Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions.

'Masked hypertension' is defined as having non-elevated clinic blood pressure (BP) with elevated out-of-clinic average BP, typically determined by ambulatory BP monitoring. Approximately 15-30% of adults with non-elevated clinic BP have masked hypertension. Masked hypertension is associated with increased risks of cardiovascular morbidity and mortality compared with sustained normotension (non-elevated clinic and ambulatory BP), which is similar to or approaching the risk associated with sustained hypertension (elevated clinic and ambulatory BP). The confluence of increased cardiovascular risk and a failure to be diagnosed by the conventional approach of clinic BP measurement makes masked hypertension a significant public health concern. However, many important questions remain. First, the definition of masked hypertension varies across studies. Further, the best approach in the clinical setting to exclude masked hypertension also remains unknown. It is unclear whether home BP monitoring is an adequate substitute for ambulatory BP monitoring in identifying masked hypertension. Few studies have examined the mechanistic pathways that may explain masked hypertension. Finally, scarce data are available on the best approach to treating individuals with masked hypertension. Herein, we review the current literature on masked hypertension including definition, prevalence, clinical implications, special patient populations, correlates, issues related to diagnosis, treatment and areas for future research.

Practical use of the pessary.

The pessary is an effective tool in the management of a number of gynecologic problems. The pessary is most commonly used in the management of pelvic support defects such as cystocele and rectocele. Pessaries can also be used in the treatment of stress urinary incontinence. The wide variety of pessary styles may cause confusion for physicians during the initial selection of the pessary. However, an understanding of the different styles and their uses will enable physicians to make an appropriate choice. Complications can be minimized with simple vaginal hygiene and regular follow-up visits.

Physostigmine in the treatment of gamma-hydroxybutyric acid overdose.

The widespread abuse of the recreational drug gamma-hydroxybutyric acid has resulted in several reports of overdose leading to coma. The use of a short-acting anticholinesterase agent such as physostigmine as a potential reversal agent has been proposed previously. We report 2 cases of gamma-hydroxybutyric acid-induced coma that rapidly reversed with intravenous administration of physostigmine.

Rectal prolapse during pregnancy. A case report.

BACKGROUND: Rectal prolapse is a bothersome surgical problem that is relatively infrequent. It usually occurs in the fifth to seventh decades of life and is more common in women. CASE: A 33-year-old woman, gravida 3, para 2, was found to have a large rectal prolapse at 33 weeks' gestation. Manual reduction was successfully performed after injecting 2% lidocaine into and around the anal sphincter. Because she could not undergo definitive surgical repair during her pregnancy, the patient was managed with an aggressive stool softening regimen and self-reduction techniques. Labor was induced in the 40th gestational week. Epidural anesthesia was employed, and delivery was accomplished via low-outlet forceps application. The patient underwent definitive surgical repair of the rectal prolapse eight weeks postpartum. CONCLUSION: Rectal prolapse is a rare condition during the childbearing years. We found no prior case reports of rectal prolapse occurring during pregnancy. While childbirth itself is not considered a risk factor for rectal prolapse, a prior history of perineal lacerations may be a risk factor. To manage rectal prolapse that occurs during pregnancy, consideration should be given to passive forceps delivery under epidural anesthesia to avoid the possibility of worsening the prolapse.

Newer pharmacologic alternatives for erectile dysfunction.

With the introduction of effective pharmacologic therapies for erectile dysfunction, more men are seeking treatment. The underlying cause of erectile dysfunction is usually a chronic medical illness or a side effect of certain drugs. Less commonly, the problem is psychogenic. Even after optimal treatment of common medical disorders such as diabetes mellitus and hypertension, erectile dysfunction may persist. Pharmacologic treatments, such as the intracavernosal or transurethral administration of alprostadil or the use of the new oral medication sildenafil, may offer patients substantial benefit. Before any of these drugs are prescribed, consideration should be given to existing medical illnesses and medications, partner satisfaction, comfort with the method of administration and the side effect profile.

Toxic ingestion of gamma-hydroxybutyric acid.

Gamma-hydroxybutyric acid (GHB) has become a popular new drug of abuse. Its effects include euphoria and disinhibition. Recently, several cases have been reported in the literature of life-threatening or lethal ingestions. We report the case of a 17-year-old male who became unresponsive after taking GHB. Gamma-hydroxybutyric acid is used outside the United States to treat narcolepsy. In the past, it was touted as a muscle-bulking aid and was taken by body-builders. It has also been implicated as a drug involved in "date-rapes." Patients who ingest excessive GHB have a markedly altered level of consciousness, as did the patient in this illustrative case. Neostigmine and physostigmine show promise as potential reversal agents. Gamma-hydroxybutyric acid overdose should be considered in any patient with altered mental status and a history of recreational drug abuse.

Breast-feeding with ectopic axillary breast tissue.

Axillary breast tissue, which may be an extension of the tail of Spence, is a normal variant that has been reported in the literature relatively infrequently, although it may be present in a number of asymptomatic women. If axillary breast tissue becomes symptomatic, this usually occurs during pregnancy or immediately postpartum when a woman begins breast-feeding. Symptoms are swelling and pain due to engorgement. A literature review revealed that management is generally conservative, with cessation of breast-feeding to allow regression of the tissue. This report describes a woman who successfully pumped her axillary breasts to relieve pain and engorgement; this allowed her to continue breast-feeding for several weeks. Axillary breast tissue should be monitored for pathologic change.

Primary upper-extremity deep venous thrombosis.

Using an illustrative case, this report reviews the entity of primary upper-extremity deep venous thrombosis, also known as Paget-Schroetter syndrome. The entity of Paget-Schroetter syndrome is important to military physicians because of its occurrence in young, healthy, active individuals such as those in our active duty population. A review of the literature was performed and it was concluded that a multimodal approach to therapy, as was done in this case, gives the best overall results.