The promise of selective aldosterone receptor antagonists for the treatment of hypertension and congestive heart failure.

Inappropriate elevations in plasma aldosterone levels have multiple actions that play an important role in the pathophysiology of hypertension and heart failure. Patients with hypertensive cardiovascular disease are at increased risk for coronary artery disease, myocardial infarction, congestive heart failure, and sudden cardiac death. Despite long-term treatment with an angiotensin converting enzyme inhibitor or an angiotensin II receptor blocker, aldosterone levels usually remain high in these patients.

Drip and ship: a new strategy for the treatment of acute coronary syndromes.

Glycoprotein (GP) IIb/IIIa inhibitors block the final common pathway of platelet aggregation by preventing fibrinogen from binding to the GP IIb/IIIa platelet receptor. In patients with unstable angina (UA) or a non-Q wave myocardial infarction (NQWMI), including those with UA refractory to medical therapy, these agents decrease the risk of death, myocardial infarction (MI), and recurrent ischemia. Most patients with acute coronary syndromes are managed in hospitals without on-site angioplasty capabilities and often require transfer for an interventional procedure.

Differing roles of body mass and the renin-angiotensin system in mediating the hypertension syndrome.

Background: Hypertension is characterized not only by a metabolic syndrome that includes obesity and insulin resistance, but also by increases in left-ventricular mass (LVM), reduced arterial compliance and altered renal function. This investigation has examined a possible role for the renin-angiotensin system as well as body mass and insulin values in mediating these cardiovascular and renal aspects of the hypertension syndrome.

Methods: This was a cross-sectional study of 142 patients identified by community screening.

Interrupting the renin-angiotensin system: the role of angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists in the treatment of hypertension.

The renin-angiotensin system has two roles in clinical hypertension: its vasoconstrictor properties directly govern blood pressure, and its actions on arterial smooth muscle, connective tissue, and endothelial integrity affect cardiovascular prognosis. Additionally, the direct actions of angiotensin II on the function and structure of the heart and renal vasculature influence clinical events. Angiotensin-converting enzyme (ACE) inhibitors have produced functional and clinical outcome benefits in clinical trials of patients with congestive heart failure, systolic dysfunction after myocardial infarction, and diabetic nephropathy.

Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus.

Laparoscopic cholecystectomy has become the gold standard in the care of patients with cholelithiasis. A standard laparoscopic cholecystectomy employs three trocar incisions outside the umbilicus, which are a source of potential wound complications and an undesirable cosmetic outcome. We describe here a modification of the laparoscopic cholecystectomy which utilizes two transumbilical trocars and two transabdominal gallbladder stay sutures and does not require abdominal wall incisions outside the umbilicus.

Guidelines for assessing outcomes of antihypertensive treatment.

Because of the changing nature of medical practice and the need to more accurately monitor and quantify the clinical benefits and cost-effectiveness of treatment, the Sixth Report of the Joint National Committee (JNC VI) recommends that the outcomes of antihypertensive therapy be classified as short, intermediate, and long term. Short-term outcomes are most relevant to the practitioner and include such measures as blood pressure control, laboratory changes, and quality of life. In contrast, long-term outcomes, typically measured in randomized clinical trials, are of particular interest to policy makers and guidelines writers, and focus on whether treatments affect survival and the incidence of major cardiovascular events.

Unsolved problems in treating hypertension: rationale for new approaches.

Two major problems continue to challenge hypertension experts and clinical practitioners. The first is the apparently simple issue of controlling blood pressure; only one-quarter of hypertensive patients in the United States have blood pressures reduced to less than 140/90 mm Hg. Even those known to be receiving treatment have barely a 50% success rate.

A three-trocar midline approach to laparoscopic-assisted colectomy.

Several techniques have been described for the trocar placement in laparoscopic-assisted colectomy (LAC). They share the placement of four or five trocars in different areas of the abdomen. A specimen extraction incision in these techniques generally incorporates only one or two trocar sites, and combined length of these incisions approximates the length of a limited laparotomy incision for open colectomy.

Translating data on antihypertensive drugs into clinical practice.

Two problems in the treatment of hypertension continue to be largely unsolved. The first, and more simple, is our inability to adequately control blood pressure in the majority of hypertensive patients. This not only reflects the difficulty of retaining patients in effective treatment programs, but also of convincing physicians to strive for optimal blood pressure levels.

Renal actions of endothelin-1 under endothelin receptor blockade by BE-18257B.

Purpose: Endothelin-1 (ET-1), a peptide produced by the vascular endothelium, causes profound renal vasoconstriction by binding to ET-A receptors. The present study examined the renal actions of ET-1 after ET-A receptors were blocked by BE-18257B to unmask the functions of ET-B receptors.

Materials And Methods: Renal hemodynamics and clearance measurements were obtained in anesthetized dogs after intrarenal infusion of BE-18257B at 100 ng.

A laparoscopic approach to posterior gastric wall leiomyomectomy.

Leiomyomas represent 2% of gastric tumors. Commonly, gastric leiomyomas are clinically silent. Most often they become clinically apparent due to bleeding from ulceration of the overlying gastric mucosa.

A new approach in the management of incarcerated hernia. Emergency laparoscopic hernia repair.

The authors describe the case of a 74-year-old male presenting with an incarcerated epigastric hernia. An algorithm for successful management of such a case is proposed.

Familial focal segmental glomerulosclerosis: nine cases in four families and review of the literature.

Idiopathic focal segmental glomerulosclerosis (FSGS) is a common cause of glomerular disease. Although previous case reports suggesting a familial form of the disease exist in the literature, its significance has not been emphasized. We report on our experience with nine cases in four families, as well as a review of the literature, and provide evidence that a familial form of FSGS might represent a distinct genotypic and phenotypic subset of idiopathic FSGS.

Contribution of endothelin-1 to renal vasoconstriction in unilateral ureteral obstruction: reversal by verapamil.

Purpose: In unilateral ureteral obstruction (UUO) vasoconstriction occurs both during and after release of UUO. ET-1, an endogenous peptide, causes marked vasoconstriction mediated by an increase in cytosolic calcium. We measured renal output of endothelin-1 (ET-1) in dogs with UUO and examined if the renal vasoconstriction that persisted after release of UUO could be reversed by a calcium antagonist, verapamil.

Activation of endothelium-derived relaxing factor system in acute unilateral ureteral obstruction.

Purpose: To investigate the effects of 1-arginine, a substrate for nitric oxide (NO) synthase, on renal hemodynamics in acute ureteral obstruction (UUO).

Materials And Methods: Renal blood flow (RBF) and ureteral pressure (UP) were measured in anesthetized dogs with or without UUO.

Results: In 9 dogs (Group 1), RBF was 212 +/- 13 ml.

Laparoscopic-assisted repair of extensive rectosigmoid injury after colonoscopy.

Treatment of colonic injury has progressed since the recognition of the value of colostomy or bowel exteriorization during the second World War. The treatment guidelines take into consideration the time interval between perforation and treatment as well as the nature, the site, and the cause of perforation. Laparoscopic primary repair of relatively small colonic perforations without spillage of bowel content has been reported.

Laparoscopic treatment of gastric volvulus: a case report.

A case report of laparoscopic treatment of gastric volvulus in an 85-year-old man is presented. The patient did not have intraoperative or postoperative complications, tolerated a diet in 48 hours, and was discharged home 4 days after surgery. A gastric volvulus can be safely treated using laparoscopic techniques.

Laparoscopic-assisted abdominoperineal proctosigmoidectomy for rectal prolapse. A new technique.

The inability to completely mobilize the redundant colon in perineal rectosigmoidectomy (Altemeier's procedure) for full-thickness rectal prolapse is a main contributor to the recurrence rate associated with the procedure. However, the presence of a redundant sigmoid after the Ripstein procedure or other rectal sling operations is the main cause of the high rate of postoperative constipation and stool impaction. Low anterior resection as the definitive treatment is associated with the higher morbidity of laparotomy and the risk of anastomotic leak.

Measurement of short-term, intermediate, and long-term outcomes of treating hypertension.

Hypertension is widely treated by primary care physicians as well as by cardiologists and other specialists. Clinical progress is often monitored by blood pressure measurements and other routine evaluations, but more sophisticated approaches may be required to learn whether treatment is effectively protecting the heart, kidneys, and other susceptible areas. Outcome measures therefore involve quantification of short-term, intermediate and long-term clinical observations; and, in addition, assessment of overall effectiveness must take into account economic factors and the levels of satisfaction perceived by patients, physicians, and health plans.