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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Grapefruit juice can alter oral drug pharmacokinetics by different mechanisms. Irreversible inactivation of intestinal cytochrome P450 (CYP) 3A4 is produced by commercial grapefruit juice given as a single normal amount (e.g. 200-300 mL) or by whole fresh fruit segments. As a result, presystemic metabolism is reduced and oral drug bioavailability increased. Enhanced oral drug bioavailability can occur 24 hours after juice consumption. Inhibition of P-glycoprotein (P-gp) is a possible mechanism that increases oral drug bioavailability by reducing intestinal and/or hepatic efflux transport. Recently, inhibition of organic anion transporting polypeptides by grapefruit juice was observed in vitro; intestinal uptake transport appeared decreased as oral drug bioavailability was reduced. Numerous medications used in the prevention or treatment of coronary artery disease and its complications have been observed or are predicted to interact with grapefruit juice. Such interactions may increase the risk of rhabdomyolysis when dyslipidemia is treated with the HMG-CoA reductase inhibitors atorvastatin, lovastatin, or simvastatin. Potential alternative agents are pravastatin, fluvastatin, or rosuvastatin. Such interactions might also cause excessive vasodilatation when hypertension is managed with the dihydropyridines felodipine, nicardipine, nifedipine, nisoldipine, or nitrendipine. An alternative agent could be amlodipine. In contrast, the therapeutic effect of the angiotensin II type 1 receptor antagonist losartan may be reduced by grapefruit juice. Grapefruit juice interacting with the antidiabetic agent repaglinide may cause hypoglycemia, and interaction with the appetite suppressant sibutramine may cause elevated BP and HR. In angina pectoris, administration of grapefruit juice could result in atrioventricular conduction disorders with verapamil or attenuated antiplatelet activity with clopidrogel. Grapefruit juice may enhance drug toxicity for antiarrhythmic agents such as amiodarone, quinidine, disopyramide, or propafenone, and for the congestive heart failure drug, carvediol. Some drugs for the treatment of peripheral or central vascular disease also have the potential to interact with grapefruit juice. Interaction with sildenafil, tadalafil, or vardenafil for erectile dysfunction, may cause serious systemic vasodilatation especially when combined with a nitrate. Interaction between ergotamine for migraine and grapefruit juice may cause gangrene or stroke. In stroke, interaction with nimodipine may cause systemic hypotension. If a drug has low inherent oral bioavailability from presystemic metabolism by CYP3A4 or efflux transport by P-gp and the potential to produce serious overdose toxicity, avoidance of grapefruit juice entirely during pharmacotherapy appears mandatory. Although altered drug response is variable among individuals, the outcome is difficult to predict and avoiding the combination will guarantee toxicity is prevented. The elderly are at particular risk, as they are often prescribed medications and frequently consume grapefruit juice.
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PMID:Interactions between grapefruit juice and cardiovascular drugs. 1544 71

Hyperglycemia is frequent during critical illness and is perceived by the clinician as part of the systemic metabolic response to stress. Of all patients with "stress hyperglycemia" only one third are known to have diabetes mellitus. Previous studies reported that patients presenting hyperglycemia during acute illness have an increased risk for nosocomial infections. Morbidity and mortality also increases in patients with myocardial infarction or stroke who develop hyperglycemia. Contemporary medical practice states that hyperglycemia under these conditions should only be treated with insulin if blood glucose levels are > 200 mg/dl. A recent trial showed that intensive insulin treatment of critically ill patients in the intensive care unit with the goal of maintaining blood glucose levels between 80 and 110 mg/dl significantly reduced morbidity and mortality without significant risk of hypoglycemia. These benefits of insulin treatment are not yet well understood, but some pathophysiological evidence suggests that hyperglycemia contributes to perpetuate the systemic proinflammatory response, and insulin--a natural endogenous hormone that has a major role in the intermediary metabolism--participates actively in the systemic anti-inflammatory response. As a result of these findings, we recommend that hyperglycemia during critical illness should be treated with insulin, in order to achieve blood glucose levels in a normal range, regardless of whether or not these patients have diabetes mellitus.
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PMID:[Hyperglycemia in critically ill patients: clinical implications for treatment]. 1569 61

A 62-year-old man presented with diminished consciousness, hypotension, hypoglycaemia and agitation. He had undergone heart surgery 1.5 weeks earlier. Due to a stroke as a postoperative complication, antihypertensive medication had been added. His lithium medication had been interrupted only on the first postoperative day. The presenting complaints were due to delirium as a result of lithium intoxication. The delirium faded away after interruption of the lithium medication and treatment with haloperidol and oxazepam. The patient and his family were informed as to the nature of the delirium and the precautions to be taken in case of any future disease or operation. Lithium should be discontinued preoperatively in all patients. If necessary, alternative psychiatric medication must be prescribed. After restarting lithium, the serum levels of lithium must be monitored.
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PMID:[Lithium use and perioperative management]. 1613 38

Hyperglycaemia following subarachnoid haemorrhage (SAH) is well recognized and has been shown to be associated with a worse prognosis. It is currently unclear whether this is a secondary phenomenon reflecting the magnitude of the stress response or whether it contributes directly to the pathophysiological disturbances within the brain. There is significant experimental work on ischaemic stroke to suggest that hyperglycaemia increases infarct volume. The authors propose that controlling blood glucose following SAH is safe and that it might improve outcome. All patients admitted with SAH were treated with insulin to control plasma glucose with a target range of 5.0-7.0 mmol/l. Episodes of hypoglycaemia were recorded. Outcome was assessed at 3 months using the Glasgow Outcome Scale. Fifty-five patients were recruited. 32/3389 (0.94%) of glucose readings fell below 3.5 mmol/l. All were treated with i.v. glucose without evidence of clinical deterioration. Insulin treatment for hyperglycaemia following SAH is feasible and safe. A randomised trial is required to assess any effect on outcome.
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PMID:Glucose/insulin infusions in the treatment of subarachnoid haemorrhage: a feasibility study. 1614 78

Excitotoxicity is an important mechanism involved in perinatal brain injuries. Glutamate is the major excitatory neurotransmitter, and most neurons as well as many oligodendrocytes and astrocytes possess receptors for glutamate. Perinatal insults such as hypoxia-ischemia, stroke, hypoglycemia, kernicterus, and trauma can disrupt synaptic function leading to accumulation of extracellular glutamate and excessive stimulation of these receptors. The activities of certain glutamate receptor/channel complexes are enhanced in the immature brain to promote activity-dependent plasticity. Excessive stimulation of glutamate receptor/ion channel complexes triggers calcium flooding and a cascade of intracellular events that results in apoptosis and/or necrosis. Recent research suggests that some of these intracellular pathways are sexually dimorphic. Age dependent expression of different glutamate receptor subtypes with varying abilities to flux calcium has been associated with special patterns of selective vulnerability at different gestational ages. For example, selective injury to the putamen, thalamus and cerebral cortex from near total asphyxia in term infants may be related to excessive activation of neuronal NMDA and AMPA type glutamate receptors, while brainstem injury may be related primarily to stimulation of neuronal AMPA/kainate receptors. In contrast, periventricular leukomalacia in premature infants has been linked to expression of AMPA/kainate receptors on immature oligodendrocytes. Insight into the molecular pathways that mediate perinatal brain injuries could lead to therapeutic interventions.
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PMID:Excitotoxicity in perinatal brain injury. 1619 90

Diabetes and hyperglycaemia are each over-represented amongst patients with acute stroke. Hyperglycaemia is associated with poor stroke outcome. Symptomatic intracranial haemorrhagic transformation is commoner in diabetes and hyperglycaemia but the treatment effect of thrombolysis appears not to be influenced by blood sugar level. Evidence from general patients treated in intensive care units suggests that intensive control of hyperglycaemia may improve early outcome; this evidence cannot be directly extrapolated to patients with acute stroke since supportive randomized controlled trial evidence describing benefits and risks of insulin administration for hyperglycaemia in stroke is scant. Nevertheless, at present the European guidelines suggest that glucose control may be advisable and place a threshold of 10 mmol/l for definite intervention; American guidelines are weaker. Glucose-potassium-insulin infusion or adjusted insulin infusions each have their proponents: both are effective but both carry a small risk of hypoglycaemia. Use of a suitable locally approved regimen seems advisable.
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PMID:Acute stroke and diabetes. 1627 80

The present study was completed to establish an epidemiologic database defining prehospital management of suspected cerebrovascular accidents (CVAs) with attention to blood glucose measurement, in the hope of developing recommendations for further treatment protocols. On review of 9495 paramedic run reports for the 24-month period from January 2001 through December 2002, from a low-volume urban emergency medical services system, 185 persons presented with CVA signs and/or symptoms. Data collected included patient chief complaint, neurologic examination, patient age, vital signs, ambulance field times, patient past medical history, and blood glucose measurement with resulting prehospital interventions, efficacy of interventions, and iatrogenic complications. Five persons (2.70%), all medication-controlled diabetics, were found to be hypoglycemic. After administration of intravenous dextrose 50% by rescue personnel, improvement in neurologic condition was noted in 100% of these cases. No sequelae as a result of such care occurred. No inappropriate use, point estimate ([0]/[5][0.00%-52.20%]), or unmet need, point estimate ([0]/[9495][0.00%-0.04%]), of care was noted. The data presented in this study suggest that given similar emergency medical service system characteristics, hypoglycemic patients presenting with neurologic deficits suggestive of CVAs constitute a rare event, associated with medical histories predictive of problems involving glucose homeostasis. Blood glucose measurement in persons presenting with CVA signs and/or symptoms is only necessary given the presence of history suspicious for hypoglycemia, or rescuer inability to obtain adequate patient information. Routine prehospital blood glucose measurement in patients with suspected CVA appears unnecessary.
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PMID:Is prehospital blood glucose measurement necessary in suspected cerebrovascular accident patients? 1698 58

The potential for addressing the underlying biological abnormalities in diabetes has eluded most investigators because of the complex mechanisms underlying the effects of diabetes on the pathogenesis of the complications. Although macrovascular complications, such as myocardial infarction, stroke and gangrene, are only partially attributable to hyperglycaemia and its attendant effects, the microvascular complications including retinopathy, nephropathy and neuropathy are directly related to the degree of hyperglycaemia. In controlled trials, a 22-34% reduction in one of these side effects was achieved for every 1% reduction in glycosylated haemoglobin. Theoretically, it should be feasible to eliminate these complications in a perfect world. However, achieving euglycaemia is nearly impossible and there is increasing data to suggest that it may be an elusive target with ever lower levels being implicated in the pathogenesis of microvascular disease and there is a price to be paid of hypoglycaemia if further intensification is pursued. A logical argument would be to block pathways that are activated by hyperglycaemia. A major pathway implicated is the activation of protein kinase C-beta in all of the targeted tissues, and there is animal data to support the notion that blocking this pathway can reverse or abrogate the untoward effects of diabetes. The possible role of the protein kinase C-beta inhibitor, ruboxistaurin, in animal studies and the recently reported clinical studies to place in perspective a possible addition to the therapeutic armamentarium of the imperfect world of diabetes control will be reviewed.
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PMID:The protein kinase C-beta inhibitor, ruboxistaurin, for the treatment of diabetic microvascular complications. 1630 93

According to great increase in the number of patients with diabetes mellitus, especially in the elderly, it is important to know clinical features of diabetic complications in the elderly. In this review, we described elderly-specific clinical characteristics of diabetic complications. First, duration of diabetes in the elderly has a broad range, and as a consequence, elderly patients exhibit a remarkable heterogeneity in their complication status. Second, as acute complications, hyperglycemic coma and hypoglycemia are especially at high risk in the elderly. Third, as for chronic complications, such as retinopathy, nephropathy, neuropathy, diabetic foot, stroke as well as ischemic heart disease, several features in the elderly patients are different from those in the non-elderly. Since these complications affect both quality of life and prognosis of the elderly, understanding these elderly-specific characteristics of diabetic complications would be necessary in the management of diabetes in the elderly.
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PMID:[Diabetic complications and their features in the elderly]. 1640 57

The medical records of 54 dogs presented to the Hebrew University Veterinary Teaching Hospital and diagnosed with heat stroke were retrospectively reviewed. Data abstracted included history, clinical and clinicopathological signs at admission, treatment, disease progression, and outcome. Exertional and environmental heat stroke were present in 63% (34 of 54) and 37% (20 of 54) of the dogs, respectively, and 78% (42 of 54) were examined between June and August. The mean temperature and heat discomfort index in the particular days of heat stroke were significantly increased (P < .001, P < .001, respectively) compared with their corresponding average daily values. In 27 dogs the body temperature was > or = 41 degrees C (105.8 degrees F). Belgian Malinois (15%, odds ratio [OR] = 24, 95% confidence interval [CI95%] 8.2-64.5), Golden and Labrador Retrievers (21%, OR = 2.08, CI95% 0.95-4.2), and brachycephalic breeds (25%, OR = 1.7, CI95%], 0.81-3.21) were overrepresented, whereas small breeds (<8 kg) were underrepresented (2%, OR = 0.08, CI95%, 0.002-0.48). Thrombocytopenia (45 of 54 dogs) and prolongation of the prothrombin (PT) and activated thromboplastin (aPTT) times (27 of 47 dogs) were recorded during hospitalization. Disseminated intravascular coagulation (P = .013) and acute renal failure (P = .008), diagnosed in 28 of 54 and 18 of 54 of the cases, respectively, were risk factors for death. The overall mortality rate was 50%. Hypoglycemia (<47 mg/dL, P = .003), prolonged PT (>18 seconds, P = .05), and aPTT (>30 sec, P < .001) at admission were associated with death. Serum creatinine >1.5 mg/dL (P = .003) after 24 hours, delayed admission (>90 minutes, P = .032), seizures (P = .02), and obesity (P = .04) were also risk factors for death. Heat stroke in dogs results in serious complications and high fatality rate despite appropriate treatment.
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PMID:Heat stroke in dogs: A retrospective study of 54 cases (1999-2004) and analysis of risk factors for death. 1649 21


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