Persius/hicric huggingface dataset:
Imipenem cilastatin compatibility reconstitution and stability

# Compatibility, Reconstitution, and Stability

## Compatibility And Stability
Before Reconstitution:
The dry powder should be stored at a temperature below 25C (77F).
Reconstituted Solutions:
Solutions of PRIMAXIN I.V. range from colorless to yellow. Variations of color within this range do not affect the potency of the product.
Vials
PRIMAXIN I.V., as supplied in single use vials and reconstituted with the following diluents (see PREPARATION OF SOLUTION), maintains satisfactory potency for 4 hours at room temperature or for 24 hours under refrigeration (5C). Solutions of PRIMAXIN I.V. should not be frozen.
0.9% Sodium Chloride Injection
5% or 10% Dextrose Injection
5% Dextrose and 0.9% Sodium Chloride Injection
5% Dextrose Injection with 0.225% or 0.45% saline solution
5% Dextrose Injection with 0.15% potassium chloride solution
Mannitol 5% and 10%
ADD-Vantage vials
PRIMAXIN I.V., as supplied in single dose ADDVantage vials and reconstituted with the following diluents (see PREPARATION OF SOLUTION), maintains satisfactory potency for 4 hours at room temperature.
0.9% Sodium Chloride Injection
5% Dextrose Injection
PRIMAXIN I.V. should not be mixed with or physically added to other antibiotics. However, PRIMAXIN I.V. may be administered concomitantly with other antibiotics, such as aminoglycosides.
LDL Cholesterol and its Association with Cancer: July 24, 2007
July 24th, 2007, C. Michael Gibson, M.S., M.D. 
View the TV interview here
Boston MA: Don't stop your statin therapy, but researchers today at Boston's Tufts Medical School report an association between the risk of subsequent cancer and a patient's LDL cholesterol at the end of lipid-lowering therapy in this week's Journal of the American College of Cardiology.
Richard Karas, M.D., senior author of the study told WikiDoc that "This is an association and we have not identified the causal links if any between cholesterol levels and cancer. It is important to note that we are not saying that statins cause cancer. Indeed some studies have shown a lower rate of cancer development among patients treated with statin therapy."
Karas went on to say "We have identified no causal links between LDL cholesterol levels and cancer".  When asked if the low LDL could simply be a marker of future risk rather than a cause of cancer, Karas replied "yes".  "It is possible that low LDL is a marker of some type of metabolic difference in those patients who go on to develop cancer". It could also be speculated that patients with high LDLs may die of cardiovascular causes, and this leaves a remaining population of patients who are at low risk of cardiovascular death, but who eventually die of other causes such as cancer. In a sense, there are competing causes of death, and low LDL cholesterol identifies a population who are at low risk of cardiovascular death, but since cancer is another leading cause of death, they die of that."
With respect to other complications of lipid lowering therapy, there were some indications that high doses of statins may be associated with myositis (muscle inflammation) and liver function tests abnormalities. Karas stated that "Although we did not find that a patient's LDL cholesterol was associated with the risk of developing myositis or liver function test abnormalities, we did find that higher doses of statins were associated with a higher risk of myositis and liver function test abnormalities."
Lancet Editor Forsees Wikis as the Future for Medical Journals
November 20, 2007 By Scott P. Williams 

# Overview
Nashville, TN: According to Faith McClellan, senior North American editor for The Lancet, the future of how medical information will be presented and disseminated is right here, right now in the form of the wiki.  In a recent talk at the Vanderbilt University School of Medicine, McClellan presented to a group of faculty and students that in order to survive, the worlds leading medical journals will have to take on forms more compatible with todays web 2.0 world.
At the lecture, McLellan expressed concern that the traditionally slow-moving medical journals are quickly losing their relevance in todays fast-paced world.  Presently there is a considerable amount of lag time between the discovery of new medical information and the informations release to the medical community and general public via publication in academic journals.  Increasingly, doctors and patients alike are demanding access to the newest medical knowledge at a rate that journals are unable to provide, due to these inherent delays in publication.
McClellan suggested that in order to keep up with this demand for rapidly available information, journals will have to adapt more modern forms of media such as wikis, blikis (blogs of wikis), blogs, podcasts, and video sharing software such as YouTube.  These open source media platforms allow for new information to be broadcast across the world to an essentially limitless audience in a timelier manner.  Not only do these new forms of media make medical information available faster, they also tend to present the information in a more condensed and user-friendly manner by focusing on the essential points of a study.
The exclusion of the details from these rapid access forms of media is concerning to many medical experts, who fear that both doctors and patients may begin making important decisions with only part of the necessary information.  With their tradition of rigorous academic review prior to the publication of a study, medical journals have sought to provide as complete of an evaluation of new medical information as possible.  This upfront critical assessment is largely lost when new information goes directly to a rapid access forum such as a wiki or a blog.  What is lost in upfront evaluation, though, may be compensated for by the public forum aspect of the new forms of media.  On a wiki, bliki or blog any user that disagrees with or questions a finding can display their concerns for all to see by commenting on or editing the information presented.
It still remains to be seen how effectively our society can self-police the posting and dissemination of proper justified medical knowledge, but the recent success of websites such as Wikipedia suggests that the future of medical news lies with public forum websites rather than traditional academic journals.
To read more about McClellans presentation click | here
News:NT-proBNP Guided vs. Sympton-Guided Heart Failure Therapy
NT-pro BNP Guided vs. Symptom-Guided Heart Failure Therapy By Michael W Tempelhof, MD
B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) have been validated as prognostic and diagnostic markers for patients with congestive heart failure. Previous studies which were limited in both study design and size, have precluded sound establishment for BNP and/or NT-proBNP as clinical markers to response of outpatient therapy for heart failure patients.
STUDY OBJECTIVE:
To compare 18-month outcomes of N-terminal BNPguided vs symptom-guided heart failure therapy.
STUDY DESIGN and METHODS:
This investigation (TIME-CHF) enrolled 499 outpatients aged 60 with systolic heart failure, NYHA class 2 heart failure symptoms, an LVEF 45%, hospitalization for heart failure within the preceding 12 months, and an NT-proBNP level 400 pg/mL for those <75 years old and 800 pg/mL for patients 75 years of age despite medical therapy. Patients were randomized to receive medical intervention dictated by clinical symptoms or by NT-proBNP levels with titration of medical therapy to reduce symptoms to <YHA class of II and BNP level of 2 times or less the upper limit of normal for the BNP-guided therapy study arm.
OUTCOMES:
Primary outcomes were 18-month survivalfree of all-cause hospitalizations and quality of life. Secondary outcomes of survival free of heart failurerelated hospitalization.
RESULTS:
- BNP-guided patients had higher rates of protocol-recommended medication uptitration, received higher doses of both classes of medication, and were more likely to receive aldosterone antagonists than those in the symptom-guided group.
- No significant difference was found in the primary endpoints of survival free rates of hospitalization for any cause; HR (95% CI)., 0.91 (0.72-1.14) p=0.39
- Survival free of heart failure related hospitalization was significantly higher in the BNP-guided group than in the symptom-guided group: HR (95% CI)., 0.68 (0.50-0.92) p=.01.
CONCLUSIONS:
Utilization of NT-pro BNP levels to guide heart failure medical therapy intervention did not significantly improve overall; 18-month survival free of any hospitalizations or improve the quality of life more than in patients receiving standard symptom guided medical therapy.
Pfisterer M et al. BNP-guided vs symptom-guided heart failure therapy: The Trial of Intensified vs Standard Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME-CHF) randomized trial. JAMA 2009 Jan 28; 301:383.

# Source
Amitriptyline hydrochloride how supplied storage and handling

# How Supplied
Amitriptyline Hydrochloride Tablets, USP are available containing either 10 mg, 25 mg, 50 mg, 75 mg or 100 mg of Amitriptyline Hydrochloride, USP.
The 10 mg tablets are white film-coated, round, unscored tablets debossed with M77 on one side of the tablet and blank on the other side. They are available as follows:
NDC 51079-131-20 - Unit dose blister packages of 100 (10 cards of 10 tablets each).
NDC 51079-131-63 - Compliance Pack of 30 tablets.
The 25 mg tablets are light green film-coated, round, unscored tablets debossed with M over 51 on one side of the tablet and blank on the other side. They are available as follows:
NDC 51079-107-20 - Unit dose blister packages of 100 (10 cards of 10 tablets each).
NDC 51079-107-19 - Robot Ready blister packages of 25 (25 cards of 1 tablet each).
NDC 51079-107-63 - Compliance Pack of 30 tablets.
The 50 mg tablets are brown film-coated, round, unscored tablets debossed with M over 36 on one side of the tablet and blank on the other side. They are available as follows:
NDC 51079-133-20 - Unit dose blister packages of 100 (10 cards of 10 tablets each).
NDC 51079-133-63 - Compliance Pack of 30 tablets.
The 75 mg tablets are blue film-coated, round, unscored tablets debossed with M over 37 on one side of the tablet and blank on the other side. They are available as follows:
NDC 51079-147-20 - Unit dose blister packages of 100 (10 cards of 10 tablets each).
The 100 mg tablets are orange film-coated, round, unscored tablets debossed with M over 38 on one side of the tablet and blank on the other side. They are available as follows:
NDC 51079-563-20 - Unit dose blister packages of 100 (10 cards of 10 tablets each).
Store at 20 to 25C (68 to 77F). 
Protect from light.
PHARMACIST: Dispense a Medication Guide with each prescription.

### Metabolism
Studies in man following oral administration of 14C-labeled drug indicated that amitriptyline is rapidly absorbed and metabolized. Radioactivity of the plasma was practically negligible, although significant amounts of radioactivity appeared in the urine by 4 to 6 hours and one-half to one-third of the drug was excreted within 24 hours.
Amitriptyline is metabolized by N-demethylation and bridge hydroxylation in man, rabbit, and rat. Virtually the entire dose is excreted as glucuronide or sulfate conjugate of metabolites, with little unchanged drug appearing in the urine. Other metabolic pathways may be involved.
Cholesterol Values During Puberty: Results of the STRIP Study
September 7, 2007 By Samantha Pathe 
Boston, MA:  Prevention of atherosclerosis and coronary heart disease has long been associated with certain dietary precautions.  Diets containing low amounts of cholesterol and saturated fats have been shown to reduce the risks of developing these diseases.  However, there have been some concerns that a low-cholesterol, low-saturated fat diet may have a negative impact on physical and cognitive development in children.  As a result, many young children are excluded from this type of diet and may therefore be at a greater risk for developing heart disease over time.
Previous studies have evaluated the effects of a low-cholesterol, low-saturated fat diet in children <7 years of age.  However, studies of the same nature that continue into adolescence have not been performed.  In a recent article published in Circulation, researchers assessed the effectiveness of dietary counseling on fat intake, cholesterol levels, growth, and development in children and adolescents.
Participants in the Special Turku Coronary Risk Factor Intervention Project (STRIP) were placed in either an intervention group or control group.  Infants in the intervention group were introduced to a low-saturated-fat, low-cholesterol diet before their first birthday.  The parents and children of both groups received nutrition counseling sporadically over a span of 14 years.  Researchers measured fat and saturated fat intake, serum cholesterol, LDL cholesterol, HDL cholesterol and triglyceride values.  In order to assess physical growth, BMI values were tracked throughout the trial.
Overall, serum cholesterol levels were lower for children in the intervention group.  Intervention influenced the sexes differently.  Boys had lower serum cholesterol and LDL cholesterol values than girls.  The authors suggest that puberty influences serum cholesterol concentrations.  Serum cholesterol and HDL cholesterol concentrations were lower in the pubertal children than the pre-pubertal children.  The low-cholesterol, low-saturated fat intake of the intervention group did not appear to impair physical growth as feared, with no significant difference in pubertal development between the groups.
1. Niinikoski H, Lagstrom H, Jokinen E, Siltala M, Ronnemaa T, Viikari J, Raitakari OT, Jula A, Marniemi J, Nanto-Salonen K, Simell O. Impact of Repeated Dietary Counseling Between Infancy and 14 Years of Age on Dietary Intakes and Serum Lipids and Lipoproteins. The STRIP Study. Circulation August 2007; doi:10.1161/CIRCULATIONAHA.107.699447. PMID: 17698729 PubMed HubMed
Clindamycin palmitate hydrochloride dosage and administration

# DOSAGE AND ADMINISTRATION
If significant diarrhea occurs during therapy, this antibiotic should be discontinued (see WARNING box).
Concomitant administration of food does not adversely affect the absorption of clindamycin palmitate HCl contained in clindamycin palmitate hydrochloride for oral solution (Pediatric) flavored granules.
Serious infections: 8 to 12 mg/kg/day (4 to 6 mg/lb/day) divided into 3 or 4 equal doses.
Severe infections: 13 to 16 mg/kg/day (6.5 to 8 mg/lb/day) divided into 3 or 4 equal doses.
More severe infections: 17 to 25 mg/kg/day (8.5 to 12.5 mg/lb/day) divided into 3 or 4 equal doses.
In pediatric patients weighing 10 kg or less, 12 teaspoon (37.5 mg) three times a day should be considered the minimum recommended dose.
Serious infections due to anaerobic bacteria are usually treated with clindamycin injection. However, in clinically appropriate circumstances, the physician may elect to initiate treatment or continue treatment with clindamycin palmitate hydrochloride for oral solution (Pediatric).
NOTE: In cases of -hemolytic streptococcal infections, treatment should be continued for at least 10 days.
Reconstitution Instructions: When reconstituted with water as follows, each 5 mL (teaspoonful) of solution contains clindamycin palmitate HCl equivalent to 75 mg clindamycin.
Reconstitute bottles of 100 mL with 75 mL of water. Add a large portion of the water and shake vigorously; add the remainder of the water and shake until the solution is uniform.
Storage Conditions: Store at 20 to 25C (68 to 77F)
Do NOT refrigerate the reconstituted solution; when chilled, the solution may thicken and be difficult to pour. The solution is stable for 2 weeks at room temperature.
Eplerenone Post-Ami Heart Failure Efficacy And Survival Study

# Acronym
EPHESUS stands for Eplerenone Post-AMI Heart Failure Efficacy and Survival Trial.

# Background
Eplerenone is an aldosterone antagonist that blocks the mineralocorticoid receptor.  In contrast to spironolactone, it does  not block the glucocorticoid, progesterone, or androgen receptors and for that reason it may may be associated with fewer side effects than spironolactone.  Pre clinical studies have demonstrated that aldosterone antagonism may improve ventricular remodeling and collagen formation among patients who sustain LV dysfunction following an MI.
The EPHESUS study builds upon the RALES study (Randomized Aldactone Evaluation Study) which demonstrated that aldosterone inhibition with the older agent spironolactone reduced mortality when added to an ACE inhibitor among patients with severe congestive heart failure.  In the older RALES study, only 10% of patients were on a beta blocker, and the benefit of an aldosterone antagonist on top of beta blockade was not adequately tested.

# Methods
Entry criteria included a left ventricular ejection fraction  meq/li and a baseline Cr of > 2.5 mg/dl.  This was an event driven trial that was continued until there were 1012 deaths.  There was a median of 16 months of follow-up.

# Results
All cause death, and cardiovascular death, and cardiovascular death plus rehospitalization were all significantly reduced over 16 months of follow-up.
Sudden death from cardiac causes was reduced (p=0.03).  Among those patients who would qualify for an AICD by MADIT II criteria (an LVEF <30%), there was a 33% reduction in sudden cardiac death.  When the analysis was restricted to those patients who were treated with optimal evidence based therapy with an ACE/ARB, aspirin, statin, beta-blockade and reperfusion therapy there was still a 26% reduction in all cause mortality.
Number Needed to Treat (NNT) = 50 patients to save one life, and 33 to prevent one cardiovascular death or rehospitalization.

# Adverse Events
As might be expected from an aldosterone inhbitor, the risk of hyperkalemia was significantly increased among those patients with a Cr clearance < 50 cc / minute on entry into the trial.  There were no deaths attributable to hyperkalemia.  As a result, potassium levels should be monitored in patients on eplerenone.  Interestingly, the risk of hypokalemia was actually twice as high as the risk of hyperkalemia.  It is notable that eplerenone reduced the risk of hypokalemia.  The investigators hypothesized that reducing the risk of hypokalemia was important in so far as the presence of hypokalemia reversed any benefit from antihypertensive therapy in the SHEP trial.
Consistent with the improved specificity of the agent, there was no increase in the risk of gynecomastia, or menstrual disorders with eplerenone.

# Summary
Among MI patients with LV dysfunction, the administration of eplerenone (Inspra, Pharmacia) in addition to evidence based therapy is associated with a 15% reduction in all cause mortality.  In addition, cardiovascular death, and CV death and hospitalization were also significantly reduced.
Electrocardiographic findings in left ventricular hypertrophy
Synonyms and keywords: LVH; LVH with strain; strain pattern

# Overview
Left ventricular hypertrophy is associated with increased QRS voltage on the EKG and a strain pattern or inverted checkmark pattern to the T wave in the lateral leads.  There are a variety of criteria used to diagnose left ventricular hypertrophy (LVH) on the EKG.

# Diagnosis

## Electrocardiography

### Sokolow and Lyon Criteria
- Add the depth of the S wave in V1 to the height of the R wave in lead V5 or V6 (whichever is taller) and if the sum is greater than 35 mm then LVH is present.
- This criterion correlates well with the thickness of the LV walls and the diameter of the LV cavity as determined by ECHO.
- Sensitivity 22% and specificity of 100%.

### Effects of Left Anterior Hemiblock on Diagnosing Acute myocardial infarction and Left Ventricular Hypertrophy
LAHB may be a cause of poor R wave progression across the precordium causing a pseudoinfarction pattern mimicking an anteroseptal infarction. It also makes the electrocardiographic diagnosis of LVH more complicated, because both may cause a large R wave in lead aVL. Therefore to call LVH on an EKG in the setting of an LAHB you should see the presence of a strain pattern when you are relying on limb lead criteria to diagnose LVH.

### Cornell Voltage Criteria
- Add the height of the R wave in lead aVL to the depth of the S wave in lead V3.
- LVH if the sum is > 28mm in men or > 20 mm in women.
- Sensitivity of 42% and specificity of 96%.

### Roberts Criteria
- Add the QRS voltage in all 12 leads and LVH is present if the voltage exceeds 175 to 225 mm.

### Estes Criteria
- R or S in limb lead: 20 mm or more
S in V1, V2, or V3: 25 mm or more  3 points
R in V4, V5, or V6: 25 mm or more
- S in V1, V2, or V3: 25 mm or more  3 points
- R in V4, V5, or V6: 25 mm or more
- Any ST shift (without digitalis): 3 points
Typical "strain" ST T (with digitalis): 1 points
- Typical "strain" ST T (with digitalis): 1 points
- LAD: 15 degrees or more: 2 points
- QRS interval: 0.09 seconds or more: 1 point
- Intrinsicoid deflection in V5 or V6 of 0.04 seconds or more: 1 point
- P terminal force in V1 more than 0.04 sec: 1 point
Total possible: 13 points
Total of 
5 points = LVH, 
4 points = probable LVH

## Electrocardiographic Examples
- Mechanism of left ventricular hypertrophy
- LVH: RV5 is 26mm, SV1 in 15mm. The sum is 41 mm (>35 mm and therefore LVH is present)
LVH: RV5 is 26mm, SV1 in 15mm. The sum is 41 mm (>35 mm and therefore LVH is present)
- Left ventricular hypertrophy
- Extreme left ventricular hypertrophy in a patient with severe aortic valve stenosis
Extreme left ventricular hypertrophy in a patient with severe aortic valve stenosis
- LVH in subendocardial ischemia with positive cardiovascular markers
LVH in subendocardial ischemia with positive cardiovascular markers
- LVH + Left Anterior Hemiblock
The EKG in the patient treated with tricyclic antidepressants

# Electrocardiographic Findings
- EKG changes are observed in 20% of patients who are at therapeutic doses
- Prolongation of the QTc, displacement of the ST segment, T wave abnormalities, QRS widening, supraventricular and ventricular tachycardias can all occur.
- In overdose, widening of the QRS is frequent, and there is also QTc prolongation

# Examples
Shown below is an image of EKG in a patient of nortriptyline intoxication demonstrating wide QRS complex and prolonged QT interval
Shown below is an image of EKG in a patient of nortriptyline intoxication demonstrating wide QRS and peaked T waves.
Shown below are the EKG images of a patient with amitriptylin intoxication showing tachycardia with heart rate 130.
Low flow low gradient aortic stenosis resident survival guide

# Overview
When severe systolic and/or diastolic myocardial dysfunction coexist with aortic stenosis, there is a decrease in the flow through the valve leading to a prominent decrease in the transvalvular gradient, a condition referred to as low flow low gradient aortic stenosis (LF-LG AS).  LF-LG AS with is defined as:
- An aortic valve areas < 1.0 cm2, and
- A mean pressure difference or gradient across the aortic valve of < 40 mm Hg

# Management
Shown below is an algorithm of the management of low flow, low gradient aortic stenosis.
Abbreviations: AVR: Aortic valve replacement; EOA: Effective orifice area; Pmean: mean pressure gradient