The place of diuretics in preventing cardiovascular events.

Low-dose diuretics are recommended for the initial choice of antihypertensive therapy in the 7th US Joint National Committee report and are accepted as an appropriate choice among other classes of drugs in the 2003 European Society of Hypertension guidelines. The rationales for the use of low-dose diuretics include the following: Renal dysfunction interfering with normal natriuresis is likely a fundamental defect in the pathogenesis of hypertension. Subtle renal insufficiency that interferes with sodium excretion is a common consequence of uncontrolled hypertension. Diuretic-based therapy has been clearly documented in placebo-controlled, randomized trials to reduce cardiovascular morbidity and mortality, particularly in the treatment of elderly hypertensives.In multiple comparative trials, diuretic-based therapy has been shown to provide equal cardiovascular protection to that provided by newer agents. Diuretics enhance the antihypertensive efficacy of all other classes of agents. As lower blood pressure goals of therapy have been found to be needed, diuretic enhancement of other agents' efficacy has become even more essential. With such low doses, side effects are minimal in degree and infrequent in appearance.

Microbiology of wound infection after caesarean section in a Jordanian hospital.

To determine the microbiology of wound infection following caesarean section and to evaluate the use of Gram stain for the predicton of subsequent microbiological culture results, 1319 surgical wounds were followed up. We did Gram stains and cultures on exudates from open wounds and on aspirates if the wounds had demonstrable fluid collection. Incidence of post-caesarean wound infection was 8.1%. Ninety-three (86.9%) of 107 infected wounds were culture positive, with Staphylococcus aureus the most frequently found organism (42%). Organisms seen by Gram stain yielded a sensitivity of 96.6%, specificity of 88.9%, positive predictive value of 97.7% and negative predictive value of 84.2% when used to predict positive culture results for bacterial wound infection.

Use of thermonuclease testing to identify Staphylococcus aureus by direct examination of blood cultures.

Blood cultures submitted to the Clinical Microbiology Laboratory, Queen Alia Military Hospital, Amman during 1999-2001 were examined to evaluate thermonuclease testing for identifying Staphylococcus aureus in blood culture broths growing gram-positive cocci. Of 170 cultures studied, 129 yielded gram-positive staphylococci and 41 yielded other gram-positive cocci. Toluidine blue-deoxynucleic acid agar plates were used to test for thermonuclease activity. Standard tube coagulase tests were performed on the isolates. Direct detection of thermonuclease activity in 76 blood culture broths containing gram-positive staphylococci showed 100% correlation with subsequent tube coagulase tests. The thermonuclease test provides a fast, specific and reliable confirmation of S. aureus bacteraemia by direct examination of blood culture broths that contain gram-positive cocci. This allows for timely, optimal antibiotic therapy.

Microbiology of wound infection after caesarean section in a Jordanian hospital

To determine the microbiology of wound infection following caesarean section and to evaluate the use of Gram stain for the predicton of subsequent microbiological culture results, 1319 surgical wounds were followed up. We did Gram stains and cultures on exudates from open wounds and on aspirates if the wounds had demonstrable fluid collection. Incidence of post-caesarean wound infection was 8.1%. Ninety-three [86.9%] of 107 infected wounds were culture positive, with Staphylococcus aureus the most frequently found organism [42%]. Organisms seen by Gram stain yielded a sensitivity of 96.6%, specificity of 88.9%, positive predictive value of 97.7% and negative predictive value of 84.2% when used to predict positive culture results for bacterial wound infection

Use of thermonuclease testing to identify Staphylococcus aureus by direct examination of blood cultures

Blood cultures submitted to the Clinical Microbiology Laboratory, Queen Alia Military Hospital, Amman during 1999-2001 were examined to evaluate thermonuclease testing for identifying Staphylococcus aureus in blood culture broths growing gram-positive cocci. Of 170 cultures studied, 129 yielded gram-positive staphylococci and 41 yielded other gram-positive cocci. Toluidine blue-deoxynucleic acid agar plates were used to test for thermonuclease activity. St and ard tube coagulase tests were performed on the isolates. Direct detection of thermonuclease activity in 76 blood culture broths containing gram-positive staphylococci showed 100% correlation with subsequent tube coagulase tests. The thermonuclease test provides a fast, specific and reliable confirmation of S. aureus bacteraemia by direct examination of blood culture broths that contain gram-positive cocci. This allows for timely, optimal antibiotic therapy

[The challenge to treat hypertensive patients with type 2 diabetes]. / Le défi du traitement de l'hypertension chez les diabétiques de type 2.

A MAJOR PROBLEM: High blood pressure and type 2 diabetes is a increasingly frequent condition. Microalbuminuria is an independent risk factor of cardiovascular complications. THERAPEUTIC STRATEGY: Because of the risk of cardiovascular disease, a treatment designed to lower the blood pressure should also reduce the microalbuminuria. Indapamid SR is an excellent choice.

Hypertension and diabetes.

Diabetes and hypertension will become increasingly common as the population becomes older and more obese. Together, they markedly increase cardiovascular and renal damage, placing all diabetic hypertensives at high risk. Fortunately, the appropriate use of lifestyle changes and multiple drugs will always slow and often stop the progression of this damage.

Management of hypertension in patients with type 2 diabetes mellitus: guidelines based on current evidence.

Hypertension and diabetes are becoming increasingly common. Most patients with both disorders have a markedly worsened risk for premature microvascular and macrovascular complications. The appropriate management of the hypertension seen in almost 70% of patients with type 2 diabetes mellitus remains controversial. However, over the past few years, many randomized, controlled trials have provided guidance for more effective therapy. These trials have established the need for a lower goal blood pressure (<130/80 mm Hg) than has previously been recommended. In addition, they have proven the efficacy of drugs from three major classes of antihypertensive agents; however, comparative trials have failed to show definite superiority of any particular class in either lowering blood pressure or reducing cardiovascular morbidity and mortality. To achieve therapy goals, multiple antihypertensive drugs are usually needed. On the basis of their apparent superiority in slowing diabetic nephropathy, angiotensin-converting enzyme inhibitors should probably be the first choice. Second and third choices should be a long-acting diuretic and a calcium-channel blocker or a beta-blocker, respectively. Attention should also be directed toward nonpharmacologic and pharmacologic control of hyperglycemia and dyslipidemia.

Treatment of coexisting diabetes and hypertension.

The rapidly growing number of patients with coexisting diabetes and hypertension must be intensively treated to protect them from their very high risk for premature cardiovascular morbidity and mortality. After careful ascertainment of their out-of-the-office blood pressure, and testing for postural hypotension, therapy should consist of both lifestyle modifications and antihypertensive drugs. Usually, two or more such drugs are needed to bring blood pressure below the 130/85 mm Hg level. In addition, control of hyperglycemia and dyslipidemia is usually required. Despite the costs and difficulties of achieving adequate control of these diseases, such patients can be protected from the debilities of diabetes and hypertension.

Hypertension trials: 1990 to 2000.

A large number of randomized controlled trials have been published over the past decade. The earlier ones established the benefits of low-dose diuretic-based therapy. The more recent ones have documented the equal overall effectiveness of therapy based on an angiotensin-converting enzyme inhibitor or a calcium antagonist. The comparative data do not clearly define a single superior drug for most hypertensive patients, so the initial choice should be individualized, on the basis of the concomitant conditions. For the rapidly increasing population of diabetic hypertensive patients, similar conclusions are obvious, with the caveat that an angiotensin-converting enzyme inhibitor should usually be the initial choice, with diuretics and calcium antagonists usually needed to accomplish adequate control. There are no concerns about the use of calcium antagonists in diabetic patients.

Management of hypertensive patients with multiple cardiovascular risk factors.

Most hypertensive patients have additional cardiovascular risk factors. Therefore, as stressed in all recent guidelines from expert committees, an evaluation of all risk factors and an assessment of each patient's individual risk status is needed before deciding upon the need for therapy and the type of therapy to be given. In particular, attention must be directed at those risk factors that may be involved in the pathogenesis of hypertension: obesity, excessive sodium intake, physical inactivity, and stress. If active therapy is needed for established hypertension, all modifiable unhealthy lifestyles should be addressed along with appropriate drug therapy.

Low-dose combination therapy: the rationalization for an ACE inhibitor and a calcium channel blocker in higher risk patients.

As more high-risk hypertensives are treated and the need for more intensive antihypertensive therapy is recognized, combination therapies are increasingly used. For initial therapy, particularly for relatively low-risk patients, low-dose combinations are often appropriate. For those who require additional therapy, higher doses of combinations may provide further efficacy while minimizing dose-dependent side effects of monotherapy, thereby improving adherence to therapy. Those combination agents should provide 24-h control with one daily dose, thereby ensuring protection in the early morning hours. Combining an angiotensin converting enzyme inhibitor and a calcium channel blocker is a rational approach to treating hypertension. Not only does it provide significantly better blood pressure control than individual components used as monotherapy, it also minimizes dose-dependent side effects. Also, combining agents from different classes results in complementary mechanisms of action that provide other cardiovascular protective benefits.