123rc/medical_text huggingface dataset:
Combined epidural and general anesthesia in aortic surgery. The perioperative course of 144 consecutive patients undergoing aortic reconstructive surgery was studied to assess the potential benefit of employing a combined epidural and light general anesthesia technique. A group of 67 patients had general anesthesia alone (GA), while in the group of 77 remaining patients, a combined epidural and general anesthesia (Epi-GA) was employed. The two groups were similar in regards to age, medical risk factors, preoperative assessment of cardiac and pulmonary function, and type of surgical reconstruction. There was no significant difference in the anesthetic, operative time, or operative fluid requirements between the two groups. There was a lower rate pressure product in the Epi-GA group during aortic cross clamping (P less than 0.05). More patients in the GA group required a prolonged ventilatory support (P less than 0.05) and a high parenteral narcotic administration (P less than 0.025) during the first 48 hours. While the mortality rate was similar for the two groups (3.0% for GA group vs 5.2% for Epi-GA group), there was a higher percent of postoperative pulmonary complications observed in the GA group (7.6%) compared to the Epi-GA group (2.6%). By facilitating early extubation and a decreased need for systemic narcotics in the early postoperative period, Epi-GA may be beneficial in the high risk pulmonary patient undergoing aortic reconstruction.
Recurrent lateral rectus palsy in childhood. Five patients with recurrent, lateral rectus palsy in childhood, examined at the University of Iowa Hospitals over a period of 22 years, are reported. During the same period, 131 abducens nerve palsy patients, younger than 18 years of age, were evaluated. Eighteen similar patients, most single case reports, are reviewed from the literature. All reported patients, including our own, shared the following features: spontaneous recovery within 6 months in the majority of patients, ipsilateral recurrence, and painless palsy. There is female and left-sided preponderance. Etiology is undetermined. Hypotheses include viral etiology, neurovascular compression by aberrant artery, and migraine.
Time of rehabilitation admission and severity of trauma: effect on brain injury outcome. Outcome after traumatic brain injury, defined by the Glasgow Outcome Scale (GOS) and length of stay in acute rehabilitation, was measured in 59 patients admitted to an intensive rehabilitation program to examine the effects of severity of the initial brain injury, severity of multiple trauma, and length of stay in the acute care hospital. Severity of initial brain injury, best measured by length of coma, was the most significant predictor of GOS outcome. Length of acute hospitalization was a small, but significant, predictor of GOS. Severity of initial brain injury, length of acute hospitalization, and gender emerged as predictors of length of rehabilitation hospital stay. Although length of acute hospitalization is apparently affected by severity of brain injury, it adds significantly--more than severity of brain injury--to the prediction of length of rehabilitation.
Clinical diagnosis of Binswanger's disease. To aid in the prospective study of Binswanger's disease, a poorly understood form of vascular dementia, a standardised criteria for its antemortem diagnosis was proposed. These criteria include dementia, bilateral radiological abnormalities on computed tomography (CT) or magnetic resonance imaging (MRI), and at least two of the following three clinical findings: A) a vascular risk factor or evidence of systemic vascular disease; B) evidence of focal cerebrovascular disease; and C) evidence of "subcortical" cerebral dysfunction. These criteria were validated in two ways. First, by retrospectively applying them to a series of 30 demented patients with various pathological diagnoses. Second, by prospectively applying them to a series of 184 patients with clinically typical Alzheimer's disease. The sensitivity and specificity of the criteria appear adequate for use in clinical research.
Patient perceptions. The cancer patient's perceptions about treatment, prognosis, and long-term care have emerged in the context of interaction with the changing healthcare system. A brief overview of cancer patients' perceptions regarding their disease and subsequent care is provided. The economic, organizational, and technological environment in which this care is provided and the patient's perceptions of that environment are discussed. In addition to economic pressures, the ever-increasing number of cancer patients, prolonged survival, and patients' perceptions have created changes in the healthcare system. These changes are mediated by important socioeconomic, cultural, and demographic characteristics of the cancer patient. Recommendations to address these changes are discussed.
Protective effect of transforming growth factor beta 1 on experimental autoimmune diseases in mice. Interleukin 1 (IL-1) and tumor necrosis factor alpha are thought to contribute to the inflammatory response associated with autoimmune diseases. Transforming growth factor beta 1 (TGF-beta 1) counteracts many effects of these cytokines and has various immunosuppressive properties. In the present study, it is shown that microgram amounts of TGF-beta 1, injected daily for 1-2 weeks, protect against collagen-induced arthritis (CIA) and relapsing experimental allergic encephalomyelitis (REAE), the animal models for rheumatoid arthritis and multiple sclerosis, respectively. When administered during induction of the disease, TGF-beta 1 prevents CIA but only delays the onset of REAE by 2-3 days. However, when administered during a remission. TGF-beta 1 prevents the occurrence of relapses in REAE. The results suggest that TGF-beta 1 has powerful anti-inflammatory effects, mimicking in some respects the beneficial effects of immunosuppressive drugs in these experimental models of autoimmune disease, but without discernable adverse effects.
Choice of drug treatment for elderly hypertensive patients. It is generally agreed that moderate and severe hypertension in the elderly should be treated, but it is not clear which drug or drugs are most appropriate. Thiazide diuretics are inexpensive and effective, but they are associated with metabolic side effects that are becoming less acceptable as newer agents become available. Beta blockers are effective, but can be associated with central nervous system side effects and are often contraindicated by coexisting disease. Recently, attention has been focused on the newer agents, including calcium antagonists and angiotensin-converting enzyme inhibitors. The advantage of calcium antagonists is that they do not produce metabolic side effects. However, they are expensive and may cause vasodilatory side effects. The angiotensin-converting enzyme inhibitors are effective and relatively free of side effects and may be particularly useful for elderly hypertensive patients with congestive heart failure.
Anterior cruciate ligament reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts. Two year results in thirty-six patients [published erratum appears in Am J Sports Med 1991 May-Jun;19(3):272] Thirty-six of 44 patients (82%) who underwent ACL reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts were evaluated at least 2 years postoperatively. A detailed subjective evaluation using the Lysholm scale was recorded as well as a functional evaluation using the Tegner activity scale. All of the patients received a detailed physical examination that included testing with the KT-1000 ligament arthrometer and the Cybex dynamometer. Complete chart reviews and radiographic evaluations were also obtained. Only 17 patients were considered to be functionally successful and performing at their desired activity level. The average KT-1000 showed a side-to-side difference of 5.9 mm at 30 pounds for the successful group and 7.9 mm for those who had functional failure. The Lysholm scores were 91.6/100 versus 61.1/100 in the failures. Eight patients (22%) at repeat surgery were noted to have complete dissolution of the graft. Large femoral cysts were noted radiographically in all of these patients. It was concluded that freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts have a high failure rate and cannot be recommended for ACL reconstruction.
Systemic atropine administration during cardiac arrest does not cause fixed and dilated pupils. OBJECTIVES: Systemic administration of atropine during CPR may postpone brain death determination because of its reputed ability to produce fixed and dilated pupils. We studied the effect of atropine administered in the usual doses as an adjunct to endotracheal intubation and for cardiac arrest to determine if it would interfere with neurological assessment. DESIGN: Two groups of children were studied. Group 1 consisted of 28 patients who received atropine (0.03 +/- 0.003 mg/kg) prior to endotracheal intubation. Group 2 consisted of 21 patients previously without evidence of brainstem disease who suffered a witnessed arrest and had prompt return of spontaneous circulation and received an atropine dose of 0.03 +/- 0.01 mg/kg. RESULTS: In group 1, pupillary size averaged 4.02 +/- 0.78 mm before and 4.75 mm +/- .84 mm after atropine (P less than .001). In group 2, the pupillary examination was conducted 30 minutes after return of spontaneous circulation. The pupillary diameter was 4.80 +/- 0.91 mm. All pupils were reactive to light in both groups. CONCLUSION: Atropine administration in conventional dose causes slight pupillary dilation but does not abolish pupillary light reactivity.
Estrogen and coronary heart disease in women. We review herein the evidence that estrogen is protective against the development of cardiovascular disease in women. To our knowledge, no studies in women have looked at endogenous estrogen levels as predictors of cardiovascular disease. Studies of surrogate measures of endogenous estrogen such as parity, age at menarche, and age at menopause have provided inconsistent results. Current use of oral contraceptives increases risk in older women who smoke cigarettes, but most studies of past use show no increased risk. Most, but not all, studies of hormone replacement therapy in postmenopausal women show around a 50% reduction in risk of a coronary event in women using unopposed oral estrogen. These important observations need to be confirmed in a double-blind, randomized clinical trial, since the protection is biologically plausible and the magnitude of the benefit would be quite large if selection factors can be excluded.
Cytogenetic analysis of a granulocytic sarcoma in a patient without systemic leukaemia. Granulocytic sarcoma is a rare complication of leukaemia. Occasionally it presents before the development of systemic leukaemia when diagnosis may be difficult. A case of granulocytic sarcoma occurring in a patient with no overt evidence of leukaemia, but in whom cytogenetic analysis of the bone marrow showed a clonal t(12;13) translocation, is reported. Cytogenetic analysis of tissues in this disease may indicate evidence of systemic disease before overt morphological changes.
Clozapine-related seizures. Clozapine is an atypical antipsychotic drug with minimal extrapyramidal toxicity recently approved by the Food and Drug Administration for hard-to-treat schizophrenic patients. We reviewed information on 1,418 patients treated with clozapine in the United States between 1972 and 1988. Forty-one of 1,418 (2.8%) patients had generalized tonic-clonic seizures during treatment with clozapine. Life-table analysis predicts a cumulative 10% risk of seizures after 3.8 years of treatment. Clozapine-related seizures appear to be dose-related. High-dose therapy (greater than or equal to 600 mg/day) was associated with a greater risk of seizures (4.4%) than medium (300 to 600 mg/day; 2.7%) or low doses (less than 300 mg/day; 1.0%). Also, rapid upward titration may increase seizure risk. Thirty-one of 41 patients were successfully continued on clozapine despite seizure occurrence, either with reduction of dose or addition of an antiepileptic medication. Recognition and treatment of clozapine-related seizures will become increasingly important as its use grows in the 1990s.
Imaging modalities in recurrent head and neck tumors. Patients with recurrent neoplasms of the head and neck present perplexing management problems, and accurate preoperative assessment of their disease is crucial. Thirty-eight patients with suspected recurrent neoplasms comprise this study: 30 had computed tomography scans, 4 had magnetic resonance images, and 4 patients underwent both computed tomography and magnetic resonance imaging to assess the anatomical extent of pathology in 34 malignant and 4 benign tumors. Contrast enhancement was essential for detecting disease on computed tomography scan. Differentiation of recurrent tumor was more difficult when the patient had undergone radiation. Magnetic resonance imaging demonstrated superior visibility in recurrent parotid and paranasal sinus neoplasm, but was less helpful in laryngeal and pharyngeal recurrences. Computed tomography demonstration of a mass with infiltration of normal fat or tissue planes or lymphadenopathy correlated highly with recurrent disease. Imaging techniques and fine points for determining recurrent neoplasms are presented.
The relationship of ABH(O) blood group antigen expression in intraepithelial dysplastic lesions to clinicopathologic properties of associated transitional cell carcinoma of the bladder. Paraffin-embedded, giant-step sections of 13 bladders with transitional cell carcinomas were stained with monoclonal anti-A or anti-B antibodies to investigate whether intraepithelial dysplastic lesions are related to obvious tumors. Normal and/or hyperplastic lesions were retained in only eight bladders; severe dysplasia and/or carcinoma in situ were found in all bladders except two. AB-antigen expression was retained in intraepithelial lesions of bladders with invasive carcinoma. Most intraepithelial lesions were AB-antigen negative in bladders with frequently recurrent tumors. In bladders with initially multiple tumors, AB-antigen expression was negative in almost one half of the intraepithelial lesions. Therefore, it appears likely that most multiple or recurrent bladder carcinomas arise from dysplastic cells in intraepithelial lesions which have acquired malignant potential; initially invasive tumors quickly develop from a limited lesion acquiring a high malignant potential without changes of cell phenotype in most intraepithelial lesions.
Prospective comparison of a conventional and an accelerated protocol for programmed ventricular stimulation in patients with coronary artery disease. BACKGROUND. This study compared the sensitivity, specificity, and efficiency of a "conventional" and "accelerated" programmed stimulation protocol in 293 patients with coronary artery disease who had a history of sustained or nonsustained monomorphic ventricular tachycardia (VT). METHODS AND RESULTS. In the conventional protocol, one and two extrastimuli were introduced during sinus rhythm and during basic drive trains at cycle lengths of 600 and 400 msec at the right ventricular apex and then at the outflow tract or septum. In the accelerated protocol, one, two, and then three extrastimuli were introduced at each of three basic drive train cycle lengths (350, 400, and 600 msec) at the right ventricular apex; the procedure was repeated at a second right ventricular site. Six hundred thirty-four electrophysiological tests were performed using one of these two protocols either in the baseline state (293 tests) or during drug testing (341 tests). The yield of sustained, monomorphic VT was 89% with the conventional protocol and 92% with the accelerated protocol during baseline tests in patients who had a history of sustained VT (p = 0.05); 20% and 34%, respectively, during baseline tests in patients with a history of nonsustained VT (p = 0.06); and 70% and 77%, respectively, during drug testing (p = 0.2). To induce sustained, monomorphic VT, 10.1 +/- 5.0 (mean +/- SD) protocol steps and 14.4 +/- 8.7 minutes were required with the conventional protocol, compared with 4.0 +/- 3.7 steps and 5.6 +/- 6.1 minutes with the accelerated protocol (p less than 0.001 for each comparison). Among the tests in which sustained, monomorphic VT was induced, sustained polymorphic VT or ventricular fibrillation was induced more often with the conventional protocol (3.6%) than with the accelerated protocol (0.9%, p = 0.05). CONCLUSIONS. The efficiency of programmed stimulation can be improved by the early use of a basic drive train cycle length of 350 msec and three extrastimuli. Compared with a conventional stimulation protocol, the accelerated protocol used in this study reduces the number of protocol steps and duration of time required to induce monomorphic VT by an average of more than 50% and improves the specificity of programmed stimulation without impairing the yield of monomorphic VT.
Shunt nephritis. Case report. The incidence of shunt nephritis has decreased over the past several years due to the increased use of ventriculoperitoneal (VP) shunts rather than the ventriculovascular systems for which this complication was originally reported in 1965. Despite this trend, the syndrome has been reported in cases of VP shunting and, for this reason, merit a renewed look. Shunt nephritis is thought to be secondary to immune complex formation and deposition in the kidney in response to Staphylococcus epidermidis. The diagnostic workup and management of this disease is discussed.
Effect of high-dose furosemide in refractory congestive heart failure. High-dose firosemide is considered effective in primary renal sodium retention but is not generally recommended in congestive heart failure. In order to evaluate efficacy and safety of high-dose furosemide (greater than 500 mg/day), the authors studied 20 patients (pts) resistant to therapy (including furosemide less than 500 mg/day) selected from 161 pts admitted for chronic heart failure. All refractory pts (15 men and 5 women, mean age sixty +/- 12 years) were in NYHA class IV and showed hyponatremia (130 +/- 5 mEq/L) and impaired renal function (BUN 31 +/- 14 mg/dL, serum creatinine 1.3 +/- 0.3 mg/dL and BUN/creatinine ratio 23 +/- 7). In addition to digitalis, dopamine, angiotensin-converting enzyme inhibitors, or vasodilators, IV high-dose furosemide (775 +/- 419 mg/day, 500-2000) was given for ten +/- five days under daily clinical and laboratory monitoring. Three pts died of low-output syndrome while 16 pts were upgraded to NYHA class III and 1 pt to class II; a mean weight reduction of 7.3 +/- 2.9 kg in ten + five days (0.80 +/- 0.4 kg/day) and a mean diuresis increase of 88 +/- 57% occurred. The maximal dose of furosemide did not correlate with serum creatinine but did correlate with BUN/creatinine ratio (r = 0.78, p less than .001). Pts were discharged on with chronic heart failure, and 43% in the subgroup in NYHA class IV with hyponatremia. High dose furosemide was effective for rapid removal of excess water and salt in "furosemide-resistant" congestive heart failure. The relationship between renal impairment and maximal furosemide doses seems to confirm the role of renal pharmacokinetics in the appearance of furosemide resistance.
Assessing the severity of dementia. Patient and caregiver. In dementia there is cognitive impairment, disability in daily life, and sometimes behavioral disturbance. These changes are a burden for the caregivers of patients with dementia. Few studies are available that examine all these aspects and their interrelationships in a single patient group. In our study we selected detailed methods for assessment of all these aspects. Interrelationships were studied in 30 mild to moderately impaired patients with dementia and their caregivers. Although the relations of cognitive deterioration to disability in daily life and of burden experienced by the caregiver to patient's condition were stronger than often reported, it was impossible to deduce the overall severity of dementia from one single aspect. Thus, for effective management of patients and caregivers, for evaluation of individual treatment or of clinical trials, attention should be paid to all the different aspects of patients' condition and caregivers' burden. Outcome measurements will then be more valid.
Decrease in mean platelet survival time in acute poststreptococcal glomerulonephritis (APSGN). In an attempt to study further the possible participation of platelets in the pathogenesis of acute poststreptococcal glomerulonephritis (APSGN), we studied the platelet survival time, as an index of platelet activation, in 22 patients with APSGN. Mean platelet survival time was computed from the disappearance of radioactivity from blood, sampled serially after injection of autologous 51Cr-labelled platelets. C1q solid phase ELISA and conglutinin (K) solid phase ELISA were used to measure the serum levels of immune complexes. The platelet survival time in APSGN patients was 113 +/- 10 h vs 197 +/- 10 h in the control group (p less than 0.001); 68% of the patients had a shortened platelet survival, lower than 95% confidence limit. There was a significant increase in the platelet survival in the six patients that were studied after recovery from acute nephritic syndrome. There was no significant association between the mean platelet times survival and CICs (circulating immune complexes). Similarly, no significant correlation was found between the mean platelet lifespan and the severity of the glomerular disease, as assessed by the serum creatinine level and the proteinuria. These results support evidence of platelet activation and consumption in APSGN and we suggest that this activation occurs in the glomeruli capillary wall, due to platelet-vascular wall interaction.
Twelve-year incidence of coronary heart disease in middle-aged adults during the era of hypertensive therapy: the Framingham offspring study [published erratum appears in Am J Med 1991 Apr;90(4):537] PURPOSE: To provide information on the incidence of coronary heart disease (CHD) in the offspring of the original cohort from the Framingham Heart Study. PATIENTS AND METHODS: From 1972 to 1974, offspring of the original participants in the Framingham Heart Study underwent a baseline examination for standard cardiovascular risk factors. At entry into the study, these offspring were 30 to 59 years old and free of CHD. They were followed for 12 years, during which time 156 of 1,663 men and 55 of 1,714 women developed CHD. RESULTS: In a multivariate proportional hazards model, CHD was significantly associated with age, lower high-density lipoprotein cholesterol (HDL-C) levels, and number of cigarettes smoked. Fasting glucose levels and low-density lipoprotein cholesterol (LDL-C) were highly associated with CHD in men, but borderline in women, while triglycerides and very-low-density lipoprotein cholesterol were not significantly associated with CHD after adjustment for HDL-C and glucose. Blood pressure medication was used in half of the hypertensive individuals, and systolic pressure was associated with CHD in women only. CONCLUSIONS: This study confirms the importance of the common CHD risk factors of cigarette smoking and LDL-C, and extends the prognostic role of HDL-C in a middle-aged cohort. The impact of blood pressure, with or without use of hypertensive medications, was reduced in this study, and the data suggest that this attenuation was due to successful treatment.