123rc/medical_text huggingface dataset:
Precipitated abstinence in orally dosed benzodiazepine-dependent dogs. The ability of graded doses of flumazenil (2, 6, 18, 36 and 72 mg/kg) and a lactose placebo to precipitate abstinence was studied in dogs treated chronically with diazepam, nordiazepam, flunitrazepam, alprazolam, oxazepam, halazepam and lorazepam by oral dosing. A scale comprised of 10 precipitated abstinence signs, the Benzodiazepine Precipitated Abstinence Scale, was developed, which yielded linear flumazenil log-dose response lines with significant slopes in dogs dependent on diazepam, nordiazepam and flunitrazepam. The effects of 18, 36 and 72 mg/kg of flumazenil in otherwise drug naive dogs were studied. In naive dogs, the most prominent effect of flumazenil was to reduce activity. All benzodiazepines studied produced dependence that was characterized by signs of precipitated abstinence; however, the intensity and quality of abstinence varied from one benzodiazepine to another. Precipitated abstinence in dogs treated chronically with diazepam and flunitrazepam was characterized by a dose-related increase in clonic convulsions and Benzodiazepine Precipitated Abstinence Scale scores. This pattern differed from that seen in nordiazepam- and alprazolam-dependent dogs, which showed a comparable flumazenil dose-related increase in clonic convulsion but only a modest increase in Benzodiazepine Precipitated Abstinence Scale scores. Oxazepam and lorazepam produced dependence that was less intense than that seen with the other benzodiazepines. Plasma levels of the benzodiazepines and their metabolites were repeatedly determined after single doses and during addiction cycles. Nordiazepam accumulated in diazepam- and nordiazepam-dependent dogs and alpha-OH alprazolam accumulated in alprazolam-dependent dogs. Other drugs and metabolites did not. These observations suggest that: 1) different benzodiazepines or their metabolites produce different types of physical dependence, suggesting that they or their metabolites have different mechanisms and sites of action; 2) plasma cumulation of the benzodiazepines or their active metabolites is an important factor in the genesis of physical dependence; and 3) metabolism of benzodiazepines plays an important role in their dependence-producing capacity, and because of differences in the way species metabolize benzodiazepines, the type of dependence produced in different species may differ.
Highly sensitized patients with delayed graft function: a management protocol. The postoperative management of the highly sensitized renal transplant recipient with delayed graft function on cyclosporine is complicated. Allografts with delayed graft function are reported to have a 20 to 30% poorer 1-year survival than allografts without delayed graft function. Several factors may be implicated in this poorer 1-year survival. A decrease in or cessation of cyclosporine dosage frequently is used in an attempt to minimize nephrotoxicity. Such under-immunosuppression can result in irreversible rejection. Occasionally, a pessimistic view of the prognosis for the transplant may result in early abandonment of the allograft with discontinuation of immunosuppression and allograft nephrectomy. We report on 3 highly sensitized patients whose kidneys had delayed graft function and were deliberately maintained on high doses of cyclosporine throughout the period of delayed graft function. Each graft achieved function (2, 4 and 5 months) after transplantation. The serum creatinine levels 20, 28 and 38 months after transplantation were 2.7, 2.0 and 1.0 mg./dl., respectively. We suggest that the maintenance of high cyclosporine levels throughout the delayed graft function period is useful in highly sensitized recipients and was an important factor in their successful outcome. A management protocol for such patients is proposed.
Oligoclonal T cell receptor gene rearrangements in blood lymphocytes of patients with acute Epstein-Barr virus-induced infectious mononucleosis. Gene rearrangement studies were performed on blood lymphocytes from eight patients with acute Epstein-Barr virus-induced infectious mononucleosis. The diagnosis in each case was based on characteristic clinical, hematologic, and serologic findings. The blood lymphocytes in each patient consisted predominantly of CD8+ T cells. EBV DNA was detected in seven patients by Southern blot analysis (EBV Bam HI W probe, Bam HI). A germline configuration was found for the immunoglobulin heavy and light chain genes (JH probe, Bam HI and Eco RI; C kappa probe, Bam HI; and C lambda probe, Eco RI). T cell receptor gene rearrangements were detected with J gamma and J beta 1 + 2 probes. Using a J gamma probe with two different restriction enzymes (Bgl II and Eco RI), the blood from each patient showed several bands corresponding to the polyclonal pattern previously described in the blood of normal individuals. Using J beta 1 + 2 probes with two different restriction enzymes (Bgl II and Bam HI), each case showed from 3 to about 12 extragermline bands of varying intensity and in different locations from case to case. In addition, each case showed relative deletion of the J beta 1 germline band. This oligoclonal pattern of T cell receptor gene rearrangements has not been previously reported in benign or malignant T cell populations.
A new method of haemodynamic assessment of mitral stenosis in atrial fibrillation: construction of a nomogram. Accurate haemodynamic assessment of mitral stenosis by hydraulic formulas requires measurement of the mean valve gradient and the cardiac output. The calculation is laborious, particularly in the presence of atrial fibrillation when averaged values obtained from multiple beat-to-beat determinations must be used. The relations between valve area, end diastolic gradient, and heart rate in 20 patients with mitral stenosis and atrial fibrillation were examined. In each patient the end diastolic pressure gradient for each cardiac cycle was related linearly to the RR interval of that cycle, and this relation was unchanged on exercise. The slope (S) and intercept (I) of this relation correlated with the degree of mitral stenosis as measured by the Gorlin valve area. The regression equations describing these relations were then used to construct a nomogram relating end diastolic pressure gradient to mitral valve area at different heart rates. When the nomogram was applied to catheterisation data from a further 30 patients the results correlated well with direct calculation of valve area by the Gorlin formula. The nomogram is simple to use, does not require measurement of cardiac output, and is independent of heart rate so that it is unnecessary for the patient to exercise during catheterisation.
Indications for use of ketoconazole in management of metastatic prostate cancer. Newer methods of androgen ablation for the treatment of metastatic prostatic carcinoma have been developed as alternatives to the standard forms of therapy, oral estrogens and surgical castration. The purpose of this review is to elucidate the indications and to determine the role of ketoconazole in the management of metastatic prostatic cancer. Eighteen patients have been treated with ketoconazole. The indications for usage have included: prompt therapeutic response, when orchiectomy is contraindicated, when estrogens are contraindicated, initial empirical therapy, and hormonally refractory disease. It can also be used in conjunction with luteinizing hormone-releasing hormone analogues. Ketoconazole is excellent for short-term usage prior to bilateral orchiectomy and when prompt therapeutic response is needed but orchiectomy cannot be performed. However, it is not particularly useful for long-term hormonal therapy.
Rectovulvar fistula in a child secondary to an unusual foreign body. Foreign bodies in the female genital tract are well recognized as a cause of pain, discharge, secretions, and infection. In the small child, the presence of a vaginal discharge is usually associated with either a common object which has been inserted or sexual abuse complicated by a sexually transmitted disease. A 3-year-old child presented with a recurrent labial secretion and drainage due to an unusual foreign body. It was only during a second operation that the possibility of a foreign body was entertained, and diagnostic testing was begun. A third operation permitted removal of the foreign body, a large bone probably of animal origin. The fistula tract was closed after a colostomy was performed. This represents the first reported case of a rectovulvar fistula not of a congenital nature.
Perinatal mortality in Victoria, Australia: role of group B Streptococcus. Group B beta-hemolytic streptococcus is the most common infective cause of neonatal morbidity and mortality. It is therefore surprising that no agreement exists for an approach to its prevention. There is also increasing evidence that occult infection may play an etiologic role in premature rupture of the membranes and preterm labor. In this report we review the role of group B beta-hemolytic streptococcal sepsis as a cause of perinatal wastage in the state of Victoria, Australia during the period 1982 to 1987. Group B beta-hemolytic streptococcus accounted for 1.7% of overall perinatal deaths, and for 30.3% (77 of 254) perinatal deaths directly attributable to infection. By comparison, over the same 6-year period, erythroblastosis accounted for 0.5% of perinatal wastage and there were only two deaths as a result of congenital syphilis. The true incidence of lethal group B beta-hemolytic streptococcal infection is probably greater because of the absence of histologic and bacteriologic studies in many perinatal deaths. We believe that intrapartum chemoprophylaxis with penicillin of all group B beta-hemolytic streptococcus-positive carrier mothers would significantly reduce neonatal morbidity and mortality from this cause.
Frequency of myocardial indium-111 antimyosin uptake after uncomplicated coronary artery bypass grafting. The reported incidence of myocardial damage after coronary artery bypass grafting (CABG) is highly related to the methods used. Since indium-111 monoclonal antimyosin antibody scintigraphy has been shown to be highly specific and sensitive for myocardial necrosis, even in small lesions, uptake of this radiotracer was evaluated after CABG. In 23 consecutive patients without previous myocardial infarction who underwent CABG for stable angina, 80 MBq indium-111 antimyosin was injected on the third postoperative day. Planar images were obtained 48 hours later and analyzed for myocardial uptake of indium-111 antimyosin. Scintigraphic results were related to creatine kinase MB levels, duration of both aortic cross-clamping and cardiopulmonary bypass, and electrocardiographic changes. In all patients surgical procedure and postoperative course was uncomplicated. Indium-111 antimyosin uptake was present in 19 of 23 patients (82%). It was diffused in 7 patients and localized in 12. No pathologic Q waves occurred postoperatively. Fourteen patients exhibited ST-segment changes. No good relation was found among indium-111 antimyosin uptake and creatine kinase MB levels, duration of cross-clamping or bypass, and ST-T changes. It is concluded that some degree of myocardial damage, though silent, is common after CABG.
Comparison of labetalol versus enalapril as monotherapy in elderly patients with hypertension: results of 24-hour ambulatory blood pressure monitoring. PURPOSE: This study compared the safety and efficacy of labetalol and enalapril as antihypertensive therapy for elderly patients. PATIENTS AND METHODS: A randomized, open-label, parallel controlled trial was conducted. After completing a 4-week placebo phase, 79 elderly (65 years or older) patients with an average standing diastolic blood pressure (BP) 95 mm Hg or above and 114 mm Hg or less were randomized to receive a 12-week course of either labetalol or enalapril in an open-label design. The patients' BP and heart rate were evaluated biweekly by trained observers unaware of the treatment status, and drug dosage was titrated (up to 400 mg twice a day of labetalol or 40 mg daily of enalapril) to achieve a standing diastolic BP of less than 90 mm Hg and a decrease of 10 mm Hg from baseline. Patients underwent 24-hour ambulatory BP monitoring (ABPM) at the end of the placebo phase and again after 8 weeks of active treatment. RESULTS: The treatment groups were comparable in their reduction of supine diastolic BP, with no significant differences between the two treatments. Labetalol demonstrated a significantly greater reduction (p less than 0.05) in standing diastolic BP at the end of the titration period compared to enalapril, but this difference was not significant by the end of the study period. Based on 24-hour ABPM readings, labetalol reduced mean 24-hour diastolic BP (p less than 0.05) and mean heart rate (p less than 0.05) more than enalapril. The labetalol-treated patients were significantly less often above their diastolic BP goal throughout the 24-hour ABPM period (p less than 0.01). The two treatments were equally well tolerated. CONCLUSIONS: The results indicate that labetalol and enalapril are equally effective in lowering supine diastolic BP in the elderly, but labetalol is more effective in lowering ambulatory BP and heart rate throughout the day.
Embolism during caesarean section. We investigated the occurrence of gas embolism during Caesarean section using a Doppler ultrasound probe and found that it occurs between uterine incision and delivery. Embolism is less common during general anaesthesia than has been reported during regional anaesthesia. Both ruptured membranes and a protracted uterine incision to delivery interval predispose to embolism.
Value of ventricular electrogram recordings in the diagnosis of arrhythmias precipitating electrical device shock therapy. An antitachycardia pacemaker-cardioverter-defibrillator that is capable of storing ventricular electrograms before and after delivery of device shock therapy was implanted in 16 patients. Three of the patients experienced out-of-hospital device shock therapy preceded by minimal symptoms. Although limitations of electrogram analysis exist and are discussed, careful analysis and registration of electrograms during all supraventricular and ventricular rhythms observed during in-hospital testing served as an important reference for subsequent arrhythmia diagnosis. By analyzing the electrogram rate and RR interval stability and configuration, a definitive diagnosis was established in all three patients (atrial fibrillation, polymorphic ventricular tachycardia and rate-sensing lead disruption, respectively). Thus, the ability to store ventricular electrograms before shock therapy represents a major advance in the management of patients who receive an electrical device to treat ventricular tachyarrhythmia.
Efficacy of potassium and magnesium in essential hypertension: a double-blind, placebo controlled, crossover study OBJECTIVE--To evaluate the antihypertensive activity of potassium given alone or in combination with magnesium in patients with mild hypertension. DESIGN--A double blind, randomised, placebo controlled, crossover trial of 32 weeks' duration. SETTINGS--Cardiology outpatient department, Sassoon General Hospitals, Pune, India. PATIENTS--37 Adults with mild hypertension (diastolic blood pressure less than 110 mm Hg). INTERVENTION--Patients received either placebo or potassium 60 mmol/day alone or in combination with magnesium 20 mmol/day in a crossover design. No other drug treatment was allowed. MEASUREMENTS--Blood pressure and heart rate assessed at weekly intervals and biochemical parameters at monthly intervals. RESULTS--Potassium alone or in combination with magnesium produced a significant reduction in systolic and diastolic blood pressures (p less than 0.001) and a significant reduction in serum cholesterol concentration (p less than 0.05); other biochemical variables did not change. Magnesium did not have an additional effect. Urinary potassium excretion increased significantly in the groups who received potassium alone or in combination with magnesium. The drug was well tolerated and compliance was satisfactory. CONCLUSION--Potassium 60 mmol/day lowers arterial blood pressure in patients with mild hypertension. Giving magnesium as well has no added advantage.
Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure. BACKGROUND. Optimal timing of cardiac transplantation in ambulatory patients with severe left ventricular dysfunction is often difficult. To determine whether measurement of peak oxygen consumption (VO2) during maximal exercise testing can be used to identify patients in whom transplantation can be safely deferred, we prospectively performed exercise testing on all ambulatory patients referred for transplant between October 1986 and December 1989. METHODS AND RESULTS. Patients were assigned into one of three groups on the basis of exercise data: Group 1 (n = 35) comprised patients accepted for transplant (VO2 less than or equal to 14 ml/kg/min); group 2 (n = 52) comprised patients considered too well for transplant (VO2 greater than 14 ml/kg/min); and group 3 (n = 27) comprised patients with low VO2 rejected for transplant due to noncardiac problems. All three groups were comparable in New York Heart Association functional class, ejection fraction, and cardiac index (p = NS). Pulmonary capillary wedge pressure was significantly lower in group 2 than in either group 1 or 3 (p less than 0.05), although there was wide overlap. Patients with preserved exercise capacity (group 2) had cumulative 1- and 2-year survival rates of 94% and 84%, which are equal to survival levels after transplantation. In contrast, patients rejected for transplant (group 3) had survival rates of only 47% at 1 year and 32% at 2 years, whereas patients awaiting transplantation (group 1) had a survival rate of 70% at 1 year (both p less than 0.005 versus patients with VO2 greater than 14 ml/kg/min). All deaths in group 2 were sudden. By univariate and multivariate analyses, peak VO2 was the best predictor of survival, with only pulmonary capillary wedge pressure providing additional prognostic information. CONCLUSIONS. These data suggest that cardiac transplantation can be safely deferred in ambulatory patients with severe left ventricular dysfunction and peak exercise VO2 of more than 14 ml/min/kg.
Hormone replacement therapy and survival after surgery for ovarian cancer OBJECTIVE--To evaluate whether hormone replacement therapy affects survival in women who have undergone bilateral salphingo-oophorectomy because of epithelial ovarian cancer. DESIGN--Retrospective analysis by review of patients' notes and questionnaires completed by general practitioners to compare the overall survival and disease free survival in patients with ovarian cancer who did or did not receive hormone replacement therapy after diagnosis. Data were analysed by Cox regression, with hormone replacement therapy as a time dependent covariate because patients who received hormone replacement did so at different times after diagnosis. SETTING--Gynaecological oncology unit of Royal Marsden Hospital. PATIENTS--373 patients aged 50 years or younger who attended the hospital from 1972 to 1988. All of the women had undergone bilateral salpingoophorectomy for epithelial ovarian cancer. In all, 78 had received hormone replacement therapy, starting at a median of four months after diagnosis. INTERVENTION--A questionnaire was sent to the general practitioners of all patients who were not recorded as having received hormone replacement therapy. MAIN OUTCOME MEASURES--Overall survival and disease free survival. RESULTS--There was no significant difference in survival between women receiving hormone replacement therapy and those not receiving it after accounting for the effects of other known prognostic factors (stage of cancer, differentiation of tumour, histological results, and time to relapse). The relative risk of dying in those who received hormone replacement therapy was 0.73 (95% confidence interval 0.44 to 1.20). In addition, there was no significant difference in disease free survival (relative risk in those receiving hormone replacement therapy was 0.90; 95% confidence interval 0.52 to 1.54). CONCLUSIONS--This study shows that hormone replacement therapy is unlikely to have a detrimental effect on the prognosis of patients with ovarian cancer, but this would be shown conclusively only by a randomised controlled trial.
Cerebral blood flow in acute mountain sickness. Changes in cerebral blood flow (CBF) were measured using the radioactive xenon technique and were related to the development of acute mountain sickness (AMS). In 12 subjects, ascending from 150 to 3,475 m, CBF was 24% increased at 24 h [45.1 to 55.9 initial slope index (ISI) units] and 4% increased at 6 days (47.1 ISI units). Four subjects had similar increases of CBF when ascending to 3,200 m 3 mo later, indicating the reproducibility of the measurements. In nine subjects, ascending from 3,200 to 4,785-5,430 m, CBF increased to 76.4 ISI units, 53% above estimated sea-level values. CBF and increases in CBF were similar in subjects with or without AMS. In six subjects, CBF was measured before and after therapeutic intervention. At 2 h CBF increased 22% (71.3 to 87.3 ISI units) above pretreatment values in three subjects given 1.5 g acetazolamide, while three subjects given placebo showed no change. Symptoms remained unaltered in all subjects during the 2 h of the study. Overall, the results indicated that increases in CBF were similar in subjects with or without AMS while acetazolamide-provoked increases of CBF in AMS subjects caused no acute change in symptoms. Alterations in CBF cannot be directly implicated in the pathogenesis of AMS.
Severity of single-vessel coronary arterial stenosis and duration of angina as determinants of recruitable collateral vessels during balloon angioplasty occlusion. To determine the factors that influence the presence of collateral vessels during coronary occlusion, we performed standardized contrast injection of the contralateral coronary artery in 58 consecutive patients, without previous myocardial infarction, undergoing percutaneous transluminal coronary angioplasty for 1-vessel disease (left anterior descending artery in 45, right coronary artery: in 10 and left circumflex artery in 3). The presence of collateral vessels during coronary occlusion, defined as partial or complete epicardial opacification by collateral vessels of the vessel dilated, was related to clinical, angiographic and electrocardiographic parameters. The angiographic appearance of collateral vessels during balloon inflation showed a weak, although statistically significant, correlation to the percent diameter stenosis before angioplasty (r = 0.28; p = 0.03) and the duration of angina (r = 0.37; p = 0.004). By combining lesion severity with the duration of angina, collateral vessels during coronary occlusion were particularly related to a lesion severity greater than or equal to 70% and duration of angina greater than or equal to 3 months (p less than 0.001). Furthermore, the presence of collateral vessels was associated with an absence of ST-segment shift (greater than or equal to 1 mm) during 1 minute of coronary occlusion (p less than 0.001).
Primary intracerebral sarcoma in childhood: case report with electron-microscope study. A case of a primary intracerebral sarcoma is described in a 5-year-old girl. Histology and immunohistochemistry excluded the diagnosis of a leiomyosarcoma, a malignant haemangiopericytoma or a fibrosarcoma; electron-microscopical findings indicated that the origin of the sarcoma was in the pia mater.