32 have been detected in oyster samples from Willapa Bay. Plans are under way to separate chemically and to measure the concentration of phosphorus-32, scandium-46, chromium-51, manganese-54, iron-59, cobalt-60, strontium-90, and some of the long-lived rare earths (which are present in Columbia River water) in West Coast sea foods (72).
Summary:Paradoxical hypertension is a relatively common complication of surgical repair of coarctation of the aorta. An early phase of systolic hypertension has been ascribed to elevated levels of norepinephrine. Activation of the renin-angiotensin system from sympathetic stimulation has been implicated in a later phase of systolic and diastolic hypertension that can result in mesenteric arteritis. The use of a rapidly acting, titratable intravenous alpha-and beta-adrenergic blocker, such as labetalol hydrochloride, addresses both of these neurohormonal mechanisms. In the intravenous form, it would appear to be an excellent choice for the management of early postoperative hypertension and it can be converted to the oral form in cases of persistent hypertension. We report for the first time the use of labetalol in two young patients for the control of paradoxical hypertension following coarctation repair.during an early phase of systolic hypertension lasting 24-48 h. Subsequent activation of the renin-angiotensin system results in moderate systolic, but marked diastolic hypertension which is associated with the syndrome of mesenteric arteritis.2 If untreated, this can lead to gangrenous bowel infarction, peritonitis, and death.Pharmacologic management in the early postoperative period usually consists of potent intravenous antihypertensive medications, but reflex tachycardia in response to vasodilatation may necessitate the use of additional medications, such as intravenous beta blockers. Hypertension occurring after the first 48 h has been treated with intramuscular reserpine. We have recently encountered two pediatric patients with intractable hypertension after coarctation repair in whom intravenous labetalol was successful in rapidly controlling hypertension. Labetalol addresses the mechanism of sympathetic stimulation and can be considered an excellent antihypertensive drug for the control of paradoxical hypertension after repair of coarctation of the aorta.
Warfarin currently is the most widely used agent in the prevention of thrombosis and embolism after prosthetic cardiac valve replacement. Since smoking has been shown to increase the requirement for medications undergoing hepatic metabolism, this study was designed to determine if a correlation exists between smoking history and warfarin daily maintenance dose (DMD) in patients undergoing cardiac valve replacement. Of 200 charts retrospectively reviewed at the New England Medical Center, 174 satisfied the criteria for inclusion in the study (normal hepatic, renal, and hematologic function, and absence of complicating medications). The study population included aortic, mitral, and combined valve replacement. Study groups consisted of 117 nonsmokers (Group A), 23 light smokers (Group B), and 34 heavy smokers (Group C). Thirty-three percent of patients required a low DMD of warfarin (less than or equal to 2.5 mg), 43 percent required a moderate DMD (greater than 2.5-7.5 mg), and 24 percent required a high DMD (greater than 7.5 mg). Each of the subgroups followed a similar pattern. In Group A, there were 31 percent low, 44 percent moderate, and 25 percent high-dose requiring patients. In Group B, there were 48 percent low, 39 percent moderate, and 13 percent high-dose requiring patients and in Group C there were 29.5 percent low, 41 percent moderate, and 29.5 percent high-dose requiring patients. Chi-square analysis did not demonstrate any statistically significant difference between smokers and nonsmokers in regard to daily maintenance warfarin dose (p = 0.5). The study population followed a normal pattern of distribution in regard to warfarin dosage. On the basis of these data we conclude that smoking history does not affect warfarin dose requirement.
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