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Standard bone films generally show demineralization within 2-3 weeks of infection onset (ure 11 order viagra sublingual 100mg free shipping losartan causes erectile dysfunction. On X-ray generic viagra sublingual 100 mg with mastercard erectile dysfunction specialist doctor, a loss of 50% of the bone calcium is generally required before demineralization can be detected generic 100 mg viagra sublingual overnight delivery erectile dysfunction treatment supplements, which explains the low sensitivity early in the course of infection. Arrowheads outline the expected location of the medial margin of the proximal phalangeal bone. Multifocal areas of cortical destruction and ill- defined lytic areas are found throughout the distal first metatarsal and both first-toe phalanges. Acosta, University of Florida Medical School) In long-bone infections, periosteal elevation may develop in addition to areas of reduced calcium (lytic lesions), and soft tissue swelling is apparent. Later in the infection (and in chronic osteomyelitis), areas of increased calcification or bone sclerosis are also seen. In vertebral osteomyelitis, early plain radiographs may reveal no abnormalities, and obvious changes may not develop for 6–8 weeks. At this time, the bone plate of the vertebra becomes eroded and appears irregular or “moth-eaten. Sagittal computed tomography scan showing typical changes of vertebral osteomyelitis. Obliteration of the disc space is seen, together with marked irregularity and sclerosis of the cortical endplates. Acosta, University of Florida Medical School) One critical finding helps to distinguish the latter two diseases. In osteomyelitis, infection almost always involves two adjacent vertebral bodies and the disc space. Most neoplastic processes involve a single vertebral body and do not extend across the disk space. This diagnostic tool very effectively guides the orthopedic surgeon and allows for a more complete surgical debridement of a sequestrum. Decreased signal intensity of the disc and infected vertebral bodies is observed on T2-weighted images, and loss of endplate definition noted on T-1 images. Left: A T2 image shows increased signal in the bone marrow of the metatarsal and the surrounding soft tissue. Right: A T1 post- contrast image shows loss of the bone marrow fat signal and cortical margins in the metatarsal. Three-phase technetium bone scan is sensitive, but produces false positive results in patients with fractures or overlying soft tissue infection. False negative results are occasionally observed in early infection or when bone infarction accompanies osteomyelitis. Gallium imaging is more specific and sensitive in cases of vertebral osteomyelitis, and demonstrates intense uptake in the disc space and adjacent vertebral bodies. To define the microbiology, two to three blood samples for culture should be drawn during the acute presentation, and in hematogenous osteomyelitis they are positive nearly 50% of the time. If blood cultures are negative, a deep-tissue sample should be obtained for aerobic and anaerobic culture (and for fungal and mycobacterial culture, if appropriate), Gram stain, and histopathologic examination. Simple needle aspiration or a swabbed sample of the periosteum does not correlate with bone biopsy cultures, and should not be relied upon to guide antibiotic therapy. Children are often treated empirically, because any operative intervention near the epiphyseal plate can result in impaired bone growth. In the occasional adult with long-bone infection, debridement or incision and drainage of soft tissue abscesses (or both) are usually required, and these procedures also allow for acquisition of deep-tissue samples for culture. Plain films require 2-3 weeks to become positive (50% loss of bone calcium required); in vertebral osteomyelitis, bone loss can take 6-8 weeks. Radiographs may show a) periosteal elevation, b) areas of demineralization and loss of a sharp bony margin (“moth- eaten” look), c) soft tissue swelling, and d) late-stage areas of increased calcification or sclerosis. Tissue sample for culture (87% positive) and histopathology should be obtained, except when blood cultures are positive. In vertebral osteomyelitis, the number of potential pathogens is large, and effective antimicrobial therapy needs to be guided by culture results. Needle aspirates should be submitted in parallel for bacteriologic and pathologic evaluation. Pathology is particularly useful in patients with previous antibiotic therapy, in which cultures may be negative, and in patients with suspected mycobacterial or fungal disease. In patients in whom the second sample fails to establish a diagnosis, the physician is faced with a choice: begin empiric therapy or request an open surgical biopsy for diagnosis. Treatment In long-bone infections, parenteral administration of an antimicrobial regimen may be begun as empiric therapy aimed at the clinically suspected pathogen or pathogens. Once the microorganisms are isolated, in vitro susceptibility testing can be performed as a guide to treatment. Treatment usually continues for 6 weeks: a) Staphylococcus aureus, methicillin-sensitive: nafcillin or oxacillin; methicillin-resistant: vancomycin. May be required a) to remove necrotic long bone; b) in vertebral osteomyelitis to treat instability, cord compression, drainage of soft tissue abscess. The optimal duration of antibiotic therapy has not been studied; however, most experts recommend a minimum of 6 weeks (see Table 11. The start of therapy must be dated from the day on which effective antimicrobial therapy, as judged by in vitro susceptibility, was begun based on cultures of the last major debridement. Antibiotic Treatment of Osteomyelitis in Adults Empiric coverage of vertebral osteomyelitis is generally not recommended. The choice of an antimicrobial drug should be guided by the results of blood cultures and of bone and soft tissue specimens obtained by biopsy or debridement before treatment. For patients who traveled to endemic areas, Brucella serology may occasionally be useful. Depending on pharmacologic characteristics, the selected drug may be administered by the oral or the parenteral route. The indications for surgery in vertebral osteomyelitis are failure of medical management, formation of soft tissue abscesses, impending instability, or neurologic signs indicating spinal cord compression. In the latter case, surgery becomes an emergency procedure (see the discussion of spinal epidural abscess in Chapter 6). The neurologic status of the patient must therefore be monitored at frequent intervals. Following initial corrective surgery, pain improves, and the patient progressively mobilizes the injured limb. A mild fever is noted, and the wound becomes more erythematous, accompanied by a slight discharge. No other clinical signs point toward the diagnosis of osteomyelitis, and no radiographic examination or other imaging procedure is fully diagnostic. Acute purulent frontal sinusitis spreading to the frontal bone and causing edema of the forehead (Pott’s puffy tumor).

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Effects of treadmill exercise on dopa- minergic transmission in the 1-methyl-4-phenyl-1 generic viagra sublingual 100 mg with amex erectile dysfunction statistics australia,2 buy viagra sublingual with a mastercard erectile dysfunction diabetes pathophysiology,3 viagra sublingual 100 mg discount female erectile dysfunction drugs,6-tetrahydropyridine-lesioned mouse model of basal ganglia injury. Profle of functional limitations and task performance among people with early- and middle-stage Parkinson’s disease. Balance and falls in Parkinson’s dis- ease: a meta-analysis of the effect of exercise and motor training. A randomized controlled trial of movement strategies compared with exercise for people with Parkinson’s disease. Effcacy of a physical therapy program in patients with Parkinson’s disease: a randomized controlled trial. A comprehensive approach to evidence-based rehabilitation of patients with Parkinson’s disease across the continuum of disability. The effectiveness of occupational therapy-related treat- ments for persons with Parkinson’s disease: a meta-analytic review. The evaluation and treatment of motor speech disorders (ie, dysarthria and apraxia of speech [AoS]) and of oropharyngeal dysphagia are typically performed by speech–language pathologists. These evaluations and treatments can accomplish the following: ▪ Determine whether speech and swallowing are affected ▪ Determine the severity of speech and swallowing involvement and the patient’s prognosis ▪ Assist in the formulation of a treatment plan ▪ Improve the patient’s functioning and quality of life ▪ Assist the medical team in making the differential diagnosis This chapter summarizes the procedures that speech–language pathologists use to evaluate speech and swallowing. The Mayo classifcation system of motor speech disorders is introduced, with an emphasis on its relevance for physicians and other health care providers. This classifcation system, now known as the Mayo system, is based on several premises: ○ Speech disorders can be categorized into different types. However, regardless of the medical or speech diagnosis, certain therapeutic principles apply: ○ Treatment should be aimed at maximizing intelligibility and naturalness. Therefore, the most common methods are discussed next, and this list is referenced in subsequent sections. Specifc treatment approaches with application to particular patient populations follow later in this chapter. This most often occurs in the presence of dyskinesia, particu- larly after prolonged levodopa therapy. Although speech perfor- mance may be improved in some patients after surgery, this is not considered an expected outcome. A description of the perceptual features of the following types of dysarthria may be found in Appendix B. Therapy may focus on techniques such as natural speech with supportive partners, alphabet boards, calendars and mem- ory aids, making choices, yes–no questions, and conversation starters. See Appendix B for a description of the perceptual features of the hyperkinetic dysarthria associ- ated with dystonia. Adductor spasmodic dysphonia, the most common type, results in a strained, strangled vocal quality, whereas abductor spasmodic dysphonia pres- ents with a voice that is intermittently breathy or aphonic. When coupled with blepharospasm, this condition is often known as Meige syndrome or Brueghel syndrome. Coordination of respiration with swallowing may be more diffcult in patients with respiratory involvement. Most frequent swallowing abnor- malities include a delay in swallow initiation and vallecular residue. In a series of unselected patients, 90% presented with swallowing abnormalities, which included premature spillage of the bolus and vallecular residue. Appropri- ate treatments for patients who have hyperkinetic dysarthria associated with other etiologies may include postural adjustments and the use of a bite block. Sensorische behandlung oropharyngealer dysphagien bei erwachsenen [Sensory therapies for oroharyngeal dysphagia in adults]. Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex. Intensive speech treatment for patients with Parkinson’s disease: short- and long-term comparison of two techniques. Voice treatment for patients with Parkinson’s disease: development of an approach and preliminary effcacy data. The effects of expiratory muscle strength training program on pharyngeal swallowing in patients with idiopathic Par- kinson’s disease. Videofuoroscopic and manometric evaluation of swallowing function in patients with multiple system atrophy. The place of perceptual analysis of dysarthria in the differential diagnosis of corticobasal degeneration and Parkinson’s disease. Pick complex: an integrative approach to frontotemporal dementia: pri- mary progressive aphasia, corticobasal degeneration, and progressive supranuclear palsy. Slowly progressive anarthria with late anterior opercular syndrome: a variant form of frontal cortical atrophy syndromes. Augmentative and Alternative Communication: Man- agement of Severe Communication Disorders in Children and Adults. Expiratory muscle strength training in the treatment of mixed dysarthria in a patient with Lance Adams syndrome. Videofuorographic observations on swal- lowing in patients with dysphagia due to neurodegenerative diseases. Involvement of respiratory muscles in adult-onset dystonia: a clinical and electrophysiological study. Laryngeal dystonia (spasmodic dysphonia): observations of 901 patients and treatment with botulinum toxin. A long beard clings to his chin, giving those who observe him a pronounced feeling of the utmost respect. Except in the winter, when the snow or ice prevents, he slowly takes a short walk in the open air each day. There are several reasons why nutrition is impor- tant in movement disorders: ▪ Nutrition may impact mobility, cognition, and swallowing function. Move- ment disorders, by defnition, result in changes in mobility and may lead to a decreased capacity to perform activities of daily living, such as cooking and shopping. Con- versely, decreased levels of activity may lead to a sedentary lifestyle and obesity, exacerbating the underlying neurological disability. All of the reasons listed above suggest that physicians caring for individuals with movement disorders should be familiar with appropriate nutritional strategies for these patients. The lasing medium is a substance, which, when stimulated by an external energy source, emits a particular wavelength of light. In other words, the lasing medium has properties that allow it to amplify light through an internal process of stimulated emission. For example, a laser containing an alexandrite rod lasing medium will be referred to as a 755 nm alexandrite laser. In addition to the lasing medium, all lasers have an optical cavity surrounding the lasing medium that contains the amplification process, a power supply or “pump” that supplies energy to the lasing medium, and a delivery system such as a fiber optic cable or articulated arm with mirrors that precisely delivers laser energy to the skin. ures 5 and 6 in Key References list lasers used for treatment of photoaged skin including their lasing medium and wavelength. By appropriately selecting laser parameters of wavelength, fluence, pulse width, and spot size, specific lesions can be targeted with maximal efficacy and safety. Short wavelengths penetrate superficially due to greater scattering of the laser beam and longer wavelengths penetrate deeper.

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Emergent pericardiocentesis is indicated for significant hypotension generic 100 mg viagra sublingual free shipping erectile dysfunction vacuum device, and it has been suggested that a pulse pressure of less than 20 mm Hg purchase generic viagra sublingual canada erectile dysfunction caused by stroke, a paradoxic pulse greater than 50% of the pulse pressure buy generic viagra sublingual 100mg on-line erectile dysfunction treatment by acupuncture, or a peripheral venous pressure above 13 mm are other absolute indications for emergent intervention [20]. Because of the high rate of recurrent effusions after a simple pericardiocentesis in patients with tamponade from malignancy, additional therapy is generally indicated. One option is to perform a pericardiostomy (pericardial window) via a surgical approach or a balloon catheter to drain the pericardial fluid. In one retrospective study that compared outcomes of 118 patients undergoing simple pericardiocentesis alone to 18 patients undergoing pericardiocentesis followed by pericardial surgery, the patients in the former group had a recurrence rate of 36% whereas none of the patients in the latter group had recurrence [21]. A recent retrospective multicenter study also suggested that patients had superior outcomes when systemic chemotherapy was combined with a pericardiostomy rather than simple pericardiocentesis or pericardial drainage [22]. Radiation therapy is noninvasive and allows treatment of the majority of the pericardium but carries a theoretical risk of radiation-induced pericarditis. As a single modality, radiation controls pericardial effusion in 67% of cases, with a particularly high success in hematopoietic tumors (93%) [23]. Systemic therapy is generally used only for diseases that are considered to be chemosensitive, such as breast cancer or lymphoma; in these individuals, it prevented recurrence in 73% of treated patients[23]. Instillation of sclerosing agents, radionuclides, and chemotherapy through indwelling catheters has been widely used with the intent to induce nonspecific inflammation with obliteration of the pericardial space or to achieve specific antineoplastic effects. Typically, a catheter is placed into the pericardial sac and drainage continued until output is less than 100 mL per day. Sclerosing agent or chemotherapy is injected into the catheter every 24 to 48 hours until fluid output is less than 25 to 50 mL per day, and the catheter is removed. A review of 20 different studies reported an overall control rate of 82% with common toxicities, including fever, pain, arrhythmias, and occasional cytopenias [23]. A wide variety of agents have been used including tetracycline, doxycycline, minocycline, bleomycin, and talc. However, use of sclerosing agents has not shown a definitive benefit over drainage alone and this technique is used infrequently [24]. Nonrandomized studies suggest that patients with hematologic malignancies and breast cancer have substantially better survival rates if systemic therapy can be instituted [26,27]. The decision to intervene in a patient with malignant cardiac tamponade depends on the patient’s histology and sensitivity to treatment as well as the patient’s condition. Patients for whom treatment of tamponade provides meaningful palliative benefit should be considered for the treatment that is likely to provide durable relief of symptoms with the minimum of morbidity and requirement for hospitalization. The associated pain, neurologic deficits, and dramatically impaired quality of life are serious problems for the patients who develop this condition and by extension, for their families. Early recognition of the signs and symptoms of cord compression may prevent serious compromise in survival and functional capacity. Epidural cord compression is defined by compression of the dural sac and its contents by an extradural tumor mass. Minimum radiologic evidence for compression is indentation of the theca at the level of clinical features, which include pain, weakness, sensory disturbance, or evidence of sphincter dysfunction [28]. Physiology Epidural cord compression by malignancy occurs as a result of metastasis or primary tumor involvement of the vertebral column, paravertebral space, or epidural space. Damage to the cord occurs when the tumor compromises the vertebral venous plexus or compresses neural tissue directly or when compromised bone impinges on the cord. The vertebral body is the most common source of compressive lesions, predominantly in the thoracic (60%), followed by the lumbar (25%) and cervical (15%) regions [30]. Tumor invasion through the intervertebral foramen and cord compression without bone involvement is most often seen with lymphoma, leading to normal plain films and radionuclide scans despite clinical compression. Etiology the most common causes of malignant cord compression are tumors with a propensity for bony metastases, including breast and lung, followed by hematopoietic, gastrointestinal, and genitourinary malignancies [32] (Table 95. Clinical Manifestations the cardinal sign of malignant cord compression is pain, present in 95% of patients at diagnosis. Isolated bowel or bladder dysfunction is rarely the presenting symptom of cord compression; however, 50% to 60% of patients can have bowel or bladder symptoms at the time of diagnosis ranging from urgency to incontinence or retention, which can indicate more severe cord involvement [30]. It has a sensitivity and specificity of 93% and 97% respectively in detection of cord compression [33]. These changes included 21% of patients in whom all paraspinal disease would not have been treated and 5% of those in whom additional levels of true cord compression would not have been treated. On the basis of laboratory studies and a single randomized controlled trial that compared high-dose dexamethasone with radiation to radiation alone, some authors support the use of high- dose dexamethasone, defined as a 96-mg intravenous bolus followed by 96 mg per day tapered over a 2-week period [35]. A reasonable alternative is a moderate dose approach with a 10-mg intravenous loading dose followed by 4 mg every 6 hours tapered over 2 weeks [36], especially in patients who are clinically stable. Ambulatory patients without progressive deficit may forgo steroids altogether during radiotherapy without undue risk [37]. However, a randomized trial published in 2005 compared direct decompressive surgery plus postoperative radiotherapy to radiotherapy alone, demonstrating a statistically significant outcome benefit to the combined approach for patients who had less radiosensitive tumors and only one area of spinal cord compression [38]. Compared with patients who received radiotherapy alone, more patients who underwent surgery were able to walk after treatment (84% vs. First-line radiation therapy remains an important option for patients with radiosensitive tumors, nonsurgical candidates, patients with multiple areas of spinal cord compression, and those who experienced symptoms of total paraplegia for longer than 48 hours at presentation. Because surgical complication rates approach 20%, radiation therapy should generally be used as the first-line intervention in patients over age 65 [39]. In patients with metastatic spinal canal compression, a single fraction of 8 Gy can effectively improve neurologic function and treat pain [40]. The development of paraparesis decreases the ambulation rate to 50%, and patients who are paraplegic at the time of therapy recover ambulation only 10% to 19% of the time after radiation therapy alone [38,41]. In paraplegic patients, outcomes appeared to be better for individuals who were candidates for upfront surgical decompression (62% of patients randomized to combined surgery plus radiation regained the ability to walk compared with 19% of those who received radiation alone), the difference was statistically significant, but the sample size was small (n = 32) [38]. Although hypercalcemia has been associated with nearly all malignancies, it is most frequently associated with multiple myeloma, breast, lung, and kidney cancers. Calcitriol, the active form of vitamin D, enhances gastrointestinal absorption and mobilizes calcium from bone. Circulating vitamin D metabolites may be increased in some lymphomas, enhancing intestinal calcium absorption and causing or exacerbating hypercalcemia [45]. Normal kidneys are capable of filtering and excreting four to five times the normal calcium concentration in the serum to maintain serum calcium homeostasis. Decreased glomerular filtration limits the kidney’s ability to filter and excrete calcium, and proximal tubular calcium and sodium reabsorption increase, leading to further increases in serum calcium concentrations. If the concentration of calcium in the glomerular filtrate exceeds its solubility, calcium may precipitate in the renal tubules, further compromising renal function. The direct osteolytic effect of tumors leads to hypercalcemia in about 20% of cases; and this phenomenon is seen most frequently in breast cancer, multiple myeloma, and lymphomas. Some malignancies are rarely associated with hypercalcemia despite a propensity for widespread metastases, including prostate cancer and small cell lung cancer. Some patients may have significant symptoms with minimally elevated calcium and require therapy, whereas other patients are minimally symptomatic despite long-standing hypercalcemia.

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Intraarterial pressure monitoring is recommended when using norepinephrine because indirect blood pressure measurement is often incorrect in patients with severe vasoconstriction buy viagra sublingual 100 mg without a prescription erectile dysfunction treatment diabetes. In patients with myocardial ischemia or infarction generic 100mg viagra sublingual visa erectile dysfunction statistics nih, the myocardial oxygen requirements are increased by all catecholamines order line viagra sublingual erectile dysfunction vitamin b12, but there is limited evidence to guide vasopressor selection in this population. Its cardiac activity includes potent inotropic and chronotropic effects, both of which will increase the myocardium’s oxygen demand. In addition to bronchodilatation, the arterial beds of the skeletal muscles, kidneys, and gut dilate, resulting in a marked drop in systemic vascular resistance. Cardiac output can be expected to increase markedly unless the increased myocardial oxygen demand results in substantial myocardial ischemia. Systolic blood pressure is usually maintained because of the rise in cardiac output, but the diastolic and mean pressures usually decrease. As a result, coronary perfusion pressure drops at the same time that the myocardial oxygen requirement is increased. This combination can be expected to have deleterious effects in patients with ischemic heart disease, especially during cardiac arrest. The main clinical usefulness of isoproterenol is in its ability to stimulate pacemakers within the heart. If the aortic diastolic pressure is already low, epinephrine is likely to be better tolerated as a stimulus to pacemakers. The infusion rate should be only rapid5 enough to effect an adequate perfusing heart rate (2 to 20 mcg per minute, or 0. Depending on the adequacy of cardiac reserve, a target heart rate as low as 50 to 55 beats per minute may be satisfactory. Precautions in the use of isoproterenol are largely due to the increase in myocardial oxygen requirement, with its potential for provoking ischemia; this effect, coupled with the possibility of dropping the coronary perfusion pressure, makes isoproterenol a dangerous selection in patients with myocardial ischemia. Isoproterenol is usually contraindicated if tachycardia is already present, especially if the arrhythmia may be secondary to digitalis toxicity. If significant hypotension develops with its use, it may be combined with another β-agonist with α-activity. However, switching to dopamine or epinephrine is usually preferable; better yet is the use of pacing for rate control. Dopamine This naturally occurring precursor of norepinephrine has α-, β-, and dopamine-receptor–stimulating activities. The dopamine-receptor activity theoretically dilates renal and mesenteric arterial beds at low doses (1 to 2 mcg per kg per minute), though the clinical relevance of this is unclear [67]. A 200-mg ampule is diluted to 250 or 500 mL in D W or 5%5 dextrose in normal saline for a concentration of 800 or 400 mg per mL. As with all catecholamine infusions, the lowest infusion rate that results in satisfactory perfusion should be the goal of therapy. Tachycardia or ventricular arrhythmias may require reduction in dosage or discontinuation of the drug. If significant hypotension occurs from the dilating activity of dopaminergic or β-active doses, small amounts of an α-active drug may be added. Dobutamine Dobutamine is a potent synthetic β-adrenergic agent that differs from isoproterenol in that tachycardia is less problematic. Dobutamine is indicated primarily for the short-term enhancement of ventricular contractility in the patient with heart failure. It may be used for stabilization of the patient after resuscitation or for the patient with heart failure refractory to other drugs. Although nitroprusside lowers peripheral resistance, dobutamine maintains perfusion by augmenting the cardiac output. A 250-mg vial is dissolved in 10 mL of sterile water and then to 250 or 500 mL D W for a5 concentration of 1. Dobutamine may cause tachycardia, ventricular arrhythmias, myocardial ischemia, and extension of infarction. In high doses, it is a powerful constrictor of smooth muscles and as such has been studied as an adjunctive therapy for cardiac arrest in an attempt to improve perfusion pressures and organ flows. Vasopressin may be especially useful in prolonged cardiac arrest as it remains effective as a vasopressor even in severe acidosis [68]. It may be used as a first-line agent in arrest in lieu of epinephrine or as the second- line agent if the first dose of epinephrine failed to cause a return in pulse. Antiarrhythmic Agents Antiarrhythmic agents have been thought to play an important role in stabilizing the rhythm in many resuscitation situations; however, the data in support of their value are scant. Amiodarone Amiodarone is a benzofuran derivative that is structurally similar to thyroxine and contains a considerable level of iodine. Gastrointestinal absorption is slow; therefore, when given orally, the onset of action is delayed while the drug slowly accumulates in adipose tissue. Amiodarone decreases myocardial contractility and also causes vasodilatation, which counterbalances the decrease in contractility. In a major study of out-of-hospital cardiac arrest due to ventricular arrhythmias refractory to shock, patients were initially treated with either amiodarone (246 patients) or placebo (258 patients). On the basis of this study, amiodarone has been given status as an option for use after defibrillation attempts and epinephrine therapy in refractory ventricular arrhythmias during cardiac arrest. It is also an option for ventricular rate control in rapid atrial arrhythmias in patients with impaired left ventricular function. Supplemental infusions of 150 mg may be given for recurrent or resistant arrhythmias to a total maximum dose of 2 g for 24 hours. Premature ventricular complexes are not unusual in apparently healthy people and most often are benign. If the patient has suffered an acute myocardial infarction and has had ventricular arrhythmias, the infusion is continued for hours to days and tapered slowly. The dosage should be reduced in patients with low cardiac output, congestive failure, hepatic failure, and age older than 70 years because of the decreased liver metabolism of the drug. Toxic manifestations are usually neurologic, and can vary from slurred speech, tinnitus, sleepiness, and dysphoria to localizing neurologic symptoms. Frank seizures may occur with or without preceding neurologic symptoms and may be controlled with short-acting barbiturates or benzodiazepines. Conscious patients should be warned about possible symptoms of neurologic toxicity and asked to report them immediately if they occur. Adenosine may also be used in the diagnosis and treatment of stable and unstable narrow complex tachycardias. Side effects caused by adenosine are transient and may include flushing, dyspnea, bronchoconstriction, and angina-like chest pain (even in the absence of coronary disease). The reentrant tachycardia may recur after the effect of adenosine has dissipated and may require additional doses of adenosine or a longer acting drug, such as verapamil or diltiazem. Theophylline and other methylxanthines, such as theobromine and caffeine, block the receptor responsible for adenosine’s electrophysiologic effect; therefore, higher doses may be required in their presence. Dipyridamole and carbamazepine, on the other hand, potentiate and may prolong the effect of adenosine; therefore, other forms of therapy may be advisable.