Biomedical subjects
R Israel
Publications and source records attributed to R Israel.
Problems with gait in older persons.
Gait problems are frequently encountered in elderly patients. Assessment can be made with tests that do not require complex equipment or excessive amounts of time. Most gait disorders result from the interplay of many factors but can respond to medical management, physical therapy, gait training, and correct use of adaptive devices.
Gallium nitrate for acute treatment of cancer-related hypercalcemia. A randomized, double-blind comparison to calcitonin.
STUDY OBJECTIVE: To determine whether gallium nitrate therapy is superior to maximally approved doses of calcitonin for acute control of cancer-related hypercalcemia. DESIGN: Randomized, double-blind comparison of active treatments. SETTING: Comprehensive cancer center. PATIENTS: One hundred ninety-eight consecutive hypercalcemic events in 164 patients screened for entry. ELIGIBILITY CRITERIA: hospitalization and intravenous hydration for at least 2 days; persistent elevated serum calcium levels of 2.99 mmol/L or greater (adjusted for serum albumin); serum creatinine levels of 221 mumol/L or less; no cytotoxic chemotherapy, radiation, or mithramycin within the preceding 7 days or during study; no concurrent use of aminoglycoside antibiotics; life expectancy greater than 4 weeks; lymphoma and parathyroid carcinoma excluded. Patients were stratified by histologic type of tumor (epidermoid or nonepidermoid). Fifty patients were randomized and treated. INTERVENTIONS: Gallium nitrate 200 mg/m2 body surface area for 5 days by continuous intravenous infusion, or salmon calcitonin 8 IU/kg body weight every 6 hours for 5 days by intramuscular injection. Patients randomized to receive gallium nitrate received sham injections of saline to simulate calcitonin; patients randomized to receive calcitonin received 1000 mL 5%-dextrose solution to simulate gallium nitrate. MEASUREMENTS AND MAIN RESULTS: All patients were evaluable. Eighteen of twenty-four patients who received gallium nitrate achieved normocalcemia compared with 8 of 26 patients who received calcitonin for an observed difference of 44% (95% confidence interval, 19% to 69%; P = 0.002). Median duration of normocalcemia before other cytotoxic or hypocalcemic therapy was 6 days for patients treated with gallium nitrate compared with 1 day for patients treated with calcitonin (P less than 0.001). Median duration of normocalcemia regardless of intercurrent treatment and without adjustment for serum albumin was 11+ days for patients treated with gallium nitrate and 2 days for patients treated with calcitonin (P less than 0.01). Mean daily fluid intake and mean daily dose of furosemide were similar in both treatment groups. No additional benefit was seen in 9 patients randomized to receive calcitonin who incidentally received corticosteroids. CONCLUSIONS: Gallium nitrate therapy is highly effective and superior to maximally approved doses of calcitonin for acute control of cancer-related hypercalcemia.
Hysteroscopic management of recurrent abortion caused by septate uterus.
Between April 1982 and April 1986, 91 patients underwent hysteroscopy for treatment of septate uteri. In 88 patients simultaneous laparoscopy was performed and one patient had a simultaneous laparotomy. Ninety procedures were performed on an outpatient basis with the patients under general anesthesia. The septum was incised with flexible scissors. Sequential estrogen-gestagen therapy was used immediately after operation to reepithelialize the freshly dissected surfaces. Patients were permitted to conceive in the first month after operation. The indications for hysteroscopy were multiple but included recurrent abortion in 79 patients. Among those patients in this category the pretreatment reproductive wastage was 95%. Most losses were in the first trimester. Among those patients who conceived after therapy, the gestational outcome markedly improved. Eighty-seven percent of the pregnancies have resulted in a living infant or have progressed beyond 20 weeks of gestation. Because the gestational outcome equals or exceeds that achieved by transabdominal metroplasty and because of its lower morbidity and the option for vaginal delivery, hysteroscopic incision of the symptomatic septate uterus should replace transabdominal metroplasty.
Monitoring techniques to predict and detect ovulation.
This study was designed to evaluate the accuracy of various methods in predicting and detecting ovulation in 14 spontaneous and 17 clomiphene citrate (CC)-induced cycles. From cycle day 11 all subjects (n = 27) were followed with daily transvaginal ultrasound; rapid measurement of serum luteinizing hormone (LH) and estradiol (E2); determination of urinary LH with First Response (Tambrands Inc., Palmer, MA) and Ovustick (Monoclonal Antibodies, Inc., Mountain View, CA) kits; and recording of basal body temperature (BBT). The results demonstrated that transvaginal ultrasound detected ovulation in all cycles. Mean daily serum LH levels were similar in both groups, and peak values of 40 mIU/ml or greater preceded the day of ovulation in all cycles. Serum E2 peak was significantly greater in CC cycles (961 +/- 96 versus 463 +/- 39 pg/ml) (P less than 0.01) and preceded the LH peak in 97% of the cycles. First Response and Ovustick predicted ovulation in 53.3% and 87.5% of the cycles, respectively (P less than 0.01). BBT nadir predicted the day of ovulation in only 10% of cycles. In conclusion, this study revealed that transvaginal ultrasound is an excellent method for detection of ovulation and that Ovustick is a very useful method for prediction of the day of ovulation.
Metoclopramide decreases renal plasma flow.
Intravenous dopamine has been shown to increase renal plasma flow in man. The role of endogenous dopamine in the maintenance of renal plasma flow has not been described. We speculated that if endogenous dopamine activity is important in the maintenance of renal plasma flow, then high doses of a potent dopamine blocking drug such as metoclopramide would decrease renal flow. To test this hypothesis, we measured renal plasma flow using a single-injection technique with 131I-labeled orthoiodohippurate. Measurements were made before and after the administration of high doses of metoclopramide (1 to 2.5 mg/kg) to 20 patients receiving metoclopramide as an antiemetic before chemotherapy. Seven control subjects underwent sequential measurements of renal plasma flow without intervening metoclopramide dosing. Mean (+/- SD) renal plasma flow did not change in the control population (from 441 +/- 198 to 437 +/- 117 ml/min), but declined significantly in the patients who received metoclopramide (443 +/- 115 ml/min before metoclopramide and 387 +/- 137 ml/min after metoclopramide; P less than 0.001). In 25% of our study population the decline in renal plasma flow was greater than 20% below baseline levels. The magnitude of the effect did not appear to correlate with the pretreatment creatinine clearance, age, or sex of the patients. We conclude that high doses of metoclopramide decrease renal plasma flow in man. These data suggest a role for dopamine in the maintenance of renal plasma flow in patients receiving intravenous hydration. Changes of the magnitude we observed may well be of clinical importance. These findings therefore also suggest the possibility of metoclopramide potentiation of cisplatin nephrotoxicity.
The hospital environment and infant feeding: results from a five country study.
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Galactorrhea and pituitary tumors in postpill and non-postpill secondary amenorrhea.
One hundred sixty-seven women with secondary amenorrhea were observed from six months to four years. In 66 patients, the amenorrhea followed the discontinuation of oral contraceptives (postpill) while in the remaining 101 the amenorrhea was not temporally pill related (non-postpill). Galactorrhea was present in 43 (65%) of those with postpill amenorrhea and in 32 (32%) of those with non-postpill amenorrhea (p less than 0.001). Tomography of the sella turcica was performed in the 75 women with galactorrhea and in the 35 without galactorrhea who did not have withdrawal uterine bleeding following progesterone administration and who had low or normal serum follicle-stimulating hormone levels (hypothalamic-pituitary failure). Forty of the 75 patients with amenorrhea and galactorrhea had radiographic evidence of a pituitary tumor whereas only eight of 35 patients with hypothalamic-pituitary failure without galactorrhea had an abnormal sella turcica (p less than 0.01). The incidence of radiographic abnormalities in those with galactorrhea was similar in both the postpill and non-postpill groups.
Hysteroscopic management of intrauterine adhesions.
Sixty-six patients who had the presumptive diagnosis of Asherman's syndrome underwent hysteroscopic evaluation and treatment. In 65 patients, hysteroscopy was performed on an outpatient basis under local anesthesia. In all but five patients, complete lysis of adhesions was accomplished during the initial hysteroscopy. Uterine perforation occurred in two of the 66 patients. The extent of the intrauterine adhesions correlated with the patients' presenting menstrual patterns, but not with prior hysterosalpingography. Of the patients who have completed surgical and hormonal therapy, 98 per cent have normal spontaneous menses. Follow-up examination of the endometrial cavity was normal in 32 of 34 patients. Seven of ten patients who wished to conceive and who had no other infertility factors have done so. The pregnancies have been uncomplicated. Hysteroscopy is the method of choice to diagnose, classify, treat, and follow-up patients with Asherman's syndrome.
Recovery of midcycle human follicular oocytes: correlation of their morphology with endomethrial and follicular histology.
The ovarian follicles of 23 of 33 women undergoing elective pelvic laparotomy during menstrual cycle days 11 to 17 were aspirated by a low-vacuum device. The study compared the ovulatory status of women in midcycle with the health of the oocytes obtained, and determined the frequency of recovery of mature oocytes without the preadministration of exogenous hormones. Maturing or mature oocytes were obtained from 22% and nonmature oocytes from 48% of the 23 women. Sixty per cent of the women in each of the maturing or mature and nonmature groups were postovulatory as judged by evaluation of the endometrial and ovarian tissue recovered. Furthermore, 20% of the maturing or mature oocytes and 65% of the nonmature oocytes showed a moderately heavy amount of cytoplasmic degeneration, which was independent of ovulatory status. Therefore, it is concluded that, because of the relatively low rate of return of oocytes, the frequent postovulatory status of patients in midcycle, and uncertainty about the viability of the oocytes so obtained, women not stimulated by exogenous hormones are ill-suited for recovery of maturing or mature follicular oocytes for in vitro fertilization studies.
Bowel obstruction and perforation with an intraperitoneal loop intrauterine contraceptive device.
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Unilateral tuboovarian abscess: a distinct entity.
In a 30 month interval at the Los Angeles County-University of Southern California Medical Center, 85 patients had tuboovarian abscesses removed that were unrelated to complications of pregnancy. Thirty-seven patients (44 per cent) of the 85 had unilateral abscesses. Twenty patients (54 per cent) of the 37 patients with a unilateral abscess were using an intrauterine contraceptive device (IUD). In 13 (65 per cent) of the 20 women using an IUD, the foreign body was a Dalkon Shield. Unilateral pelvic abscesses can occur with or without the presence of an IUD.
Diagnostic laparoscopy: a prognostic aid in the surgical management of infertility.
Laparoscopy was utilized as the final step in the infertility investigation of 155 indigent patients. Unnecessary laparotomy was avoided in 72 (46 per cent) of these patients. Depending upon the endoscopic findings, the presence of additional infertility factor(s) either positively or negatively affected prognosis. With the same anesthetic, 83 (54 per cent) of the 155 patients underwent conservative infertility operations. Unless even greater selectivity can be achieved by prior diagnostic laparoscopy, the postoperative term pregnancy rate (11 per cent) does not justify infertility operations in a population prone to pelvic inflammatory disease, particularly in those individuals with other infertility factors.
Rectovaginal endometriosis: an isolated enigma.
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Pregnancy following 29 cycles of clomiphene citrate therapy: a case report.
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A comparison of steerable and rigid hysteroscopy for uterine visualization and cannulation of tubal ostia.
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Male pseudohermaphroditism consistent with 17,20-desmolase deficiency.
A 16-year-old phenotypic female with XY genotype presented an unusual form of nonfamilial male pseudohermaphroditism. Seemingly a normal girl during childhood, the patient failed to undergo pubertal changes presenting with scant pubic hair, absent axillary hair, lack of breast development, retarded bone age and primary amenorrhea. Neither uterus nor adnexa were palpable above the blind-ending vagina. Serum testosterone and estradiol were barely detectable by radioimmunoassay, while LH and FSH reached castrate levels. Two small testes were removed from the pelvic sidewalls which, on biopsy, showed atrophy and hyalinization of seminiferous tubules, but clusters of Leydig cells without signs of hypertrophy or hyperplasia. Administration of testosterone resulted in urinary nitrogen retention and a decrease in serum LH and FSH. Radioimmunoassay of various serum or plasma steroids and gas chromatographic determination of urinary steroids prior to and following ACTH stimulation yielded results which permitted to rule out 20,22-desmolase, 3beta-hydroxysteroid dehydrogenase, 17-hydroxylase and 17beta-hydroxysteroid dehydrogenase deficiency. Low plasma dehydroepiandrosterone sulfate (DHEA-S) and androstenedione (delta4 A) concentrations, low urinary 17-ketosteroid and particularly low dehydroepiandrosterone (DHEA) excretion and the minimal rise of plasma DHEA-S and delta4 A and of urinary DHEA in response to ACTH in conjunction with a normal response of other serum and urinary C-21 steroids are consistent with 17,20-desmolase deficiency. Direct confirmation of this defect, however, seems impossible in the absence of in vitro studies of testicular steroidogenesis.
Intrauterine adhesions secondary to elective abortion. Hysteroscopic diagnosis and management.
Ten patients who developed Asherman's syndrome following elective first trimester abortion underwent outpatient hysteroscopy under local anesthesia. Six of the 10 patients had hysterosalpingograms prior to surgery. Correlation between the radiographic findings and those at hysteroscopy was poor. Treatment consisted of hysteroscopic lysis of adhesions, placement of an IUD or Foley catheter, and sequential estrogen-progestin administration. Normal menses were resumed in all women. Hysteroscopy was also used for followup in 4 patients. Outpatient hysteroscopy under local anesthesia is safe and is the method of choice for diagnosing, treating, and following patients with Asherman's syndrome.