123rc/medical_text huggingface dataset:
Movement disorders--limb movement and the basal ganglia. The primary concern of this article is to review experimental methods that may lead to a better understanding of the functional role of the basal ganglia in the control of movement. Two models of basal ganglia impairment are considered: Parkinson's disease and Huntington's disease. The review focuses primarily on akinesia and bradykinesia because they are key abnormalities of basal ganglia dysfunction. In general, through electromyography and kinematic analysis of movement, it may be possible to characterize specific movement disorders. Specifically, if damage sustained by the central nervous system is traced to a certain structure, it may provide insight on the extent of involvement and functional role of that structure in the control of movement. Much of the data reviewed suggests that the basal ganglia may play a specific role in the initiation and regulation of force control.
Cardiovascular effects of the somatostatin analog octreotide in acromegaly. OBJECTIVE: To determine the cardiovascular effects of the somatostatin analog octreotide in patients with acromegaly. DESIGN: Prospective nonrandomized study. SETTING: Referral-based endocrinology clinic. PATIENTS: Seven patients with active acromegaly, three of whom had refractory congestive heart failure. The other four patients were free of symptoms associated with heart failure. INTERVENTIONS: All patients were treated with octreotide, 100 to 500 micrograms subcutaneously three times daily. The three patients with heart failure continued to receive cardiovascular therapy (angiotensin converting enzyme inhibitors, digitalis, diuretics). MEASUREMENTS AND MAIN RESULTS: During octreotide therapy, patients showed a rapid decrease in growth hormone and insulin-like growth factor 1 (IGF-1): Mean levels (+/- SD) fell from 28.1 +/- 32.7 micrograms/L to 5.2 +/- 8.3 micrograms/L and 740 +/- 126 micrograms/L to 372 +/- 64 micrograms/L, respectively (P less than 0.025). Plasma volume returned to normal and heart rate decreased significantly. In the four patients without heart failure, right-heart catheterization done before and after 3 months of octreotide therapy showed an 18.3% +/- 11% reduction in stroke volume and a return to normal of the cardiac index. The three patients with congestive heart failure, evaluated before and after 40 days and up to 2 years of therapy, showed a dramatic clinical improvement that was associated with an increase in stroke volume (by 24% to 51%). In these patients, the cardiac index remained in the normal range, filling pressures were markedly decreased, and pulmonary wedge pressure returned to normal. This improvement was sustained for up to 3 years in the two patients with heart failure who were receiving long-term treatment. CONCLUSION: The rapid and sustained cardiac improvement seen in our patients shows that octreotide therapy for patients with acromegaly may be highly beneficial, even in those patients with advanced cardiac failure.
Fluorometric determination of pseudocholinesterase activity in postmortem blood samples. A fluorometric assay using 3-(p-hydroxyphenyl) propionic acid (HPPA) was conducted to determine the activity of pseudocholinesterase (ChE) [Enzyme Commission (EC) No. 3.1.1.8] in postmortem blood samples so as to test for organophosphate poisoning. By the enzymatic reaction of ChE, its substrate, benzoylcholine, produces choline, which is oxidized by choline oxidase to generate hydrogen peroxide. HPPA is oxidized by hydrogen peroxide and peroxidase to become the fluorogenic dimer whose concentration is measured fluorometrically at an excitation emission wavelength of 320 nm and an elimination emission wavelength of 404 nm. The selectivity and sensitivity of the present method were found to be superior to those of conventional pH and spectrophotometric methods.
Adenovirus colitis in the acquired immunodeficiency syndrome. Adenovirus was identified in colonic tissue by transmission electron microscopy or culture in 5 of 67 (7.4%) homosexual men seropositive for human immunodeficiency virus (51 with the acquired immunodeficiency syndrome) with diarrhea. Colonoscopy showed the mucosa to be normal in 3 cases and mildly inflamed in 2. Light microscopy showed foci of mucosal necrosis that contained chronic inflammatory cells and degenerating and necrotic epithelial cells with amphophilic nuclear inclusions. By transmission electron microscopy, hexagonal viral particles characteristic of adenovirus were identified within the inclusions. Only 1 patient was concomitantly infected by a second potential enteric pathogen. It was concluded that adenovirus, an uncommon enteric pathogen in immunocompetent adults, causes intestinal pathology and may be associated with diarrheal illness in persons with the acquired immunodeficiency syndrome.
Effect of aortic sclerosis on bone mineral measurements by dual-photon absorptiometry. Measurements of the bone mineral content (BMC) of lumbar spine by dual-photon absorptiometry (DPA) are performed mainly in the anteroposterior (AP) projection. Due to superimposition of the abdominal aorta, the BMC measured for patients with aortic calcification usually is too high. To determine the influence of aortic calcifications, DPA scans were performed in the AP-projection on 100 dissected abdominal aortae with different degrees of atherosclerosis placed on a human lumbar spine cast in lucite. The measured values were compared with those obtained in the same projection without the aortae. The average increase of the BMC values relative to the mean for the vertebrae L2 to L4 for aortae with severe complicated lesions, i.e., those containing larger amounts of calcium, was 0.03 g/cm2, with a maximum deviation of 0.09 g/cm2. Aortae with fatty streaks or fibrous plaques did not cause significant increases of the BMC. The mean deviation for aortae with mild complicated lesions, i.e., those containing smaller amounts of calcium, was within the range of instrument precision.
Tarsal tunnel syndrome in athletes. Case reports and literature review. Tarsal tunnel syndrome is being seen in increasing frequency in the athletic population, especially in the running athlete. The sports medicine physician must be cognizant of this entity, including proper diagnostic testing and management.
Dental enamel defects in first-degree relatives of coeliac disease patients. To find out whether dental changes can be used to screen for coeliac disease among apparently healthy relatives of patients with the disorder, 56 healthy first-degree relatives of such patients were subjected to dental examination and small bowel biopsy. 25 had coeliac-type general permanent-tooth enamel lesions. All 7 who had histological evidence of coeliac disease also had enamel lesions. The finding that enamel defects may occur without small bowel changes must be borne in mind in screening. The coeliac-type enamel changes were strongly associated with HLA-DR3, and most of the DR3 alleles belonged to the extended haplotype A1; B8; DR3 group.
Inverted papilloma of renal pelvis: flexible ureteroscopic diagnosis and treatment. A case is reported of inverted papilloma of the renal pelvis in a patient with previous transitional cell carcinoma of the bladder. The renal pelvic lesion was diagnosed and treated with a flexible ureteropyeloscope. Although nephroureterectomy was avoided, the patient must be carefully followed endoscopically and radiographically for recurrence of lesions throughout the urinary tract. This case represents the first report of the endoscopic diagnosis and treatment of an inverted papilloma of the renal pelvis. It demonstrates the vast potential for endoscopic diagnosis, treatment, and surveillance throughout the urinary tract.
Obstructive sleep apnoea in children undergoing routine tonsillectomy and adenoidectomy. Sleep screening was used to discover the incidence of sleep apnoea in 50 children undergoing routine adenotonsillectomy for recurrent upper respiratory tract infections, randomly selected from the waiting list. Preoperative assessment included a detailed parental history, physical examination, and lateral cephalometry, in order to identify factors that might alert the clinician to a diagnosis of obstructive sleep apnoea. There were 2 equal groups of snorers and non-snorers (grade 0); 1 patient was found to have the sleep apnoea syndrome (IV), 9 patients had obstructive snoring with apnoeic episodes (III), 3 patients had snoring with a disrupted sleep pattern (II), and 12 patients snored with no disruption of sleep (I). In identifying patients with apnoea, a history of snoring was unhelpful, whereas one of breathing irregularities was found to be highly specific. Nasal obstruction correlated poorly; however, there was a significant relationship between tonsillar position and size and sleep grade (Chi-squared P less than 0.01). Stepwise regression analysis showed a large contribution to the grading was made by the size of the oropharyngeal airway measured by lateral cephalometry. The children in grade II-IV were re-studied 3 months post-operatively and all reverted to grades 0 or I.
Continuous extracorporeal fluid removal in children with low cardiac output after cardiac operations. Eleven hypervolemic and oliguric children with low cardiac output after cardiac operations were treated by slow continuous ultrafiltration or continuous arteriovenous hemofiltration. A mean negative fluid balance of 1.63 +/- 0.37 ml/kg/hr (standard error of the mean [SEM]) significantly improved the hemodynamic status within 59 +/- 6.1 hours (SEM). Although the central venous pressure decreased significantly from 15.2 +/- 0.84 to 8.8 +/- 0.92 mm Hg (p less than 0.0001), the mean arterial pressure increased significantly from 41.5 +/- 2.54 to 53.5 +/- 2.21 mm Hg (p less than 0.001). In addition, pH increased significantly from 7.31 +/- 0.01 (SEM) to 7.43 +/- 0.001 (SEM) (p less than 0.001) and oxygenation index (arterial oxygen tension/inspired oxygen fraction) from 119 +/- 15.2 (SEM) to 214 +/- 27.0 (SEM) (p less than 0.001). Hemodynamic improvement during slow continuous extracorporeal fluid removal allowed a significant decrease of the catecholamine infusion rate. After normovolemia had been achieved, continuous arteriovenous hemofiltration had to be continued in four children because of persistent anuria. Eight patients could be weaned from artificial ventilation and vasopressor support. Two patients died without recovery of renal function and one with restored renal function. Slow continuous ultrafiltration and continuous arteriovenous hemofiltration improve the cardiovascular function in children with low cardiac output by optimizing the preload conditions of the failing heart. In addition, they improve acid-base balance and pulmonary gas exchange.
Morphological findings contributing to a failed Fontan procedure. Twelve-year experience. A group of 37 patients (age range, 3 months to 29 years) who died after the modified Fontan procedure (within 2 months), representing 15% of the 245 patients undergoing this procedure from 1976 through 1988, was reviewed to determine the causes of death. The three morphological groups were 1) univentricular atrioventricular connection (n = 19), 2) tricuspid atresia (n = 9), and 3) other complex malformations (n = 9). Subaortic stenosis was present in 15 patients (40%) in this group compared with 31 of 208 early survivors (15%) (p = 0.008). Pulmonary artery banding, identified as a risk factor in our previous experience, was performed in 14 patients, nine of whom had subaortic stenosis. Nine palliative procedures for subaortic stenosis were performed in eight patients--before the Fontan procedure in three patients and concurrently with the Fontan procedure in five patients. Myocardial hypertrophy and signs of acute ischemic injury were common findings at autopsy (n = 25) and were particularly prominent in all patients with univentricular heart of left ventricular morphology associated with subaortic stenosis and previous pulmonary artery banding (n = 7). We conclude that the present majority of deaths occurring after the modified Fontan procedure are myocardial in nature and attributable to advanced myocardial hypertrophy that is potentiated by previous pulmonary artery banding and subaortic stenosis.
Veterans Administration Cooperative Study Group on Hypertensive Agents: effects of age on treatment results. In three double-blind studies of 1,396 hypertensive patients, the age-related effects of hydrochlorothiazide or bendroflumethazide were compared with those of propranolol, nadolol, or captopril, given singly or in combination with a thiazide. Patients in each treatment group were divided into those aged 55 to 69 years and those aged under 55. Whereas no age-related differences were apparent with propranolol, nadolol alone, or captopril alone, in all three studies the blood pressure-reducing effect was found to be greater in the older group of thiazide-treated patients than in the younger thiazide-treated group. The antihypertensive drugs studied are at least as effective in older as in younger hypertensive patients and the antihypertensive response with diuretics is greater in older patients than in younger patients.
Reoperation for persistent outflow obstruction in hypertrophic cardiomyopathy. This study compares results of a second left ventricular myotomy and myectomy (M + M) with those of mitral valve replacement (MVR) as reoperative procedures for persistent left ventricular outflow obstruction after M + M in hypertrophic cardiomyopathy. Comparison of the second M + M group (n = 12) with the MVR group (n = 11) disclosed significant difference (p less than 0.05) in mean age at the initial operation (29 +/- 11 years versus 40 +/- 8 years), interval between operations (46 +/- 57 months versus 18 +/- 13 months), and age at reoperation (33 +/- 10 years versus 42 +/- 8 years); and insignificant differences in mean preoperative functional class, cardiac index, left ventricular outflow gradients at rest or with provocation, and hospital mortality at reoperation (2/12 versus 1/11). At 6 months after reoperation, comparison of results of a second M + M with MVR showed that mean functional class, cardiac index, and left ventricular outflow gradient at rest were similarly improved, but the outflow gradient with provocation was significantly higher in the second M + M group (57 +/- 44 mm Hg versus 14 +/- 9 mm Hg, p less than 0.05). Total follow-up was 108 patient-years (100% complete) with an average of 5.9 years per patient in the second M + M group and 3.4 years per patient in the MVR group. Actuarial survival, including hospital mortality, at 3 and 5 years was 83% and 76%, respectively, after the second M + M, which was similar to 92% and 77% after MVR.
Heparin as an adjunctive treatment after thrombolytic therapy for acute myocardial infarction. The rationale for considering heparin therapy as an adjunct to thrombolytic treatment for patients with acute myocardial infarction is to prevent rethrombosis after successful thrombolysis. The risk of reocclusion is high immediately after thrombolysis because blood flowing through the newly opened coronary artery is exposed to thrombin bound to fibrin in the residual thrombus. Clinical studies of patients with venous thrombosis and acute myocardial infarction indicate that there is a relation between the anticoagulant response to heparin and clinical efficacy and that the concept of a therapeutic heparin level is valid. Subcutaneous doses of approximately 15,000 U twice a day fail to provide an adequate anticoagulant response at 24 hours in the majority of patients, whereas intravenous administration of a bolus of 5,000 U followed by continuous infusion of 30,000 U per 24 hours produces an adequate anticoagulant response at 24 hours in approximately 80% of patients. Studies of patients with myocardial infarction who received streptokinase showed a significant beneficial effect on mortality when 12,500 U of heparin was administered subcutaneously 2 times per day. In contrast, the single largest study evaluating heparin 12,500 U administered subcutaneously 2 times per day as an adjunct to recombinant tissue-type plasminogen activator (rt-PA) treatment did not show a beneficial effect on mortality. However, studies using full-dose intravenous heparin therapy demonstrated that heparin improves patency after coronary thrombolysis with rt-PA.
Long-term treatment of hereditary angioedema with attenuated androgens: a survey of a 13-year experience. Fifty-six patients affected with hereditary angioedema have been followed during long-term prophylaxis with attenuated androgens. The treatment was started in patients who had one or more severe attacks per month. In 24 patients, the therapy lasted for more than 5 years. The minimal effective dose usually did not exceed 2 mg/day of stanozolol or 200 mg/day of danazol. Only in two patients were these doses not sufficient to achieve the complete disappearance of symptoms. Irregular menstruation, but rarely amenorrhea, was the only significant side effect. One patient had to stop the therapy because of laboratory signs of hepatic cell necrosis. In one patient, danazol was administered during the last 8 weeks of pregnancy without side effects for the mother but with transient signs of virilization for the female baby. To find a biochemical marker for the minimal effective dose of androgen derivatives, we measured the plasma levels of C1 C1 INH complexes at different doses of stanozolol in four patients with hereditary angioedema. We found that these complexes, elevated before treatment, promptly reverted to normal values during androgen therapy and remained normal with any reduction of the dose of the drug as long as the patient remained symptom free. Therefore, the measurement of C1 C1 INH complexes appears to reflect the activity of the disease and not the amount of androgen that is administered.
Bacterial meningitis in neonates and children. A high index of suspicion of meningitis is needed when evaluating neonates and young infants because clinical findings can be minimal and are often subtle and nonspecific. Analysis of the CSF constitutes the most effective method to document meningeal bacterial infection, although overlap with normal CSF values can occur, especially in newborns and very young infants. The introduction of highly active third-generation cephalosporins (ceftriaxone, cefotaxime) and their safety and efficacy in treating a broad array of bacterial pathogens that cause meningitis in all age groups has simplified selection of initial antibiotic therapy. In neonates, however, conventional antibiotic therapy with ampicillin and an aminoglycoside is appropriate because of its proven record of safety and efficacy, and because routine use of cephalosporins in the hospital nursery could lead to selection of resistant strains among gram-negative enteric bacilli. Despite the availability of modern intensive care management of infants and children with bacterial meningitis and the advent of potent antibiotics, case fatality rates and morbidity remain high. Because of this, recent research has focused on the complex interaction between bacteria and the host and on means to attenuate the meningeal inflammatory response. The clinical benefits demonstrated recently with the use of dexamethasone therapy in infants and children with bacterial meningitis underscore the importance of anti-inflammatory therapy to reduce audiologic and neurologic sequelae. Future studies of new methods to modulate meningeal inflammation such as the use of monoclonal antibodies directed against cytokines or of agents that interfere with leukocyte-endothelial interactions are indicated. The implication of routine H. influenzae type b immunization in young infants with the conjugated vaccines and optimal intrapartum prophylaxis against group B streptococcal disease in newborns will have an important impact on the incidence of meningitis in infants and children.
Comparative yield of Salmonella typhi from blood and bone marrow cultures in patients with fever of unknown origin. Over three years, a comparative study on 100 selected patients with fever of unknown origin was undertaken to determine the yield of Salmonella typhi from their blood and bone marrow cultures. The results indicate that in patients who had an infection with S typhi the organism was isolated from the bone marrow in all of them and from the blood in only 66%. This suggests that bone marrow cultures may be attempted when blood cultures are negative for bacterial growth after three to four days of incubation.
The effect of ursodiol on the efficacy and safety of extracorporeal shock-wave lithotripsy of gallstones. The Dornier National Biliary Lithotripsy Study BACKGROUND. In the treatment of gallstones with extracorporeal shock-wave lithotripsy, the bile acid ursodiol is administered to dissolve the gallstone fragments. We designed our study to determine the value of administering this agent. METHODS. At 10 centers, 600 symptomatic patients with three or fewer radiolucent gallstones 5 to 30 mm in diameter, as visualized by oral cholecystography, were randomly assigned to receive ursodiol or placebo for six months, starting one week before lithotripsy. RESULTS. The stones were fragmented in 97 percent of all patients, and the fragments were less than or equal to 5 mm in diameter in 46.8 percent. On the basis of an intention-to-treat analysis of all 600 patients, 21 percent receiving ursodiol and 9 percent receiving placebo (P less than 0.0001) had gallbladders that were free of stones after six months. Among those with completely radiolucent solitary stones less than 20 mm in diameter, 35 percent of the patients receiving ursodiol and 18 percent of those receiving placebo (P less than 0.001) were free of stones after six months. Biliary pain, usually mild, occurred in 73 percent of all patients but in only 13 percent of those who were free of stones after three and six months (P less than 0.01). There were few adverse events. Only diarrhea occurred with a significantly different frequency in the two groups: 32.6 percent were affected in the ursodiol group, as compared with 24.7 percent in the placebo group (P less than 0.04). Severe biliary pain occurred in 1.5 percent of all patients, acute cholecystitis in 1.0 percent, and acute pancreatitis in 1.5 percent; endoscopic sphincterotomy was performed in 0.5 percent, and cholecystectomy in 2.5 percent. CONCLUSIONS. Extracorporeal shock-wave lithotripsy with ursodiol was more effective than lithotripsy alone for the treatment of symptomatic gallstones, and equally safe. Treatment was more effective for solitary than multiple stones, radiolucent than slightly calcified stones, and smaller than larger stones.
Reconstructive surgery in chronic venous obstruction of the lower limbs. Forty-one patients with chronic venous insufficiency due to venous trunk obstruction of the lower limbs underwent 43 flow reconstruction procedures consisting of either free veno-venous bypass or venous transposition. The indicating symptoms for these procedures were (1) progressive chronic edema, (2) claudication while walking, or (3) trophic lesions. Doppler ultrasound and plethysmographic techniques were employed in the diagnosis while phlebography was considered the most useful and most essential technique. Iliac vein obstruction was the most common venous obstruction, followed by superficial femoral vein obstruction. Two patients were operated on for combined obstruction at both levels. Free veno-venous bypass was the most frequently used procedure. In two cases of cavo-iliac obstruction, an original technique of femoro-axillary veno-venous bypass yielded good results. Temporary arteriovenous fistulas to improve patency at sites distal to venous bypass were used in the most complex cases. Good results were obtained in 80% of the operated cases. Postoperative follow-up phlebograms were obtained in 30 of 43 operations.