123rc/medical_text huggingface dataset:
Thoracic epidural anesthesia improves global and regional left ventricular function during stress-induced myocardial ischemia in patients with coronary artery disease. The aim of the present investigation was to study the effects of high thoracic epidural anesthesia (TEA), including the cardiac sympathetic segments, on ischemic ST-segment changes and left ventricular global and regional wall motion abnormalities. Ten patients with a two- or three-vessel coronary artery disease, all treated with the beta-adrenergic blocker metoprolol because of severe stable angina pectoris, performed two identical exercise stress tests, the first without TEA (control exercise) and the second with TEA (TEA exercise). Before each stress test, intravenous metoprolol was given to achieve maximal or near maximal beta-adrenoceptor blockade. Systolic and diastolic arterial pressures (radial artery cannula), heart rate, and rate-pressure product, as well as global and regional ejection fractions, using equilibrium radionuclide angiography in the left anterior oblique projection, were measured at rest and during maximal exercise. ST-segment analysis (V3 or V5) was performed, and the regional wall motion score was calculated at control exercise and TEA exercise. Intravenous metoprolol or intravenous metoprolol plus TEA at rest did not cause any significant changes of any of the variables. During TEA exercise, systolic arterial pressure, diastolic arterial pressure, and rate-pressure product, but not heart rate, were significantly lower compared to control exercise. The global and anterolateral ejection fractions were significantly higher (52.8% versus 46.5% and 53.2% versus 46.0%, respectively, P less than 0.05), and the regional wall motion score was significantly lower (8.8 versus 11.8, P less than 0.01) during TEA exercise than during control exercise. ST-segment depression was significantly lower during TEA exercise (-1.03 versus -1.84 mV, P less than 0.01).
Chronic pulmonary thromboembolism in dogs treated with tranexamic acid. BACKGROUND. Many questions remain regarding the pathogenesis, natural history, diagnosis, and treatment of chronic thromboembolic pulmonary hypertension in patients. To answer such questions, we developed an animal model of this disorder. The brisk thrombolytic response of canines to acute embolism has, previously, prevented the establishment of such a model. METHODS AND RESULTS. The fibrinolytic inhibitor tranexamic acid was given orally to canines before, and for intervals after, pulmonary emboli were released from venous thrombi formed in vivo in femoral veins or the inferior vena cava. Preliminary studies disclosed that embolic residuals from femoral vein thrombi were not sufficient to cause significant, persistent pulmonary hypertension. With repetitive, larger thrombi embolized from the inferior vena cava, however, persistent pulmonary hypertension was achieved in most animals. CONCLUSIONS. Resolution of emboli in the canine can be inhibited by tranexamic acid. As in humans, a spectrum of embolic residuals is encountered, and the perfusion lung scan consistently underestimates the extent of embolic residuals. Studies of this animal model continue.
Acute febrile neutrophilic dermatosis in childhood (Sweet's syndrome). We report a case of Sweet's syndrome in childhood. Our patients suffered from repeated fevers, chest infections and had characteristic erythematous plaques. The severity of his illness increased with age and warranted oral steroid treatment. We review 16 cases reported to date in the literature and comment on the management and prognosis of the disease in childhood.
Renormalization of high cardiac output and of left ventricular size following long-term recombinant human erythropoietin treatment of anemic dialyzed uremic patients. To obtain information on the effects of the correction of uremic anemia on cardiac function and size, nine normotensive dialyzed patients were studied before, during and six months after the start of i.v. treatment with recombinant human erythropoietin (rHuEPO). Pulsed-doppler echocardiographic determinations of the cardiac index (CI) and M-Mode echocardiographic estimations of the indexed left ventricular end diastolic diameter (LVEDDi), interventricular septum (IVSi), left ventricular posterior wall (LVPWi), with calculations of the left ventricular mass index (LVMi), were made on every occasion. Mean (+/- SD) hemoglobin (Hb) concentration before rHuEPO was 5.9 +/- 1.3 g/dl and rose significantly (p less than 0.0001) up to the third month, then remained constant. Baseline CI (3.4 +/- 0.6 l/min/m2bsa) was significantly higher (p less than 0.0001) than in healthy subjects (2.5 +/- 0.5 l), and decreased after the third month to a value (2.8 +/- 0.5 l) no longer different from that of controls. From pooled baseline and third month data, an inverse relationship between Hb and CI was found (p less than 0.0001). Baseline LVEDDi (32.7 +/- 4.3 mm/m2bsa), IVSi (6 +/- 1.1 mm/m2bsa) and LVPWi (5 +/- 0.8 mm/m2bsa) were all significantly higher than in controls. After three months of therapy, the only change was a decrease in LVPWi while after six months all indices, including the LVMi, decreased to values no longer higher than in controls. From pooled baseline and six months data, an inverse relationship between Hb and LVMi was found (p less than 0.0001). We conclude that treatment of uremic patients by rHuEPO is able to renormalize their already increased cardiac output soon after correction of the anemia.
Combined tensor fasciae latae musculocutaneous flap and sartorius musculocutaneous flap for the repair of wide defects of the lower leg. The tensor fasciae latae musculocutaneous flap has great advantages for reconstruction of the abdominal wall, but the medial border of its territory is limited to the thigh. In order to expand the territory, a combined tensor fasciae latae musculocutaneous flap and sartorius musculocutaneous flap was devised. This flap was successfully used to resurface a large defect in the lower leg as a distally based musculocutaneous flap. The advantages of this flap are its extremely large territory, the fact that total necrosis of the flap cannot occur, and that as a proximally or distally pedicled flap it is suitable for large defects in the abdominal wall, lower leg, and gluteal region.
Perianal streptococcal cellulitis with penile involvement. Perianal streptococcal cellulitis is described occurring in a 5-year-old boy. The condition also involved the penis and presented as a possible case of sexual abuse. The correct diagnosis was established by culturing beta-haemolytic streptococci group A from the penile and perianal skin.
The empiric use of naloxone in patients with altered mental status: a reappraisal. STUDY OBJECTIVE: To determine whether clinical criteria (respirations of 12 or less, mitotic pupils, and circumstantial evidence of opiate abuse) could predict response to naloxone in patients with acute alteration of mental status (AMS) and to evaluate whether such criteria predict a final diagnosis of presence or absence of opiate overdose as accurately as response to naloxone. CASES AND SETTING: Seven hundred thirty patients with AMS who received naloxone for diagnostic or therapeutic purposes at the discretion of two large, urban, paramedic base teaching hospitals. METHODS: We reviewed paramedic run sheets and audiotapes on all 730 patients as well as available hospital records of all patients who demonstrated any response to naloxone to determine whether overdose was responsible for their clinical presentations. We also reviewed hospital records for a selected sample of naloxone nonresponders. MAIN RESULTS AND CONCLUSION: Only 25 patients (3.4%) demonstrated a complete response to naloxone, whereas 32 (4.4%) manifested a partial or equivocal response. Nineteen of 25 complete responders (76%), two of 26 partial responders (8%) (with known final diagnosis), and four of 195 non-responders (2%) (with known final diagnosis) were ultimately diagnosed as having overdosed. Respirations of 12 or less or the presence of any one of the three clinical findings as a group were each highly sensitive in predicting response to naloxone, and at least as sensitive as response to naloxone in predicting a diagnosis of opiate overdose. Selective administration of naloxone for AMS would have decreased the use of this drug by 75% to 90% while still administering it to virtually all naloxone responders who had a final diagnosis of opiate overdose.
Admission and mid-stay MedisGroups scores as predictors of death within 30 days of hospital admission. We examined the ability of MedisGroups, a severity measure based on clinical data abstracted from the medical record, to predict mortality 30 days following admission. MedisGroups measures severity both on admission and approximately one week into the hospital stay. The data base was a random sample of 20,985 admissions of Medicare beneficiaries with one of six conditions from 833 hospitals in seven states between January 1985 and May 1986. In all six conditions, higher admission and mid-stay severity scores were generally associated with higher risk of death. Across the six conditions, the R-squared values for predicting death using admission scores ranged from 0.01 to 0.16; R-squared values using mid-stay scores ranged from 0.03 to 0.34; and R-squared values from combining admission and mid-stay scores ranged from 0.05 to 0.41. Admission MedisGroups score was thus only modestly predictive of 30-day mortality. While the mid-stay score was more powerful, it may not be an appropriate severity adjuster to screen for quality using hospital mortality rates because it could be influenced by substandard care.
Cardiovascular sequelae of therapeutic thoracic radiation. Mediastinal radiation damages endothelial cells, with resulting loss of capillaries and ischemia at the level of the microcirculation. These changes lead to increases in collagen and proliferation of fibrous tissue throughout the heart. Cardiac dysfunction following radiotherapy is surprisingly common and may be due to pericardial, myocardial, valvular, conduction system, or coronary artery disease. Greater awareness of cardiotoxicity has prompted changes in radiation techniques that appear to reduce clinical cardiovascular complications.
Clinical significance of intratesticular arterial anatomy. Testicular atrophy has been reported in 2 to 18% of the patients following orchiopexy for cryptorchidism. A possible cause of this atrophy is interference with the testicular blood supply by placement of a testicular traction suture through the tunica albuginea. Arterial casts of 32 adult human testes were created following placement of a 3-zero silk traction suture through the lower pole of the testis to determine the effects of this suture upon intragonadal arterial circulation. Significant arterial blockage, manifested as failure of the parenchymal branches to fill, was observed in 14% of the casts produced via injection through the internal spermatic artery and in 100% of the casts produced via injection through the deferential artery. The results of this study support discontinuing the routine use of parenchymal testicular traction sutures during orchiopexy.
Axillary lymphadenectomy for intraductal carcinoma of the breast. During a ten year period, 175 axillary lymph node dissections were done as part of the treatment for intraductal carcinoma of the breast; 98 patients were treated with modified radical mastectomy and 77 were treated by mammary preservation, consisting of excision of the lesion, axillary dissection and radiation therapy. One of 175 axillary node dissections yielded positive nodes. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for use in most instances. It should be reserved for lesions demonstrating microinvasion.
Comparison of gall bladder bile and endoscopically obtained duodenal bile. In 10 patients with gall stone disease (eight women, two men; mean (SD) age 47.4 (13) years), bile was obtained by endoscopic aspiration after stimulation of the gall bladder with ceruletid and also by fine needle puncture of the gall bladder under local anaesthetic. The total lipid concentration of the puncture bile samples was mean (SD) 11.9 (4.7) g/dl, significantly higher than the endoscopic bile samples (3.9 (3.3) g/dl, p less than 0.001). Total bile acids, phospholipids, and biliary cholesterol (expressed in mol%) and cholesterol saturation index showed no significant differences between the two types of samples. The glycocholic acid concentration in the endoscopically obtained bile (27.7 (6.6) mol% v 23.3 (5.4) mol%; p less than 0.01) was significantly higher than the puncture bile samples. Puncture bile exhibited a significantly shorter nucleation time (3.5 (3.3) days v 19.6 (11.9) days; p less than 0.001). For determination of the nucleation time, endoscopic bile aspiration after gall bladder stimulation with ceruletid led to adequately concentrated samples in 50% of the study subjects. Cholesterol monohydrate crystal formation in native bile was observed in six samples of puncture bile and in three samples of the endoscopically obtained bile. The presence of cholesterol crystals and the determination of nucleation time in the puncture bile were the best discriminants between cholesterol and pigment gall stones and correlated well with computed tomogram analysis.
Familial autosomal recessive rigid spine syndrome with neurogenic facio-scapulo-peroneal muscle atrophy. Two sisters and a first cousin presented with rigid spine and facio-scapulo-peroneal muscle atrophy. The patients belonged to a family with two first-cousin marriages. Electromyography, muscle and nerve biopsy showed neurogenic muscle atrophy without peripheral nerve involvement. Follow up did not show progression of the disease. This is the first observation of an association of neurogenic facio-scapulo-peroneal and rigid spine syndrome. The double first-cousin marriage suggests autosomal recessive inheritance.
Development of a traumatic intracranial hematoma after a "minor" head injury. We have analyzed features of patients who had what appeared initially to be a minor head injury but who developed an acute traumatic intracranial hematoma. Over a 10-year period, 183 patients who were able to open their eyes spontaneously, were oriented to person, place, and time, and who obeyed commands when they were first seen at a hospital subsequently underwent operation for an acute intracranial hematoma. The hematoma was extradural in 54% of these patients. A history of altered consciousness or symptoms of headache and vomiting were present in 61% of the patients; 33% had a focal neurological deficit, and 43% had either focal deficit or signs of a basal skull fracture. A skull fracture was shown radiologically in 60% of patients, including 52% of those not clinically suspected of having an intracranial lesion. Six months after injury, 77% of the patients had made a moderate or good recovery. The possibility that a patient who has recently sustained a head injury might develop an acute intracranial hematoma can never be completely discounted, even when there are no abnormal clinical signs, and a skull x-ray retains a useful place in the investigation of selected patients with a minor head injury.
Intra-abdominal abscess in regional enteritis. Intra-abdominal abscess (IAA) developed in 129 of 610 patients (21.2%) with Crohn's disease confined to the small bowel. The location of the abscess was intraperitoneal (IPA) in 109 (17.9%) and retroperitoneal (RPA) in 20 (3.3%). There was a marked preponderance of male patients in the retroperitoneal group (ratio, 18:2) (p less than 0.0001). All 129 patients were operated on. Thirteen of one hundred nine patients (12%) with IPA were reoperated on for recurrent abscess, and nine (8.2%) for other reasons. External fistula developed in 24 patients (22%) after simple incision and drainage. Four (3.7%) died; one from hepatitis, and three from sepsis 5, 14, and 90 days after surgery. Of the 20 patients with RPA, two (10%) were reoperated on for recurrent abscess and four (20%) for other reasons. External fistula developed in two patients (10%). There were no deaths in this group. A small number of patients with IAA complicating regional enteritis had persistent sepsis causing postoperative death, which is, however, six times lower than in our comparable series of Crohn's (ileo)colitis.
Acute hemodynamic effects of intravenous diperdipine, a new dihydropyridine derivative, in coronary heart disease. The acute hemodynamic effects of a new dihydropyridine calcium channel blocker, diperdipine, which is suitable for intravenous administration, were studied by right and left cardiac catheterization in 16 patients with coronary heart disease. Diperdipine markedly reduced systemic vascular resistance and improved stroke index and left ventricular ejection fraction. Mean pulmonary artery and wedge pressures were slightly increased as a possible consequence of enhanced venous return, whereas right atrial and left ventricular end-diastolic pressures were not significantly changed. Nevertheless, an increase in preload was clearly indicated by an augmented left ventricular end-diastolic volume index after administration of diperdipine. Left ventricular contractility, which was estimated by the end-systolic pressure-volume ratio and by dP/dt max was not significantly changed, though analysis of individual data suggests a minimally negative inotropic effect. However, such a minor effect on left ventricular contractility was largely counterbalanced by the marked reduction of afterload, which produced a sharp improvement of stroke index. Enhancement of left ventricular ejection fraction and reduction in systemic vascular resistance were inversely and directly correlated to control values. Overall, diperdipine was well tolerated, but one patient had a major untoward reaction that consisted of an ischemic episode that was possibly related to drug administration. In conclusion, intravenous diperdipine appears to be a potent arteriolar dilating agent that does not affect left ventricular contractility.
Mechanical sutures in perforation of the thoracic esophagus as a safe procedure in patients seen late. Between 1976 and 1988, we treated 13 perforations of the thoracic esophagus, excluding ruptured carcinoma and intraoperative wounds, by mechanical sutures without exclusion. The delay between perforation and treatment ranged from eight to 168 hours, more than 24 hours in 11. The length of perforation was 0.5 to 15.0 centimeters. Suture was covered with a flap in ten instances; an antireflux procedure was associated with five instances. No digestive ostomies were performed. There was one death; a patient who was comatose upon arrival. The results of this small series suggest that myotomy exposing the mucosa and a flap are two essential elements of the technique; perforations of less than 6 centimeters, even when seen late, may be treated by primary surgical closure.
A rational attitude toward serum alanine aminotransferase measurement by blood banks, based on a longitudinal study of a cohort of repeat blood donors. A cohort of 879 blood donors was followed over a 3-year period. Of the 3858 units of blood collected, 112 (2.9%), obtained from 64 donors, had an alanine aminotransferase (ALT) activity over 45 IU per L; of these, 39 had a single ALT elevation. The incidence of ALT increase was 2.01 per 100 units, or 5.1 per 100 donors, per year. The pattern of elevated ALT was followed in 72 donors, 54 of whom were from the 64 cited above. At the second blood donation (BD2), about 5 months later, 62.5 percent had a normal ALT value, and most (91%) retained those values at blood donation 3 (BD3). However, 19 (70.3%) of the 27 whose ALT levels had not returned to normal at BD2 had an increased value at BD3. These results led to the formulation of the following algorithm to improve the management of blood donors; at the first donation, the ALT assay is done after the blood collection, but, at the next donation, the ALT level is measured before donation if the preceding ALT activity had been abnormal. If ALT is elevated, blood is not collected. Three consecutive ALT elevations are a criterion for permanent exclusion of the donor.
Drug-induced supraventricular tachycardia: a case report of fluoxetine. We report the occurrence of supraventricular tachycardia and hypotension in a 54-year-old woman after maintenance therapy with fluoxetine. Although cases of tachycardia and palpitations have been reported, supraventricular tachycardia and hypotension have not been directly attributed to fluoxetine.
One-year outcome after cerebral infarction in whites, blacks, and Hispanics. Little is known about outcome after cerebral infarction for different ethnic groups. Of 590 stroke patients hospitalized from 1983 to 1986 at the Neurological Institute, cerebral infarction over age 39 years occurred in 135 whites, 177 blacks, and 82 Hispanics. Outcome after cerebral infarction differed by ethnicity. The 1-month mortality rate was similar in whites and blacks and least in Hispanics. Whites had a slightly greater risk of recurrent stroke or death than blacks or Hispanics until 6 months after infarction, when their risk stabilized, while the risk in blacks and Hispanics continued to rise for the entire year of follow-up. By 1 year, the rate of recurrent stroke or death was 34.8 +/- 4.2% in whites, 31.1 +/- 3.6% in blacks, and 21.4 +/- 4.8% in Hispanics (p = 0.04). Differences were found in the distribution of various stroke risk factors in the three ethnic groups. A Cox proportional hazards model demonstrated that the ethnic differences in stroke risk factors and infarct subtype were responsible for the ethnic differences in outcome. An abnormal first electrocardiogram was a risk factor for stroke recurrence or death in all three ethnic groups, while a nonlacunar infarct subtype and a history of diabetes were significant only in Hispanics. Understanding the associations of stroke determinants with ethnicity may lead to more focused secondary prevention of recurrent stroke.
Adult T-cell leukemia/lymphoma of the tongue. A case of posterior tongue lymphoma associated with adult T-cell leukemia (ATL) that occurred as a lesion in the lingual dorsal portion is reported in a 64-year-old woman. Initially, a diagnosis of Hodgkin's lymphoma was considered as no findings associated with ATL except lymphadenopathy and serum anti-ATLA antibodies were present. Combined radiotherapy and chemotherapy were administered with favorable results; however, 4 months later, Pneumocystis carinii pneumonia developed, and 2 months later, generalized lymphadenopathy and hypercalcemia evolved. At this time, a diagnosis of ATL was made. The patient died of renal dysfunction 6 months after the initial presentation. In suspected cases of ATL and malignant diseases of T-cell lineage, namely, malignant lymphoma and mycosis fungoides, the presence of HTLV-1 infection should be confirmed by testing for anti-ATLA antibodies.