The American journal of medicine
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To understand the pathophysiology of thyroid heart disease, it is necessary to recognize that thyroid hormone has effects on both the peripheral circulation and the myocardium. One of the earliest responses to thyroid hormone administration is a decline in systemic vascular resistance and an increase in cardiac output and cardiac contractility. In many ways, this response is similar to the cardiovascular response to exercise and is associated with increased left ventricular work. ⋯ Thyroid hormone also plays an important role in the regulation of blood pressure. Diastolic hypertension is a common accompaniment of hypothyroidism. By understanding the mechanisms by which thyroid hormone affects both the peripheral circulation as well as the myocardium, it is possible to predict the clinical response to the treatment of various thyroid disease states.
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For 40 years, disulfiram has been the alcohol-aversive drug used most frequently by American physicians in the treatment of alcohol dependency disorders. We reviewed the clinical literature regarding the risks, benefits, indications, and efficacy of this controversial drug and summarized current knowledge of this therapy. ⋯ Disulfiram will produce an aversive reaction with ethanol, usually at a dose between 250 mg/day and 500 mg/day, although some patients may not have an aversive reaction at this level. Cardiac, hepatic, and neurologic toxicity can also occur within this dosage range. If disulfiram is to be used, the patient must clearly understand the risks of drinking while taking the drug, and the physician and patient must agree about the need for continued clinical supervision and monitoring for efficacy and side effects. The physician must also recognize that disulfiram is only an adjunctive therapy and that continued support, supervision, and other therapeutic measures are required. Disulfiram is probably effective in reducing the frequency of alcohol consumption in the compliant patient over the short term (e.g., 6 months). Certain subgroups of patients, such as those who are older, those who are more socially stable, and those who are well-motivated, may experience a beneficial effect for longer periods. The drug may be most effective in reducing short-term alcohol consumption when the compliance of the patient is supervised, although consideration of this kind of therapy includes the practical problems of supervising the patient and concerns that the supervising person may be placed in a difficult position. Prescription of disulfiram without accompanying education, counseling, and concomitant alcoholism therapy is not beneficial. Disulfiram has no proven effect on the long-term outcome of alcoholism.
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The risk of overwhelming sepsis in asplenic patients has been recognized increasingly over the past several decades, but the underlying mechanisms are not fully understood, and there is controversy over the true magnitude of risk and the value of specific interventions. Review of recent series indicates that postsplenectomy sepsis is more likely after splenectomy in childhood than after splenectomy in adulthood but may occur after splenectomy at any age. ⋯ Predisposition to pneumococcal sepsis and to other infections reflects the role of the spleen in mechanical filtration of particulate material in the bloodstream, generation of opsonins and other soluble mediators of phagocytosis, and anatomic juxtaposition of different elements of the immune system. Whereas pneumococcal vaccine is indicated in asplenic patients, the value of other interventions requires further evaluation.