure, nonpharmacologic therapies such as a dietary restrictions, lifestyle changes, exercise strategies, and patient education are initiated as well as pharmacologic therapy. Angiotensin-converting-enzyme inhibitors, diuretics, and digoxin all are considered traditional therapy in the management of chronic heart failure associated with left ventricular systolic dysfunction. The role of newer therapies such as beta-blockers and angiotensin II receptor antagonists in the treatment of heart failure is in the process of being defined. Furthermore, new data is appearing concerning calcium channel blockers, spironolactone, and combinations of the various agents. Appropriate use of the traditional agents accompanied by a through understanding of the newer therapies and their roles is essential to the continued reduction of the morbidity and mortality associated with heart failure.

Dietary supplement use has increased during the past decade. Epidemiologic studies suggest that patients turn to dietary supplements because of a reluctance to take prescription medications or a lack of satisfaction with the results. They often perceive dietary supplements to be a safer or more natural alternative. Patients with mental health conditions, including depression, anxiety, and sleep disorders, are among those who use dietary supplements. St. John's Wort is used to treat depression. Clinical studies comparing dietary supplements with low-dose antidepressants (maprotiline, amitriptyline, or imipramine at 75 mg/day) or high-dose antidepressants (imipramine at 150 mg/day) find no significant difference between treatments. Kava kava is used to treat anxiety. Clinical trials demonstrate it to be superior to placebo, and roughly equivalent to oxazepam 15 mg/day or bromazepam 9 mg/day. Agents discussed for use in sleep disorders include melatonin, valerian, 5-hydroxytryptamine, catnip, chamomile, gotu kola, hops, L-tryptophan, lavender, passionflower, skullcap, and valerian. Familiarity with the evidence for use and the possible resulting risks can help health professionals to guide patient decisions regarding use of dietary supplements.

The recent publication of the American College of Chest Physicians (ACCP) Fifth Consensus Conference on Antithrombotic Therapy provides the primary care clinician with a thorough guideline for the treatment and prevention of thromboembolic diseases. These recommendations are reviewed in this article as they relate to the outpatient management of patients receiving warfarin. Common drug-drug, drug-food, and drug-disease interactions also are reviewed along with practical dosing recommendations.

The therapeutic use of glucocorticoids are extensive despite numerous adverse effects related to their use. The fear of hypothalamic-pituitary-adrenal (HPA) axis suppression and adrenal crisis often prolongs glucocorticoid therapy unnecessarily. Glucocorticoids are the most common cause of drug-induced osteoporosis and cataract formation. Other effects of concern to the primary care provider include increased blood pressure, blood glucose, and cholesterol. Glucocorticoid therapy also may lead to avascular necrosis, growth retardation, and myopathy. Practical dosing strategies such as alternate-day therapy reduce the risk of developing most adverse effects. Several tapering regimens exist that lessen the potential for steroid withdrawal syndrome. Identifying common glucocorticoid drug interactions averts drug toxicity. By appropriately monitoring patients on long-term glucocorticoid therapy, adverse outcomes are minimized.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely prescribed medications in the world. Their use is associated with significant morbidity, commonly including gastrointestinal, renal, and hepatic effects. Other less common effects include otic, central nervous system (CNS), ophthalmic, allergic, and dermatologic effects. Recognizing and diagnosing potential complications are imperative to obtain favorable outcomes in patients on NSAIDs. Among the NSAIDs currently on the market, there exists a wide variability of incidence of organ-specific side effects. Some of these side effects are class specific, but most are not. Much research also is being performed in the field of COX-2-specific inhibitory agents, which would theoretically reduce the gastrointestinal insult of these drugs. Patient awareness through education is crucial in decreasing morbidity and preventing the adverse effects of these drugs.

A pressure ulcer is an area of localized tissue destruction directly related to prolonged pressure. The loss of skin integrity produces significant consequences not only for the individual, but also for the community, with reported costs of $8.5 billion for pressure-ulcer care. Because of these costs, health care providers should be seeking prevention programs that identify high-risk individuals and implement preventive measures before the ulcer begins. Once the individual develops an ulcer, assessment of healing is critical to determine the appropriate treatment. Successful treatment depends on the principles of debridement, cleansing, bacterial control, wound dressing, and occasionally, surgical intervention.