RESUMO
This article reviews potential drug interactions that exist between ketoconazole or fluconazole and other drugs. English-language data sources included human subjects' computerized databases and published indexes. Case reports and studies demonstrate decreased dosage requirements of cyclosporine sodium, methylprednisolone sodium succinate, and possibly anticoagulants and phenytoin after ketoconazole or fluconazole administration, suggesting hepatic enzyme inhibition. Increased dosage requirements of ketoconazole are necessary after rifampin administration, suggesting rifampin's induction of hepatic microsomal enzymes. Possibly a similar effect may occur with concomitant fluconazole and rifampin. The effect of ketoconazole administration on prednisolone sodium phosphate and theophylline warrants further study. Fluconazole, a more selective agent for fungal P-450, seems to be of less concern regarding the potential for drug interactions than ketoconazole.
Assuntos
Fluconazol/farmacologia , Cetoconazol/farmacologia , Interações Medicamentosas , HumanosRESUMO
Marfan syndrome is a hereditable disorder of connective tissue that causes several distinct cardiovascular abnormalities, including aortic regurgitation, dissection, and aneurysm. These cardiac manifestations can be identified with echocardiography, computer tomography, and angiography. Standard treatment of an acute hypertensive crisis in Marfan syndrome uses propranolol and sodium nitroprusside. This patient with Marfan syndrome whose case is reported herein presented with chest pain, hypertensive crisis, and aortic insufficiency; labetalol was used successfully to treat the acute hypertensive crisis and magnetic resonance imaging (MRI) was used to differentiate between aortic dissection and an expanding aortic aneurysm. This report is unique in that labetalol was used to control the hypertensive crisis in Marfan syndrome and MRI was used as the initial diagnostic modality in an emergency setting.
Assuntos
Aneurisma Aórtico/etiologia , Dissecção Aórtica/diagnóstico , Hipertensão/tratamento farmacológico , Labetalol/uso terapêutico , Imageamento por Ressonância Magnética , Síndrome de Marfan/complicações , Doença Aguda , Aorta , Aneurisma Aórtico/diagnóstico , Humanos , Hipertensão/etiologia , Masculino , Pessoa de Meia-IdadeRESUMO
The technique of pulmonary lymphoscintigraphy was used to evaluate pulmonary lymphatic flow and to assess reestablishment of lymphatic drainage after lung transplantation. A first group of six control dogs underwent percutaneous transthoracic injection of a radiocolloid into the periphery of the left upper and lower lobes. Radiocolloids are large molecules tagged with radioisotopes that are absorbed only through lymph and are concentrated in tributary lymph nodes. Twenty-four hours after injection the dogs underwent scintigraphic studies of the chest and upper part of the abdomen. Mediastinal lymph nodes were visualized in all animals. A second group of four dogs underwent partial reimplantation of the native left lung, with interruption of all lymphatic connections between the lung and mediastinum. Lymphoscintigraphic studies of the left lung were obtained on the third postoperative day and then weekly for 4 weeks. Three of the four dogs in this group did not have visible mediastinal nodes 3 days after the operation. Nodes were visualized in all animals at 1 week and at all following studies. A third group of five dogs were subjected to left lung allotransplantation by means of standard surgical techniques, as well as immunosuppression. The animals were studied with radiocolloid injections and lung lymphoscintigraphy at weekly intervals for 6 weeks. Mediastinal nodes were visualized for the first time 2 to 4 weeks after the operation and at every subsequent study. We conclude that lung lymphoscintigraphy is a reliable technique for the study of pulmonary lymphatic flow. This experiment demonstrates that lymphatic drainage after lung transplantation is reestablished as early as the second postoperative week.
Assuntos
Transplante de Pulmão/fisiologia , Sistema Linfático/fisiologia , Compostos de Tecnécio , Animais , Antimônio , Coloides , Cães , Transplante de Pulmão/diagnóstico por imagem , Linfocintigrafia , Regeneração , TecnécioRESUMO
We previously demonstrated that lymphoscintigraphy could be used to study pulmonary lymphatic flow. Radiocolloids, high-molecular-weight proteins tagged with radioactive markers, are injected percutaneously in the periphery of the lung. These molecules enter the lymph, are transported via lymphatic channels, and concentrate in the tributary hilar and mediastinal lymph nodes, where they can be visualized by nuclear scan. The goal of this study was to determine whether pulmonary lymphoscintigraphy could be used to detect allograft rejection after lung transplantation. Thirteen mongrel dogs underwent left lung allotransplantation. Cyclosporine 15 mg/kg per day and azathioprine 1 mg/kg per day were given orally for postoperative immunosuppression. Lymphoscintigraphic studies were obtained 1 week after the operation and then at weekly intervals. In five dogs (group A), immunosuppression was continued until the animal died or was put to death 6 weeks later. Lymphoscintigraphy demonstrated reestablishment of lymphatic drainage between the lung graft and the mediastinum in all the animals 2 to 4 weeks after transplantation. In eight dogs (group B), immunosuppression was discontinued after reestablishment of graft lymphatic drainage was documented by two consecutive lymphoscintigraphic studies. The dogs continued to be studied with weekly scans. In group B, lymphatic drainage from the lung graft to the mediastinum disappeared 1 to 4 weeks after immunosuppression was stopped. Rejection was diagnosed clinically and confirmed histologically with open lung biopsies and/or autopsies in all animals. This study shows that canine allograft lung rejection is associated with disappearance of lymphatic drainage from lung graft to mediastinum, which can be documented by pulmonary lymphoscintigraphy, a minimally invasive technique that can be easily repeated. Pulmonary lymphoscintigraphy may be useful for early detection of lung allograft rejection.
Assuntos
Rejeição de Enxerto/diagnóstico por imagem , Transplante de Pulmão/fisiologia , Linfonodos/diagnóstico por imagem , Sistema Linfático/fisiologia , Mediastino/diagnóstico por imagem , Doença Aguda , Animais , Cães , Rejeição de Enxerto/fisiopatologia , Terapia de Imunossupressão , Pulmão/diagnóstico por imagem , Pulmão/fisiologia , Pulmão/fisiopatologia , Transplante de Pulmão/diagnóstico por imagem , Linfonodos/fisiologia , Linfonodos/fisiopatologia , Sistema Linfático/fisiopatologia , Linfocintigrafia , Mediastino/fisiopatologia , Transplante HomólogoRESUMO
OBJECTIVE: The purpose of this experiment was to evaluate the potential for a skeletal muscle ventricle connected to the circulation between the left ventricle and the aorta to provide effective, long-term cardiac assist. METHODS: Skeletal muscle ventricles were constructed from the latissimus muscle in 10 dogs. After conditioning, the skeletal muscle ventricles were connected to the left ventricle and the aorta with 2 valved conduits. The skeletal muscle ventricle was programmed to contract during diastole. RESULTS: At time of implantation, skeletal muscle ventricles stimulated at 33 Hz and in a 1:2 ratio with the heart significantly decreased left ventricular work by 56% (P <.01) and at 50 Hz by 65% (P <.01). At a 1:2 ratio, the power output of the skeletal muscle ventricles was 59% of left ventricular power output at 33 Hz (P <. 01) and 93% at 50 Hz (P <.01). Animals survived 7, 11, 16, 17, 72, 99, 115, 214, and 249 days. Three deaths were directly related to the skeletal muscle ventricle. One animal is alive at 228 days. In the animal that survived 249 days, skeletal muscle ventricle power output at 8 months with a 33 Hz stimulation frequency and a 1:2 contraction ratio was 57% of left ventricular power output and 82% at 50 Hz. At a 1:1 ratio, skeletal muscle ventricle power output was 97% and 173% of the left ventricle at 33 and 50 Hz, respectively. CONCLUSIONS: Left ventricular assist with a skeletal muscle ventricle connected between the left ventricle and the aorta is the most hemodynamically effective configuration we have tested and can maintain significant power output up to 8 months.
Assuntos
Aorta Torácica/cirurgia , Coração Auxiliar , Pericárdio/cirurgia , Ventrículo de Músculo Esquelético/fisiologia , Função Ventricular , Animais , Circulação Assistida/métodos , Velocidade do Fluxo Sanguíneo , Débito Cardíaco , Modelos Animais de Doenças , Cães , Estimulação Elétrica , Seguimentos , Insuficiência Cardíaca/cirurgia , Ventrículos do Coração/cirurgiaRESUMO
The study proposed to determine if a preclinical basic science index comprised of anatomy, behavioral medicine, biochemistry, microbiology, pathology, pharmacology, and physiology courses or any one of these basic science courses would predict student performance during surgical clerkship. The basic science index demonstrated a correlation of 0.55 and 0.35 with the individual student's written and oral clerkship scores, respectively. A stepwise multiple regression using a backward stepping algorithm was applied; the dependent variables were oral and written clerkship scores, and the independent variables were the basic science courses. Microbiology, pathology, and physiology course scores were predictors of written score (R = 0.60). Pathology course scores were the sole predictor of oral score (R = 0.43). Medical student basic science performance was not a strong forecaster of performance on the surgical clerkship. The pathology basic science score was the only consistent predictor of performance on the written and oral evaluations given at the end of the clerkship.
Assuntos
Estágio Clínico , Educação de Graduação em Medicina , Escolaridade , Ciência , Estudantes de Medicina , Previsões , Cirurgia Geral/educação , Humanos , Estatística como AssuntoRESUMO
Placement of a Swan-Ganz catheter can cause many complications. This case report presents a new complication of Swan-Ganz catheter insertion--placement of the Swan-Ganz catheter tip in the coronary sinus.
Assuntos
Cateterismo Cardíaco/instrumentação , Cateteres de Demora , Ponte de Artéria Coronária , Vasos Coronários , Pressão Propulsora Pulmonar , Idoso , Feminino , Hemodinâmica , Humanos , Complicações Pós-Operatórias/diagnósticoRESUMO
Distortion of the pulmonary artery anastomosis due to the size mismatch between the recipient's pulmonary trunk and the donor's pulmonary artery was the cause of acute right ventricular failure after cardiac transplantation. The problem was corrected with a two-suture technique, which has been used subsequently.
Assuntos
Transplante de Coração/métodos , Artéria Pulmonar/cirurgia , Técnicas de Sutura , Anastomose Cirúrgica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Função Ventricular Direita/fisiologiaRESUMO
Recent data indicate that the gastrointestinal bleeding due to angiodysplasia associated with aortic stenosis (Heyde's syndrome) can be alleviated by aortic valve replacement with a bioprosthesis. This report details a situation in which valve replacement with a mechanical prosthesis and the subsequent anticoagulation promoted gastrointestinal bleeding from angiodysplastic lesions. Only when the mechanical prosthesis was replaced with a porcine prosthesis and the anticoagulation discontinued did the gastrointestinal bleeding stop.
Assuntos
Estenose da Valva Aórtica/complicações , Malformações Arteriovenosas/complicações , Bioprótese , Transtornos da Coagulação Sanguínea/complicações , Hemorragia Gastrointestinal/etiologia , Próteses Valvulares Cardíacas , Anticoagulantes/efeitos adversos , Valva Aórtica , Estenose da Valva Aórtica/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , SíndromeRESUMO
A series of 106 consecutive ductal closures in premature infants was reviewed to assess the incidence of left vocal cord paralysis. To our knowledge, this syndrome is described for the first time in premature infants. In our experience, it is a relatively benign complication that completely resolves clinically in several weeks. This complication occurred in 5.2% of patients closed by suture ligature and in none of those closed by a surgical clip. Although the series is too small for this difference to be statistically significant, we believe it strongly favors the use of the clip, with less dissection.
Assuntos
Permeabilidade do Canal Arterial/cirurgia , Doenças do Prematuro/cirurgia , Complicações Pós-Operatórias/etiologia , Paralisia das Pregas Vocais/etiologia , Humanos , Recém-Nascido , Ligadura/instrumentação , SuturasRESUMO
An intraaortic balloon pump (IABP) was inserted through the ascending aorta during a coronary artery bypass operation. Five days later, after removal of the IABP and ligation of the end-to-side Dacron graft, the patient became acutely anuric. Abdominal aortography demonstrated a large "trapeze-shaped" thrombus which occluded both renal arteries. Following thrombectomy the patient recovered, with eventual return of renal function to the preoperative state.
Assuntos
Circulação Assistida/efeitos adversos , Balão Intra-Aórtico/efeitos adversos , Obstrução da Artéria Renal/etiologia , Trombose/etiologia , Idoso , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/cirurgia , Radiografia , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/cirurgia , Trombose/diagnóstico por imagem , Trombose/cirurgiaRESUMO
Xanthogranulomatous pyelonephritis is a renal inflammatory process associated with chronic obstruction and renal calculi. A patient with xanthogranulomatous pyelonephritis presented with the acute onset of hemoptysis and a lung mass. At thoracotomy the mass was resected and found to be a renal calculus embedded within inflammatory tissue.
Assuntos
Hemoptise/etiologia , Cálculos Renais/complicações , Pneumopatias/etiologia , Pielonefrite/complicações , Idoso , Feminino , HumanosRESUMO
Cyclosporine (CyA) is commonly prescribed as an immunosuppressive to prevent rejection of organ transplants. Numerous pharmacokinetic drug interactions of potential clinical significance exist because other drugs may induce or inhibit the metabolism of CyA. Case reports and studies demonstrate that rifampin, phenytoin, phenobarbital, and carbamazepine may induce the hepatic metabolism of CyA, causing decreased CyA concentrations. Graft rejection through inadequate immunosuppression may be associated with subtherapeutic or decreased CyA levels. Erythromycin, ketoconazole, calcium channel blockers, and sex hormones appear to inhibit CyA metabolism, causing increased CyA concentrations. Signs and symptoms of renal, hepatic, or neurotoxicity may be evident with increased or toxic CyA levels. Mutual inhibition of metabolism occurs between CyA and corticosteroids. Intravenous sulphadimidine and trimethoprim may cause decreased CyA concentrations by an unknown mechanism.
Assuntos
Ciclosporinas/farmacocinética , Corticosteroides/farmacologia , Anticonvulsivantes/farmacologia , Bloqueadores dos Canais de Cálcio/farmacologia , Eritromicina/farmacologia , Humanos , Cetoconazol/farmacologia , Rifampina/farmacologia , Sulfonamidas/farmacologiaRESUMO
Student oral and written surgical clerkship performances may be related to the clerkship structure and the time of year the students rotate through the clerkship. The influence of calendar block, hospital site (university hospital, affiliated private tertiary-care hospital, and rural preceptor experience), and the mix of general surgical versus subspeciality rotations on oral and written student surgery clerkship scores was analyzed. Multivariate analysis of variance revealed significant differences in score for calendar block (p = 0.02) only; this difference resided in the written examination. The various combinations of rotations were not different from one another in terms of measured outcome.
Assuntos
Estágio Clínico , Educação de Graduação em Medicina , Avaliação Educacional , Cirurgia Geral/educação , Estudantes de Medicina , Currículo , Hospitais Rurais , Hospitais de Ensino , Hospitais Universitários , Humanos , Análise Multivariada , PreceptoriaRESUMO
Rapid atrial pacing by means of temporary atrial pacing wires was used to effect a regular sinus rhythm in a patient with 2:1 atrioventricular block and frequent premature atrial contractions. The change in rhythm allowed effective intra-aortic balloon counterpulsation and markedly improved the hemodynamic situation.
Assuntos
Estimulação Cardíaca Artificial , Ponte de Artéria Coronária , Doença das Coronárias/cirurgia , Bloqueio Cardíaco/fisiopatologia , Hemodinâmica , Complicações Pós-Operatórias/fisiopatologia , Feminino , Átrios do Coração/fisiopatologia , Frequência Cardíaca , Humanos , Pessoa de Meia-Idade , Taquicardia/fisiopatologiaRESUMO
Hyperthermia has shown promise as an anticancer therapy, but its application to lung neoplasms has been limited by whole body hyperthermia complications and the intrathoracic location of lung neoplasms. Previous studies have shown that interstitial hyperthermia could be performed through a thoracotomy approach and that animals tolerated the procedure without biochemical or hematologic abnormalities. The normal lung's local blood flow pattern and parenchymal changes due to hyperthermia of various temperatures and durations were studied. The experimental protocol applied hyperthermia through interstitial electrodes at temperatures of 39 degrees, 41 degrees, 43 degrees, and 45 degrees C. Tissue blood flow was measured with radioactive microspheres at 20, 40, and 60 minutes of hyperthermia. Histologic examination was performed of biopsy specimens taken from the heated area, from 2 and 5 cm from the heated area, and from distant parenchyma. These initial studies demonstrate that interstitial hyperthermia in the normal lung does not cause a decrease in pulmonary vascular resistance, that interstitial hyperthermia in the normal lung at temperatures of 43 degrees or 45 degrees C for durations of longer than 20 minutes decreases local pulmonary blood flow, that interstitial hyperthermia causes mild vascular disruption at temperatures of 39 degrees C or greater in the heated area but does not affect adjacent or distant lung parenchyma, and that lung hyperthermia causes generalized vascular disruption with severe widening of the pulmonary interstitium and severe hemorrhage in the heated areas when temperatures of 43 degrees or 45 degrees C are applied. Because interstitial hyperthermia affected only local lung damage, it may be applicable in the treatment of localized lung tumors.
Assuntos
Hipertermia Induzida , Pulmão/patologia , Circulação Pulmonar , Animais , Cães , Hipertermia Induzida/efeitos adversosRESUMO
Current noninvasive methods of imaging esophageal lymph nodes have an accuracy, specificity, and sensitivity of 70%. Using a flexible esophagoscope, technetium-99m antimony sulfide colloid was injected in the esophageal submucosa of six dogs who then underwent nuclear scans to identify lymph-node location. The euthanized animals underwent dissection of cervical, thoracic, and abdominal lymph nodes. Student's t-test showed no statistical difference in the number of lymph nodes visualized in the neck (3.5 +/- 0.6), parietal thorax (1.2 +/- 0.4), visceral thorax (2.2 +/- 0.7), and abdomen (1.0 +/- 0.0) on premorbid nuclear scans and in the number of radiolabeled lymph nodes found in the neck (3.2 +/- 0.9), parietal thorax (1.2 +/- 0.2), visceral thorax (1.8 +/- 1.0), and abdomen (1.2 +/- 0.2) on dissection of the carcass. The positions of the lymph nodes based on the premorbid nuclear scans matched the locations of the radiolabeled lymph nodes at dissection. Dissected tissue was pathologically confirmed as lymph node. The position and number of lymph nodes in the cervical, intrathoracic, and abdominal regions on nuclear scan correlated with the position and number of lymph nodes found on anatomic dissection. This technique may have a higher sensitivity and specificity than current noninvasive techniques in the staging of esophageal lymphatic metastasis.