123rc/medical_text huggingface dataset:
Utility of upright tilt-table testing in the evaluation and management of syncope of unknown origin PURPOSE: Vasovagally mediated hypotension and bradycardia are believed to be common, but difficult to diagnose, causes of syncope. Upright tilt-table testing has been proposed as a possible way to test for vasovagal episodes. This study investigated the clinical utility of this technique in the evaluation and management of patients with syncope of unknown origin. PATIENTS AND METHODS: Twenty-five patients with recurrent unexplained syncope and six control subjects were evaluated by use of an upright tilt-table test for 30 minutes, with or without an infusion of isoproterenol (1 to 3 micrograms/minute given intravenously), in an attempt to provoke bradycardia, hypotension, or both. Of the 25 patients, there were 14 males and 11 females, with a mean age of 50 +/- 16 years. Six control patients with no history of syncope were also studied. All tilt-positive patients received therapy with either beta-blockers, disopyramide, transdermal scopolamine, or hydroflurocortisone, the efficacy of which was evaluated by another tilt-table test. RESULTS: Syncope occurred in six patients (24%) during the baseline tilt and in nine patients (36%) during isoproterenol infusion (total positives, 60%). None of the controls had syncope during the test. All patients who had positive test results eventually became tilt-table-negative by therapy, and over a mean follow-up period of 16 +/- 2 months no further episodes have occurred. CONCLUSION: From this study we conclude that upright tilt-table testing combined with isoproterenol infusion is clinically useful in the diagnosis of vasovagal syncope and the evaluation of pharmacologic therapy.
Alternating hepatic intra-arterial floxuridine and fluorouracil: a less toxic regimen for treatment of liver metastases from colorectal cancer. Hepatic intra-arterial (HIA) infusion of floxuridine (FUDR) via an implanted pump has shown promise in the treatment of colorectal cancer metastasized to the liver. However, the potential benefit of this therapy may be offset by the high incidence of treatment-limiting biliary toxicity. Although weekly HIA bolus of fluorouracil (5-FU) is effective against metastatic colorectal cancer to the liver with no biliary toxicity, it is limited by systemic side effects. In December 1986, we began a phase II trial of alternating HIA FUDR and 5-FU via the implanted pump in an attempt to extend the duration of treatment by obviating the limiting biliary (FUDR) and systemic (5-FU) drug toxic effects. Patients received continuous HIA FUDR at 0.1 mg/kg of body weight per day on days 1 through 8 followed by an HIA bolus of 5-FU at 15 mg/kg given via the pump sideport on days 15, 22, and 29, with the cycle repeated every 35 days. Sixty-eight patients were enrolled in this trial, and 64 were fully evaluable. Of the 64 patients, 30 (47%) previously had received chemotherapy. Major response (complete response plus partial response) was observed in 32 (50%) of 64 patients, and the median survival from pump implantation in all patients was 22.4 months. In contrast to the experience with the single-agent HIA FUDR regimen, no patient had treatment terminated because of drug toxicity. Alternating HIA FUDR and 5-FU has efficacy similar to that of HIA FUDR given alone, but when closely monitored and adjusted appropriately, is not associated with toxic effects requiring treatment termination.
Hemodialysis-associated febrile episodes: surveillance before and after major alteration in the water treatment system. Surveillance for bacteremic or pyrogenic episodes associated with hemodialysis was undertaken before and after the reconstruction of the water treatment system at our University medical center. The new water system included a holding tank with iodination treatment. The water delivered to individual dialysis stations had only occasional positive bacterial cultures (3 of 21 samples before completion of construction, 2 of 16 samples afterwards) and intermittent detection of endotoxin (6 of 21 samples before completion of construction, 9 of 16 samples afterwards) at monthly sampling. Among 51 individual dialysis treatments (25 patients) before reconstruction and 56 treatments (29 patients), after, only 2 and 3 febrile events were identified, respectively. All of these were associated with underlying infectious illness and not with the hemodialysis procedure itself. Overall, we conclude that pyrogenic episodes associated directly with hemodialysis treatment are infrequent, and that the addition of a water storage tank with iodination treatment does not appear to increase the risk of bacteremia or pyrogenic episodes.
Nd:YAG-laser in the microsurgery of frontobasal meningiomas. Forty-three patients with big frontobasal meningiomas underwent a microsurgical removal of the tumor. The 1.32 microns Nd:YAG-laser has proved useful in this prospective series particularly with the contactless shrinkage of the tumors and the necrotization of the dural and bony attachments. Tumor shrinkage was achieved by radiating the tumor surface with the Nd:YAG-laser. This technique facilitated the microsurgical dissection and reduced the blood loss by half. The Nd:YAG-laser necrotization of the dural and bony attachments reduced the recurrence rate following grade two resections from 20% to zero. The postoperative quality of life was excellent with a complete rehabilitation in 76% of the patients. The use of the 1.32 microns Nd:YAG-laser improved significantly the results of microsurgery for frontobasal meningioma.
Induction of arthritis in rats by aqueous suspensions of mycobacteria without the use of oil. We report for the first time the induction of arthritis by an aqueous, rather than an oil, suspension of killed tubercle bacilli. This was accomplished in the highly susceptible dark Agouti strain of rats, by intraperitoneal injection during the healing phase of chemically induced peritonitis. The same procedure (injection after the induction of peritonitis) augmented the incidence of arthritis produced by bovine type II collagen and Freund's complete adjuvant. Enhanced delivery of antigen from the peritoneal cavity to regional lymph nodes in the postinflammatory state was responsible for this increase in the induction of arthritis.
The role of infections in the rheumatic diseases: molecular mimicry between bacterial and human stress proteins? Infections can cause or exacerbate the rheumatic diseases in several ways, including immune cross-reactivity between bacterial heat shock proteins and similar proteins in normal human tissues. This may lead to autoimmunity in rheumatoid arthritis and systemic lupus. In addition, increased activation of the gene regulating the synthesis of a heat shock protein has been found in scleroderma fibroblasts. As an infection-induced model for other rheumatic diseases, rheumatic fever (RF), with its well-established link to prior group A streptococcal infection, will be revisited. The lessons learned from RF and other rheumatic diseases directly linked to infection will be applied to ankylosing spondylitis, rheumatoid arthritis, Sjogren's syndrome and polymyositis, for which a mounting body of circumstantial evidence suggests a probable infectious cause. The interplay of genetic susceptibility and infection with particular organisms and the implications of this new information for present and future therapy of the rheumatic diseases will also be presented.
The role of elective lymph node dissection in the management of patients with thick cutaneous melanoma. A retrospective search of patients seen at the Duke Melanoma Clinic from 1970 to 1986 identified 308 clinically Stage I patients, with 4.0 to 10.0 mm cutaneous melanomas. Five-year and ten-year survival was 56% and 43%, respectively. Elective lymph node dissection (ELND) was done in 116 patients (37.7%); there was no difference in disease-free interval (DFI) or survival between these patients versus patients treated with wide excision only (P = 0.9). Thirty-two patients (27.6%) had pathologically positive nodes on ELND. These patients had a shorter DFI (P = 0.05) and survival (P = 0.03) compared with patients with negative node dissections. When further divided by Breslow's thickness, this difference persisted in patients with 4.0 to 6.0 mm lesions (P = 0.01). However, for thicker lesions (greater than 6.0 mm), there was no difference in survival between the node-negative and node-positive groups (P = 0.9). The mean follow-up was 7.1 years. Elective lymph node dissection was not done in 192 patients; 78 of these recurred first in the regional nodes. These 78 patients were compared with the 32 patients who had pathologically positive nodes by ELND to see if patient survival was improved by early removal of nodal disease. There was no difference in DFI (P = 0.5) or survival (P = 0.3) between these two groups. It is concluded that ELND may provide prognostic information for patients with thick cutaneous melanomas. However, there was no change in DFI or ultimate survival when patients were followed, and nodes removed when clinically positive. The authors do not recommend ELND for patients with thick melanomas because the risk of distant metastases outweighs any benefit of regional node dissection.
Proliferating trichilemmal tumor: report of a case and review of the literature. The authors report a case of proliferating trichilemmal tumor and review the related literature. Although considered biologically benign, malignant proliferating trichilemmal tumor have been reported. The authors emphasize the importance of recognizing that the tumors can occur in individuals in their 20s and 30s, and that the tumors should be excised with a margin of normal tissue. Routine follow-up is recommended.
The association of elevated plasma homocyst(e)ine with progression of symptomatic peripheral arterial disease. Plasma homocyst(e)ine (the sum of free and bound homocysteine, homocystine, and the mixed disulfide homocysteine-cysteine, expressed as homocysteine) levels were determined by high performance liquid chromatography in 214 patients with symptomatic (claudication, rest pain, gangrene, amputation) lower extremity arterial occlusive disease and/or symptomatic (stroke, cerebral transient ischemic attacks) cerebral vascular disease and in 103 control persons. Mean plasma homocyst(e)ine was significantly higher in patients than in controls (14.37 +/- 6.89 nmol/ml vs 10.10 +/- 2.16, p less than 0.05). Thirty-nine percent of patients (83 of 214) had plasma homocyst(e)ine values greater than control mean + 2 standard deviations. Plasma homocyst(e)ine values were contrasted to age, male sex, diabetes, hypertension, smoking, renal failure, and plasma cholesterol. No difference was found in the incidence and/or level of any of these risk factors when patients with normal plasma homocyst(e)ine were compared to those with elevated plasma homocyst(e)ine, both by univariate and multivariate analysis. Patients with elevated plasma homocyst(e)ine were more likely to demonstrate clinical progression of lower extremity disease and of coronary artery disease, but not of cerebral vascular disease than were patients with normal plasma homocyst(e)ine, and the rate of progression was more rapid (p = 0.002). Progression of lower extremity disease as assessed in the vascular laboratory was also more common in patients with elevated plasma homocyst(e)ine (p = 0.01). We conclude that elevated plasma homocyst(e)ine is an independent risk factor for symptomatic lower extremity disease or cerebral vascular disease or both. Symptomatic patients with lower extremity disease and with elevated plasma homocyst(e)ine also appear to have more rapid progression of disease.
Comparison of supraannular and subannular pledgeted sutures in mitral valve replacement Ten fresh canine hearts were used to compare the peak left ventricular pressure required to disrupt prosthetic mitral valves sutured in place with horizontal mattress sutures with either subannular or supraannular pledgets. Each group consisted of 5 animals. A 29-mm Medtronic mitral valve was secured in the mitral position with ten pledgeted sutures. The aorta was cannulated and normal saline solution was infused into the left ventricle until valvar disruption occurred. The peak pressure and the location and mechanism of disruption were then noted. At the peak left ventricular pressure required for valvar disruption, no individual sutures were broken. Instead, in all specimens a subannular myocardial rupture occurred in the posterior portion of the mitral annulus along the extent of the atrioventricular groove. In addition, the posterior wall of the left atrium dissected upward subsequently. Significantly greater pressures were required in the group with subannular suture placement as compared with the supraannular group (354 +/- 37 versus 236 +/- 33 mm Hg; p less than 0.0007). These data suggest that placement of horizontal mattress sutures with pledgets in the subannular position is superior to the currently recommended method of supraannular suture placement in mechanical valves.
Interleukin-2 therapy in patients with metastatic malignant melanoma: a phase II study. Forty-seven patients with metastatic malignant melanoma were treated with two 5-day cycles of 100,000 U/kg recombinant interleukin-2 (IL-2) intravenously (IV) every 4 hours separated by 1 week. This dose and schedule of IL-2 were identical to those used in a previous combined IL-2 and lymphokine-activated killer (LAK) cell phase II clinical trial of the IL-2/LAK Working Group. Patient eligibility criteria, and clinical management guidelines were similar to those used in the previous trial. Forty-six patients were assessable for response. Objective responses were observed in 10 of 46 patients (two complete responses [CRs], eight partial responses [PRs]) or 22% with responses occurring in lung and liver as well as lymph nodes and subcutaneous sites. The median response duration was 8 months. Toxicity was significant; three patients developed myocardial infarction, and one patient died during therapy. Overall the toxicity and response rate for single-agent IL-2 are similar to that observed with IL-2 administered in combination with LAK cells in the previous trial. These results suggest that single-agent therapy with IL-2 when administered in this schedule has significant antimelanoma activity in humans, and that LAK cells generated from peripheral blood add little to the antimelanoma activity of this dose and schedule of IL-2.
Cognitive deficits in children: adaptive behavior and treatment techniques. Impaired cognitive functioning impedes the development of age-appropriate adaptive behavior, thus adding to the burdens of many children with epilepsy. Detailed neuropsychological assessment can identify the underlying ability-related impairments that contribute to the adaptive behavior deficiencies evidenced, particularly in the home and school settings. This information can serve as the basis for a multidisciplinary treatment plan tailored to individual needs. Ideally, the need for such a treatment plan should be perceived early in childhood, so that it can be developed and applied preventively. The same remedial principles also apply in older children and are here set out in detail.
Obstructive jaundice: use of expandable metal endoprosthesis for biliary drainage. Work in progress. Expandable metal endoprostheses were implanted transhepatically in 61 patients with obstructive jaundice. Fifty-three patients had malignant and eight had benign obstructions. Because of the small diameter of the compressed stent (7 F), primary implantation of the stent without a previous catheter drainage was preferred. Postprocedural complications occurred in three patients (5%) (biliary pleuritis, peritonitis, hepatic artery aneurysm). The 30-day mortality rate was 8.2%. Reocclusions were observed in six of the patients with malignant obstructions (11%) (observation period, 1-10 months; mean, 4.5 months) and in two of the patients with benign stenoses (25%) (observation period, 3-21 months; mean, 9 months). The higher reocclusion rate of benign obstructions must be interpreted with care because of the small number of patients. From their preliminary experience, the authors conclude that expandable metal endoprostheses offer patency rates equal to those of plastic stents. The implantation trauma is reduced due to the small 7-F introducing catheter system.
Adjuvant chemotherapy of breast cancer. Many women will not be cured of breast cancer by even the best early detection and surgical techniques because of micrometastases present at diagnosis. Adjuvant therapy has extended the disease-free interval for most patients and lengthens overall survival for many. Combination chemotherapy has become the standard form of adjuvant treatment for premenopausal women with breast cancer and positive lymph nodes after primary therapy. With minimal toxicity, disease-free and overall survival are improved. Results are less impressive or less clear-cut for postmenopausal women or any woman with negative lymph nodes. Long-term toxicities of adjuvant chemotherapy may include second malignancies and cardiac dysfunction. Although these complications probably are rare, they must be considered seriously when weighing chemotherapy for patients in whom its benefits may be slight. Innovations likely to become standard in adjuvant therapy decision making include risk assessment with new prognostic indicators (growth fraction, oncogene expression) and investigation of dose intensification using bone marrow growth factors and autologous stem-cell support.
Primary adenocarcinoma of the bladder: favorable prognostic significance of deoxyribonucleic acid diploidy measured by flow cytometry. Flow cytometric nuclear deoxyribonucleic acid ploidy analysis was done successfully on 38 specimens of primary bladder adenocarcinoma treated between 1954 and 1985. Of the specimens 10 (26%) were deoxyribonucleic acid diploid, 8 (21%) were tetraploid and 20 (53%) were aneuploid. Distribution of ploidy patterns between the 14 histological low grade and 24 high grade tumors was similar. Of 38 tumors 35 (92%) showed muscle invasion. One tumor arose in a previously exstrophied bladder, 10 were of urachal origin and 27 arose in an anatomically normal bladder. Of the urachal origin tumors 80% were deoxyribonucleic acid aneuploid. At 5 and 10 years after diagnosis 80 and 70%, respectively, of the patients with diploid tumors were free of disease. By contrast, at 5 and 10 years after treatment only 20 and 12%, respectively, of the patients with nondiploid tumors have not had disease progression (p less than 0.001 log-rank test). None of the 6 patients with diploid, high grade, high stage, muscle invasive tumors had subsequent progression. In contrast, 16 of 17 patients (94%) with high grade, high stage, nondiploid tumors had either local or distant tumor recurrence (p less than 0.0005). Nuclear deoxyribonucleic acid ploidy pattern appears to be the most significant prognostic information currently available to stratify expected prognosis for patients with muscle invasive adenocarcinoma of the bladder. This test probably should be a standard tool in the clinical management of patients with this rare bladder malignancy.
The epidemiology of acute respiratory tract infection in young children: comparison of findings from several developing countries. Coordinated Data Group of BOSTID Researchers. Investigators from 10 countries studied the epidemiology of acute respiratory tract infection (ARI) among children 0-59 months old. Data on incidence rates, by age, gender, and season; on pathogenic agents; on case-fatality rates; and on selected risk factor findings are presented. Incidence rates from six of the community-based studies ranged from 12.7 to 16.8 new episodes of ARI per 100 child-weeks at risk, and rates of lower respiratory tract infection (LRI) ranged from 0.2 to 3.4 new episodes per 100 child-weeks at risk. Children spend from 21.7% to 40.1% of observed weeks with ARI and from 1% to 14.4% of observed weeks with LRI. The incidence rates for ARI are highest in younger children. Viruses, especially respiratory syncytial virus, are isolated more frequently than bacteria from children with episodes of LRI. Risk factors exhibited different patterns of association with ARI in different studies. Interventions could have great impact on high-risk levels common in the study populations. These studies provide interesting and useful data on the epidemiologic dynamics of ARI.
Antigen specific serum antibody response to Chlamydia trachomatis in patients with acute pelvic inflammatory disease. Sera from 35 patients with acute pelvic inflammatory disease (PID) with and without Chlamydia trachomatis confirmed by culture and sera from 19 control patients with neither evidence of pelvic infection nor C trachomatis infection were studied for the presence of serum IgG, IgA, and IgM antibodies to C trachomatis using enzyme immunoassay (EIA) and immunoblotting techniques. There was no correlation between the antibody concentrations in the EIA and the spread of chlamydial infection, as determined by cervical, endometrial, and laparoscopic sampling for chlamydia. The immunoblot analysis showed antibodies to the major outer membrane protein (MOMP) of C trachomatis elementary bodies in all patients who had had C trachomatis isolated. Reactivity was also frequently observed against the 68, 62, 60, 45, and 31 kilodalton antigens. About 20 antigenic polypeptides were identified. Differences in antibody prevalence to specific chlamydial antigens, however, were not related to the site of chlamydial isolation or serum antibody concentrations observed with the EIA. The results indicate that patients with PID with and without upper genital tract infection with C trachomatis cannot be differentiated by reactivity of sera to specific chlamydial polypeptide antigens. The determination of a specific serum IgA antibody response by EIA was the most effective single test to discriminate between patients with and without acute chlamydial infection.
Uterine rupture. Uterine rupture is a sudden, unforeseeable event that carries a high rate of maternal and perinatal mortality. When the diagnosis of uterine rupture is suspected, prompt surgical intervention with an experienced pelvic surgeon and blood product replacement should be considered. At the time of uterine rupture, the patient should be evaluated for possible repair or hysterectomy. It appears, based on the aforementioned information, that repair is a reasonable consideration. In those patients who have undergone a repair, early delivery by elective cesarean after assessment of fetal lung maturity at or around 36 weeks gestation would appear prudent. In those patients with a prior cesarean, continuous electronic fetal monitoring to detect intrapartum fetal distress would appear prudent. In these patients fetal distress is the most common sign or symptom of uterine rupture and frequently precedes any other clinical manifestations of this complication.