Myths and medicine.
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History, 19th Century↗
Biomedical subjects
K C King
Publications and source records attributed to K C King.
The dental care of the psychiatric patient.
The dental care of the psychiatric patient requies careful observatio and history taking. Medications used in the treatment of psychiatric illnesses demand care in treatment planning and prescibing. The nature and sequellae of many psychiatric conditions have a direct bearing on the clinical picture presented by the patient and the success of dental care. Implementation of care must have a significant component of flexibility in terms of treatment outcomes and the time and method of providing treatment. Particular emphasis must be placed uppon the establishment of effective oral hygiene programmes. The psychiatric patient suffers not only from a socially debilitating disease but also from society's opprobrium. With a modicum of effort, the dental profession can rise above that.
Adolescent↗
Presenting research: effective paper presentations and impressive poster presentations.
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Audiovisual Aids↗
Addressing student concerns in home health care: clinical strategies.
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Adaptation, Psychological↗
Lorazepam in the treatment of refractory neonatal seizures.
We report the results of treatment of intractable seizures with lorazepam in seven neonates. All of the patients were part of a prospective study, who failed to respond to 40 mg/k of phenobarbital. Lorazepam was given intravenously at 0.05 mg/k and repeated up to a total dose of 0.15 mg/k if necessary. The diagnosis of seizures and the efficacy of treatment was assessed clinically and by EEG during the administration of lorazepam in three patients and on clinical grounds in four patients. Six patients were full term and one was premature; there were five males and two females. Four patients had hypoxic-ischemic encephalopathy, two had intracranial hemorrhage, and one had bacterial meningitis. Two patients received one dose of lorazepam, three received two doses, and two received three doses. Six patients responded with a complete cessation of seizures within three minutes of their last dose; the remaining patient (who received two doses) had a reduction in seizures. No patients developed apnea or hypotension during or immediately after the infusion of lorazepam and no other adverse effects were observed. Four patients remained seizure-free for the rest of the neonatal period and no other anticonvulsant medications were added. Seizures recurred in one patient at 16 hours; subsequent intermittent seizures were managed with additional phenobarbital. In another patient, seizures recurred at 12 hours and subsequent intermittent seizures were managed with phenytoin. In one patient, seizures continued with reduction of frequency and duration. We conclude that lorazepam may be effective in the treatment of neonatal seizures refractory to phenobarbital and that further treatment with intravenous phenytoin may be unnecessary under these circumstances.
Drug Therapy, Combination↗
Maturational changes of theophylline pharmacokinetics in preterm infants.
The pharmacokinetics of theophylline were studied at steady state by stable isotope methodology in nine individual preterm infants. Maturational variables such as postnatal age, postconceptional age, gestational age, duration of treatment, and body weight at the time of the study were analyzed for their influence on theophylline kinetics during the first 6 months of life. The strongest statistical correlations were found between the logarithm of theophylline half-life (t1/2) and the postnatal age (r = 0.98; p less than 0.001) and the postconceptional age (r = 0.96; p less than 0.001). Step-wise multiple regression analysis revealed postnatal age as the most powerful predictor for theophylline t1/2 in the neonatal period (partial correlation coefficients were 0.78 for postnatal age, 0.19 for postconceptional age, and 0.10 for gestational age). Gestational age, duration of treatment, and weight did not correlate significantly with any pharmacokinetic parameters. We propose that theophylline metabolizing function of the liver increases in a logarithmic fashion during the first 6 months of life.
Age Factors↗
Functional enteroinsular axis in full-term newborn infants.
The term "enteroinsular axis" refers to the enhancement of insulin release by hormones secreted from the gut. Gastric inhibitory polypeptide (GIP) is one of the major hormones that mediates this function. The purpose of the present study was to examine whether the enteroinsular axis is functional in newborn infants born at term gestation. Between d 2 and d 4 of life, glucose was infused for 2 h intravenously or orogastrically to 44 fullterm newborn infants, of whom 18 were appropriate for gestational age, nine large for gestational age, eight small for gestational age; nine infants were born to diabetic mothers. Glucose was infused at either 8 mg/kg/min intravenously or 16 mg/kg/min orogastrically to achieve similar plasma glucose concentrations. Plasma insulin and GIP concentrations were compared. Plasma GIP concentration increased significantly with enteral glucose administration in all infants but remained unchanged with parenteral glucose infusion. The responses of plasma insulin and the insulin/glucose ratio were significantly greater in infants receiving enterally than parenterally infused glucose. However, when glucose was infused orogastrically at a lower rate (8 mg/kg/min), plasma GIP concentrations rose, but no enhancement of insulin response was detected, suggesting the importance of the role of circulating glucose in the "enteroinsular axis". The infants of diabetic mothers and the large-for-gestational-age infants had more rapid insulin response to orogastrically administered glucose, but their GIP responses were similar to that of normal infants. These findings suggest that, at term gestation, the newborn infants have a "functional" enteroinsular axis in response to glucose, i.e. the rising plasma GIP contributed in part to the enhanced insulin response to enterally infused glucose.(ABSTRACT TRUNCATED AT 250 WORDS)
Enteral Nutrition↗
Should all pregnant women be screened for hepatitis B?
To assess the sensitivity of historical risk factors for identification for hepatitis B surface antigen (HBsAg)-positive parturients, 4399 pregnant women were consecutively screened for HBsAg. Information regarding risk for hepatitis B infection was obtained from each HBsAg-positive parturient. Twenty-three HBsAg-positive subjects were identified (5.2/1000 deliveries). The HBsAg carrier rate (18/2231, or 8.1/1000 deliveries) was significantly higher in women of black, Asian, or Hispanic origin than in the remaining ethnic groups (non-Hispanic whites plus all others, 5/2168, or 2.3/1000 deliveries) (chi square, 5.95; p = 0.016). Risk factors for identification of HBsAg-positive women were present in 10 of 22 asymptomatic subjects (sensitivity, 45%; 95% confidence interval, 24% to 68%). Much of the information required to assess one of these risk factors, previous infection, involved detailed questioning and is unlikely to be obtained in the context of conventional obstetrical care. Routine maternal HBsAg screening programs may be needed if transmission of hepatitis B from mother to infant is to be prevented.
Carrier State↗
Role of glucose in the regulation of endogenous glucose production in the human newborn.
The role of plasma glucose concentration in the regulation of endogenous glucose production in the human newborn was examined by infusing glucose at 2.6-4.6 mg/kg . min as a continuous infusion to eight normal term appropriate for gestational age infants, five preterm, and six small for gestational age infants. All infants were healthy, had no overt clinical problems and were studied 6 h after their last feed. Glucose production rates were measured during the basal state and during glucose infusion by tracer dilution using [6,6(2)H2]glucose. The rate of glucose production during the basal state was similar in preterm and term appropriate for gestational age infants (appropriate for gestational age 3.53 +/- 0.32, preterm 3.49 +/- 0.38 mg/kg . min, mean +/- SD), while it was higher in the small for gestational age infants (4.25 +/- 0.98, p less than 0.03) as compared with appropriate for gestational age. During glucose infusion, the peak glucose concentration was related to the rate of glucose infusion. The endogenous glucose production rates during glucose infusion were variable in the three groups. However, a negative correlation between peak glucose concentration and endogenous glucose production rate was observed (r = 0.59, p = 0.006). The insulin response to glucose infusion was comparable in all infants. In addition, three small gestational age and one preterm infants, who had become hypoglycemic in the immediate newborn period, were studied while they were receiving parenteral glucose and their plasma glucose had stabilized at 55.5 +/- 10.25 mg/dl. Tracer kinetic studies showed persistence of endogenous glucose production in these infants even though they were receiving high rates of exogenous glucose infusion.(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Glucose↗
Management of third-trimester diabetic pregnancies with the use of continuous subcutaneous insulin infusion therapy: a pilot study.
Six women with juvenile-onset diabetes were managed as outpatients during the third trimester of pregnancy with continuous subcutaneous insulin infusion therapy. Twenty-four-hour metabolic profiles for plasma glucose, beta-hydroxybutyrate, and triglycerides were monitored prior to, 1 week, 5 weeks, and 10 weeks after initiation of continuous subcutaneous insulin infusion therapy and compared with the metabolic profiles of 10 normal (nondiabetic) pregnant women. Near-normal metabolic profiles were achieved in these patients after 5 weeks of therapy in this pilot study. Patient motivation, compliance, and understanding of their illness were crucial in achieving the therapeutic goals of normoglycemia.
3-Hydroxybutyric Acid↗
Developmental aspects of theophylline metabolism in premature infants.
The metabolic degradation of theophylline was studied in nine premature infants with postconception ages of 28 to 42 wk. Urinary and plasma metabolites (caffeine; theobromine; 3-methylxanthine; 1,3-dimethyluric acid; and 1-methyluric acid) and unchanged theophylline were analyzed with selected ion monitoring gas chromatography-mass spectrometry. The anticipated decrease in plasma caffeine (which is absent in adult human and children) did not occur in the postconception age range studied, but the urinary percentages of unchanged theophylline decreased from 61% at a postconception age of 28 to 32 wk to 43% at 38 to 42 wk. This suggests increasing theophylline metabolism with age due to developing hepatic cytochrome P-450 enzyme systems. The increased degradation of theophylline is largely explained by the production of 1,3-dimethyluric acid (from 20% to 34%). In infants of an older postconception age, theobromine, a caffeine metabolite, was also detected. To explain the difference of caffeine pathway between adults and premature infants, it is hypothesized that the caffeine pathway of theophylline is equally active in both age groups. The absence of caffeine metabolite in adults is due to the maturing caffeine-metabolizing enzymes, which degrade caffeine immediately to its metabolites.
Aging↗
Fetal renal maturation. Studies on urinary beta 2 microglobulin the neonate.
Beta 2 microglobulin [B2m] and creatinine [Cr] concentrations were measure in the urine of 27 newborn infants. At birth, urinary [B2m] and [B2m]/[Cr] ratios were significantly lower in infants born beyond 36 weeks' gestation. Serial measurements, postnatally, showed a progressive decrease in the urine [B2m]/[Cr] ratio of infants born prematurely. These findings suggest an increase in tubular uptake of B2m with increasing gestational and postnatal age. The current findings tend to support the hypothesis that the decrease in [B2m] observed in amniotic fluid beginning at approximately 36 weeks' gestation reflects maturation of fetal proximal renal tubular function.
Amniotic Fluid↗
Propoxyphene and acetaminophen. Possible effects on the fetus.
Propoxyphene (Darvon) and acetaminophen (Tylenol) are widely prescribed analgesic agents. Both can cross the placenta, and propoxyphene can produce serious withdrawal symptoms in newborns. Neither propoxyphene nor acetaminophen is considered a teratogen, yet, three malformed infants who were antenatally exposed to propoxyphene have previously been reported. We report a fourth case of an infant, with withdrawal symptoms and cranial-facial and digital malformations, born to a women who used propoxyphene and acetaminophen throughout her pregnancy. We suggest that possibility that the antepartum use of propoxyphene and acetaminophen, in combination, may be teratogenic.
Abnormalities, Drug-Induced↗
Regulation of glucose production in newborn infants of diabetic mothers.
The glucose homeostasis in the infants of normal and diabetic mothers was elevated by examining the effects of exogenous glucose infusion at 4 mg/kg . min and quantifying the rats of glucose production and utilization. Five infants of insulin-dependent diabetic mothers (IDM), one infant of a gestationally diabetic mother and five infants of normal mothers were studied between 2-4 h of age. The rates of glucose production and utilization before and during glucose infusion were quantified by tracer dilution technique using [6,62H2] glucose tracer and gas chromatography-mass spectrometry. Fractional glucose uptake (Kt) was measured at the end of infusion by administering 0.5 g/kg glucose pulse. All diabetic women were under rigid metabolic control during pregnancy. Although basal plasma glucose levels at e 2-4 h were lower in the IDMs as compared with normal newborns (43.4 +/- 3.7 and 65.2 +/- 3.6 mg/dl, mean +/- S.E., respectively), the glucose production and utilization rates were not significantly different (3.35 +/- 0.26 and 3.39 +/- 0.08 mg/kg . min); therefore, the metabolic clearance rates were higher inthe IDMs (7.69 +/- 0.41 ml/kg . min) as compared with the normal newborn infant (5.20 +/- 0.20 ml/kg . min). Glucose infusion resulted in a greater suppression of endogenous glucose production rate in the normal newborn infants than in the IDMs. Glucose infusion resulted in an acceleration of Kt in the normals (2.38 +/- 0.25%/min). We conclude that rigid regulation of maternal diabetes normalizes glucose production rate in IDM; however, intermittent maternal hyperglycemia may result in altered regulation of hepatic glucose production.
Blood Glucose↗
Theophylline metabolism in premature infants.
The theophylline metabolite pattern in premature infants was studied with gas chromatography-mass spectrometry. The identities of metabolites were established by retention time indices and mass chromatograms. In the steady state of a multiple-dose regimen, the urinary metabolites of theophylline identified and quantified were caffeine (9.6 plus or minus 4.8%), theophylline (50.4 plus or minus 6.7%), 3-methylxanthine (1.3 plus or minus 0.7%), 1,3-dimethyluric acid (27.7% plus or minus 8.8%), and 1-methyluric acid (9.3 plus or minus 5.4%). Those in plasma were caffeine (21.4 plus or minus 6.1%), theophylline (73.6 plus or minus 6.5%), 3-methylxanthine (0.7 plus or minus 0.4%), 1,3-dimethyluric acid (2.6 plus or minus 1.2%), and 1-methyluric acid (0.6 plus or minus 0.3%). Occasionally, theobromine, the metabolic breakdown product of caffeine, was found in urine and plasma in small quantities. The demethylation pathway occurring predominantly in adults was substituted by N-methylation to caffeine in premature infants; the other major metabolic pathway of theophylline in adults, C-8 oxidation to 1,3-dimethyluric acid, was slightly diminished. We concluded that the enzyme systems responsible for the C-8 oxidation of theophylline are relatively active in premature infants and that the development of the enzyme systems responsible for oxidative demethylation of theophylline lags behind. The oxidation and demethylation pathways of theophylline in premature infants are significant.
Aminophylline↗
Postnatal development of theophylline metabolism in preterm infants.
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Adult↗
Obesity in pregnancy: risks and outcome.
Obesity has been associated in the literature with other pregnancy risks such as hypertension and diabetes mellitus, but disagreement persists about the expected course and complications of labor. Also, the effects of obesity on intrauterine growth and gestational duration have not been well defined. This study of 2746 consecutive deliveries used a computer-based uniform perinatal record to compare 300 pregnancy risk and outcome factors for obese and nonobese patients. The 279 obese women (more than 90 kg at some time during the pregnancy) were found to be older and of higher parity than the 2467 who were not obese. Those in the obese group were at increased antepartum risk and had increased frequencies of chronic hypertension, inadequate pregnancy weight gain, twin gestation, and diabetes mellitus. Oxytocin induction and repeat cesarean sections were performed more frequently for the obese patients, with no increase in complications during the current labor. The frequency of labor abnormalities, oxytocin augmentation, and primary cesarean section was similar to that of the comparison group. Examination of infant outcome revealed similar Apgar scores and perinatal mortality in the 2 groups, but fewer low-birth-weight infants (under 2500 g) and more macrosomic babies (over 4000 g) occurred in the obese population. This increase in birth weight was accounted for not only by an increase in the birth weight percentile, but also by a significant lengthening of the period of gestation.
Adult↗
Glycohemoglobin (HbAIc): a predictor of birth weight in infants of diabetic mothers.
Hemoglobins AIa-c (fast Hb), minor variants of HbA, are elevated in patients with diabetes mellitus. Recent studies indicate a relationship of fast hemoglobins, especially HbAIc (glycosylated form), to chronic hyperglycemia. Since infant oversize has been attributed to maternal hyperglycemia and fetal hyperinsulinemia, the hemoglobin HbAIc fraction was compared to birth weight (actual and relative to gestational age) and to maternal glucose tolerance. Normal (13), probably normal (8), gestational diabetic (10), and insulin-dependent women (14) were studied in the third trimester; women with advanced diabetic vascular disease were excluded. When corrected for gestational age, relative birth weights correlated in a significant linear regression with HbAIc (n = 45, r = 0.57, P less than 0.001). Third trimester maternal glucose tolerance (Kt) of women, not insulin dependent, correlated in a signigicant manner with both HbAIc (P less than 0.05) and birth weight for gestational age (P less than 0.01).
Birth Weight↗