Pitfalls in accelerometer-based measurement of physical activity: The presence of reactivity in an adult population.

When a behavior is monitored, it is likely to change, even if no change may be intended. This phenomenon is known as measurement reactivity. We investigated systematic changes in accelerometer-based measures over the days of monitoring as an indicator of measurement reactivity in an adult population. One hundred seventy-one participants from the general population (65% women; mean age = 55 years, range: 42-65 years) wore accelerometers for 7 consecutive days to measure sedentary behavior and physical activity (PA). Latent growth models were used (a) to investigate changes in accelerometer wear time over the measurement days and (b) to identify measurement reactivity indicated by systematic changes in sedentary time (ST), light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA). Over the measurement days, participants reduced accelerometer wear time by trend (rate of change [b] = -4.7 min/d, P = .051, Cohen's d = .38), increased ST (b = 2.4 min/d, P = .018, d = .39), and reduced LPA (b = -2.4 min/d, P = .015, d = .38). Participants did not significantly reduce MVPA (P = .537). Our data indicated that accelerometry might generate reactivity. Small effects on ST and LPA were found. Thus, the validity of accelerometer-based data on ST and LPA may be compromised. Systematic changes observed in accelerometer wear time may further bias accelerometer-based measures. MVPA seems to be less altered due to the presence of an accelerometer.

Risk of breast cancer among young women: relationship to induced abortion.

BACKGROUND: Certain events of reproductive life, especially completed pregnancies, have been found to influence a woman's risk of breast cancer. Prior studies of the relationship between breast cancer and a history of incomplete pregnancies have provided inconsistent results. Most of these studies included women beyond the early part of their reproductive years at the time induced abortion became legal in the United States. PURPOSE: We conducted a case-control study of breast cancer in young women born recently enough so that some or most of their reproductive years were after the legalization of induced abortion to determine if certain aspects of a woman's experience with abortion might be associated with risk of breast cancer. METHODS: Female residents of three counties in western Washington State, who were diagnosed with breast cancer (n = 845) from January 1983 through April 1990, and who were born after 1944, were interviewed in detail about their reproductive histories, including the occurrence of induced abortion. Case patients were obtained through our population-based tumor registry (part of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute). Similar information was obtained from 961 control women identified through random digit dialing within these same counties. Logistic regression analysis was used to estimate odds ratios and confidence intervals (CIs). RESULTS: Among women who had been pregnant at least once, the risk of breast cancer in those who had experienced an induced abortion was 50% higher than among other women (95% CI = 1.2-1.9). While this increased risk did not vary by the number of induced abortions or by the history of a completed pregnancy, it did vary according to the age at which the abortion occurred and the duration of that pregnancy. Highest risks were observed when the abortion was done at ages younger than 18 years--particularly if it took place after 8 weeks' gestation--or at 30 years of age or older. No increased risk of breast cancer was associated with a spontaneous abortion (RR = 0.9; 95% CI = 0.7-1.2). CONCLUSION: Our data support the hypothesis that an induced abortion can adversely influence a woman's subsequent risk of breast cancer. However, the results across all epidemiologic studies of this premise are inconsistent--both overall and within specific subgroups. The risk of breast cancer should be reexamined in future studies of women who have had legal abortion available to them throughout the majority of their reproductive years, with particular attention to the potential influence of induced abortion early in life.

PIP: Epidemiologists compared data on 845 white women who were diagnosed with breast cancer between January 1983 and April 1990, were born after 1944, and lived in King, Pierce, or Snohomish counties in Washington State with data on 961 white women with no breast cancer from the same counties. They wanted to determine whether induced abortion increases the risk of breast cancer. Restricting cases to women born after 1944 allowed the researchers to focus only on legal induced abortions. When the researchers limited the analysis only to women who had been pregnant at least once, the risk of developing breast cancer in women who had had at least 1 induced abortion was 50% greater than those who had not had an induced abortion. This risk differed depending on the age at which the women underwent the induced abortion and the duration of that pregnancy. A gestational age (at the time of the first aborted pregnancy) of 9-12 weeks carried the highest risk of breast cancer (RR = 1.9 vs. 1.4 for =or 8 weeks and =or 13 weeks). Further, the breast cancer risk was greatest among women who underwent the induced abortion when they were less than 18 years old (relative risk [RR] = 2.5). It was especially high for women who were less than 18 years old and who had the abortion between 9 and 24 weeks of gestation (RR = 9). It was also high for those who were at least 30 years old at the time of the abortion (RR = 2.1). Spontaneous abortion was not associated with an increased risk (RR = 0.9). Neither the number of induced abortions nor the history of a completed pregnancy were associated with an increased risk of breast cancer. These findings suggest that an induced abortion during the last month of the first trimester increases the risk of breast cancer and that women who were at a very young age at the time of the first induced abortion face an increased risk of breast cancer.

Breast self-examination in relation to the occurrence of advanced breast cancer.

Two hundred nine female enrollees of the Group Health Cooperative of Puget Sound who developed advanced-stage breast cancer during the period 1982-1988 were interviewed about their practice of breast self-examination (BSE), use of other breast cancer screening modalities, and medical and reproductive histories. Each subject's description of how she performed the examination was scored according to her mention of up to 10 recommended BSE techniques. A random sample of 433 women without advanced-stage breast cancer from the same population was interviewed for comparison. Relative to women not practicing BSE, the risk of advanced-stage breast cancer among BSE users was 1.15 (95% confidence interval, 0.73-1.81). Frequency of BSE did not differ between women with advanced-stage breast cancer and control subjects, whether in all subjects or in subgroups defined by age, use of mammography, or frequency of clinical breast examinations. While self-described proficiency in BSE was generally low in both case and control subjects, the small percentage of women reporting more thorough self-examinations, regardless of frequency, had about a 35% decrease in the occurrence of advanced-stage breast cancer compared to women who did not perform BSE. These results suggest that, while carefully performed BSE may avoid the development of some advanced-stage breast cancers, BSE as practiced by most Seattle-area women is of little or no benefit.

Cimetidine use and risk of prostate and breast cancer.

Histamine (H2) receptor antagonists, such as cimetidine and ranitidine, became available in the late 1970s and presently number among the most commonly used drugs. Cimetidine has been hypothesized to exert a cancer preventive effect on the prostate due to its ability to inhibit the binding of dihydrotestosterone to androgen receptors. Other hormonal effects of this drug include increases in serum prolactin levels and inhibition of 2-hydroxylation of estradiol. We assessed risk of prostate and breast cancers in a cohort of 48,512 members of the Group Health Cooperative of Puget Sound prescribed cimetidine or another H2 blocker between 1977 and 1995. Standardized incidence ratios were calculated comparing the observed numbers of cancers to those expected based on population rates in western Washington State. Because cimetidine, but not other H2 blockers, influences hormonal activity and metabolism, we conducted nested case-control studies comparing cancer risk among individuals treated with cimetidine to individuals who used other H2 blockers. Risks of breast and prostate cancers were identical among users of cimetidine and users of other H2 blockers (relative risk, 1.0 for both cancers). We observed no trend in risk of breast cancer according to time since first or last cimetidine prescription or number of cimetidine prescriptions filled. For prostate cancer, our findings were similar save for a modest increase in risk among men who had filled > or =21 cimetidine prescriptions (relative risk, 1.4; 95% confidence interval, 1.0-1.9). Our results suggest that use of cimetidine does not influence risk of female breast cancer. Further, these data provide little evidence to support the previously hypothesized preventive effect of cimetidine on risk of prostate cancer.

Chemoprevention of cervical cancer with folic acid: a phase III Southwest Oncology Group Intergroup study.

Several epidemiological reports and experimental investigations have suggested a preventive role for folic acid in the etiology of cervical cancer. The effect of p.o. folic acid supplementation on the natural history of cervical intraepithelial neoplasia (CIN) was evaluated in a multiinstitutional prospective, randomized, double-blind, placebo-controlled trial. Three hundred thirty-one women with biopsy-proven koilocytic atypia, mild CIN, or moderate CIN were randomized to receive oral folic acid (5 mg) or a similar-appearing placebo daily for 6 months following a 1-month run-in placebo period. Colposcopy, Papanicolaou smear, and serum vitamin levels (folate, retinol, alpha-tocopherol, beta-carotene, and retinyl palmitate) were monitored every 3 months. Demographic, medical, dietary, and sexual history data were obtained from personal interviews. The primary end point of the study was improvement in both Papanicolaou smear and colposcopic picture after 3 and 6 months of treatment as compared to the start of treatment. After 6 months of treatment there was no significant difference between the two study groups in the percentage of patients improved. Median serum folate levels in the treatment arm at 3 and 6 months (29.0 and 20.0 micrograms/dl) were significantly higher than those in the placebo arm (7.8 and 7.1 micrograms/dl, respectively). Mean serum levels of retinol, retinyl palmitate, alpha-tocopherol, and beta-carotene did not differ significantly between the two treatment arms. Our data support the conclusion that supplementation with folic acid (5 mg/day) does not enhance the regression of early epithelial abnormalities of the cervix.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for synchronous primary endometrial and ovarian cancers.

PURPOSE: The incidence of synchronous primary endometrial and ovarian cancer is 2- to 10-fold higher than that expected based on the incidence of each cancer alone. We sought to evaluate reasons for this in a case-control study. METHODS: We combined data on a maternal history of cancer and reproductive and menstrual factors from 56 women with synchronous multiple primary disease who had participated in three population-based studies of gynecologic cancer. For comparison, we analyzed the same information from 280 women with endometrial cancer alone, 280 with ovarian cancer alone, and 280 without a history of either cancer. RESULTS: The reduced risk of multiple primary disease associated with high parity (2 or more births vs 0: OR = 0.37, 95% Cl, 0.19-76) and long-term use of oral contraceptives (12 or more months vs none: OR = 0.60, 95% Cl, 0.24-1.5) tended to be more pronounced than that associated with endometrial cancer alone or with ovarian cancer alone. CONCLUSIONS: Though limited by relatively small numbers, our results suggest that the presence of some common etiologies is a basis for the unusually high co-occurrence of endometrial and ovarian cancers.

Prevalence and correlates of recreational physical activity in women aged 50-64 years.

OBJECTIVE: To evaluate the prevalence of recreational physical activity in middle-aged women and to identify characteristics predisposing women to an active or sedentary lifestyle. DESIGN: In this population-based survey study of 492 women aged 50-64 years, women were interviewed between 1988 and 1993 regarding their recreational exercise habits, other health habits, and medical history. Women were selected from the general population of western Washington State through random-digit-dialing of telephones. Physical activities in a recent 2-year period were recorded, including specific types, frequency, and duration of each activity. RESULTS: Fewer than half of the women reported doing any regular physical activity and only 27% engaged in any high intensity exercise. Obesity, current cigarette smoking, low income, low education, and some dietary factors were associated with a sedentary lifestyle. CONCLUSIONS: These results suggest that only about half of middle-aged women engage in any regular recreational exercise, and that less than 25% follow the National Institutes of Health recommended guidelines for light to moderate exercise for at least 30 min per day, 6 days per week.

Non-contraceptive hormones and the risk of rheumatoid arthritis in menopausal women.

BACKGROUND: Several reproductive factors appear to affect a women's risk of developing rheumatoid arthritis. This study's purpose was to determine whether use of non-contraceptive hormones is among them. METHODS: A population-based case-control study was conducted in King County, Washington and Group Health Cooperative of Puget Sound, a prepaid health plan. New cases of rheumatoid arthritis in peri- or postmenopausal women (n = 135) were verified through clinical examination and compared with 592 controls. Both groups were interviewed in person about hormone use and demographic and reproductive factors. RESULTS: The age-adjusted relative risk (RR) among women who had ever used non-contraceptive oestrogens was 1.04 (95% confidence interval [CI]: 0.70-1.55), and among women who had ever used progestins it was 0.66 (95% CI: 0.40-1.08). For current users of oestrogen only, the RR was 0.97 (95% CI: 0.62-1.53), and among current users of oestrogen plus progestin it was 0.81 (95% CI: 0.45-1.45). Multivariate analyses yielded similar results. There was little evidence of a dose-response relationship with duration of use or with frequency of progestin use. CONCLUSIONS: Use of non-contraceptive oestrogens appears to have little effect on the risk of developing rheumatoid arthritis in menopausal women. There may be a modest reduction in risk among progestin users.

Maternal cigarette smoking and tubal pregnancy.

As part of a case-control study of tubal pregnancy, we sought to evaluate the potential etiologic role of maternal cigarette smoking. Between 1975-1979, 192 women who were treated for a tubal pregnancy in five Seattle hospitals were interviewed with regard to smoking habits and reproductive, contraceptive, and medical histories. For comparison, 459 Seattle-area women who delivered during the same period were also interviewed. Current cigarette smokers had a more than twofold increase in risk of tubal pregnancy (adjusted relative risk 2.2; 95% confidence interval 1.4-3.4) when compared with women who had never smoked. The risk for women who had stopped smoking before conception was 1.6 (95% confidence interval 1.0-2.8). There was no consistent trend between the risk of tubal pregnancy and the duration of smoking, average number of cigarettes smoked per day, age at which a woman began to smoke, pack-years of cigarettes smoked, or (among former smokers) the recency of smoking. Although several sources of bias in the present study may have created a spurious association between cigarette smoking and the occurrence of tubal pregnancy, it could well be that an increased risk of tubal pregnancy is yet another untoward consequence of cigarette smoking.

The relationship of abruptio placentae with maternal smoking and small for gestational age infants.

A population-based case-control study was conducted to examine the relationship between maternal smoking and the occurrence of abruptio placentae and to assess the joint relationship of smoking and small for gestational age (SGA) status with abruption. Cases (N = 1089) reported on Washington state birth certificates from 1984-1986 were compared with randomly selected births (N = 2323) from the same period. The occurrence of placental abruption was associated with both smoking (relative risk = 1.6; 95% confidence interval 1.3-1.8) and SGA status (relative risk = 2.6; 95% confidence interval 2.0-3.3). The association with SGA status was identical for smokers and non-smokers. Thus, the increase of SGA infants in women whose pregnancies are complicated by abruption is not explained by maternal smoking, and in some cases may result from placental dysfunction induced by the process of placental separation.

Previous abdominal surgery and tubal pregnancy.

To determine the role of previous abdominal surgery in tubal pregnancy risk, we compared 337 women diagnosed with tubal pregnancy during 1981-1986 with 893 population-based controls concerning their medical, reproductive, and sexual histories. After excluding types of abdominal surgery that involve the fallopian tubes directly and after adjusting for age, gravidity, and reference year, we found no increased risk for tubal pregnancy related to previous cesarean delivery (relative risk 0.6, 95% confidence interval 0.3-1.2), ovarian surgery (relative risk 1.2, 95% confidence interval 0.6-2.5), or removal of an unruptured appendix (relative risk 1.2, 95% confidence interval 0.7-2.2). An increased risk was noted for tubal pregnancy associated with previous ruptured appendix (relative risk 1.8, 95% confidence interval 0.6-5.5), but the increase was well within the limits of chance. With the possible exception of ruptured appendix, our study indicates that abdominal surgery that does not directly involve the fallopian tubes has little or no influence on the occurrence of tubal pregnancy.

Risk of endometrial cancer in relation to use of low-dose, unopposed estrogens.

OBJECTIVE: To determine whether a low dosage (0.3 mg/day) of unopposed conjugated estrogens can be used without incurring an elevated risk of endometrial cancer. METHODS: In this case-control study, cases (n = 484) consisted of women diagnosed with endometrial cancer between 1985 and 1991 in three counties in Western Washington. Controls (n = 780) were identified using random digit dialing within the same three counties. Subjects were interviewed in person to obtain basic demographic and medical history information, as well as specific information about hormone use. RESULTS: Eighteen cases and eight controls had taken 0.3 mg/day of unopposed conjugated estrogens and no other dose or preparation of estrogens (risk relative to that of women who had not taken postmenopausal hormones = 5.4, 95% confidence interval [CI] 2.3, 13.0). The risk was particularly high in women whose use of this dose was both current and of more than 8 years' duration (odds ratio = 9.2, 95% CI 2.9, 29.0). The elevation in risk in users of 0.3 mg/day was similar in size to that associated with the daily unopposed use of 0.625 mg of conjugated estrogens. CONCLUSION: The results suggest that a dosage of 0.3 mg per day of unopposed conjugated estrogens is associated with an increased risk of endometrial cancer.

Characteristics of women who use perineal powders.

OBJECTIVE: To examine demographic and behavioral factors related to perineal application of powders. METHODS: Controls from three case-control studies (N = 1206) were asked identical questions about the use of genital powders by direct perineal application. The relationship of perineal powder application with demographic factors, reproductive factors, body mass index (BMI), douching, and alcohol and tobacco use was assessed. Data were analyzed by multiple logistic regression. RESULTS: Women who douched (prevalence odds ratio [prevalence OR] 2.0, 95% confidence interval [CI] 1.0, 3.9), drank alcohol (prevalence OR 1.8, 95% CI 1.2, 2.8), smoked cigarettes (prevalence OR 1.3, 95% CI 1.0, 1.8), or were in the highest BMI quartile were more likely to engage in perineal use of powder (prevalence OR 1.6, 95% CI 1.1, 2.6). There appeared to be a close response relationship between the number of perineal applications of powder and BMI (P < .002). CONCLUSION: Body mass index might confound the relationship between perineal powder application and the development of ovarian cancer. Other factors, such as alcohol and tobacco use and douching, are related to perineal use of powder and may represent similar behavioral characteristics.

Tubal infertility in relation to prior induced abortion.

One hundred twenty-seven women who had been given diagnoses of tubal infertility between 1979 and 1981 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, we adjusted for the effects of variables that in this population were related both to having an induced abortion and to the occurrence of infertility, i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A. H. Robins Company, Richmond, VA) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70 to 1.89). For women with two or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39 to 4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72 to 1.97). Our results suggest that legal abortion, as performed during the past decade in the United States, does not carry an excess risk for future tubal infertility.

PIP: 127 women who had been given diagnoses of tubal infertility between 1979-81 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who had conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, the authors adjusted for the effects of variables that in this population were related to both having an induced abortion and to the occurrence of infertility; i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A.H. Robins Co., Richmond, Virginia) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70-1.89). For women with 2 or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39-4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72-1.97). Results suggest that that abortion, as performed during the past decade in the U.S., does not carry an excess risk for risk tubal infertility.

The association between Chlamydia trachomatis serology and pelvic damage in women with tubal ectopic gestations.

OBJECTIVE: To determine whether pelvic damage is associated with positive Chlamydia trachomatis serology in women with tubal ectopic pregnancy. DESIGN: Cross-sectional retrospective study. SETTING: A prepaid health maintenance organization. PATIENTS: Two-hundred eighty-one women admitted with confirmed tubal ectopic pregnancy were interviewed for history of sexually transmitted diseases. Chlamydia serology was obtained for 135 subjects, and operative findings were available for 121 of these. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Pelvic damage, as determined by review of operative findings of the pelvis at the time of ectopic surgery. RESULTS: Pelvic damage was associated with positive chlamydia serology with an adjusted odds ratio of 4.2 (95% confidence interval: 1.8 to 9.7). Moderate and severe pelvic damage were more strongly associated with positive serology than mild damage. CONCLUSIONS: Women with ectopic pregnancies and antibodies to C. trachomatis are more likely to have damaged pelves than women with ectopic pregnancies without such antibodies. Prevention or early treatment of C. trachomatis infection may reduce pelvic damage and, therefore, reduce incidence of ectopic pregnancy.

Epidemiology of endometrial cancer.

PIP: This review of endometrial cancer summarizes the demographic characteristics of patients with the disease, their hormonal risk factors related to endogenous and exogenous estrogens and medical history, and other risk factors. Endometrial cancer increased in incidence in the US in the early 1970s, but then declined again in the last 2 decades. Possible reasons are classification including estrogen- induced hyperplasia, but also increased use of exogenous estrogens primarily in post-menopausal women, who are the predominant victims. Postmenopausal estrogen usage decreased at the same time. The highest incidence occurs in Polynesian women, although US Caucasians have more endometrial cancer then Blacks or European women. Endometrial cancer is common in women with estrogen-secreting ovarian cancer. Women with polycystic ovaries, where the steroid androstenedione is secreted and converted to estrone in peripheral tissues, but progesterone is lacking, are higher risk for endometrial hyperplasia and cancer. Obese women are also at risk (estimated 20-fold), as they have low sex binding globulin and higher estrogen levels. Any exogenous estrogen, by any route, even if stopped for a week per month confers higher risk for endometrial cancer, as shown by virtually all case control studies. Very little data exists on the actual effect of taking progestins with postmenopausal estrogens. These tumors are less invasive, more differentiated, and often detected earlier than non-estrogen dependent endometrial cancers. Other putative risk factors, e.g., diabetes, hypertension, gall bladder disease, radiation exposure, and family history of breast cancer have no solid evidence for association. Smoking, however, is associated with a lower risk of endometrial cancer.^ieng

Occupation and breast cancer risk in middle-aged women.

The authors analyzed data from a population-based case-control study of breast cancer in middle-aged women residing in King County, Washington, to examine the relation between occupation and breast cancer risk. A total of 537 cases and 492 controls completed in-person interviews. Subjects provided job titles and years of employment for their three main occupations since age 18. While there were case-control differences in the frequency with which certain jobs were reported, all were within the limits of chance, given no true association. Also, few additional increases in risk were associated with long-term employment. Relative risk (RR) estimates were elevated for women working in precision textile and apparel jobs (six cases and one control, RR = 5.2). To a lesser extent, RR estimates were also elevated for receptionists, cosmetologists, and the category of painters/sculptors/printmakers. A slight increase in risk was associated with several occupations, including nursing and teaching.

Standardized pain flowsheet: impact on patient-reported pain experiences after cardiovascular surgery.

BACKGROUND: Administration of analgesics per patient request or random pain assessments may provide inadequate pain management. OBJECTIVE: To examine the impact of nurses' use of a standardized pain flowsheet to document pain assessment and pharmacologic management on patient-reported pain intensity. METHODS: A pre-post intervention design was used to compare 61 patients. In the preimplementation group, traditional charting of pain presence or absence was documented in the narrative notes and pharmacologic management was recorded on the medication profile. In the postimplementation group, the intensity of pain and pharmacologic management were documented on a pain flowsheet. Within 24 hours after transfer to the step-down unit, patients were interviewed regarding pain intensity experienced in the surgical heart unit and at the time of questioning. The distribution of these pain intensity scores was compared. RESULTS: The postimplementation group reported significantly lower pain intensity ratings for the average amount of pain experienced while in the surgical heart unit, the least amount of pain experienced while in the surgical heart unit, and the pain experienced at the moment of questioning. CONCLUSIONS: Use of a standardized pain flowsheet to assess pain intensity and document pharmacologic intervention may improve pain management in postsurgical cardiovascular patients.

Anesthetic management of the cocaine abuse patient.

Cocaine is an extremely addictive local anesthetic which can produce stimulation of the sympathetic nervous system due to the inhibition of catecholamine reuptake at the synaptic junction. Because of the rapid metabolism of cocaine, the probability of a patient presenting to the operating room with acute intoxication is unlikely. However, the physiological effects of chronic cocaine abuse on various organ systems have an impact on anesthesia management. A preoperative review of major organ systems is essential. Selective beta 1 antagonists (i.e., esmolol) may need to be titrated with a direct vasodilator (i.e., nitroprusside) to manage hypertension and tachycardia. The nonselective beta antagonist effects of labetalol are much more potent than its alpha antagonist effects, which could result in unopposed alpha vasoconstriction. In addition, the equal affinity of the alpha adrenergic antagonist, phentolamine, for both alpha 1 and alpha 2 receptors may result in significant tachycardia. Nitroglycerin has also been used in management of hypertension associated with coronary vasoconstriction. There is controversy regarding management of ventricular dysrhythmias and asystole. Lidocaine is an amide local anesthetic that may have addictive effects, in the presence of cocaine, which may lower the seizure threshold. In addition, the use of epinephrine to treat asystole is controversial in the presence of a state of excess catecholamines induced by cocaine. General anesthesia may include barbiturates, nitrous oxide, and opioids. Inhalational agents may be used with caution due to their myocardial depressant effects. Regional anesthesia may be a good choice if coagulopathies and hypovolemia are corrected before the procedure.