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

Duplex scanning has emerged as an accurate noninvasive method of evaluating patients with extracranial cerebrovascular disease; it has research, clinical and economic implications. The risks associated with cerebral angiography are numerous and well-known. During 1990-1995, 227 carotid endarterectomies (CEA) were performed without preoperative arteriography in 192 patients. 91% were performed under local anesthesia. Indications for surgery without angiography were: renal insufficiency (in 5), allergy to contrast material (11), and need for urgent surgery (25). In 81% CEA was performed due to the preference of both the neurologist and surgeon. In only 2 cases there was a discrepancy in duplex evaluation. 3 patients had postoperative strokes (total stroke rate 1.56%), only 1 of which was disabling (0.52%). 2 died during the immediate postoperative period (mortality 1.04%): 1 on the 2nd postoperative day due to asphyxia caused by a huge neck hematoma which appeared suddenly after discharge (related death, 0.52%); the other died several days after coronary surgery which followed CEA (unrelated death). Our study confirms that patients with well-defined symptoms, appropriate physical findings, and concurrent CT and duplex scans, can safely undergo CEA without preoperative angiography. It is extremely important however, that the duplex scan be a reliable study from a laboratory which has validated its results by sequential comparison of previous duplex and angiographic data. Angiography remains appropriate in patients with atypical symptoms; with conflicting findings between history, physical and duplex data; when there is proximal disease; or in an asymptomatic patient when the duplex scan suggests total occlusion.
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PMID:[Carotid endarterectomy without angiography]. 885 66

Stimulation of the imidazoline I1-receptor represents a new mode of antihypertensive action, inhibiting peripheral alpha-adrenergic tone by a central mechanism. Moxonidine is an imidazoline I1-receptor modulator. Acute hemodynamic studies indicate that moxonidine results in an acute fall of both blood pressure and systemic vascular resistance, whereas heart rate, cardiac output, stroke volume, and pulmonary artery pressures are not affected. The ejection fraction is not significantly affected. Left ventricular end-systolic and -diastolic volumes are reduced. There is regression of left ventricular hypertrophy after 6 months of treatment. Epinephrine, norepinephrine, and renin levels are all reduced, a finding consistent with central inhibition of sympathetic tone. After oral administration Tmax is about 1 h and bioavailability approaches 90%. Moxonidine is mostly excreted unchanged; biotransformation is unimportant. The T1/2 is 2.5 h, prolonged by renal insufficiency. The antihypertensive effect lasts longer than would be expected from the half-life, suggesting possible retention in the CNS. Open studies with moxonidine have revealed decreases on the order of 20-30 mm Hg systolic and 10-20 mm Hg diastolic blood pressure. Most patients are controlled by 0.2-0.4 mg daily. Moxonidine has been compared with representatives from each important class of antihypertensive drugs, with diuretics, clonidine, calcium antagonists, angiotensin-converting enzyme inhibitors, and both alpha- and beta- blocking drugs. Blood pressure control has been similar with moxonidine and these other agents. The overall incidence of side effects was similar, although moxonidine has a lower incidence of side effects than clonidine. Meta-analysis of controlled studies with moxonidine indicates that moxonidine causes similar decreases in blood pressure in both male and female subjects, in those below 50 years, those 50-60 years, and those over 60 years old, regardless of body weight. As with some other drugs, higher systolic blood pressure are associated with larger falls of systolic blood pressure, and the same is true for diastolic blood pressure.
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PMID:Effective antihypertensive therapy: blood pressure control with moxonidine. 887 98

Long-term outcome was studied in 233 patients who had undergone renal artery revascularization (51 with balloon angioplasty, 182 with surgery) between 1976 and 1992. Patients (excluding renal transplants) were treated for renal vascular hypertension without or with renal insufficiency (serum creatinine > 1.6 mg/dl. All patients still alive (n = 188) were contacted to determine current blood pressure, medications, serum creatinine, and subsequent significant medical events. In patients who had died the cause of death was determined and renal function status at the time of death noted from medical records. Some follow-up information was obtained on all 233 patients; follow-up serum creatinine data were obtained in 193 (82.8%) patients. Some 24 patients (10.3%) became dialysis-dependent. Using a multiple logistic regression analysis only, preoperative creatinine maintained significance (P < 0.001) for increased dialysis risk. There was no statistically significant association of dialysis for type of revascularization (percutaneous transluminal angioplasty, autogenous artery, saphenous vein, endarterectomy or synthetic material), simultaneous or previous aortic or other vascular surgery (carotid endarterectomy, femoropopliteal bypass, etc.), pathology (atherosclerosis or fibromuscular dysplasia), number of renal arteries stenosed or treated, length of follow-up, age, coronary artery disease, congestive heart failure, stroke, chronic lung disease or type II diabetes. It is concluded that, in patients with renal artery stenosis, the timing of renal artery revascularization relative to the level of renal function is the most important determinant for long-term renal salvage.
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PMID:Late renal function in patients undergoing renal revascularization for control of hypertension and/or renal preservation. 890 17

The purpose of this study was to determine the characteristics of gouty arthritis in an urban Guatemalan population. We reviewed the medical records of 148 (145 males and 3 females) patients with a diagnosis of acute gouty attack seen at an urban rheumatology clinic in Guatemala City between 1982 and 1993. Mean age at diagnosis was 49 years (range 21-87), mean age of onset was 42 years, mean duration of disease 7.4 years, family history of gout 42 (28%), peak prevalence 5th decade 39 (26%). Seventy-one (48%) had monarticular, 49 (33%) oligoarticular, and 22 (15%) polyarticular attacks, respectively. Podagra was seen in 34 (23%) patients; however, 108 (73%) developed it at any moment of their life. Tophaceous gout was seen in 33 (22%). Mean serum urate concentrations (enzymatic method) were higher than 7.0 mg % in 90 (60%) patients. At follow-up, 44 (30%) patients never returned to our clinic, and a large majority of them [66 (45%)] were seen only during acute attacks. Associated disorders included hypertension (43%), obesity (27%), nephrolithiasis (16%), ischaemic heart disease (7%), renal insufficiency (2%), stroke (0.6%), and diabetes mellitus (0.6%), and two died due to sepsis; high alcoholic intake was found in 58 (39%) patients. In conclusion, our findings indicate that gout is not an unusual disorder in the Guatemalan population. It presents with the same characteristics as those reported in Caucasians, with the possible exception of a lower frequency of diabetes mellitus as an associated disorder.
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PMID:Characteristics of gouty arthritis in the Guatemalan population. 913 25

It is believed that the hypertensive effect of diaspirin crosslinked hemoglobin, a viable blood substitute, can be resolved by polymerization, which reduces the diffusion of this derivative into the interstitial space between nitric oxide-producing endothelium and the target vascular smooth muscle. We studied the systemic and renal responses to infusion of three cell-free human hemoglobins in anesthetized isovolemic rats: unmodified (HbA0), crosslinked (alpha-DBBF), and polymerized crosslinked (poly alpha-DBBF). HbA0 produced a significant increase in mean arterial blood pressure (MAP) throughout the 60-minute infusion. alpha-DBBF, on the other hand, produced a more marked and prolonged increase in MAP over 120 minutes. Only a moderate increase in MAP was observed in rats after a 30-minute infusion with poly alpha-DBBF. The extent of renal insufficiency produced by these proteins, as determined by the glomerular filtration rate, was in the following order: HbA0 > poly alpha-DBBF > alpha-DBBF. Infusion of poly alpha-DBBF, under hypovolemic but not isovolemic conditions in rats, produced an increase in heart rate, cardiac output, and stroke volume and a decrease in total peripheral resistance after 60 minutes. Chemical polymerization to increase the size of alpha-DBBF does not appear to improve its hemodynamic properties in rats, especially under partial exchange transfusion, a more clinically relevant indication for a hemoglobin-based blood substitute.
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PMID:Effects of polymerization on the hypertensive action of diaspirin cross-linked hemoglobin in rats. 917 23

Moxonidine is a centrally acting antihypertensive. Its action is mediated by imidazoline I1 receptors located in the rostral ventro-lateral medulla (RVLM). Animal experiments show much smaller amounts are required to reduce blood pressure (BP) when it is given intracisternally, or injected directly into the RVLM, compared to intravenous dose. The antihypertensive action of microinjection of moxonidine into the RVLM in the spontaneously hypertensive rat (SHR) is abolished by pretreatment with imidazoline I1 blockade from efaroxan, but alpha(2) blockade from SKF 86466 has much less effect. Similarly the fall of BP in the SHR from intravenous moxonidine is reversed by the microinjection of efaroxan into the RVLM. Receptor binding studies demonstrate that moxonidine binds with an affinity for the imidazoline I1 receptor that is thirty-three times more effective than is alpha(2) receptor binding, while for clonidine the difference is only four times. Moxonidine reduces adrenaline, noradrenaline and renin levels in man, a finding consistent with central inhibition of sympathetic tone. Acute haemodynamic studies indicate that moxonidine results in a fall of BP due to a decline in systemic vascular resistance, while the heart rate, cardiac output, stroke volume and pulmonary artery pressures are not affected. Left ventricular end systolic and diastolic volumes are reduced. Left ventricular hypertrophy has been found to regress after 6 months treatment with moxonidine. After oral administration Tmax is about 1 h, bioavailability approaches 90%. Moxonidine is mostly excreted unchanged, biotransformation is unimportant. The T1/2 is 2.5 h, which is prolonged by renal insufficiency. However, suggesting possible retention in the central nervous system (CNS), the antihypertensive effect lasts longer than would be expected from the half-life, as moxonidine is suitable for once daily administration. Moxonidine is an effective antihypertensive agent. It has been compared with representatives from each important class of antihypertensive drugs, with clonidine, diuretics, both alpha- and beta-blocking drugs, calcium antagonists and ACE inhibitors. BP control has been similar with moxonidine and these other agents. The side effect profile of moxonidine is favourable, its lack of effect on central alpha(2) receptors is important in this regard.
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PMID:Pharmacology and clinical use of moxonidine, a new centrally acting sympatholytic antihypertensive agent. 932 37

Antihypertensive drug treatment has been shown to significantly decrease cardiovascular morbidity and mortality rates in hypertensive subjects and to reduce the occurrence of major hypertension-related complications, such as stroke, coronary artery disease, congestive heart failure and renal insufficiency. Despite these favorable effects, several issues related to antihypertensive treatment remain to be clarified. This paper will discuss some of these issues, with particular reference to the effects of blood pressure lowering on renal diseases and coronary heart disease. It will also discuss the ongoing clinical trials aimed at clarifying some unsolved issues of antihypertensive treatment. The objective of the International Nifedipine GITS Study Intervention as a Goal in Hypertensive Treatment was to provide information on the effects of calcium antagonist treatment on high blood pressure values and on hypertension-related cardiovascular complications in a high-risk hypertensive population.
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PMID:Primary prevention of cardiovascular disease. 939 91

Hyperhomocysteinemia is regarded as a risk factor for stroke but its pathogenetic role has not yet been established in Black patients. We studied 24 Black patients admitted with cerebral thrombosis, and compared them with age- and sex-matched apparently healthy controls from the same community. Total homocysteine (tHcy) (free homocysteine, protein-bound homocysteine, the disulfide homocystine and the mixed disulfide homocysteine-cysteine) concentration was 10.91 (4.95-23.05) mumol/l in the stroke patients and 8.73 (3.95-15.10) mumol/l in controls (p = 0.031). This difference could not be explained by differences in vitamin B12, vitamin B6 or folate status. A subgroup of nine stroke patients with hypercreatininaemia (> 90 mumol/l, 75% of control concentrations) had significantly higher plasma tHcy concentrations [median (range) 9.10 (5.40-15.10) mumol/l] compared with controls [8.65 (3.96-13.89) mumol/l] (p = 0.002). Plasma tHcy concentrations of stroke patients with normal serum creatinine concentrations were not significantly different to those of controls. Hyperhomocysteinemia in Black patients with stroke may be partially caused by renal insufficiency. Therefore, while hyperhomocysteinemia may increase the risk of stroke, it is unlikely to be a primary initiating factor.
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PMID:Hyperhomocysteinaemia in black patients with cerebral thrombosis. 941 45

Between 1988 and 1992, 565 type 2 diabetic patients were examined for nephropathy and diabetes-associated diseases during hospital treatment. Stages of nephropathy were defined as no clinical sign of nephropathy (N = 280), microalbuminuria (N = 38), overt proteinuria (N = 105), impaired renal function (N = 55), and chronic dialysis therapy (N = 87). In dialyzed patients, HbA1c averaged 6.8%, and, in the other groups, HbA1c was between 7.6% and 8.3% (normal range, 3.8%-6.1%). Cataract was not associated with the severity of nephropathy. Stroke was most common in the stage of renal insufficiency (34%). The following complications, as found in medical history or as current event, showed a significant association with the stage of nephropathy and occurred most frequently in dialysis patients (percentage is displayed for patients with nephropathy in comparison to diabetic dialysis patients): hypertension (53%-89%), left ventricular hypertrophy (39%-81%), myocardial infarction (14%-36%), peripheral vascular disease (27%-77%), foot lesions (7%-75%), minor or major amputations (3%-23%), proliferative retinopathy (6%-46%), blindness (2.9%-16.1%), and internal carotid artery stenosis (15%-36%). In this preselected cohort of diabetic patients, a high morbidity was found already without nephropathy that increased several-fold in the course of the development of nephropathy. Our data identify patients with diabetic nephropathy as a high-risk group for excess morbidity.
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PMID:Morbidity in 565 type 2 diabetic patients according to stage of nephropathy. 955 88

This study was undertaken to compare postoperative epidural analgesia (PEA) with patient-controlled analgesia (PCA) regarding complications, particularly pulmonary, death, intensive care unit and hospital stay, and hospital and physician charges. The elective consecutive infrarenal abdominal aortic procedures performed by two vascular surgeons over a 1 year period were retrospectively analyzed. Although nonrandomized, of the 80 patients reviewed, 40 received PEA and 40 received PCA. The following demographic data were obtained: age, sex, diabetes mellitus, hypertension, coronary artery disease, prior coronary revascularization, stroke, renal insufficiency, smoking, and chronic obstructive pulmonary disease. Epidural catheters were placed preoperatively and maintained for an average of 4 days postoperatively. All patients underwent routine aortic reconstruction via midline transperitoneal incisions. The demographics were similar in both groups. Likewise, surgical intensive care unit stay and complications were similar in both groups. The average length of stay in patients receiving PEA was 7.59 days, compared with 6.68 days for the PCA group. Following discharge from the hospital, no additional complications were encountered and no readmissions required during a 4-week follow-up. Average charge (hospital and physician) per patient for PEA was $2489.00 compared with $443.00 for patients receiving PCA (no physician charges generated for PCA). The results do not support the routine use of PEA following abdominal aortic operations. Savings are more than $2000.00 per patient for PCA compared with PEA.
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PMID:Postoperative epidural analgesia following abdominal aortic surgery: do the benefits justify the costs? 967 33


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