123rc/medical_text huggingface dataset:
Antihypertensive therapy. To stop or not to stop? The benefits of continuous antihypertensive therapy have been extensively documented. However, lack of compliance with the prescribed regimen, excessive cost, and troublesome adverse effects of some antihypertensive agents led to the consideration of intermittent therapy or even complete discontinuation of therapy as an effective alternative to lifelong medication. Prospective studies dealing with this subject reported inconsistent results. Nevertheless, they allowed us to identify selection criteria of candidates for step-down or discontinuation of antihypertensive therapy. Such candidates include patients with mild essential hypertension who have one or more of the following characteristics: young age, normal body weight, low salt intake, no alcohol consumption, low pretreatment blood pressure, successful therapy with one drug only, and no or only minimal signs of target organ damage. Stopping antihypertensive therapy without subsequent rise in arterial pressure was shown to be possible in a subset of patients with mild essential hypertension for a period of months to years. This approach appears to be safe, provided that blood pressure is monitored frequently, and may improve compliance, save treatment costs, and reduce adverse effects of certain drugs, although its long-term consequences for morbidity and mortality remain to be determined.
Clinical significance of hematologic parameters in non-Hodgkin's lymphoma at diagnosis. Three hundred seventeen patients with non-Hodgkin's lymphoma (NHL) (54 low grade, 180 intermediate grade, 76 high grade, and seven unclassified) treated with chemotherapy were evaluated for the presence of hematologic abnormalities at diagnostic staging. Anemia was present in 42%, leukopenia in 6%, thrombocytopenia in 13%, leukocytosis in 26%, and thrombocytosis in 14% at presentation. The presence of bone marrow involvement by lymphoma was more likely to be associated with leukopenia and thrombocytopenia than the absence of bone marrow involvement. Although anemia was slightly more common in patients with bone marrow lymphoma than in those without marrow lymphoma, the difference was not statistically significant. Hematologic parameters were similar for patients with B-cell or T-cell lymphoma. Evidence of bone marrow failure with multiple cytopenias was present in 26 patients (8%). Leukoerythroblastosis was present in 2%. Circulating lymphoma was present in 9.5%. Anemic patients had a shorter survival time than nonanemic patients, whether bone marrow was involved by lymphoma or not. Survival was not affected by the presence of leukopenia or mild leukocytosis, but, in patients without marrow lymphoma, leukocytosis with a leukocyte count greater than 20 x 10(9)/l was associated with short survival length. Thrombocytopenia was associated with short survival time only in patients with bone marrow involvement by lymphoma. Patients with multiple cytopenias or leukoerythroblastosis had short survival times, but the presence of circulating lymphoma did not alter survival when compared with other patients with bone marrow involvement by lymphoma. These data suggest that hematologic evaluation at the time of diagnostic staging of NHL provides useful prognostic information that may have therapeutic implications.
Elevated expression of the genes for transforming growth factor-beta 1 and type VI collagen in diffuse fasciitis associated with the eosinophilia-myalgia syndrome. Full-thickness skin biopsies obtained from four patients with rapidly progressive diffuse fasciitis associated with the Eosinophilia-Myalgia syndrome (EMS) were examined for the expression of transforming growth factor-beta 1 (TGF-beta 1), type VI collagen, and fibronectin genes employing immunohistochemistry and in situ hybridizations. The immunohistochemical studies demonstrated increased deposition of TGF-beta, type VI collagen, and fibronectin epitopes in the extracellular matrix of the fascia in comparison to the adjacent dermis in the same specimens. Increased levels of type VI collagen mRNA, as evidenced by positive in situ hybridization signals with an alpha 2(VI) collagen cDNA, were also found in the fascia in comparison with the dermis. In situ hybridizations of affected fascia with a human sequence-specific TGF-beta 1 cDNA demonstrated numerous fibroblasts displaying positive hybridization signals indicative of high levels of transcripts for this cytokine. In contrast, no hybridization signal for TGF-beta 1 was detected in fibroblasts in the adjacent dermis. These findings suggest that TGF-beta 1 may play an important role in the development of the connective tissue alterations present in EMS-associated diffuse fasciitis.
Intra-aortic balloon counterpulsation in newborn lambs infected with group B streptococcus. To determine the efficacy of intra-aortic balloon counterpulsation (IABC) in neonatal group B Streptococcal (GBS) infection, we studied five lambs, 10-14 days old, weighing from 4.7 to 6.7 kg. The lambs were instrumented with arterial and venous catheters, and a 5 French intra-aortic balloon catheter with balloon volumes of 3-5 ml was inserted into the femoral artery. A continuous infusion of heat-killed GBS organisms was infused at a rate of 1.7 to 6.2 x 10(8) org/kg/min, until a 30-50% decrease in cardiac output was attained. IABC was then instituted for 30 minutes, hemodynamic measurements repeated, and IABC was stopped. GBS infusion caused significant decreases in cardiac output (282 +/- 62 vs. 165 +/- 38 ml/min/kg) and pH (7.39 +/- 0.02 vs. 7.33 +/- 0.06), and significant increases in mean pulmonary artery pressure (14.4 +/- 2.1 vs. 36.2 +/- 12.1 mm Hg) and pulmonary vascular resistance (1.20 +/- 0.38 vs. 5.08 +/- 1.49 mm Hg/L/min/kg). Institution of IABC during continuous GBS infusion significantly increased cardiac output (225 +/- 1.27 ml/min/kg). The institution of the IABC also resulted in a significant decrease in pulmonary vascular resistance (2.6 +/- 1.3 mm Hg/L/min/kg). The authors conclude that IABC improves cardiac output and decreases pulmonary vascular resistance in newborn lambs with GBS infection.
Serial Doppler echocardiographic follow-up of left ventricular diastolic function in cardiac amyloidosis. A spectrum of left ventricular diastolic filling abnormalities noted on Doppler echocardiography has been demonstrated in patients with cardiac amyloidosis. To determine how these filling abnormalities evolve over time and the significance of any change, serial pulsed wave Doppler studies of left ventricular inflow were performed over 12.6 +/- 4.9 months in 41 consecutive patients (36 men and 15 women, mean age 59 +/- 11 years) with typical two-dimensional echocardiographic features of cardiac involvement. The measurements were peak left ventricular inflow in early diastole (E) and atrial contraction (A) velocities, E/A ratio, deceleration time and isovolumetric relaxation time. Patients were classified by mean left ventricular wall thickness into an early group (less than 15 mm) of 24 patients and an advanced group (greater than or equal to 15 mm) of 17 patients. The total group showed an increased E/A ratio (1.7 +/- 0.9 versus 1.4 +/- 0.9, p = 0.009) and decreased deceleration time (164 +/- 57 versus 174 +/- 51 ms, p = 0.11) at follow-up compared with baseline study. The early group showed significant changes in the E/A ratio (1.6 +/- 1.0 versus 1.2 +/- 0.7, p = 0.001) between the two studies. Seven patients (29%) in the early group showed a change from an abnormal relaxation or "normal" pattern to one of restriction, coincident with increased symptoms in six of these patients. Fifteen (88%) of the 17 patients in the advanced group did not show significant changes in the measures during the follow-up study, but these patients already showed a restrictive pattern.
Lumbar puncture frequency and cerebrospinal fluid analysis in the neonate. A prospective study was performed to assess the frequency and diagnostic utility of lumbar punctures in neonates both during their first week of life and thereafter. During the two 6-month periods from January 1, 1985 to June 30, 1985, and February 1, 1986 to July 31, 1986, 712 neonates underwent 728 lumbar punctures during their first week of life primarily as part of the evaluation for suspected infection, either congenital or postnatal. There were eight patients with positive spinal fluid cultures in the first week of life, but only one patient simultaneously had a positive blood culture and a clinical course consistent with meningitis. In contrast, a considerably higher yield, approximating five times that of the first week of life, was obtained in patients undergoing a lumbar puncture after the first week of life.
32-gauge spinal catheters through 26-gauge needles Small diameter intrathecal catheters potentially combine the certainty of intrathecal injection and the advantage of repeatability, without the risk of a high incidence of headache after dural puncture. We report problems placing such catheters.
Pharmacokinetics of paracetamol after cardiac surgery. Plasma concentration was measured after rectal and nasogastric administration of paracetamol 15 mg/kg to 28 febrile children aged between 9 days to 7 years who had undergone cardiac surgery. After equivalent doses, rectal administration in neonates and children on the first postoperative day was found to produce plasma concentrations below the therapeutic range with higher concentrations after nasogastric paracetamol on the second postoperative day. There was less variance in plasma paracetamol concentrations in neonates. Both plasma elimination half life and area under the plasma concentration time curve were significantly increased in neonates after suppository dosing compared with older children. There was no difference in antipyretic effect between the two routes of administration, but this was much lower than that previously reported in febrile children.
Doppler echocardiographic assessment of the St. Jude Medical prosthetic valve in the aortic position using the continuity equation. To test whether the continuity equation can be applied to the noninvasive assessment of prosthetic aortic valve function, Doppler echocardiography was performed in 67 patients (mean age, 58 +/- 14 years) within 10 +/- 6 days after valve replacement with St. Jude Medical valves. All patients were clinically stable and without evidence of valve dysfunction. Valve size ranged from 19 to 31 mm, and ejection fraction ranged from 30% to 75%. With the parasternal long-axis view, the left ventricular outflow diameter measured just proximal to the prosthetic valve correlated well with valve size (r = 0.92). Doppler-derived maximal gradients ranged from 9 to 71 mm Hg. Effective prosthetic aortic valve area by the continuity equation ranged between 0.73 cm2 for a 19-mm valve and 4.23 cm2 for a 31-mm valve. With analysis of variance, effective orifice area differentiated various valve sizes (p less than 10(-14)) better than did gradients alone (p = 0.003) and correlated better with actual valve orifice area (r = 0.83 versus - 0.40). A Doppler velocity index, the ratio of peak velocity in the left ventricular outflow to that of the aortic jet, averaged 0.41 +/- 0.09 and was less dependent on valve size (r = 0.43). Thus, the continuity equation can be applied to the assessment of prosthetic St. Jude valves in the aortic position. By accounting for flow through the valve, it provides an improved assessment over the sole use of gradients in the evaluation of prosthetic valve function.
Left retroperitoneal exposure for distal mesenteric artery repair. Distal disease in the mesenteric arteries has usually been repaired transabdominally since it is believed that only the proximal centimeter of each vessel is accessible through the retroperitoneum. We treated five patients with chronic visceral ischemia and lesions extending beyond the orifice using a retroperitoneal approach. Exposure was obtained with a left flank incision through the tenth interspace. The left crus of the diaphragm was divided in order to control the supraceliac aorta. The mesenteric vessels were identified and dissected until their entrance into the peritoneum. There were no difficulties in exposing the superior mesenteric artery (SMA) as it coursed under the pancreas and over the duodenum for an approximate length of 5 to 10 cm. The uncinate process of the pancreas was not a limiting factor for exposure of the SMA in this region and further distal exposure could be obtained by incising the peritoneum. The trifurcation of the celiac artery and the splenic artery were accessible through this exposure; however, only the first centimeter of the hepatic and gastric branches could be reached. Revascularization was performed with endarterectomy (2 patients) and bypass (3 patients). Bowel viability was assessed at the conclusion of the procedure by incising the peritoneum. There were no complications from this exposure and no patient required reoperation for ischemic bowel. We conclude that the left retroperitoneal approach is not only acceptable for orifice lesions but is also applicable for distal disease.
Early-onset dementia and extrapyramidal disease: clinicopathological variant of Gerstmann-Straussler-Scheinker or Alzheimer's disease? A case of progressive dementia and extrapyramidal signs beginning at age 29, with a ten year course until death, is presented. Necropsy examination showed an assortment of plaque types (including striatal plaques), neurofibrillary tangles, granulovacuolar degeneration, and depigmentation of the substantia nigra and locus ceruleus. This case had pathological features found in both Gerstmann-Straussler-Scheinker disease and in Alzheimer's disease. While somewhat similar to several other cases with features of both diseases, it differs in the presence of dystonia and striatal plaques. Although such cases may be difficult to categorize at present, they must be considered in the differential diagnosis of early onset dementia.
National survey of the pattern of care for carcinoma of the lung. A national survey of the patterns of care for carcinoma of the lung sponsored by the Commission on Cancer of the American College of Surgeons has documented continuing changes in epidemiology, treatment, and outcome. The project consisted of a long-term study of 15,219 patients whose diagnosis was made in 1981 and a short-term study of 19,074 patients whose diagnosis was made in 1986. The male/female incidence ratios have continued to decrease and the decrease has moved into the older age groups. Although the percentage of adenocarcinoma is increasing at the expense of squamous carcinoma, the latter is still the most prevalent histologic type. The accuracy of percutaneous needle biopsy and transbronchial biopsy of lung nodules reported from this group of 941 hospitals was high and equal to that reported by single institutions. The percentage of patients having a resection did not increase from 1981 to 1986, but for smaller lesions a move was apparent toward more lung-sparing resections. Little change has occurred in the use of adjuvant radiotherapy, particularly in stage III disease, where approximately 50% of the patients received postoperative irradiation. An improvement in the overall 5-year survival when compared with Surveillance, Epidemiology, and End Results data was noted. Whether this is a true improvement in survival or is the result of selection because of an unrecognized change in the pattern of care for patients with a carcinoma of the lung is unknown.
Rehabilitation in brain disorders. 3. Intervention strategies. This self-directed learning module highlights advances in the principles of management of brain disorders. It is part of the chapter on rehabilitation in brain disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. The chapter is composed of four articles, and each builds on principles established in the others. This article covers rehabilitation philosophy, management of cognitive remediation, and behavioral management, with attention to communication disorders, social factors, vocational/educational/avocational issues, treatment of motor deficits, dysphagia, sensory dysfunction, sexual dysfunction, and substance abuse. Advances that are covered in this section include pharmacologic and rehabilitative interventions for acute, chronic, and progressive brain injuries and diseases. The learner is directed to articles 1, 2, and 4 in this chapter for supporting information.
Electrocorticographic confirmation of focal positron emission tomographic abnormalities in children with intractable epilepsy. The relationship between focal disturbances of glucose utilization demonstrated by positron emission tomography (PET) and electrophysiologic abnormalities defined by intraoperative electrocorticography (ECoG) was studied in eight children (aged 13 months to 12 years) who underwent cortical resection because of intractable seizures. None of the children had pure temporal lobe epilepsy. Computed tomography (CT) and/or magnetic resonance imaging (MRI) were normal in four of the eight children. The scalp electroencephalogram (EEG) showed lateralized interictal epileptiform abnormalities in all eight and lateralized ictal onset in five of eight. In seven children, interictal PET showed focal hypometabolism; the eighth child had focal, ictal hypermetabolism. ECoG at the time of surgery showed epileptiform spiking, slowing, and/or suppression of normal background activity that in every case corresponded to the focus on PET scan. The ECoG findings support the notion that in children with epilepsy focal metabolic abnormalities on PET correspond to electrophysiologically abnormal areas of cortex, which are presumably also the epileptogenic regions. Such areas can appear normal on anatomic imaging studies (CT and MRI). When ictal scalp EEG data are ambiguous or contradictory, PET provides a less invasive means than chronic grid or depth electrode recording for evaluating whether a localized epileptogenic area exists.
Mistaken diagnoses in continuous muscle fiber activity of peripheral nerve origin. The syndrome of continuous muscle fiber activity of peripheral nerve origin has manifestations that resemble those of many other more common neurologic disorders during childhood and infancy. This similarity often leads to misdiagnosis when an adequate index of suspicion is not entertained and a comprehensive electromyographic examination is not performed. Two affected patients from 1 family are reported to illustrate the type of diagnostic errors that were made before the establishment of the correct diagnosis.
Eosinophilia-myalgia syndrome. A clinical case series of 21 patients. New Mexico Eosinophilia-Myalgia Syndrome Study Group. We reviewed 21 cases of eosinophilia-myalgia syndrome to describe the range of clinical findings in these patients. Most patients were women (20 [95%]) and middle-aged (mean, 46 years) and had taken the food supplement L-tryptophan (95%). All cases involved eosinophilia (eosinophil count, greater than or equal to 2.0 x 10(9)/L) and incapacitating myalgias. Fourteen (88%) of the 16 patients tested had mild liver function abnormalities. Aldolase levels were abnormal in all patients tested. Muscle biopsies were done in five patients; four showed eosinophilic perimyositis, and one had interstitial inflammation. No physical finding was pathognomonic or universal, but muscle tenderness, tachycardia, and rash were the most common signs found during physical examinations. Seven patients were treated with prednisone, and six showed improvement in muscle pain and a decrease in eosinophilia. The cause of this disorder is still unknown.
Effect of atopy on the natural history of symptoms, peak expiratory flow, and bronchial responsiveness in 7- and 8-year-old children with cough and wheeze. A 12-month longitudinal study. Recurrent lower respiratory tract symptoms are common and disabling in childhood, but little is known of their natural history and relationship to asthma. We report a 12-month longitudinal study designed to determine the influence of atopy on respiratory symptoms and bronchial responsiveness in 7- and 8-yr-old children. A postal questionnaire inquiring into the presence of respiratory symptoms was sent to 3,698 children aged 7 and 8 yr. Those reporting either current wheeze (14.8%) or current cough in the absence of wheeze (12.8%) were randomized, and a sample was invited to attend for skin testing. The following groups of symptomatic children entered the longitudinal study: 48 atopic children with cough, 48 atopic children with wheeze, 48 nonatopic children with cough, and 48 nonatopic children with wheeze. All children recorded twice daily the best of three peak expiratory flow (PEF) measurements and completed a 10-point symptom score card, each day for 1 yr. They also recorded all treatment taken and made a note of relevant life events. Each child was seen monthly for general assessment and for measurement of methacholine bronchial responsiveness. Despite the arduous nature of the study 183 of the 192 children (95.3%) successfully completed the 12 months of observation. Symptom groups were compared with regard to FEV1, bronchial responsiveness, symptom chronicity and severity, and diurnal and day-to-day variation in PEF. Atopy was associated with a lower FEV1, increased prevalence of bronchial hyperresponsiveness, greater within-day and between-day variation in PEF, and greater severity of respiratory symptoms compared with the absence of atopy.
Stercoral perforation of the colon. Stercoral perforation of the colon is rare. The 64 reported cases are reviewed to define the syndrome of stercoral perforation, and to facilitate accurate diagnosis and treatment. Features of localized or generalized peritonitis were universal; however, only 11 per cent were correctly diagnosed before operation. Recognition that the disease involves a segment of colon rather than only the focal point of perforation is essential to adequate surgical treatment. It is postulated that this is the reason for the higher postoperative mortality following closure of the perforation and proximal colostomy (57 per cent) or exteriorization alone (43 per cent), compared with resection of the diseased segment and exteriorization (32 per cent). Resection and exteriorization is therefore the treatment of choice is most situations.
Visual illusions in a patient with lateral medullary syndrome. The disturbance of visual perception associated with nystagmus is a rare phenomenon. This is a case of a 61-year-old woman who developed progressive right hemisensory deficit, left facial sensory deficit, vertigo, staggering to the left, left ptosis, vertical diplopia, and ataxia of the left upper extremity. She had rotatory nystagmus in primary position, which increased in amplitude with left gaze. The above signs and symptoms were consistent with lateral medullary syndrome. During her rehabilitation, the patient complained of visual disturbances typical of oscillopsia. These disturbances, or illusions, are compensatory mechanisms for nystagmus and its resultant retinal error. The purpose of this case presentation was to study the pathophysiology underlying oscillopsia in patients with nystagmus and to stimulate awareness of such visual disturbances in stroke patients.