Fibromyalgia

(Great Britain—The Practitioner, May 1998, p. 407.) Although “fibromyalgia syndrome” was formally described in 1981, identical or closely related conditions have been discussed in the medical literature for almost 100 years. The key features of fibromyalgia are musculoskeletal pain in the upper and lower body that persists for at least three months, specific tender points on digital pressure and sleep disturbance. Associated conditions include fatigue, depression, headache, irritable bowel syndrome, anxiety and a syndrome similar to Raynaud's phenomenon. Fibromyalgia is most prevalent in women between 30 and 50 years of age and may account for 2 percent of visits to primary care physicians. Laboratory values are usually within normal ranges, and physical examination may be normal apart from tender points. Despite the lack of objective evidence of abnormality, one quarter of patients report that their symptoms are sufficiently severe to prevent working and to significantly interfere with daily activities. Medication, including analgesics, antidepressants and muscle relaxants, may be helpful in reducing symptoms but generally are not efficacious. Programmed exercises and encouragement for patients to manage their own condition may be useful, but the most effective therapy appears to be explaining the condition and allowing the patient opportunities to fully discuss and learn about the condition.

Hypertension During Pregnancy

(Canada—Canadian Family Physician, June 1998, p. 1245.) Severe chronic maternal hypertension with diastolic pressure consistently above 110 mm Hg (especially during the first trimester) dramatically increases the risk of unfavorable outcomes for both mother and fetus. In evaluating drug treatment for hypertension during pregnancy, the potential for teratogenicity and fetal toxicity must be considered. Methyldopa has been extensively studied and has proved to be effective and safe for both mother and fetus. Hydralazine also has been demonstrated to be efficacious, with few reports of adverse effects. Calcium channel blockers have been tested in small numbers of patients but have not been linked to congenital malformations or poor perinatal outcomes. Beta-adrenergic drugs have been associated with fetal bradycardia and intrauterine growth retardation, but it has not been established to what extent these adverse effects are attributable to hypertension as opposed to therapy. In women with salt-sensitive hypertension or left ventricular dysfunction, diuretic therapy is effective and safe for treatment of hypertension but should be discontinued if fetal growth retardation or preeclampsia is suspected. Fetal toxicity has been reported with the use of angiotensin converting enzyme inhibitors. During the second and third trimesters, these agents may induce fetal kidney failure.

New Drugs for Hypertension

(Australia—Australian Family Physician, April 1998, p. 235.) Several new drugs are under development to improve the effectiveness and acceptability of therapy for hypertension, based on improved understanding of the pathophysiology of the disease. Trials of angiotensin II receptor antagonists, designed to provide more complete blockade of the renin-angiotensin system than angiotensin converting enzyme (ACE) inhibitors, report efficacy and improved tolerability for these agents. Dual metalloprotease inhibitors act as ACE inhibitors, with the added blockade of related enzymes resulting in additional vasodilation plus reduction in renin production. Endothelin receptor antagonists are designed to block vasoconstricting peptides, which are believed to play an important role in essential hypertension. These and other advances should allow individualized antihypertensive therapy, improving compliance as well as efficacy.

Gradual Loss of Vision

(Australia—Australian Family Physician, March 1998, p. 143.) The most common causes of gradual vision loss in adults are diabetes, cataract, macular degeneration and open-angle glaucoma. Vision loss associated with diabetes is usually a result of diabetic retinopathy, which increases in prevalence with the duration of the disease and is inversely related to the adequacy of glycemic control. Cataract is characterized by gradual opacification of the lens, which presents as blurring, myopia and difficulty in coping with glare. Macular degeneration is a common cause of irreversible central vision that results in difficulty in recognizing faces and the loss of reading and driving abilities. Treatment is rarely helpful, but peripheral vision is usually maintained. Chronic open-angle glaucoma is asymptomatic until significant irreversible vision field loss has occurred. Screening and treatment can prevent loss of vision, but the lack of symptoms makes compliance a significant issue with this condition.