Use of antihypertensive agents in the management of patients with acute ischemic stroke.

BACKGROUND: To protect the ischemic penumbra, guidelines have recommended against treating all but the severest elevations in blood pressure during acute ischemic stroke. OBJECTIVE: To determine how often antihypertensive agents were used in routine clinical practice and whether this use was consistent with guideline recommendations. METHODS: The records of patients discharged with ischemic stroke in 2000 at Baystate Medical Center in Springfield, MA, were reviewed. Adherence was evaluated by examining the use of antihypertensive agents in the context of daily blood pressure recordings during the first 4 days of hospitalization. Therapy was considered appropriate in the setting of severe hypertension (systolic blood pressure of >220 mm Hg or mean arterial blood pressure of >130 mm Hg) and potentially harmful in the setting of relative (systolic blood pressure of <120 mm Hg or mean arterial blood pressure of <85 mm Hg) or absolute (systolic blood pressure of <90 mm Hg or mean arterial blood pressure of <60 mm Hg) hypotension. RESULTS: One hundred (65%) of the 154 ischemic stroke patients were treated with antihypertensive agents. Forty-two percent of those who had received therapy prior to admission had their regimen intensified, and 36% of previously untreated patients had therapy initiated. Sixteen (11%) patients had hypertension severe enough to warrant treatment upon arrival, and 34 (22%) had at least one episode of severe hypertension during the first 4 hospital days. Sixty-five (65%) patients developed relative hypotension on a day when antihypertensive agents were administered, and five (5%) developed absolute hypotension. CONCLUSIONS: Most patients with acute ischemic stroke are treated with antihypertensive agents despite the absence of severe hypertension. Although low blood pressure is common among treated patients, frank hypotension is unusual.

Performance of recommended screening tests for undiagnosed diabetes and dysglycemia.

OBJECTIVE: To evaluate the performance, in settings typical of opportunistic and community screening programs, of screening tests currently recommended by the American Diabetes Association (ADA) for detecting undiagnosed diabetes. RESEARCH DESIGN AND METHODS: Volunteers aged > or =20 years without previously diagnosed diabetes (n = 1,471) completed a brief questionnaire and underwent recording of postprandial time and measurement of capillary blood glucose (CBG) with a portable sensor. Participants subsequently underwent a 75-g oral glucose tolerance test; fasting serum glucose (FSG) and 2-h postload serum glucose (2-h SG) concentrations were measured. The screening tests we studied included the ADA risk assessment questionnaire, the recommended CBG cut point of 140 mg/dl, and an alternative CBG cut point of 120 mg/dl. Each screening test was evaluated against several diagnostic criteria for diabetes (FSG > or =126 mg/dl, 2-h SG > or =200 mg/dl, or either) and dysglycemia (FSG > or =110 mg/dl, 2-h SG > or =140 mg/dl, or either). RESULTS: Among all participants, 10.7% had undiagnosed diabetes (FSG > or =126 or 2-h SG > or =200 mg/dl), 52.1% had a positive result on the questionnaire, 9.5% had CBG > or =140 mg/dl, and 18.4% had CBG > or =120 mg/dl. The questionnaire was 72-78% sensitive and 50-51% specific for the three diabetes diagnostic criteria; CBG > or =140 mg/dl was 56-65% sensitive and 95-96% specific, and CBG > or =120 mg/dl was 75-84% sensitive and 86-90% specific. CBG > or =120 mg/dl was 44-62% sensitive and 89-90% specific for dysglycemia. CONCLUSIONS: Low specificity may limit the usefulness of the ADA questionnaire. Lowering the cut point for a casual CBG test (e.g., to 120 mg/dl) may improve sensitivity and still provide adequate specificity.

Implementing practice guidelines for diabetes care using problem-based learning. A prospective controlled trial using firm systems.

OBJECTIVE: A controlled trial with 15-month follow-up was conducted in two outpatient clinics to study the effects of using the problem-based learning technique to implement a diabetes clinical practice guideline. RESEARCH DESIGN AND METHODS: A total of 144 patients with type 2 diabetes aged 25-65 years in two internal medicine outpatient clinics were enrolled in the study. African-Americans and Hispanics made up > 75% of the patients. Doctors and staff in one of the clinics were trained in the use of a clinical practice guideline based on Staged Diabetes Management. A problem-based learning educational program was instituted to reach consensus on a stepped intensification scheme for glycemic control and to determine the standards of care used in the clinic. HbA1c was obtained at baseline and at 9 and 15 months after enrollment. RESULTS: At 9 months, there was a mean -0.90% within-subject change in HbA1c in the intervention group, with no significant changes in the control group. The 15-month mean within-subject change in HbA1c of -0.62% in the intervention group was also significant. Among intervention patients, those with the poorest glycemic control at baseline realized the greatest benefit in improvement of HbA1c. The intervention group also exhibited significant changes in physician adherence with American Diabetes Association standards of care. CONCLUSIONS: Clinical practice guidelines are an effective way of improving the processes and outcomes of care for patients with diabetes. Problem-based learning is a useful strategy to gain physician support for clinical practice guidelines. More intensive interventions are needed to maintain treatment gains.

Community-acquired invasive group A beta-hemolytic streptococcal infections in Zuni Indians.

BACKGROUND: Outbreaks of invasive group A beta-hemolytic streptococcal (GABS) infections have recently been reported. We observed a high incidence of invasive GABS disease among Native Americans at a small rural community hospital between 1982 and 1991. METHODS: A retrospective chart review was performed, and all cases of invasive GABS disease were studied for their clinical features. RESULTS: Sixteen cases of invasive GABS infection were identified during the 10-year study period. The rate of invasive GABS infection was 13.3 cases per 100,000 population per year. Mortality was 25%. Nearly half of the patients presented with systemic signs of sepsis without any obvious source of infection. CONCLUSIONS: Our experience documents a high rate of invasive GABS infections in a defined Native American population. To determine whether this population has a unique susceptibility to GABS disease requires further study.