The limits of proxy decision making: undertreatment.
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Aged↗
Biomedical subjects
T Fried
Publications and source records attributed to T Fried.
Acute interstitial nephritis. Why do the kidneys suddenly fail?
Acute interstitial nephritis is a clinical and pathologic entity with diverse causes. The most common cause at present is reaction to drug use, but infection, a concomitant uveitis syndrome, and other rare causes have been reported. Acute interstitial nephritis should always be considered in a patient with acute renal failure, because it is a treatable cause that may result in interstitial fibrosis and irreversible disease if not arrested.
Acute Disease↗
An overview of common soccer injuries. Management and prevention.
The most common injuries in soccer involve the ankle and knee joints, and the muscles and ligaments of the thigh and calf. Rehabilitation to restore strength and endurance after healing is extremely important to prevent a recurrence of the injury, which is much more severe and disabling than the initial injury. Sprains and strains of the hamstring and quadriceps, and injuries to the external and internal structures of the knee joints are frequent and relatively more disabling. Recent progress in the technical aspect of investigative medicine, such as magnetic resonance (MRI) imaging/quantitative only computer tomography (CT) scanning, ultrasonic imaging of soft tissues and isokinetic measurement of muscle characteristics, lead to better diagnosis and management of soccer injuries. Appropriate nutritional and physiological preparation, maintaining fluid and electrolytes during the game and restoration of the reserves following completion of exhaustive activities will help to minimise injuries.
Craniocerebral Trauma↗
[Intensified insulin therapy in the management of gestational diabetes].
A total of 35 pregnancies in 28 Pregestational Diabetic Patients (PDP) were followed with the goal of achieving and maintaining near normoglycemia (as many pre-postprandial glycemias as possible between 60-140 mg/dl); 13 patients (16 pregnancies) were assigned to Subcutaneous Continuous Preprogrammed Insulin Infusion (SCII) because of high risk pregnancies (HRP) (at least one of the following: former history of spontaneous abortions, stillbirths, premature deliveries and/or sterility). The remaining 12 PDP's (15 pregnancies with no past history of the above nature) were treated with Multiple Conventional Insulin Injections (MCII). Both groups were comparable regarding the following clinical parameters: age, time of onset and class of diabetes. All patients were instructed in performing 3 to 7 daily Self Capillary Blood Glucose controls (SCBG). Mean follow-up observation period was (mean +/- SEM) 28.5 +/- 2.5 weeks for SCII and 3.2 MCII and 28.8 +/- 3.2 weeks for MCII. All the 3 PDP drop out's (4 pregnancies) belonged to the CMII group. No drop out's were recorded in the SCII group. Both insulin therapy approaches were similarly effective in improving metabolic control in that comparable levels of mean blood glucose (MBG) and HbA1 were attained by SCII and MCII (Fig. 1). Compliance, as evidenced by average of daily SCBG was also similar in both groups (Fig. 2). Such satisfactory metabolic control was achieved mostly because of an increase in the percentage (65%) of "fair" glycemias (60-139 mg/dl) and not because of an increase in hypoglycemias (< 60 mg/dl) which could have canceled out an undesirable degree of hyperglycemias thus rendering "false satisfactory" MBG's and HbA1 (Fig. 1). With the above degree of metabolic control obtained there occurred no severe hypoglycemic episodes requiring medical intervention. All newborns to the PDP's who remained under treatment showed an adequate APGAR (X +/- SEM, 9.5 +/- 0.2) regardless of the modality (SCII or MCII) of insulin delivery used (Tables 1, 2). The single malformed baby found in this series was born to a patient on SCII who happened to start on the intensified insulin treatment rather late in her pregnancy (21st week) and, in addition, the patient self medicated with high doses of chlorpromazine because of recurrent vomiting episodes. Incidence of neonatal hypoglycemia (HY) or macrosomy (MS) was comparable in both groups (Tables 1, 2). It is to be pointed out, however, that PDP's who bore the babies with no HY or MS had presented a larger number of low glycemic values than mothers who bore the babies with HY and/or MS.(ABSTRACT TRUNCATED AT 400 WORDS)
Adult↗
Does magnesium play a role in the hypokalemia of Bartter's syndrome?
A patient with Bartter's syndrome manifested hypomagnesemia in addition to hypokalemia. Under conditions of maximal free water production, he had a fractional distal solute reabsorption of 0.65, a value consistent with a renal defect in sodium chloride reabsorption in the thick ascending limb of the loop of Henle. This is also the site of 65% to 70% of urinary magnesium reabsorption. With magnesium supplementation and amiloride, the urinary potassium decreased and the serum potassium increased. Atrial natriuretic peptide concentrations in the plasma were low. Evaluation of family members showed five of nine offspring had hypokalemia with no disorder in the parents, an apparent autosomal recessive mode of inheritance. This is a US government work. There are no restrictions on its use.
Adult↗
Renal and hemodynamic effects of atrial natriuretic peptide in patients with cirrhosis.
The effects of anaritide, a 25-amino-acid synthetic analogue of ANP, were evaluated in 28 patients with cirrhosis complicated by ascites and/or edema. Each patient received two doses of the agent, as well as an infusion of placebo. Six different doses were tested ranging from 0.015-0.300 microgram/kg/min. The infusions lasted for 2 hours and were flanked by both baseline and recovery periods. There was a significant effect of placebo on urinary sodium and chloride excretion rates but no effect on urine flow rate. In response to anaritide, the urine flow rate increased at 0.03, 0.06, 0.075, and 0.100 microgram/kg/min. The sodium and chloride excretion rates increased at all doses except the highest dose. There was no definite effect of anaritide on urinary potassium, calcium, and phosphate excretion rates. There was also no significant effect on creatinine clearance. The mean arterial pressure decreased in response to the 0.060, 0.075, and 0.100 microgram/kg/min doses. In addition, five of the patients receiving the highest dose (0.300 microgram/kg/min) had decreases in their systolic pressures to 90 mm Hg or less. In conclusion, anaritide is natriuretic and diuretic in patients with cirrhosis complicated by ascites and/or edema. Its effect, however, on arterial pressure may limit its therapeutic potential in this patient population.
Atrial Natriuretic Factor↗
Effect of exogenous ANP on initial renal function following 24-hour cold preservation.
The impact of synthetic atrial natriuretic peptide (sANP) on renal function following cold ischemic injury was studied in a canine autotransplant model. Following a prenephrectomy inulin clearance determination (CIn), the left kidney was excised, flushed with Eurocollins solution, and cold-stored for 24 hours. Immediately following reperfusion and a 10 minute equilibration period, baseline CIn was measured over a 20-minute time interval (Collection Period I). Experimental animals (N = 11) then received 1 mcg/kg sANP by intravenous bolus followed by a continuous infusion at 0.3 mcg/kg/min for 30 minutes. CIn was measured throughout the infusion (Collection Period II). Normal saline was substituted for sANP in control animals (N = 11). CIn was also measured 24 hours following reimplantation in seven control and seven sANP-treated animals. Autograft inulin clearance increased from 0.32 +/- 0.11 ml/min during Period I to 2.5 +/- 0.6 ml/min during sANP infusion (P less than 0.01). This increase in CIn associated with ANP infusion was accompanied by increases in urine flow rate (V) (0.15 +/- 0.05 ml/min to 0.98 +/- 0.21 ml/min, P less than 0.01) and renal blood flow (RBF) measured by electromagnetic flow probe (85 +/- 17 ml/min to 171 +/- 13 ml/min, P less than 0.05). No significant changes in CIn, V, or RBF occurred in control animals between periods I and II. Although systemic blood pressure declined during sANP infusion, it did not decrease to an extent that compromised peripheral perfusion. CIn determined 24 hours after autograft reimplantation in the ANP-treated animals approximated or exceeded values determined during ANP infusion (Period II).(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Atrial natriuretic factor: a historic perspective.
Atrial natriuretic factor (ANF) is a relatively newly discovered hormone. Its discovery was the culmination of almost a half century of research. This article reviews some of the data leading up to its discovery. In addition, the issue of its physiologic role in volume expansion is considered.
Atrial Natriuretic Factor↗
Transcutaneous electrical nerve stimulation: its role in the control of chronic pain.
An assessment was made of the effectiveness of long-term transcutaneous electrical nerve stimulation (TENS) in the treatment of chronic posttraumatic pain. Compensation Board files showed that 846 patients received TENS from 1975 to 1979, with more than 70% having intractable back pain. Of this group using TENS, 44.6% were free of disability, and an additional 36.2% were capable of modified work. Questionnaire responses were obtained from 563 of 637 patients receiving TENS in 1978 or 1979. At the six-month follow-up, most respondents (472, 83.8%) reported continuing benefit from TENS, including a reduction of pain (418, 74.2%), less need for medication (322, 57.2%), and improved sleep patterns (331, 58.8%). Only 13.6% of those who had returned to work reported no benefit from TENS, while 18.4% of those still unemployed reported no benefit. Among those who had returned to work (264 cases, 46.9% of respondents), benefit was reported equally by those with back injuries and by those with other injuries. The responses observed in this trial seem larger and more long-lasting than could be obtained by a placebo effect, and further attempts at a controlled trial may be warranted. However, there are major practical difficulties to such an investigation, and the resulting controversy could reduce the therapeutic effectiveness of TENS in conditions where alternative treatments are either ineffective or undesirable.
Back Pain↗
Renal ischemic injury in the dog: characterization and effect of various pharmacologic agents.
Renal ischemia has been implicated as a major factor in the pathogenesis of acute renal failure. Despite several differences between the intrarenal norepinephrine infusion and renal artery occlusion models, they have been assumed to be prototypic models of ischemic renal injury. In our previous studies, an intrarenal infusion of norepinephrine caused a marked reduction in inulin clearance 3 hours after infusion. This reduction could be significantly attenuated by the concurrent infusion of mannitol, furosemide, or bradykinin. The effects of these three protective agents were evaluated before and after variable durations of renal artery occlusion to establish the similarities between the models and the magnitude of versatility of these protective agents. In the renal artery occlusion model, capsular fascia was stripped to eliminate collateral flow and ensure maximal renal ischemia. Three hours after 120 minutes of renal artery occlusion (n = 7), inulin clearance returned to 5.7% +/- 2.2% (SEM) of the control values and was not statistically different from that observed in the norepinephrine model. Intrarenal infusion of mannitol, furosemide, or bradykinin prior to and during the occlusion period, however, had no protective effect. Shorter durations of renal artery occlusion were evaluated to ensure an equivalent or decreased severity of acute renal failure compared with the norepinephrine model. After 90 or 60 minutes of renal artery occlusion, the clearance of inulin returned to 10.9% +/- 3.3% (n = 8) and 31.1% +/- 8.2% (n = 4) of control values, respectively. An intrarenal infusion of mannitol, furosemide, or bradykinin still had no significant protective effect, despite the decreased insult in the 60-minute renal artery occlusion studies. In summary, these findings demonstrate fundamental differences between renal artery occlusion and the norepinephrine model of renal functional impairment, and they suggest that the insult associated with norepinephrine infusion may involve factors other than cessation of blood flow.
Acute Kidney Injury↗
Responses to sustained use of anabolic steroid.
Description is given of six body-builders who had been taking Methandrostenolone (up to 20 mg/day in intermittent courses for a year or more). At the time of examination there was no subjective disturbance of sexual function, but testosterone levels were low relative to laboratory standards and luteinizing hormone levels were also reduced - particularly in relation to testosterone concentrations. Abnormal liver function tests were seen in three of the six subjects, and one had mild diabetes with high serum cholesterol, triglycerides and uric acid. The weight gain of the group was not outstanding, and the only possible finding was a high haemoglobin and haematocrit in one of the six subjects.
Adult↗
A team approach to sports medicine.
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Adolescent↗
Assessment of a lower extremity training program.
The response to a lower extremity program has been studied in workmen undergoing progressive rehabilitation following injury to the lower leg or ankle region. When first seen, the isometric strength of the injured limb was substantially reduced relative to its counterpart, and aerobic power was also poor, relative to normal standards. Substantial gains of isometric strength occurred over a four- to six-week period of therapy. Measurements above the site of injury suggested a 13% gain of strength, and measurements below the injury indicated a gain of 34%. On the other hand, there were minimal changes of thigh circumference over this period. Soft tissue radiographs taken in the posteroanterior and lateral planes showed a small (1%) increase of muscle tissue and a somewhat larger (5%) loss of subcutaneous fat. Dynamic exercise at a fixed percentage of aerobic power was associated with similar subjective discomfort and a similar accumulation of lactate before and after rehabilitation.It is concluded that the apparent improvement in isometric strength over the period of rehabilitation is due to (1) initial voluntary limitation of effort and (2) increase in skill. The use of soft tissue radiographs may afford a more objective basis for the evaluation of future muscle training programs.
Accidents, Occupational↗
Deterioration and restoration of physical fitness after trauma.
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Body Weight↗