The American journal of medicine
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The third-generation cephalosporins are useful for empiric therapy of most of the severe infections in adults as a result of their broad spectrum of antimicrobial activity (particularly against clinically important gram-negative bacteria), good tissue penetration, and lack of serious adverse effects. This review examines their use in respiratory tract infections, bacterial meningitis, skin-structure infections, and urinary tract infections in adult patients. Penicillin G remains the optimal therapy for severe community-acquired pneumonia, since Streptococcus pneumoniae still accounts for the majority of cases. ⋯ However, in meningitis in which gram-negative bacilli are suspected and where specific problems include antibiotic resistance among these organisms and the inadequate penetration of many antibiotics into the cerebrospinal fluid, third-generation cephalosporins are the drugs of choice, and they have markedly improved the clinical outcome. Most skin-structure infections are due to S. aureus and are best treated by an anti-staphylococcal penicillin or an older cephalosporin. Nevertheless, the third-generation cephalosporins have proved to be highly effective agents for infections of skin and soft-tissue infections associated with both gram-positive and gram-negative pathogens in patients at risk from these organisms or in the elderly.
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The limited data available from the long-term clinical trials on the treatment of hypertension, as well as several short-term studies, indicate that the lowering of blood pressure in minority patients is feasible over the long term with a marked decrease in morbidity and mortality. The presence of left ventricular hypertrophy and diabetes in a higher number of black compared with white patients does not appear to be a major determining factor in the choice of initial monotherapy. ⋯ When these latter agents are added to a diuretic, however, a good blood pressure response is achieved. There are few data available on the results of long-term treatment in Asian or Hispanic persons.
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The treatment of high blood pressure in black people is often complicated by a variety of factors. These include the tendency of black hypertensive patients to have three to five times the cardiovascular mortality of white hypertensive patients, black hypertensives' more frequent progression to end-organ damage and stroke, and socioeconomic conditions that impede access to proper health care. In addition, blacks have a unique hemodynamic profile, one that alters the efficacy of many antihypertensive drugs. ⋯ First, they present a better profile in terms of overall cost and compliance, thanks to their lower relative cost and once-a-day dosing. Second, when diuretics are combined with another antihypertensive therapy, such as an ACE inhibitor or a calcium-entry blocker, responsiveness may be further improved. This combination therapy may be especially important in black hypertensives, who exhibit a higher incidence of concurrent diseases such as left ventricular hypertrophy and congestive heart failure.
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Despite recent advances in both prevention and treatment, cardiovascular disease remains the leading cause of mortality in the United States. One of the major modifiable risk factors for cardiovascular disease, hypertension, is a leading cause of stroke, kidney disease, and diseases of the heart and coronary circulation. Essential hypertension is the most common cause of systemic blood pressure elevation and it responds readily to both pharmacologic and non-pharmacologic treatment. ⋯ For both blacks and Hispanics, however, the decreases in cardiovascular mortality have been less striking. Many factors could account for this disparity, among them the availability of health care facilities in minority neighborhoods, and the health-care-seeking behavior of the patients themselves. Understanding epidemiologic and pathophysiologic data regarding differences between blacks, Hispanics, and non-Hispanic whites will help reduce hypertension-related morbidity and mortality.
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Complaints of insomnia and disordered sleep are pervasive among the elderly, and reduced total sleep time and changes in sleep architecture are considered to be normal in the aging process. Additionally, numerous medical and psychiatric disorders that are highly prevalent in the geriatric population are known to affect sleep adversely. ⋯ Moreover, approximately 23 percent of Americans over age 85 reside in long-term care facilities, and institutionalization is an important risk factor for disordered sleep and for sedative hypnotic prescription. Consequently, the evaluation of any sedative hypnotic agent must include substantial assessment of efficacy, safety, and tolerance in geriatric patients.