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PubMed1991

[Clinical study of renal cell carcinoma as incidental finding].

Reports on renal cell carcinoma (RCC) as an incidental finding have been increasing in recent years as the imaging modalities including ultrasonography (US) and computerized tomography (CT) scan have gained popularity in clinical medicine. Because effective treatment in RCC is only surgical removal of the involved kidney even at present, it is imperative for urologists to find and to diagnose the RCC in early stage. Whether RCC found incidentally is in early stage cancer is not determined at present. To determine if the RCC found incidentally is in early stage cancer and if the survival rate is better than that of the RCC found with symptoms, we undertook the following study. Between December 1972 and March 1990, 65 patients with RCC were registered at the Department of Urology, Teikyo University Hospital. Of 65 patients 20 with RCC as an incidental finding were subjected to this study. 34 patients with RCC found with symptoms including hematuria were subjected to control group. Causes of the diagnosis in 20 patients included workup for non-urological diseases in 11 patients (55.0%), workup for urological disease other than RCC in 5 patients (25.0%) and routine medical checkup in 4 patients (20.0%). First-line imaging modalities for the diagnosis was US in 9 patients (45.0%), DIP in 6 patients (30.0%) and CT in 5 patients (25.0%). Size of the tumor, pathological stage (pT) and grade in these 20 patients were tended to be smaller and lower, respectively, but these results were not significant as compared to those of the control group. Incidence of the remote metastasis, at the time of diagnosis, however, was significantly lesser than that of the control group (p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1991

The ulnar impaction syndrome.

The ulnar impaction syndrome can be defined as the impaction of the ulnar head against the triangular fibrocartilage complex and ulnar carpus resulting in progressive degeneration of those structures. The differential diagnosis in patients who present with ulnar wrist pain and limitation of motion can also include ulnar impingement syndrome and arthrosis or incongruity of the distal radioulnar joint. Structural abnormalities involving the distal radioulnar joint, distal radius, and ulnar carpus must be carefully elucidated prior to developing a treatment plan. When such abnormalities are identified and appropriately addressed, surgical treatment can be expected to be effective in the majority of cases. It is important to remember that in the absence of obvious structural abnormalities, the ulnar impaction syndrome may result from daily activities that result in excessive intermittent loading of the ulnar carpus. In this group of patients, treatment is directed at decreasing ulnar load by shortening the distal ulna in any of several ways. If relative instability of the ulnar ligamentous complex is a factor, then ulnar shortening by recession is the treatment of choice. Malunion of the distal radius resulting in ulnar impaction syndrome is best treated by addressing the deformity; that is, corrective radial osteotomy. Patients who present with a combination of ulnar impaction syndrome along with distal radioulnar joint, abnormalities must have both of these abnormalities addressed at the time of surgery. The matched ulnar resection and the hemiresection interposition arthroplasty are both effective procedures; however, the Suave-Kapandji procedure also can be used to address relative ligamentous laxity at the ulnar aspect of the wrist. The Darrach procedure is presently not recommended as a first-line treatment in these cases; however, when used as a salvage procedure, satisfactory results can be obtained in properly selected patients. Careful preoperative evaluation and planning are therefore the key to successful treatment of the ulnar impaction syndrome.

Biomechanical Phenomena↗

PubMed1991

Nine years' experience with ABMT in 128 patients with Hodgkin's disease: an Italian study group report.

One-hundred, twenty-eight patients with Hodgkin's disease in remission or who had failed a mechlorethamine, vincristine, procarbazine and prednisone (MOPP), a doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) and/or lomustine, etoposide and prednimustine (CEP) regimens have been treated with a high-dose therapy (HDT) containing cyclophosphamide, etoposide, carmustine (CVB) and autologous bone marrow transplantation (ABMT). Forty patients were treated while they were in resistant or progressive disease states using alternating MOPP/ABVD protocol; 15 patients received ABMT in first relapse; 51 patients had a complete remission (CR) with first-line therapy but later relapsed and then received conventional salvage therapy; 16 achieved no response or progression ("resistant relapse" patients) and 35 responded partially or completely ("sensitive-relapse" patients). The other 22 patients received ABMT in remission. Following HDT, 56 patients (52.8%) achieved CR and 23 patients (21.6%) achieved a partial remission for an overall response rate of 74.4%. Sixteen patients failed to respond and died in progressive disease 1 to 10 months (median 6 months) after ABMT. High-dose therapy produced severe toxicity including vomiting (100%), mucositis (75%) and liver enzymes and alkaline phosphatase elevations (51%). There were 10 treatment-related deaths. A multivariate analysis identified poor performance status and resistant-relapse patients as very important adverse risk factors for survival immediately after ABMT. These results, while validating this procedure for inducing remissions in advanced highly-treated patients, at the same time confirm the need of employing this approach in first relapse or in second complete remission after standard therapy and before ABMT or, in first complete remission in very high risk Hodgkin's disease patients. Our experience in 15 very poor prognosis Hodgkin's disease patients transplanted in first CR demonstrated to be much significant.

Adult↗

PubMedDate not supplied

Bacteriology of acute otitis media in adults.

OBJECTIVE: --The objective of this study was to determine the bacteriology of acute otitis media in adults. Although this has frequently been studied in children, no data have recently been reported from adults in the United States. Additionally, information on the prevalence of Haemophilus influenzae as a causative organism in acute otitis media in adults has not been available. DESIGN: --Middle-ear aspirates for cultures were obtained by myringotomy from adults meeting entry criteria. SETTING: --Emergency department, Eye and Ear Hospital of Pittsburgh, Pa. PATIENTS: --Thirty-four patients (volunteer sample) met the eligibility requirements. Exclusion criteria included history of chronic otitis media, recent antibiotic therapy, immunosuppressive illnesses, or prior otologic surgery. INTERVENTION: --Ten days of oral cefuroxime axetil (250 mg) was prescribed. MAIN OUTCOME MEASURES: --Patients were followed closely for at least 6 weeks. Aerobic and anaerobic cultures were incubated and evaluated per the scheduled protocol. RESULTS: --Haemophilus influenzae and Streptococcus pneumoniae were grown on culture of specimens from nine and seven patients (26% and 21%), respectively. Twenty-two percent (2/9) of the H influenzae isolates and the single isolate of Moraxella catarrhalis produced beta-lactamase (9% overall). CONCLUSIONS: --The present results suggest that, as in children, amoxicillin would be an appropriate first-line agent for empiric therapy of acute otitis media in adults. Antimicrobials inactive against H influenzae (eg, penicillin V, cephalexin, erythromycin, or tetracyclines) are not appropriate for initial therapy. Antimicrobials with efficacy against organisms producing beta-lactamase, such as cefuroxime axetil, which was used to treat the study patients, do not appear to be required for routine initial therapy in adults. However, they would be appropriate when an organism producing beta-lactamase is isolated from the middle ear or when a patient fails to improve rapidly on amoxicillin therapy.

Acute Disease↗

PubMed1991

[Contribution of imaging to the study of aortic aneurysms].

All aortic aneurysms require a positive diagnosis, a differential diagnosis and an assessment of extension. Several exploratory methods can be contemplated. In patients with warning symptoms, conventional radiology may point to the diagnosis. The reference method remains retrograde aortography which may be either conventional and seriographic or, better, radiocinematic with orthogonal projections and, if possible, digital. The site and morphology of the aneurysm, and in particular its inner channel are thus demonstrated. Computerized tomography is less invasive and usually of great value, notably for the horizontal, thoracic and abdominal aorta, not only to confirm the diagnosis but also to determine the size of the inner channel, parietal thrombi and aortic walls, as well as relations with nearby structures. Other, totally non-invasive methods are widely utilized to explore aortic aneurysms. These are ultrasonography and its variants (notably Doppler-echocardiography and the transoesophageal route), and magnetic resonance imaging which provides three-dimensional and anatomical views of the vessel. These last two examinations alone usually confirm and outline the aortic aneurysms. They must therefore be utilized as first-line examination, arteriography it is various forms being reserved for emergencies or special cases.

Aorta, Abdominal↗

PubMed1991

[Surgical therapy of urinary incontinence in the male].

From 1973 to 1990 a total of 340 male patients suffering from incontinence of various etiologies were treated by implantation of an artificial urinary sphincter. In 165 patients the sphincter was placed at the bladder neck, while 175 needed an implantation at the bulbous urethra. Because of the better results with regard to continence, we prefer the bladder neck implantation. The youngest patient treated was 12 years old and the oldest, 91. Most of the patients were between 40 and 80 years old. The highest continence rates were achieved in patients with postprostatectomy urinary incontinence. Among those with a bladder neck implant continence was achieved in 93.3% of all cases, while 87.4% of those with an artificial sphincter at the bulbous urethra achieved continence. The mechanical complication rate was low with 7.05%, whereas tissue-related complications occurred in a total of 25.3% of cases. Revision was necessary in 30.9% of cases during the first few years after implantation; it was striking that the incidence of revision fell dramatically 1 year after implantation. This is also true for any second revision, which usually becomes necessary within the first year after the first revision. In total, however, two-thirds of the patients do not require revision during the first 5 years. These data show that the implantation of an artificial sphincter is the safest and most successful method for the treatment of urinary incontinence in the male. This method is superior to all other operative treatments and should be considered the first-line treatment, especially in post-prostatectomy urinary incontinence.

Adolescent↗

PubMed1991

[Ideal treatment of malaria attack: more questions than answers? Experience of a department of infectious diseases].

The number of cases of malaria imported to western Europe from tropical areas is steadily growing, due to the increased number of people traveling to endemic regions and to the spread of Plasmodium strains resistant to chemoprophylaxis. This has prompted the WHO to frequently update its guidelines concerning preventive therapy. We report on 143 consecutive cases of benign attacks of malaria in patients returning primarily from western and central Africa. Plasmodium falciparum was responsible for 80% of the cases. Forty-one percent of the patients had followed their preventive regimen correctly; mefloquine failed in 3 of them. Three early relapses were observed after curative treatment, including 2 patients who had received intravenous quinine for more than 5 days. Because P. falciparum infection is potentially lethal, we suggest that the treatment of malaria attacks be optimized, by systematically dosing serum quinine levels, in order to adjust the administered doses, and, as a first-line therapy, by prescribing a combination of drugs to patients at high risk of resistance.

Adolescent↗

PubMed1991

[Hepatic metastasis of unknown primary site].

In this retrospective study, 91 patients (30%) out of a series of 304 with metastatic cancer of unknown primary site were found to have liver metastases. The liver was the only metastatic site in 28 (31%) cases and was associated with other sites in 63 (69%) cases. Median age was 62 yr in 61 male patients and 59 yr in 30 female patients. Thirty patients were submitted to an extensive investigation in search of the primary tumor, including systematic endoscopies: no primary cancer was found in these patients. In 61 other patients, only symptom-oriented investigations were performed and the primary cancer was found in 11 cases. The histologic type was adenocarcinoma in 71 (78%) cases, undifferentiated in 11 (12%) cases, epidermoid in 5 (6%) cases and determined by cytology alone in 4 cases. The median survival was 4 months in patients with metastases in the liver only, and 5 months in the other patients. This difference was not significant, so prognostic factors such as the Karnofsky index, weight loss, CEA and LDH levels were evaluated in the entire group; these factors do not have significant prognostic value. By contrast, when patients were able to receive chemotherapy, median survival was better (4 months) than without (median survival: 1 month; P = 0.005). In addition, in the case of objective response to chemotherapy, the median survival was 9 months versus 3.5 months for patients without objective response (P = 0.001). Seventy-three out of 91 patients (80%) were treated with chemotherapy regimen; 65 patients were evaluable: the objective response rate was 11 +/- 7% (7/65). Different regimens were used. With a non-toxic combination of fluorouracil, vinblastine and cyclophosphamide, 3 partial responses greater than or equal to 50% out of 43 patients (7 +/- 8%) were obtained. No significant advantage was observed when adriamycin was added to FU (4/13): 31 +/- 25%. Second- or third line chemotherapy regimen due to progression of the disease after the first-line combination provided only one objective response out of 36 patients. According to this retrospective study we recommend that overinvestigation be avoided in patients, with liver metastases of unknown primary site and that these patients be treated with non-toxic drug combinations.

Adenocarcinoma↗

PubMed1991

Amrinone during porcine intraperitoneal sepsis.

Seven Yucatan minipigs with chronic, severe intraperitoneal sepsis were given amrinone i.v. (loading dose of 0.75 mg/kg, followed by continuous infusion of 10, 20, 40, and 80 micrograms/kg/min) during the hyperdynamic phase of sepsis. Hemodynamic variables and oxygen utilization, delivery, and extraction were recorded throughout the study. Pulmonary capillary wedge pressure was kept constant to ensure a fixed ventricular filling pressure. Intravenous amrinone modestly augmented cardiac index without altering heart rate. Mean systemic and pulmonary arterial pressures decreased. Systemic and pulmonary vascular resistance fell significantly (P less than 0.05). Amrinone did not significantly alter oxygen utilization or oxygen extraction, although oxygen delivery increased (P less than .05). During the hyperdynamic phase of sepsis in this animal model, amrinone elicits vasodilatation with a modest improvement in stroke volume index. Consequently, cardiac output and oxygen delivery increased modestly. Because of its vasodilating properties and small salutary effects, amrinone is not an optimal first-line medication for hemodynamic stabilization during hyperdynamic sepsis.

Amrinone↗

PubMed1991

Tuberculosis in patients infected with the human immunodeficiency virus.

A retrospective study of tuberculosis was undertaken among 125 patients infected with human immunodeficiency virus (HIV) who attended our regional infectious disease unit between 1986 and 1989. Nine TB-positive patients (five English, three Africans, one Indian) were identified. In three patients who presented with pyrexia of unknown origin and no objective evidence of any organ involvement, the diagnosis of TB was established from examination of sputum induced by nebulized hypertonic saline. Four other patients had extrapulmonary disease while another two had only pulmonary manifestations of TB. Chest radiographs from five patients were normal, while the other four showed cavities with consolidation, pleural effusion, miliary opacities and hilar enlargement, respectively. All but two mycobacterial isolates were fully sensitive to standard first-line chemotherapeutic drugs. Response to treatment was rapid and only complicated in one patient. There were no relapses following treatment without maintenance therapy after a mean follow-up of 22.2 months (range 9-48). Three patients died, of causes unrelated to TB. Tuberculosis may occur at any stage of HIV disease and is an important cause of fever in HIV-infected British patients, even when chest radiographs are normal and previous BCG vaccination has been performed.

Adult↗

PubMed1991

Management of malignant ventricular arrhythmias using antitachycardia devices.

Cardioverter defibrillators were implanted in 26 patients at Charleston Area Medical Center for management of cardiac arrest (7 patients), and drug refractory sustained ventricular tachycardia (19 patients). A variety of operative approaches and concomitant surgical procedures were utilized in the implantation of these devices. No operative deaths occurred. A superficial wound infection was the only operative complication. During the follow-up period (9.3 +/- 5 months), 11 of 26 patients (46 percent) had a defibrillator discharge and one death occurred (3 percent), which was due to heart failure. Patients with malignant ventricular arrhythmias may present with sustained monomorphic ventricular tachycardia with associated syncope, pre-syncope or without any associated symptoms. Unfortunately, cardiac arrest may be the initial presentation. The use of antitachycardia devices such as implantable cardioverter defibrillators and antitachycardia pacemakers has allowed physicians to more successfully treat patients with malignant ventricular arrhythmias. In a significant number of patients with these arrhythmias, such devices are now used as first-line therapy.

Adult↗

PubMed1991

Penicillinase-producing Neisseria gonorrhoeae in a subset of nonemergent patients: I. A trend in the Washington, DC area.

A significant increase in penicillinase-producing isolates of Neisseria gonorrhoeae has been detected and documented in the District of Columbia. Currently, the prevalence of beta-lactamase isolates is approaching 50%, with the greatest number of cases being detected in the 18- to 23-year-old age group, in both males and females. Indicators suggest that this trend, which was first noted in 1987, will become more pronounced in the future. Ceftriaxone is now the first-line drug of choice in treating suspected gonococcal infections.

Adolescent↗

PubMed1977

Drug prescribing in rheumatoid arthritis in Otago.

The drug therapy prescribed for a group of 50 patients with rheumatoid arthritis in Otago prior to specialist referral was examined. Thirty-two patients were receiving some first-line anti-inflammatory drugs and six were receiving no therapy at the time of their first hospital clinic visit. Salicylates had been prescribed first in only 16 of the 50 patients while this drug had been withdrawn because of side effects in about one-third of the patients who had been treated with it prior to specialist referral. Seven patients had received phenylbutazone and six corticosteroids as the first treatment for their rheumatoid arthritis. About one-third of the patients were receiving more than one anti-inflammatory drug at the time of their initial clinic visit.

Adult↗

PubMed1979

Bretylium tosylate: a review.

The chemistry, pharmacology, pharmacokinetics, clinical uses, adverse effects, drug interactions and dosage of bretylium tosylate, a recently approved antiarrhythmic agent, are reviewed. Bretylium tosylate is used to treat life-threatening ventricular arrhythmias, principally ventricular fibrillation and ventricular tachycardia, that have not responded to treatment with first-line antiarrhythmic agents. The drug has a direct positive inotropic effect on the myocardium and blocking effect on postganglionic sympathetic nerve transmission. The drug is poorly absorbed orally, requiring either i.m. or i.v. administration. Drug excretion occurs primarily through the kidney, necessitating dosage modification in renal disease. Hypotension is the most commonly observed adverse reaction to bretylium tosylate. Rapid i.v. administration may cause severe nausea and vomiting, and i.m. injection at the same site may cause atrophy and necrosis of muscle tissue. Quinidine and procainamide may potentiate the hypotensive effects of bretylium. Bretylium will aggravate digitalis-induced arrhythmias. Bretylium's use in resistant ventricular tachyarrhythmias requires close clinical monitoring.

Arrhythmias, Cardiac↗

PubMed1979

[Current chemotherapy of pulmonary tuberculosis].

Tuberculosis has today lost much of its dread for mankind: in 1976, 1823 persons contracted tuberculosis and 182 died of pulmonary tuberculosis in Switzerland. In contrast, 1375 died of pneumonia, 1309 of non-specific airway disease and 2202 of bronchial cancer in the same year. The present data on morbidity and mortality in Switzerland resemble those of the other industrial European countries or the USA. The decrease in morbidity and mortality of pulmonary tuberculosis was caused-among other factors-by chemotherapy. Chemotherapy not only profoundly changed the infectivity of tuberculous patients and made ambulatory, domiciliary treatment possible, but cured pulmonary tuberculosis. The introduction of the bactericidal rifampicin led to the latest major landmark in the chemotherapy of tuberculosis in the past 20 years: namely, short-course chemotherapy. Together with the other first-line drugs (isoniazid, streptomycin, ethambutol), rifampicin shortened the duration of chemotherapy from 18--24 to 9--12 months. Short-course chemotherapy is today the therapy of choice for most patients with pulmonary tuberculosis.

BCG Vaccine↗

PubMed2026

[Tics and Tourette Syndrome].

Tics disorders and Tourette syndrome (TS) are neurodevelopmental conditions characterized by motor and/or vocal tics with onset in childhood. Their clinical presentation is heterogeneous and fluctuating over time, with exacerbations related to emotional, environmental, and medical factors. Diagnosis is clinical and based on medical history and neurological examination, following DSM-5-TR criteria, with ancillary testing rarely required. The prevalence of TS is estimated at 0.7%, while transient tic disorders affect up to 10% of children. The natural history is generally favorable, with symptom improvement during adolescence, although a subset of patients continues to experience tics into adulthood. Most individuals with TS present psychiatric comorbidities, particularly attention-deficit/hyperactivity disorder and obsessive-compulsive disorder, which significantly impact quality of life and should be prioritized in management decisions. Treatment is recommended only when tics cause functional impairment and follows a stepwise approach including psychoeducation, behavioral interventions, and individualized pharmacological therapy. Comprehensive behavioral intervention for tics is considered first-line treatment when available. Alpha-2 adrenergic agonists and dopamine antagonists are the most commonly used pharmacological options. Neuromodulation therapies are reserved for severe, refractory cases. These recommendations from the Ibero-American Academy of Pediatric Neurology summarize current evidence and provide a practical, updated framework for the diagnosis and management of tic disorders and Tourette syndrome in pediatric patients.

Humans↗

PubMed1978

Rheumatoid arthritis.

Management should help relieve symptoms, increase or maintain function, produce few side effects and keep the cost to a minimum. Aspirin remains the first-line drug; other nonsteroidal anti-inflammatory drugs may be useful when aspirin cannot be tolerated. Symptoms and signs of rheumatoid disease may be suppressed by corticosteroids, but only gold compounds, penicillamine and cytotoxic therapy have been shown to decrease disease activity and lessen permanent joint damage.

Adrenal Cortex Hormones↗

PubMed1976

Role of DTIC (NSC-45388) in the chemotherapy of sarcomas.

DTIC was one of the first of several new agents evaluated by the Southwest Oncology Group (SWOG) and the M.D. Anderson Hospital and Tumor Institute (MDAH) in the therapy of adult patients with metastatic sarcomas. It yielded an overall response rate of 17%. This is similar to that seen in a review of 138 patients who represent the total number reported in either published or unpublished data. The subsequent addition of DTIC to adriamycin in several studies carried out at the MDAH and in the SWOG has increased the complete and partial remission rate over that seen with adriamycin alone, and more importantly has increased remission duration and survival. DTIC is currently used in combination with adriamycin in the first-line therapy of patients with metastatic sarcomas and should be considered for patients who have relapsed on primary therapy not including DTIC.

Clinical Trials as Topic↗