Modification of high blood pressure after myocardial infarction

A Statewide Primary Care Approach to Cardiovascular Risk Factor Control in High‐Risk Diabetic and Nondiabetic Patients With Hypertension

Patients with multiple cardiovascular risk factors benefit from having them all controlled, but this rarely occurs. Fifty-seven primary care providers were enrolled in a program to monitor cardiovascular risk factor control. Data were obtained on 7315 hypertensives. This analysis focuses on 3460 high-risk hypertensives including 2199 with diabetes and 1261 with clinical cardiovascular disease. Blood pressures were <140/90 mm Hg and <130/80 mm Hg in only 44.3% and 20.4% of diabetics and 49.6% and 26.6% nondiabetics, respectively, despite the use of an average of 2.7+/-1.8 antihypertensive medications. Among high-risk dyslipidemic hypertensives, the low-density lipoprotein cholesterol level was <100 mg/dL in only 34% of diabetic and 33% of nondiabetic patients. Among 1696 diabetic hypertensives, the most recent glycosylated hemoglobin value averaged 7.5%, with 46.6% less than 7%. Among 805 diabetic, dyslipidemic hypertensives, all three risk factors were controlled to goal in only 6.6% with higher rates in whites than in African Americans (14.8% vs. 1.6%, p<0.001). An angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or both were prescribed in 89.9% of diabetic and 70.8% of nondiabetic patients, p<0.05. Primary care providers use evidence-based combination therapy in high-risk hypertensive patients with and without diabetes. These findings confirm the low rates of multiple risk factor control and highlight challenges of reaching evidence-based goals in primary care.

The limitations of gastro-jejunal (G-J) feeding tubes in children: a 9-year pediatric hospital database analysis

BACKGROUND

A gastro-jejunal (G-J) feeding tube is a safe and useful temporizing method of providing enteral access in children. Although G-J tubes are often used to obviate the need for a surgical jejunostomy, their long-term use is often associated with mechanical failure.

AIM

To review the clinically effective durability of G-J feeding tubes in providing enteral access in children.

METHODS

We performed a retrospective review of 102 patients at the Johns Hopkins Children's Center from 1994-2003 whose underlying diagnosis necessitated the need for postpyloric enteral access.

RESULTS

Long-term follow-up was obtained in 85 (48 M; 37 F) patients with a median (range) age of 2.0 (0.1-18.0) yr. The most common indication for G-J tube placement was gastroesophageal reflux with aspiration in 51 patients and feeding intolerance and vomiting in 19 patients. The mean (range) number of tube replacements was 2.2 (1-14) over a median (range) duration of follow-up of 39 (2-474) days. The indication for G-J tube replacement included: tube displacement (58), a clogged tube (41), and a cracked tube or ruptured balloon (35). In 52 cases, the cause for G-J tube replacement was undetermined.

CONCLUSIONS

G-J feeding tubes are associated with the frequent need for tube maintenance and replacement and may not be the most feasible clinical option in providing long-term (>1 month) enteral access in children intolerant to gastrostomy tube feeds. Future studies are needed to develop innovative percutaneous jejunostomy tube placement techniques that facilitate long-term enteral access.