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Preoperative assessment of thyroid nodules: the surgeon's point of view.

A selective approach to patients with thyroid nodules, in order to differentiate between negative findings and uncertain or positive results requiring surgery, has been outlined. Fine needle aspiration biopsy (FNAB) is the most reliable and cost-effective technique currently available to distinguish benign from malignant thyroid disease. In those lesions diagnosed by FNAB as 'follicular lesions', radionuclide scanning, serum calcitonin and CEA determination, color doppler ultrasonography and the response to TSH suppressive therapy may be of assistance. Despite such screening procedures, the majority of follicular lesions remain indeterminate, and surgery is therefore necessary before a correct diagnosis can be made.

Biopsy, Needle↗

Treatment of tremors in complex regional pain syndrome.

A 14-year-old girl presented with Complex Regional Pain Syndrome, Type I (CRPS-1) of the left ankle after a remote history of sprain. Allodynia, pain, temperature and color changes, and swelling were successfully treated with physical therapy, transcutaneous electrical nerve stimulation (TENS), gabapentin, amitriptyline, and tramadol. Five weeks later, she presented with a continuous, involuntary, intermittent coarse tremor of the left foot causing increased pain. The electromyogram showed rhythmic discharges of 3 Hz frequency lasting 20-80 milliseconds in the left tibialis, peroneus and gastrocnemius, suggestive of either basal ganglia or spinal origin. Tremor and pain were controlled with epidural bupivacaine, but the tremor reappeared after discontinuing epidural blockade. Carbidopa/levodopa 25/100 (Sinemet) was started and the tremor disappeared after two days. With continued physical therapy, pain and swelling resolved within two months and carbidopa/levodopa was discontinued after five weeks with no recurrence of the tremor. Our success in the treatment of CRPS-associated tremor in this young girl with carbidopa/levodopa suggests that this patient may have had underlying movement disorder which was unmasked by the peripheral injury.

Adolescent↗

A comparative analysis of the effects of the fixed combination of timolol and dorzolamide versus latanoprost plus timolol on ocular hemodynamics and visual function in patients with primary open-angle glaucoma.

AIMS: The aim of this study was to assess the effects of fixed combination of timolol and dorzolamide and latanoprost plus timolol on retinal, choroidal, and retrobulbar hemodynamics and visual function in primary open-angle glaucoma (OAG) subjects. METHODS: Sixteen (16) OAG patients (age, 63.5 +/- 10.8 years; 9 male) were evaluated in a randomized, crossover, double-blind study design after 4 weeks of treatment of latanoprost with timolol and fixed combination of timolol and dorzolamide. After randomization, 9 right eyes and 7 left eyes were included in the hemodynamic portion of the study. Measurements included: adverse events check, visual acuity, contrast sensitivity, blood pressure, heart rate, intraocular pressure (IOP), and fundus examination. Ocular blood flow was assessed using confocal scanning laser Doppler flowmetry, color Doppler imaging, and scanning laser ophthalmoscopy. RESULTS: Both therapies were effective at lowering IOP, whereas there was no statistically significant difference between latanoprost plus timolol and the fixed combination of timolol and dorzolamide (13.9% and 12.2% reduction, respectively; P = 0.5533). Fixed combination of timolol and dorzolamide significantly increased central retinal artery end diastolic blood flow velocity (P = 0.0168) and lowered resistance to flow (P = 0.0279). Temporal posterior ciliary artery peak systolic and end diastolic velocities were significantly increased with the fixed combination of timolol and dorzolamide (P = 0.0125 and 0.0238, respectively). Latanoprost plus timolol had no significant effects on ocular blood flow during 4 weeks of treatment. There were no statistically significant differences in adverse events, blood pressure, heart rate, visual acuity, contrast sensitivity scanning laser ophthalmoscopy, or Heidelberg Retinal Flowmeter for any treatment period. CONCLUSIONS: Fixed combination of timolol and dorzolamide therapy might increase blood flow in OAG patients while attaining a similar IOP reduction compared to latanoprost plus timolol. Visual function, however, was not different in this short-term comparison between the two treatments.

Adrenergic beta-Antagonists↗

[Carotid body tumors. Apropos a case and a review of the literature].

Chemodectomas are rare tumors arising from paraganglionic cells located at the level of carotid bifurcation. They are usually benign and non functioning, presenting as a slow growing cervical mass. A preoperative diagnosis is mandatory, based on doppler color flow imaging and angiography. Surgery is the only therapy providing total eradication of this tumor. Subadventitial resection is the most established technique, although resection of a large mass may require carotid replacement by interposition graft. Cranial nerve palsy and stroke are the perioperative complications most frequently encountered. The Authors report here a case of carotid body tumor and a review of the literature in order to define clinical characteristics of the tumor and proper diagnostic and therapeutic approaches to this rare neoplasm.

Aged↗

Cervical pregnancy. A case report.

A cervical pregnancy was treated successfully with systemic methotrexate and folic acid. Serial beta-human chorionic gonadotropin levels, color Doppler velocimetry and hysteroscopy were used to monitor therapy. In view of the substantial morbidity associated with this form of ectopic pregnancy, medical management is an option for treatment.

Adult↗

[Follow-up in glaucoma].

The follow-up and management of glaucoma are based on the measurement of IOP, on psychophysical examination, and morphological evaluation of the papilla, the nerve fiber layer, and the chamber angle. Applanation tonometry is still the method of choice for IOP measurement. Disinfection with 70% alcohol protects against AIDS. Air-puff applanation tonometry is not exact enough. Although certain authors would like to define primary open-angle glaucoma solely on the changes of the papilla and visual field, we still cannot do without pressure as an indicator for the presence of glaucoma and the quality of therapy follow-up. Additional psychophysical examinations such as color perception, contrast sensitivity, flicker perimetry, and pattern ERG are not yet perfected for the practice and do not replace computerized threshold perimetry. The later has taken a giant step forward with the new evaluation program. However, in spite of these advancements in perimetry, morphology of the papilla and of the nerve fiber layer has assumed such a central role that it must be included in routine glaucoma follow-up. At present, standardized "hand planimetry" is still superior to scanners and laser ophthalmoscopes.

Fluorescein Angiography↗

[Illegal practice of medical care].

The unlawful practice of medical science is the subject of the following article. Cases from actual practice and fundamental legislation are discussed. Whereas the practice of medical science and healing on legal basis shows a wide spectrum, the illegal one is even much more colorful.

Complementary Therapies↗

Hypothyroid Hashimoto's thyroiditis with scintigraphic and echo-color Doppler features mimicking autonomous adenoma.

We investigated a 48-yr-old woman on L-T4 therapy (100 microg/d) for primary autoimmune hypothyroidism, diagnosed 15 yr earlier, presenting a firm oval lump in the right thyroid lobe and symptoms of mild thyrotoxicosis. Free T4, free T3, TSH, anti-thyroperoxidase, anti-TG and anti-thyroid microsomal antibodies were determined. Thyroid US and color flow Doppler sonography (CFDS), 99mTechnetium (99mTc), radioiodine scintiscan and US guided fine needle aspiration cytology (FNAC) were performed. On L-T4 therapy, thyroid function tests showed subclinical hyperthyroidism with high anti-thyroid antibody titers. Thyroid US and CFDS revealed a voluminous hypoechoic hypervascularized nodule with increased peak systolic velocity (type III pattern) in the right lobe; the extranodular tissue volume was markedly reduced and hypoechoic. The presence of an autonomous functioning nodule associated to Hashimoto's thyroiditis (HT) was suspected, L-T4 therapy was temporary withdrawn, and the patient re-evaluated 2 months later. Off L-T4 therapy, thyroid function tests revealed marked primary hypothyroidism, while thyroid US and CFDS were unchanged. 99mTc thyroid scan showed a focal increased uptake corresponding to the nodule in the right lobe with nearly absent uptake in the remaining thyroid tissue. Only a faint, patchy thyroid distribution of 131I was detected by radioiodine scan, and RAIU was very low. Cytological examination by FNAC revealed normal follicular cells and several lymphocytes. The final diagnosis was therefore hypothyroid HT with pseudo-nodular thyroid tissue of the right lobe. To our knowledge, this is the first report of HT mimicking both scintigraphic and CFDS features of an autonomous functioning nodule.

Adenoma↗

Recent progress in the treatment of portwine staining by argon laser: some observations on the prognostic value of relative spectro-reflectance (RSR) and the histological classification of the lesions.

Over a period of more than three years 1264 patients with a portwine stain have been treated by argon laser. This form of therapy is more effective and worthwhile than the other procedures we have used in the past. The histological classification of the various types of portwine stain and the measurements of Spectro-reflectance (RSR) obtained by the spectrophotometric colour difference meter (Murakami) provide valuable and reliable prognostic criteria for this form of treatment.

Adolescent↗

Color vision tests to identify elevated digoxin levels.

The purpose of this study was to determine the usefulness of color vision screening in identifying patients with elevated digoxin levels (greater than or equal to 2.0 ng/ml). Test-retest color vision measurements were obtained on 56 subjects with elevated digoxin levels and 93 non-digoxin subjects. Two tests, the Ishihara and Sahlgren's Saturation Test (SST), identified digoxin levels of 2.9 ng/ml or more. These tests also yielded a high percentage of improved retest scores among subjects with elevated digoxin levels (greater than or equal to 2.7 ng/ml) of more than 4-days duration and a low percentage of improved retest scores among the non-digoxin group. The Ishihara, SST, and other bedside color vision tests may prove useful in the routine monitoring of patients on digoxin therapy, especially those with a high risk for toxicity.

Adult↗

Old and new controversies in the alternative treatment of attention-deficit hyperactivity disorder.

Use of complementary and alternative medicine (CAM) for treatment of attention-deficit hyperactivity disorder (ADHD) has become widespread in both referral and primary care populations. We review the purported mechanism of action and available evidence for selected CAM therapies for ADHD. Enduring controversies, such as elimination of artificial food additives, colors, and/or preservatives; the effect of sugar on behavior in children; and the use of EEG biofeedback, have been well studied but lack support as effective sole treatments for ADHD. The initial evidence for some emerging CAM therapies, such as essential fatty acid supplementation, yoga, massage, homeopathy, and green outdoor spaces, suggests potential benefits as part of an overall ADHD treatment plan. More rigorously designed studies are needed to evaluate their effectiveness as single therapy for ADHD.

Attention Deficit Disorder with Hyperactivity↗

A clinical study of hair removal using the long-pulsed ruby laser.

BACKGROUND: Laser hair removal is rapidly becoming a widely used modality. Clinical studies are needed to assess these hair removal systems. The long-pulsed ruby laser is one such modality for the removal of unwanted hair. OBJECTIVES: To evaluate the efficacy of the long-pulsed ruby laser (694 nm, 3-msec pulsewidth, 7- or 10-mm spot size) in removing unwanted hair, and to provide treatment guidelines for the proper utilization of this laser system. METHODS: Forty-eight areas of unwanted facial and body hair from 25 patients with blonde, brown, or black hair were treated with the long-pulsed ruby laser at fluences between 10 and 40 J/cm2. Hair regrowth was measured at 4 weeks after the first treatment, 4 weeks after the second treatment, 4 weeks after the third treatment, and 16 weeks after the third treatment by counting the number of terminal hairs compared with baseline pretreatment values. All complications and treatment outcomes were documented. RESULTS: The mean percent of regrowth after the first treatment was 65.5%, 41% after the second treatment, and 34% after the third treatment. Overall, regardless of skin type or targeted body region, patients who underwent three treatment sessions demonstrated an average 35% regrowth in terminal hair count compared with baseline pretreatment values 6 months after initial therapy. CONCLUSION: Long-pulsed ruby laser treatment resulted in significant hair growth delay in most cases. Repeated laser treatments produced an increased number of vellus hairs, an increase in growth delay, and a decreased percentage of hair regrowth.

Abdomen↗

Resistance of pelvic arteries and plasma lipids in postmenopausal women: comparative study of tibolone and continuous combined estradiol and norethindrone acetate replacement therapy.

OBJECTIVE: We sought to compare vascular resistance and plasma lipids in postmenopausal women assigned to tibolone (a synthetic estrogen replacement steroid) therapy or continuous combined hormone replacement therapy. STUDY DESIGN: Pulsatility and resistance indexes in pelvic arteries (color Doppler transvaginal ultrasonography) and lipids were monitored in this double-blind 1-year trial of 100 women randomized to either 2.5 mg tibolone or 2 mg 17beta-estradiol plus 1 mg norethindrone acetate daily. RESULTS: Both indexes of the arcuate arteries (uterine arteries) were significantly reduced beyond 3 and 6 months (12 months) from baseline, respectively, by the combined regimen compared with tibolone alone. Tibolone increased the resistance index of arcuate arteries but did not affect uterine arteries. There was no effect of either regimen on the internal iliac arteries. The medians of the percentage changes from baseline of high-density lipoprotein cholesterol (triglycerides) were significant between groups after 1 year, as follows: -17% (-16%) in the tibolone group and -4% (+15%) in the combined group, respectively. Both regimens similarly reduced total and low-density lipoprotein cholesterol and lipoprotein Lp(a). CONCLUSION: Hormone replacement therapy may induce different or opposite changes of both vascular resistance and lipids. It is unknown whether these findings may modify cardiovascular risk.

Anabolic Agents↗

Sustained reduction in valvular regurgitation and atrial volumes with tailored vasodilator therapy in advanced congestive heart failure secondary to dilated (ischemic or idiopathic) cardiomyopathy.

Afterload reduction therapy can acutely improve hemodynamic function in patients with advanced heart failure; however, it is unknown if initial reductions in mitral and tricuspid regurgitation and atrial volumes can be sustained with oral therapy. Atrial volumes and atrioventricular valve regurgitation were measured using 2-dimensional and Doppler echocardiography with color-flow imaging in 14 patients with dilated heart failure (ejection fraction 17 +/- 4%) before and after 3 +/- 1 days of intensive vasodilator and diuretic therapy tailored to hemodynamic goals. Echocardiography was repeated again after 6 +/- 2 months on oral vasodilators and a flexible diuretic regimen. Acute therapy reduced systemic vascular resistance from 1,760 +/- 460 to 1,010 +/- 310 dynes.s.cm-5, pulmonary artery wedge pressure from 30 +/- 5 to 17 +/- 4 mm Hg, and right atrial pressure from 13 +/- 5 to 7 +/- 3 mm Hg, and led to a 61% increase in stroke volume (from 36 +/- 10 to 58 +/- 14 ml) (p less than 0.01). Mitral and tricuspid regurgitation, determined by color-flow fraction, initially decreased from 0.34 +/- 0.17 to 0.20 +/- 0.20 and from 0.33 +/- 0.15 to 0.13 +/- 0.13, respectively (p less than 0.001). This reduction was sustained at 6 months. Significant decreases occurred with acute therapy, with further reductions at 6 months in both mean left atrial volume (from 100 +/- 25 to 80 +/- 19 to 65 +/- 15 cm3) and right atrial volume (from 85 +/- 23 to 64 +/- 23 to 52 +/- 14 cm3) (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗

[Diagnosis and therapy of optic neuritis].

Time-consuming and complicated electrophysiological methods need only be applied in unclear cases of optic neuritis. In the majority of patients it is possible to demonstrate opticus conduction disturbance with exact clinical subjective and objective tests. Some neuroophthalmological investigations that are well-suited for routine use are described more closely. Our own investigations of 190 patients demonstrated - in accordance with the modern medical literature - that the nowadays usual therapeutic measures do not influence the course of an optic neuritis essentially.

Color Vision Defects↗

Evidence for persistence of mitoxantrone within the peritoneal cavity following intraperitoneal delivery.

In clinical trials examining the intraperitoneal (ip) administration of mitoxantrone as therapy of platinum-refractory small-volume residual ovarian cancer, the characteristic "blue color" of the agent has been demonstrated to stain the surface of the peritoneal cavity and to persist for > or = 1 month following the last course of therapy. To determine if this blue staining material contains potentially cytotoxic concentrations of mitoxantrone, we analyzed tissue obtained at exploratory laparotomy in six women who had last received the agent administered ip from 6-22 weeks prior to surgery. Concentrations of mitoxantrone ranged from < 0.1 to 13.8 micrograms/g of tissue examined. Since any mitoxantrone present on the peritoneal surface will be highly protein bound, any residual drug may not have cytotoxic potential. The dose-response curves of mitoxantrone in a human clonogenic cytotoxicity assay against the RPMI 2780/S human ovarian cell line were virtually identical when the cells were incubated in either 5 or 50% fetal bovine serum, suggesting that protein binding will not significantly impair mitoxantrone-induced tumor cell killing. We conclude that the ip administration of mitoxantrone may lead to prolonged exposure of surface tumor to the high local concentrations of the active cytotoxic agent. This effect may contribute significantly to the antineoplastic potential of ip mitoxantrone in patients with small-volume residual ovarian cancer.

Dose-Response Relationship, Drug↗

Is the combination of superselective transcatheter autologous clot embolization and duplex sonography-guided compression therapy useful treatment option for the patients with high-flow priapism?

The aim of this study was to report feasibility, benefit and complications of superselective transcatheter autologous clot embolizations and duplex sonography-guided compression therapy in four patients with delayed post-traumatic high-flow priapism. Medical records of four consecutive patients diagnosed with delayed post-traumatic high-flow priapism (arterial priapism) were reviewed. High-flow priapism occurred mean 41.8 (6-92) h after the trauma developed. The patients were presented to hospital mean 8.3 (5-15) days after priapism occurred. The patients were assessed by penile color flow Doppler sonography. After the pathologically increased, arterial flow or arteriocavernosal fistula was seen, combination therapy with superselective transcatheter autologous clot embolizations and duplex sonography-guided compression was performed. If complete detumescence could not be achieved, this therapy was applied in the following day. In patients who had resistance to the second embolization, superselective embolization with microcoil was performed. Follow-up included penile color flow Doppler sonography at the following day, 1 month and 3 months after the procedure. International Impotence Symptoms Score (IIEF) was obtained during the follow-up. The treatment was successful in one, partially successful in one and not successful in two of the four patients. This therapy was reperformed to the latter three patients. After the treatment, high-flow priapism disappeared in one of the three patients and embolization with methalic microcoil was needed to perform to the other two patients. At 1 day after the treatment, color flow Doppler sonography and physical examinations were normal in all four patients. In the 1st and 3rd months of the follow-up, color flow Doppler sonography and the NPT tests were normal in three of the four patients. Slight erectile dysfunction was detected in one patient. Combination of superselective transcatheter autologous clot embolizations and duplex sonography-guided compression therapy may be considered as one of the first-line treatment options in adult patients with delayed post-traumatic high-flow priapism.

Adult↗

Magnetic resonance imaging and morphometric histologic analysis of prostate tissue composition in predicting the clinical outcome of terazosin therapy in benign prostatic hyperplasia.

PURPOSE: To determine whether magnetic resonance imaging (MRI) or quantitative color-imaged morphometric analysis (MA) of the prostate gland are related to the clinical response to terazosin. METHODS: Thirty-six male patients with symptomatic benign prostatic hyperplasia (BPH) with a serum prostate-specific antigen level of 4-10 ng/mL underwent MRI with body coil, transrectal prostate ultrasonography and biopsy prior to terazosin therapy. For MRI-determined stromal and non-stromal BPH, the ratio of the signal intensity of the inner gland to the obturator internus muscle was evaluated. Histologic sections were stained with hematoxylin and eosin. The MA of the specimens was performed by Samba 2000. Results of the two techniques were interpreted according to the terazosin therapy results. RESULTS: The mean stromal percentage was 60.5 +/- 18.0%. No statistically significant relationship was found between the clinical outcome of terazosin and the MRI findings. The MA results showed a significant relationship between the percentage of stroma and the percent change of the peak urinary flow rate, but not with the percent change of the international prostate symptom score after terazosin therapy (P < 0.05). CONCLUSION: Magnetic resonance imaging alone is not sufficient in predicting the response to terazosin therapy. Morphometric analysis of BPH tissue composition can be used in predicting the clinical outcome of terazosin therapy but it is suitable only in patients for whom prostatic biopsy is necessary in order to rule out prostate cancer.

Adrenergic alpha-Antagonists↗