By V. Joey. Marymount University. 2019.
It is generally m anifested by subarachnoid hem or- phy (M RA) buy terramycin 250 mg mastercard, A terramycin 250mg free shipping, and spiral com puted tom ography (CT) angiogra- rhage order terramycin once a day, which usually presents as an excruciating headache. In this phy, B, in two different patients, both with ADPKD, show an setting, the first-line diagnostic procedure is CT. M anagem ent asym ptom atic intracranial aneurysm (ICA) on the posterior com - should proceed under neurosurgical guidance. Screening can be achieved by either M RA or spi- com pared with 1. Current indications for screening are present- in ADPKD patients with a fam ily history of ICA. O n the basis of decision analyses (taking into account ICA prevalence, annual of ICA? Screening could also be offered to patients in high-risk occupations and those Brain MR angiography Repeat every who want reassurance. Guidelines for prophylactic treatm ent are the sam e ones used in or spiral CT scan: ICA? Yes Conventional angiography Discuss management with neurosurgeon ADPKD: PRESYM PTOM ATIC DIAGNOSIS ADPKD: ULTRASONOGRAPHIC DIAGNOSTIC CRITERIA Presymptomatic diagnosis Is advisable in families when early management of affected patients would be altered Age Cysts (eg, because of history of intracranial aneurysm) 15–29 2, uni- or bilateral Should be made available to persons at risk who are 18 years or older who request the test 30–59 2 in each kidney Should be preceded by information about the possibility of inconclusive results and ≥60 4 in each kidney the consequences of the diagnosis: If negative, reassurance Minimal number of cysts to establish a diagnosis of ADPKD in PKD1 families at risk. If positive, regular medical follow-up, possible psychological burden, risk of disqualification from employment and insurances FIGURE 9-28 Autosom al-dom inant polycystic kidney disease (ADPKD): ultra- sonographic diagnostic criteria. Presymptomatic diagnosis is aimed at both detect- the absence of cyst before age 30 years does not rule out the diag- ing affected persons (to provide follow-up and genetic counseling) nosis, the false-negative rate being inversely related to age. Until a specific treatment for ADPKD ultrasound diagnosis rem ains equivocal, the next step should be is available, presymptomatic diagnosis in children is not advised either contrast-enhanced CT (m ore sensitive than ultrasonography except in rare families where early-onset disease is typical. Presymp- in the detection of sm all cysts) or gene linkage (see Figure 9-29). A tomatic diagnosis is recommended when a family is planned and sim ilar assessm ent is not yet available for the PKD2 form. Two m arkers flanking the 1 2 Affected PKD1 gene were used. Unknown status les (1 through 6) and the other (p 26. In this family, the haplotype 2a is transmitted with the disease (see affected persons II5, III1, and III3). Thus, IV4 has a 99% chance of being a carrier of the m utated PKD1 gene, whereas her sisters (IV1, IV2, II IV3) have a 99% chance of being disease free. Such analysis requires b b that other affected and unaffected fam ily m em bers (preferably from III 1 2 3 two generations) be available for study. Use of m arkers on both sides of the tested gene is required to lim it potential errors due to 2 3 2 5 4 2 a b b a a a recom bination events. Linkage to PKD1 is to be tested first, as it accounts for about 85% of cases. Transplantation nowadays is considered in any or to immunosuppressants? ADPKD patient with a life expectancy of more than 5 years and No with no contraindications to surgery or im m unosuppression. Pretransplant workup should include abdominal CT, echocardiogra- Pretransplant workup: phy, myocardial stress scintigraphy, and, if needed (see Figure 9-26), Yes Eligibility for transplantation? Pretransplant nephrectomy is advised for patients with a history of renal cyst infection, particularly No if the infections were recent, recurrent, or severe. Very large kidneys Yes Although kidney size is rarely an impediment to peritoneal dialysis, Yes or abdominal hernia? TSC is an auto- som al-dom inant m ultisystem disorder with a m inim al prevalence of 1 in 10,000 [30, 31]. It is characterized by the developm ent of m ul- Finding Frequency, % Age at onset, y tiple ham artom as (benign tum ors com posed of abnorm ally arranged and differentiated tissues) in various organs. The m ost com m on Skin m anifestations are derm atologic (see Fig. Renal involvem ent occurs in 60% of cases and includes Facial angiofibromas 80 5–15 Forehead fibrous plaques 30 ≥5 cysts (see Fig. Retinal involvem ent, occurring in 50% of “Shagreen patches” (lower back) 30 ≥10 cases, is alm ost always asym ptom atic. Liver involvem ent, occurring Periungual fibromas 30 ≥15 in 40% of cases, includes angiom yolipom as and cysts. Involvem ent Central nervous system of other organs is m uch rarer [31, 32]. Cortical tubers 90 Birth Subependymal tumors 90 Birth (may be calcified) focal or generalized seizures 80 0–1 Mental retardation/ 50 0–5 behavioral disorder Kidney Angiomyolipomas 60 Childhood Cysts 30 Childhood Renal cell carcinoma 2 Adulthood Eye Retinal hamartoma 50 Childhood Retinal pigmentary abnormality 10 Childhood Liver (angiomyolipomas, cysts) 40 Childhood Heart (rhabdomyoma) 2 Childhood Lung (lymphangiomyomatosis; 1 ≥20 affects females) B FIGURE 9-32 (see Color Plate) Tuberous sclerosis com plex (TSC): skin involvem ent. Facial angiofibrom as, forehead plaque, A, and ungual fibrom a, B, characteristic of TSC. Previously (and inappropriately) called adenom a sebaceum , facial angiofibrom as are pink to red papules or nodules, often concentrated in the nasolabial folds. Forehead fibrous plaques appear as raised, soft patch- es of red or yellow skin. Ungual fibrom as appear as peri- or subungual pink tum ors; they are found m ore often on the toes than on the fingers and are m ore com m on in fem ales. Other skin lesions include hypomelanotic macules and “shagreen patches” (slightly elevated A patches of brown or pink skin). Brain CT shows several subependymal, periventricular, calcified nodules characteristic of TSC. Subependymal tum ors and cortical tubers are the two characteristic neurologic features of TSC. Calcified nodules are best seen on CT, whereas noncalcified tum ors are best detected by m agnetic resonance im aging. Clinical m anifestations are seizures (including infantile spasm s) occur- ring in 80% of infants, and varying degrees of intellectual disability or behavioral disorder, reported in 50% of children. A B FIGURE 9-34 Tuberous sclerosis com plex (TSC): kidney involvem ent. Contrast- of fat into the tumor, but it is not always possible to distinguish enhanced CT, A, and gadolinium -enhanced T1 weighted m agnetic between AM L and renal cell carcinoma. The main complication of resonance im ages, B, of a 15-year-old wom an with TSC, show AM L is bleeding with subsequent gross hematuria or potentially life- both a large, hypodense, heterogeneous tum or in the right kidney threatening retroperitoneal hemorrhage. O ccasionally, AM L is a benign tum or com posed of atypical blood vessels, polycystic kidneys are the presenting m anifestation of TSC2 in early sm ooth m uscle cells, and fat tissue. W hile single AM L is the m ost childhood: in the absence of renal AM L, the im aging appearance is frequent kidney tum or in the general population, m ultiple and bilat- indistinguishable from ADPKD. Polycystic kidney involvem ent leads eral AM Ls are characteristic of TSC. In TSC, AM Ls develop at a to hypertension and renal failure that reaches end stage before age younger age in fem ales; frequency and size of the tum ors increase 20 years.
It is not clear if certain procedures achieve better outcomes in subgroups of patients order terramycin 250 mg on line, based either on underlying cardiac characteristics or ES-31 duration or type of AF buy cheap terramycin 250 mg on-line. It is also not clear if anticoagulation can be stopped safely after rhythm control has been achieved or the best timing for stopping anticoagulation order cheapest terramycin and terramycin. Although there are numerous drug therapies available for rhythm control of AF, the included RCTs all compared different combinations of drugs, limiting our ability to synthesize results. In addition, most studies of drug therapies reported only outcomes related to rhythm control; fewer reported long-term outcomes or complications related to therapy. Future studies are needed to compare the effectiveness of the most commonly used agents for rhythm control, and future studies are needed to evaluate longer term outcomes, including mortality, heart failure, and quality of life as well as adverse effects, particularly for agents such as amiodarone that are known to have the potential for significant adverse effects. Research Gaps: Rate- Versus Rhythm-Control Therapies While studies have shown that a rate-control strategy is at least as good as a rhythm-control strategy, this may be true only in patients similar to the patients enrolled in the clinical trials— i. Studies that focus on younger patients or patients with more symptomatic AF would be of interest. Also, trials evaluating longer term outcomes tended to include pharmacological agents, particularly for rhythm control. Few studies compared rate-control therapies with procedural-based rhythm-control therapies. These newer procedural-based rhythm-control therapies should be compared with rate-control therapies for longer term outcomes, including mortality, cardiac events, and stroke, as well as for adverse effects. Conclusions In assessing clinical outcomes associated with rate- versus rhythm-control strategies, our review of recent evidence agrees with prior reviews demonstrating little overall difference in outcomes between these two strategic approaches. However, it is important to acknowledge that these studies have focused primarily on a subset of patients with AF (typically older patients with fewer symptoms), and differences between the strategic approaches in other patients are largely unknown. In addition, there is a wide range of options within each strategic approach. Very few studies evaluated the comparative safety and effectiveness of specific rate-control drugs or procedures, especially within specific subgroups of patients who are likely to be encountered in clinical practice (such as those with heart failure). In addition, very few studies were done to assess outcomes associated with strict versus more lenient rate-control targets. The wide variety of rhythm-control drugs and procedures also posed a challenge to quantitative assessments of the comparative safety and effectiveness of these different drugs and procedures. Importantly, the review highlights the need for more data on the effect of these procedures on final outcomes such as mortality, stroke, and cardiovascular hospitalizations. ACC/AHA/ESC 2006 Guidelines for the Quality of life and exercise performance in Management of Patients With Atrial patients in sinus rhythm versus persistent Fibrillation: a report of the American atrial fibrillation: a Veterans Affairs College of Cardiology/American Heart Cooperative Studies Program Substudy. J Association Task Force on Practice Am Coll Cardiol. Guidelines and the European Society of PMID: 16904540. The Guidelines (Writing Committee to Revise impairment of health-related quality of life the 2001 Guidelines for the Management of in patients with intermittent atrial Patients With Atrial Fibrillation): developed fibrillation: implications for the assessment in collaboration with the European Heart of investigational therapy. J Am Coll Rhythm Association and the Heart Rhythm Cardiol. Functional status in rate- versus rhythm- Prevalence of diagnosed atrial fibrillation in control strategies for atrial fibrillation: adults: national implications for rhythm results of the Atrial Fibrillation Follow-Up management and stroke prevention: the Investigation of Rhythm Management AnTicoagulation and Risk Factors in Atrial (AFFIRM) Functional Status Substudy. Hagens VE, Ranchor AV, Van Sonderen E, Prevalence of atrial fibrillation in elderly et al. Effect of rate or rhythm control on subjects (the Cardiovascular Health Study). PMID: natural history of atrial fibrillation: 14736444. Poole-Wilson PA, Swedberg K, Cleland JG, 1991;22(8):983-8. The with chronic heart failure in the Carvedilol Framingham Study. Or Metoprolol European Trial (COMET): 1996;27(10):1760-4. Valsartan reduces the incidence of atrial fibrillation in patients with heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT). Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. ACC/AHA/ESC 2006 Guidelines for the HRS/EHRA/ECAS Expert Consensus Management of Patients With Atrial Statement on Catheter and Surgical Ablation Fibrillation: full text: a report of the of Atrial Fibrillation: recommendations for American College of Cardiology/American personnel, policy, procedures and follow-up. Heart Association Task Force on Practice A report of the Heart Rhythm Society (HRS) Guidelines and the European Society of Task Force on Catheter and Surgical Cardiology Committee for Practice Ablation of Atrial Fibrillation developed in Guidelines (Writing Committee to Revise partnership with the European Heart the 2001 Guidelines for the Management of Rhythm Association (EHRA) and the Patients With Atrial Fibrillation): developed European Cardiac Arrhythmia Society in collaboration with the European Heart (ECAS); in collaboration with the American Rhythm Association and the Heart Rhythm College of Cardiology (ACC), American Society. Heart Association (AHA), and the Society PMID: 16987906. Endorsed and approved by the governing bodies of the 15. Statement on Catheter and Surgical Ablation 2011 ACCF/AHA/HRS Focused Update on of Atrial Fibrillation: recommendations for the Management of Patients With Atrial patient selection, procedural techniques, Fibrillation (Updating the 2006 Guideline): patient management and follow-up, a report of the American College of definitions, endpoints, and research trial Cardiology Foundation/American Heart design: a report of the Heart Rhythm Society Association Task Force on Practice (HRS) Task Force on Catheter and Surgical Guidelines. Van Gelder IC, Groenveld HF, Crijns HJ, et Rhythm Association (EHRA), a registered al. Lenient versus strict rate control in branch of the European Society of patients with atrial fibrillation. N Engl J Cardiology (ESC) and the European Cardiac Med. Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Surgical Maze procedure as a treatment for Management of New Onset Atrial atrial fibrillation: a meta-analysis of Fibrillation. Hopkins University Evidence-based Practice Center under Contract No. Rockville, Cardiac resynchronization therapy reduces MD: Agency for Healthcare Research and left atrial volume and the risk of atrial Quality; January 2001. Implantation Trial with Cardiac Resynchronization Therapy). Effect of cardiac resynchronization on the incidence of atrial fibrillation in patients 27. Management of atrial fibrillation: review of 2006;114(1):18-25. Methods Guide for Effectiveness and echocardiography. AHRQ series paper 5: grading the strength Chapters available at of a body of evidence when comparing www. Evidence-based Practice Center Systematic Effective Health Care Program. PMID: 21463926 ES-35 Introduction Background Definition and Impact of Atrial Fibrillation Atrial fibrillation (AF) is a supraventricular tachyarrhythmia (any tachycardic rhythm originating above the ventricular tissue) and is characterized by uncoordinated atrial activation 1 with consequent deterioration of mechanical function.
Because of such that ionic composition of the body is restored toward increased pore size trusted 250 mg terramycin, high-flux membranes (KUf >20 mL/h/mm Hg) normal during the dialytic procedure buy genuine terramycin on-line. This topic is discussed in are associated with much higher clearances of average to high mol- detail in chapter 2 safe terramycin 250 mg. Because blood Although hemodialysis is effective in removing uremic toxins flow rates over 50 to 100 mL/min result in little or no further and provides adequate control of fluid and electrolyte abnor- increase in the clearance of these molecules, clearance is primarily malities, the procedure does not provide for the endocrine or membrane-limited. In contrast, clearance values for urea are not metabolic functions of the normal kidney. Therefore, the dialy- significantly greater with a high-flux membrane compared with a sis prescription often includes medications such as erythropoi- high-efficiency membrane because the blood flow rate, and not the etin and 1,25(OH)2 vitamin D. The dose of erythropoietin membrane, is the principal determinant of small solute clearance. Vitamin D therapy is often used in patients undergoing membrane is one in which minimal reaction occurs between the dialysis to help limit the severity of secondary hyperparathy- humoral and cellular components of blood as they come into roidism. Dosages usually range from 1 to 2 µg given intra- contact with the surface of the dialyzer. Trea t m e n t FIGURE 6-1 Diffusion Diffusional and convective flux in hem odialysis. Dialysis is a Blood Dialysate process whereby the composition of blood is altered by exposing it to dialysate through a semipermeable membrane. Solutes are transported Urea, 100 mg/dL Urea, 0 mg/dL across this membrane by either diffusional or convective flux. A, In diffusive solute transport, solutes cross the dialysis m em brane in a direction dictated by the concentration gradient established across the m em brane of the hem odialyzer. At a given tem perature, diffusive transport is directly proportional to both the solute concentration gradient across the membrane and the membrane surface area and inversely proportional to m em brane thickness. Bicarbonate, 20 mEq/L Bicarbonate, 35 mEq/L (Continued on next page) A Dialysis membrane The Dialysis Prescription and Urea M odeling 6. Experimental (eg,caffeine, midodrine, ephedrine, phenylephrine, carnitine) The rate of ultrafiltration is determ ined by the m agnitude of this pressure gradient. M ovem ent of water tends to drag solute across the m em brane, a process referred to as convective transport or sol- vent drag. The contribution of convective transport to total solute FIGURE 6-2 transport is only significant for average-to-high m olecular weight The com m on treatm ents for hem odynam ic instability of patients solutes because they tend to have a sm aller diffusive flux. It is im portant to begin by excluding reversible causes associated with hypotension because failure to recognize these abnorm alities can be lethal. Perhaps the m ost com m on rea- son for hem odynam ic instability is an inaccurate setting of the dry weight. O nce these conditions have been dealt with, the use of a high sodium dialysate, sodium m odeling, cool tem perature dialysis, and perhaps the adm inistration of m idodrine m ay be attem pted. All of these m aneuvers are effective in stabilizing blood pressure in dialysis patients. FIGURE 6-3 ACCEPTABLE M ETHODS TO M EASURE Acceptable m ethods to m easure hem odialysis adequacy as recom - HEM ODIALYSIS ADEQUACY* m ended in the Dialysis O utcom es Q uality Initiative (DO Q I) Clinical Practice Guidelines. These guidelines m ay change as new inform ation on the benefit of increasing the dialysis prescription becom es available. For the present, however, they should be con- •Formal urea kinetic modeling (Kt/V) using computational software sidered the m inim um targets. W hen prescribing the blood flow KoA 900 High-efficiency rate for a hem odialysis procedure the following m ust be considered: 300 dialyzer KoA 650 the relationship between the type of dialysis m em brane used, blood flow rate, and clearance rate of a given solute. For a sm all solute KoA 300 Conventional such as urea (m olecular weight, 60) initially a linear relationship 200 dialyzer exists between clearance and blood flow rates. Sm all solutes are therefore said to be flow-lim ited because their clearance is highly 100 flow-dependent. At higher blood flow rates, increases in clearance rates progressively decrease as the characteristics of the dialysis m em brane becom e the lim iting factor. The efficiency of a dialyzer 0 in rem oving urea can be described by a constant referred to as 0 100 200 300 400 KoA, which is determ ined by factors such as surface area, pore Blood flow rate, mL/min size, and m em brane thickness. Use of a high-efficiency m em brane (KoA >600 m L/m in) can result in further increases in urea clearance rates at high blood flow rates. In contrast, at low blood flow rates no significant difference exists in urea clearance between a conventional and a high-efficiency m em brane because blood flow, and not the m em brane, is the prim ary determ inant of clearance. FIGURE 6-5 2000 W ater perm eability of a m em brane and control of volum etric ultrafiltration in hem odialysis. The water perm eability of a dialysis 1800 m em brane can vary considerably and is a function of m em brane thickness and pore size. The water perm eability is indicated by its 1600 ultrafiltration coefficient (KUf). The KUf is defined as the num ber KUf=60 mL/h/mm Hg KUf=4 mL/h/mm Hg of m illiliters of fluid per hour that will be transferred across the 1400 m em brane per m m H g pressure gradient across the m em brane. A high-flux m em brane is characterized by an ultrafiltration coeffi- 1200 cient of over 20 m L/h /m m H g. W ith such a high water perm eabili- ty value a sm all error in setting the transm em brane pressure can 1000 KUf=3 mL/h/mm Hg result in excessively large am ounts of fluid to be rem oved. As a result, use of these m em branes should be restricted to dialysis 800 m achines that have volum etric ultrafiltration controls so that the am ount of ultrafiltration can be precisely controlled. These High-flux dialyzer m em branes have sim ilar clearance values for low m olecular weight Normal kidney solutes such as urea (m olecular weight, 60). In this respect both types of m em branes have sim ilar KoA values (over 600 m L/m in), 150 where KoA is the constant indicating the efficiency of the dialyzer in rem oving urea. As a result of increased pore size, use of high- flux m em branes can lead to significantly greater clearance rates of high m olecular weight solutes. For exam ple, 2-m icroglobulin is not rem oved during dialysis using low-flux m em branes (KUf <10 m L/h/m m H g, where KUf is the ultrafiltration coefficient). W ith som e high-flux m em branes, 400 to 600 m g/wk of 2-m icroglobulin 100 can be rem oved. The clinical significance of enhanced clearance of 2-m icroglobulin and other m iddle m olecules using a high-flux dia- lyzer is currently being studied in a national m ulticenter hem odial- ysis trial. Another consideration in the choice of a dialysis m em brane is whether it is biocompatible. In chronic renal failure some evidence exists to suggest 60 Polymethyl methacrylate that long-term use of biocom patible m em branes m ay be associated with favorable effects on nutrition, infectious risk, and possibly m ortality when com pared with bioincom patible m em branes [5–9]. In the study results shown here, the effect of biocom patibility on 40 renal outcom e in a group of patients with acute renal failure who Cuprophane required hem odialysis was exam ined. Patients received dialysis with a cuprophane m em brane (a bioincom patible m em brane known to 20 activate com plem ent and neutrophils) or a synthetic m em brane m ade of polym ethyl m ethacrylate (a biocom patible m em brane associated with more limited complement and neutrophil activation). As compared with the bioincompatible membrane, those patients treated with the synthetic biocompatible membrane had a significantly shorter duration of renal failure in term s of num ber of treatm ents and duration of dialysis. In the setting of acute renal failure, particularly in patients after transplantation, a biocom patible m em brane m ay be the preferred dialyzer. The clearance of urea also 280 is influenced by the dialysate flow rate.
Similarly generic 250mg terramycin mastercard, pharmacotherapy can reduce the chance of relapse Given the lack of easily experienced positive effects from to clinically significant drinking and increase the chance taking medications for alcoholism order terramycin 250 mg free shipping, it is not surprising that the patient will stay in treatment sufficiently to learn new medication compliance is an important factor in the efficacy behavioral coping skills purchase 250 mg terramycin overnight delivery. For example, in a 12-week, double-blind, naltrexone can act immediately to reduce the severity of a placebo-controlled trial using naltrexone in conjunction slip and a return to hazardous drinking. When combined with addiction counseling, with a total sample of 98 ran with cognitive and behavioral strategies to cope with triggers domized subjects, naltrexone had a modest effect in reduc for relapse, the synergistic effects of the combined approach ing alcohol relapse rates. However, among subjects who can be seen when the naltrexone is stopped, as the patient took at least 80% of their prescribed medication, the relative can now rely on learned skills to avoid and cope with a effectiveness of naltrexone was much improved, as 52% of lapse. CONCLUSION Compliance-Enhancement Techniques The past two decades have shown dramatic changes in the To enhance motivation to remain in treatment and comply understanding of the pharmacology of alcohol. Recent understanding of the ple feedback, developing an empathic therapeutic relation, pharmacology of alcohol has led to the development of new working collaboratively with the patient to develop treat medications that improve treatment outcome and help ment goals, and continuing to assess treatment adherence. Of the new medications, the opiate antagonist the BRENDA approach to historical compliance rates at naltrexone and acamprosate offer the most immediate the Treatment Research Center at the University of Penn promise. For specific populations, serotoninergic medica sylvania (103) suggests that BRENDA can enhance treat- tions, tricyclic antidepressants, and mood stabilizers offer 1456 Neuropsychopharmacology: The Fifth Generation of Progress hope for treatment. A Veterans combinations remains fertile avenues for research. Disulfiram implant: a double-blind pla cebo controlled follow-up on treatment outcome. Alcohol Clin enhancing techniques can be safely and effectively inte Exp Res 1991;15(3):532–536. The delta opioid receptor antagonist ment to a wide range of health care providers. Ultimately, naltrindole attenuates both alcohol and saccharin intake in rats the intensity and/or nature of the behavioral intervention selectively bred for alcohol preference. Psychopharmacology (Berl) may interact with the effects of medication to determine 1995;120(2):177–185. The delta 2-opioid receptor antagonist the ultimate outcome of treatment. Given dramatic reduc naltriben selectively attenuates alcohol intake in rats bred for tions in the availability of intensive treatment, such as inpa alcohol preference. Pharmacol Biochem Behav 1995;52(1): tient rehabilitation, and the fact that few individuals seek 153–159. Effect of mu opioid receptor blockade pharmacotherapies should extend the range of patients who on alcohol intake in rats bred for high alcohol drinking. The delta 2-opioid receptor antagonist naltriben interventions and increase the probability that individuals reduces motivated responding for ethanol. Psychopharmacology with alcohol dependence are identified in primary care set (Berl) 1999;147(1):81–89. The opioid receptor antagonist nalmefene re duces responding maintained by ethanol presentation: preclini cal studies in ethanol-preferring and outbred Wistar rats. Naloxone attenuates voluntary ethanol in- REFERENCES take in rats selectively bred for high ethanol preference. Prevalence and correlates of alcohol use and DSM-IV col Biochem Behav 1990;35(2):385–390. Periodic naltrexone and propensity to take alco Longitudinal Alcohol Epidemiologic Survey. Opiates and alcohol self- Assoc Am Physicians 1999;111(2):109–118. Comparative effectiveness and costs of inpa 841–847. A comparison of the effects of the opioid moderate alcohol withdrawal syndrome [see comments]. N Engl antagonists naltrexone, naltrindole, and beta-funaltrexamine on J Med 1989;320(6):358–365. Meta-analysis of benzodiazepine use in sumption using a limited access procedure in the rat. CMAJ 1999;160(5): Clin Exp Res 1998;22(9):2186–2191. Recommended drug treatment strate ethanol self-administration by naltrexone. 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Effect of naltrexone on alcohol 'high' in col Exp Ther 1995;275(1):518–527. Experience of a 'slip' among alcoholics delta opioid receptors in the brain of the C57BL/6 and DBA/ treated with naltrexone or placebo. Am J Psychiatry 1996;153(2): 2 mice, selected for their differences in voluntary ethanol con 281–283. Ethanol oral self-administration is increased in ethanol intoxication. Am J Psychiatry 1994;151(10): mutant mice with decreased beta-endorphin expression. Naloxone retards the expression of a subjective side effects: a preliminary study. Alcohol Clin Exp Res genetic predisposition toward alcohol drinking. Importance of delta opioid receptors in tor responses to alcohol in heavy drinking subjects.
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